Women’s Oral Health Issues and Management - The Importance of Prevention, Intervention and Education

- Okay. Okay. Hello everyone, as you're joining, we are gonna give it a few more minutes, and then we'll get started in about, around 12:02. So I'll let everyone join in, and welcome to our webinar here today. Okay. And as people are still joining, I'll say this as like another little reminder, as well, but throughout the presentation, please feel free to enter questions either in the Q&A section or in the chat, and we will have Dr. Michelle Kohler respond to those at the very end of the present

ation. If you have to pop off, we'll make sure to send a follow-up with those answers for you, but please feel free to put any questions in the chat or in the Q&A section, and we will take part in that afterwards. I'm gonna give it one more minute for people to join, and then I'm gonna pass it over, but while people are joining, my name is Maria Carr, I am the Director of our Go Red for Women, I'm here with the American Heart Association, we just celebrated our 20th anniversary of the Go Red for

Women Movement and this is the beginning of our centennial celebration of the American Heart Association, as a whole, and we are so grateful to our partners, Delta Dental of Michigan, they have been amazing partners with us, and we're excited to have this webinar that is called Field, sponsored by them for you all today, focusing around women's oral health issues as far as it comes to prevention and the importance of intervention and education. And with that said, I am now going to pass it over

to the amazing Dr. Michelle Kohler, who is going to take it away, so please enjoy, take notes, this is being recorded, so we'll send it up as a follow-up, and I'm going to pass it over, so enjoy. Thank you all for being here. - All right, thank you, Maria. I appreciate the introduction, thank you so much for that. I'm gonna go ahead and share my screen here, so please let me know if that comes up. It should be the full presentation there, full screen. Can you confirm that you can see that Maria

? All right. - It looks great. - Okay, perfect. So this is my second Go Red for Women presentation, very excited to have the opportunity to do this again this year, and so we're gonna be focusing on a little bit of a different topic, certainly women's oral health issues, but probably a little bit more on women's oral health issues as we age, and the importance of prevention, intervention, and education. So I'll go ahead and get started here. So in the first slide, just a little overview of what

we're gonna talk about today, and oral health needs, they do change over time, and certainly for women, hormonal changes come into the picture much more than we see in men. And we're gonna talk about kind of the three major time periods, so pre-teen, teenage years, that's when we're thinking about puberty, and the onset of the menstrual cycle, then pregnancy, and of course, menopause, so we're moving into those older adult years. But we'll talk a little bit about young kids, and infants, and thi

ngs like that, because dental recommendations are similar as the patient ages, but can diverge a little bit, especially as we get older, and medical conditions really come into play here. But one thing that I really want to emphasize, and I will continue to do throughout the presentation is that your dentist can identify a lot of signs and symptoms of medical conditions. And when you go to your dentist, they should be updating your medical history, as well as your medication list, they should be

taking blood pressure, and then, of course, observing internally how things look in the mouth, but also anything external in the head, neck and face. So we can definitely identify a lot of things when you're in the dental chair. So newborn and infant years here, I'm gonna get started with the very, very young, and actually during pregnancy, tooth development starts very, very early on, so only in the fifth and six weeks of pregnancy. Nutrients from the mother have a significant effect here, I n

amed just a couple of those, but calcium and magnesium, we're also looking at vitamins A and D, all of these important for sound enamel formation, and the development of the tooth itself. And we also see some concern here around what we call craniofacial anomalies, which are developmental defects that can contribute to different size and shape of the oral cavity, how the dental arches come together, and of course, the face overall. Cleft lip cleft palate, that's probably the two that you've hear

d of, and probably the more common ones, and I have a couple of pictures over here on the right hand side, so the top is cleft palate, you can see that little opening there toward the back of the mouth, and then the lower picture is cleft lip. And both of these are repaired very, very early on for that baby, because you can see how it would be an issue for nutrition. So for that baby to be able to take a bottle, and you know, create the suction that they need to be able to get the formula, or th

e breast milk, and things like that there. But there's certainly other craniofacial conditions that we think about, but microsomia, that's when the head is underdeveloped there, the jaws can also be very small, craniosynostosis, that's when the sutures in the brain, they fuse early on, Treacher Collin syndrome is another one with underdeveloped facial bones, a smaller lower jaw, but a lot of these can be influenced by genetics, and so if the parent has this condition can be a problem, of course,

for children, but these can also be novel changes, or just spontaneous DNA modifications that cause these syndromes in kids. But we also have to think about, so not only smaller teeth and smaller frame, so thinking about the jaws and how they come together, they may be smaller but delayed tooth eruption, and then specific issues with the enamel on the teeth, which is that hard, outer surface that protects things. So there's also some high-risk behaviors from the mother that can contribute to th

ese things as well that we'll get into, later on. Now some of the developmental changes here, there are, believe it or not, some hormonal changes occurring in infants. So within the first three months, or six months, they do get a postnatal surge, so right after they're born, particularly reproductive hormones, we know things are certainly changing for the mother, as well, hopefully getting things back on track within the first six months, but those hormonal balances do affect the oral environme

nt, particularly when we think about the gum tissue. So if as a parent, you're seeing a lot of redness or swelling and things like that, that does need to be looked at by a dentist. And environmental influences are also important here as well for young kids. And when you start seeing teeth come in, so that should be about six months, and certainly over the next couple of years, you're gonna see all of those baby teeth come in, really wanna take a look at what's going on with the teeth. Are they

coming in on time? Do they look okay? Does the enamel look okay? Are you seeing smaller teeth, yellow teeth? Are they coming in in the right spots there? But environmental influences can also be important, again, those high-risk behaviors. So I list a couple of here from cigarettes and alcohol, there's also some household products that we think about in these very young developmental years, some medications, and things like that. So all of this really needs to be discussed at the dentist if you

do have concerns around development for the young child. And when I get to recommendations, we'll talk a little bit more about some of these, but all good things to consider. And the pictures here on the right hand side, clearly just of an older child, so wasn't able to find anything for the very, very young, but it does give you an idea how some things can change. So you can see these teeth are coming in in a very different way, they're not coming in in alignment, you can see they're malformed

in some cases through some of the angles on the pictures here, the teeth actually narrow quite a bit, you see some changes in coloration. All of these things you can still identify in very young kids as the teeth are coming in, but certainly this is a better view in an older child. So our recommendations here, I did pull quite a bit from our resource that we have at Delta Dental, it's called "From Drool to School" there, and it's providing young mothers or any mother really with information abou

t their child's oral health from being a baby and then all the way up into those elementary school years. But, of course, the first recommendation that we really wanna make is to get the child to the dentist, hopefully when that first tooth comes in, but no later than one year of age, establishing that routine of going to the dentist, and that comfort with seeing them, having someone looking in the mouth, and you know, having a mirror, an explorer or something like that in the mouth, it's always

good to start that sooner rather than later. But for home care, we're really looking at trying to wipe a couple of times a day with a damp washcloth. So especially before the first tooth comes in, but this can continue after they do start to come in as well and really does help the child get used to having something in there. It makes for an easier transition when you start using a toothbrush. We also try to really inform parents about putting the child to bed with a bottle. And regardless of w

hether it's formula, or it's milk, or it's juice in there, all of those things can lead to extensive decay, and more quickly than anyone can realize. So we recommend stopping that bottle between 12 to 18 months, but if you're going to send the child to bed with a bottle, then definitely consider water, because if they are, you know, sucking on that bottle all night, then unfortunately, the conditions in the mouth, they can't really reestablish themselves at normal. So we're thinking about the pH

balance in the mouth, really want that to end up in a more neutral space, that way the bacteria don't grow in the mouth, and then we don't have that significant risk for decay. Another thing I wanna notice here really is the sharing of cups, silverware, you know, either between the parent and the child, or with siblings, because that can certainly transfer cavity-causing bacteria, which we're concerned about, you know as dentists and clinicians, and things like that, but also viral diseases lik

e the cold, flu, herpes simplex, and we'll talk a little bit more about that later on, so no sharing if possible. Now the next thing here we're really looking at in these preschool years, so we're kind of moving to that two to five-year-old age group, and thinking about the hormonal changes here. And again, believe it or not, there are a few that we're really thinking about, so cortisol and growth hormone are the two I pulled out here, and growth hormone really makes a lot of sense at this age,

because obviously the child is growing a considerable amount right now, not just their bones, but also that facial structure there. We're seeing a lot of teeth coming in, again, those baby teeth, and so if growth hormone is out of whack, then we see the teeth not maturing like we would expect, not coming into the mouth, and those jaws are underdeveloped. And then for cortisol, the relationship here is really with caries. So if you have elevated salivary cortisol levels, you see a lot of bacteria

l growth. So they're able to feed on that cortisol, and they take advantage of the fact that the immune system is allowing for more inflammation there. So cortisol is considered more of a stress hormone, just have some functions within the brain for learning and memory, but also with glucose storage, but the inflammation part is what we really think of here. And a couple of things I wanted to include just to give you an idea of what we see out there in kids in this age group, so the top chart th

ere is dental caries experience, you can see some groups are on the low side, maybe that 15% range, 20%, others extending into 35%, and I have these charts throughout the presentation, so you can see how that changes as we age. But I would note that on some of these graphs, some certain populations are missing, and one that I call out specifically here is our American Indian and Alaskan Native population, they are at almost 56% at four-years-old. So could be very different among the different de

mographics. So something to keep in mind as a parent, and of course, if you're a clinician. And then I would also add here that sometimes hormones aren't the key driver for poor oral health here, social determinant health factors, certainly individuals and their poverty status are important, different race and ethnicities have different experience with caries, different genders, so something to consider, as well as diet and nutrition, and I talk a little bit more about diet and nutrition as we g

et into the elementary school ages. So another thing to really consider here in these preschool years, as we're moving away from the bottle, and we talked about that at like 12 to 18 months here, but sometimes other habits come into play, but thumb and pacifier use is important to point out here. And you can see the picture over there on the right hand side, the back teeth are touching very clearly, the front teeth are not. And you can see how nice around that opening is, so perfect for fitting

a thumb in there, or a pacifier, and you can see how the jaw shape is a little bit different, it's a little more narrowed towards the front, more V shape than U shape. But it's an important concern for this population if that habit continues really beyond that two- or three-year-old age group, so frequency is, of course, important, are they maybe just sucking their thumb when they're taking a nap, or are they doing it all day long when they're playing, or, you know, when they're watching TV, or

doing something like that, the longer it's occurring during the day, the more effect it will have. And then also some suction is a problem, as well. So some children are very aggressive with thumb sucking or pacifier use, and the more suction, the more changes you will see as far as the oral structures are concerned. And one thing I would note here is that if this habit continues into that elementary school age timeframe, so you're thinking eight, nine, 10, 12, sometimes it takes surgical correc

tion to fix what has happened, and to be able to bring those teeth together again, that can be very, very expensive for families, and very difficult on the child, so the sooner these habits stop, the better. And then also wanted to bring up fluoride use here. So this is important, of course, throughout the ages for women, but certainly, when we're thinking about young kids and the teeth are still developing, you're starting to get the permanent teeth coming in, fluoride is important. And you kno

w it was once considered one of the 10 great public health achievements in the 20th century, but you've probably heard that some communities now are defluoridating, and they're removing it from the water. Certainly there's concerns around fluorosis, but there really also are some general concerns in the communities about what is being put in the water, and just being very cautious around that. So you can certainly understand that when we think about like the Flint water crisis, and things like t

hat, there are very real concern here, but fluoride is important certainly for the prevention of caries, and dentists, clinicians should really be identifying those sources if the water is defluoridated, that that patient is using. So there's other ways to get fluoride, toothpaste, of course, there's fluoride treatments in the dental office, and then some bottled waters do have fluoride, if you're on well water, that may have some naturally occurring fluoride, as well. So there's certainly other

areas of exposure and always where the conversation with your dentist if you're concerned about it, but the picture over at the right on the bottom part of the slide, so you can see, there's a very general example, you can see just a little bit of white spots on that left hand picture there, and then for heavier fluorosis, it actually turns brown, and you can see that more on the right hand side on those teeth there, which is of course a very significant cosmetic concern for patients. Now for o

ur preschool years, and the dental recommendations here, we talked about the bottle there, and ending the pacifier use and thumb sucking, and one thing to consider with the bottle is that it's not replaced with a sippy cup. And if it is replaced with a sippy cup, then again you're using just water, because, of course, milk and juice in those, you're really just substituting one for the other, and if it's being used all day, then there is a significant risk for decay, because the pH in the mouth

is not returning to normal, and that is allowing the growth of bacteria, which becomes significant issue for decay. Definitely wanna make sure that you're using fluoride toothpaste with the child, if they're under three, it should be rice-sized, you can use about a pea-sized shaped amount for those older kids, they need to be brushing at least twice a day, and of course encouraging that visit to the dentist, and establishing a dental home, so you can get comprehensive continuous care for, you kn

ow, as they age, and move into adulthood. So elementary school years here, we're gonna touch on some hormonal changes there, very similar to what we discussed for the last age group, some dental conditions and then social determinant of health factors here as they move into a little bit of a different peer group, and start going to school on a regular basis. But cortisol and growth hormone, still the main focus here in this age group, and again with cortisol, those elevated counts for bacteria t

hat cause caries, and then for growth hormone, lack of overall craniofacial growth, so smaller jaws, jaws that don't fit together and lack of enamel, and slow tooth eruption are all concerns here. And the photo over to the side there, what you can see for these teeth, it's actually a lack of enamel on the outside. So that darker color is due to the dentin that's on the inner part of the tooth there. And without the enamel on the top, that's that hard surface, these teeth are very soft, they're o

f course very yellowed here, and you can see they're also not the correct shape. So unfortunately this child will need a lot of work to restore them to a functional dentition, and unfortunately probably some extractions, as well. It really is important then to be going to the dentist, having the child checked if you have some concerns about the way that they're growing, when the teeth are coming in, and how they look when they are coming in. So a couple other dental conditions here to mention, s

o erosion, that's kind of the washing away of the tooth surface, if they are eating and drinking a lot of acidic things, that becomes a concern, fluorosis we've talked about before, and then of course this picture here with the enamel defects, but as the child goes to school, the social determinant of health factors, there's many influences coming in there. So of course they had parent and family before, but now we're thinking about peer relationships, there's also some more cultural relationshi

ps, and as well as like their community. So what are they being served for launch at school? Is it nutritious? What other access do they have to soda, or juice, or even sports drinks? And I'll kind of get to that a little bit later on, but things do change a little bit in elementary school. So the caries statistics here, just wanted to highlight again the dental caries experience, and you'll see that for the age groups, it's overall somewhat similar to what we saw in that two- to five-year-old a

ge group, although the nine to 11 years on that top graph, you'll see it's starting to creep up there. And that is a trend that we will see throughout the other age groups, the dental caries experience does increase as we age, and we start seeing more and more people that have been affected by decay. And then I also included a graft on here at the bottom for just the prevalence as far as male versus female, you can see here males do tend to have a little bit more caries experience than females,

but it has decreased, over time. So we are doing a lot better with oral health prevention just in the dental community, and having people going to the dentist, and understanding that connection between oral health and overall health. Certainly, the social determinants of health come into play here again with differences between the ethnicities and of course, poverty status, and I'll continue with these, so you can see the different charts, and how it changes over time, but I cannot emphasize eno

ugh the importance of some of the school-based dental programs, and the mobile services here. It's really important to meet kids where they're at, and for parents, it's hard to take time off work sometimes without, you know, the risk of being fired, without losing that hourly pay, to be able to take their child to the dentist, or maybe they have transportation issues. So if the child is in school, and these services can be offered, it's a great thing for increasing oral health access. So even if

it's just a screening, or it's doing some sealants, or cleaning, all of that is very, very important, because then the parent knows what the child has as far as dental needs are concerned, and can get them to the dentist. And one big win for us here in Michigan that I wanted to note is the new Kindergarten Oral Health Assessment. So that law was just passed earlier this year, and it is recommending an oral health assessment for every child that is coming into kindergarten, and we're glad to see

it, because we know vision screenings, hearing screenings, all of that has been very much a part of coming into school and now we see oral health being added to that. So dental recommendations here, healthy eating habits, like I mentioned before. So school lunches, hopefully they're incorporating fruits and vegetables, proteins, and things like that, more balanced nutrition, and staying away from some of the sugar, and the sweets of candy and chocolate, the sugary drinks like pop and juice, and

now we start seeing sports drinks come into play here, and you know, sometimes they have access to vending machines and things like that, where they can purchase these, and can really be detrimental, if they are using those or they're eating all day long. So establishing good home care becomes very, very important here, definitely brushing at least twice a day, and they need to start flossing, those permanent teeth are coming in, the teeth usually now at this age group, they're definitely touch

ing, which increases the risk that food is going to get stuck in-between them and needs to be removed with floss. So the routine really needs to be brushing, flossing, rinsing, and then of course, no food or drink after brushing before they go to bed, unless it's water. And that way, again, it really establishes that normal pH while they're sleeping, allows the mouth some time to rest, and hopefully decreases those bacterial counts. We are losing baby teeth at this point in time, we've got perma

nent teeth coming in, and it's important to visit the dentist, certainly fluoride treatments at the dentist, and the use of sealants, which is the photo that I have over on the side, it's the procedure of applying a sealant, these preventive measures become very, very important for protecting those teeth as they move into those teenage years, and you know, we see more and more changes in the body. So now into the preteen and teenage years here, this is where for women, we really see a lot of the

se hormonal changes, and we start to diverge from what we're seeing with boys, and those increased hormones associated with puberty, definitely what we would expect. The estrogen and the progesterone, they're certainly becoming much higher than they were before, these women are starting their menstrual cycle, and that affects the conditions in the mouth sometimes on a very regular basis, monthly, when that comes into play. But increased gingival bleeding, overgrowth of bacteria, sometimes we see

some of the swelling of the gums, and things like that, all of that can really be minimized with good oral hygiene, but in some cases, can lead to some aggressive changes, so it needs to be monitored, the child needs to be seeing the dentist. We also sometimes see aphthous ulcers and recurrent herpes infections, sometimes that really functions with that menstrual cycle, so we need to be aware of that, and certainly as they move further into those teenage years, behavioral changes come into play

, as well. And these high-risk habits may start to appear, hopefully not, but certainly something to be aware of, but drinking alcohol, tobacco use, although we have seen smoking decrease, we are seeing more vaping and things like that, but there are significant oral effects associated with smoking, increased risk of oral cancer, but certainly periodontal disease, and tooth loss, and then unfortunately, illicit drugs, when you think about like methamphetamine and things like that being used caus

es a wide variety of issues, anything from dry mouth, and tooth grinding, to extensive caries, and the loss of teeth, again. A couple of photos over here on the right hand side, so the top two A and B are really looking at like an oral cancer lesion, so that's the white spot over there in the corner of the mouth, something to keep an eye on for sure, but on the bottom, on the bottom left, that's an aphthous ulcer and you can see how red and irritated around the edge it is. So this is an uncomfor

table condition, and definitely still as well on that lower right hand side, you can see the blistering effect there from the herpes simplex lesions, and those can actually fill with fluid, and they can break, and crust over, which is what you're seeing here, but again, can be very painful. Also a cosmetic issue for these teenage girls, especially if they're coming every month along with the menstrual cycle. Okay, so caries statistics here, and I will, you know, draw your attention to that top c

hart there in the caries experience, you can see it kind of going through the roof, but 12 to 15 years, less of dental caries experience as compared to the 16- to 19-year-olds, but it really has gone from that 30, 35% mark, now we're all the way to almost 50% for 12 to 15 years, and almost the 70%, so a lot of changes here. And when we think about some of the intervention pieces, this is really a key period of time to try to establish really good oral hygiene habits, and establish like long-term

positive oral health outcomes. So if the child hasn't been to the dentist, absolutely needs to go at this point in time, because the bacterial changes here that have been building up over time, now they really move into that long-term, they've colonized the mouth, and we're gonna continue to see an increase in caries if something doesn't change. A lot of influences here, talked a little bit about the hormones piece, but of course, social determinants of health, those high-risk behaviors and hea

lth habits, what are the parental behaviors and mindset? That's also important, if the parent isn't going to the dentist, and doesn't necessarily value oral health, they may not be taking the child to the dentist either. And then of course, peer influences, really for teenagers, that's where we think about all of that coming into play can really change how they feel about oral health, and the things that they are doing, you know, as far as what they're eating and drinking, all of that has an eff

ect on the oral cavity. So dental recommendations here are still the same as far as the routine at home, brushing twice a day at a minimum, flossing once a day, using mouthwash if you can't brush, that's at least a good step toward trying to keep some of that plaque, and keep it from building up on the teeth there. It's definitely better than nothing, we know at school, these teenagers, they certainly can't brush, but they can at least rinse out if they have a chance to do that. Also have to thi

nk about here, seeing a lot of orthodontics and braces. Braces can be very difficult as far as keeping the teeth clean. So the good habits that need to be established here are definitely important, certainly when a teenager has the brackets on the teeth, they can decay around the brackets, and actually when you remove the brackets, you may see that brown staining from the caries when they were on there. And you know, there's nothing like getting through a full two years of orthodontics only to t

ake those brackets off, and see defects on the teeth. It's very disappointing for the child and for the parent, so really critical, oral hygiene here. Regular dental visits are definitely important, and if they're starting to see a lot of changes particularly associated with like the menstrual cycle and things like that, significant gingival bleeding, cleanings may need to occur every three to four months instead of six months. We're trying to avoid here is the irreversible damage, so once you l

ose gum tissue, once you lose bone, then that can't really be fixed in a lot of cases. So we wanna make sure that those irreversible things are not happening. There are some treatments available for, you know, girls that suffer from those aphthous ulcers, and the herpes lesions on a regular basis, just a couple of those pictured here that they can use, but acyclovir for the herpetic lesions can be very helpful, prescribed by a physician, so they can either do tablets that that child can take, or

a topical cream for once it does actually appear on the lip, but for those that are getting them regularly, sometimes those tablets are a great idea, that way they can start taking the tablet around the same time as the menstrual cycle, and then hopefully it'll keep that blister from forming, or at least keep it very, very small. Okay, so moving on here to the early adults or reproductive years, so here we're thinking about kind of the early 20s, 30s and things like that even into the 40s, and

again menstrual cycle, we've talked about that before here certainly comes into play for this population, as well. We know it's estrogen and progesterone causing those changes in the tissues, we really need to keep an eye on, and nothing really has changed here, looking for that redness, and the spontaneous bleeding, the swelling and things like that. But once a patient starts taking oral contraceptives, which is very common for women in this age group, can also influence the oral conditions. An

d one thing that's really interesting, we're starting to see some research on it is the potential link to an increased risk for periodontitis, which is when you're losing bone around the teeth, and eventually the teeth can become loose, and you'll have to have that tooth removed, or in some cases, it can actually fall out if the bone goes to the point where there's just no support left. So with long-term use, we are seeing some risk there, and it's something that they're tracking very closely in

the research. Now for pregnancy, this really goes into a whole host of different issues. So we see those hormone levels go through the roof, they peak during the third trimester there, but the level of bacteria increase, the rise of inflammation coming up here, so definitely can see some irreversible outcomes at this point in time as related to the gum tissue, and certainly for periodontal disease. But poor oral health has a very long history in the research of being linked to adverse outcomes

in pregnancy, particularly for the baby. So we're gonna go into those on the next slide. But as far as the diagram here, I just wanted to give an idea of how many diseases and medical conditions can affect oral health. And you can see there's a whole wheel of 'em here, and just to point out in the pink on the top there, cardiovascular disease. And so we know, Go Red for Women, the American Heart Association really want to make sure women understand heart disease is a risk for them, so thought I

would point that out, but there's a lot of things really here in this wheel that women need to consider. So for pregnancy, again, breaking down some of these adverse outcomes that have been very closely linked with poor oral health, of course, there's other factors, we'll talk about those, chronic health conditions, such as diabetes, cardiovascular disease, high blood pressure, even medications and things like that can affect, you know, outcomes for babies, but just a couple of things to talk ab

out here, and we're gonna start with a few definitions, so preterm birth is prior to 37 weeks of gestation, but babies born before 32 weeks, much higher rates of death and disability, and then low birth weight is less than five and a half pounds, but 20 times more likely to not survive, in about 8% of infants in the US, which 8% seems low, but still too many babies affected by this. And then preeclampsia, so this is a condition that can occur after the 20th week of pregnancy, or even in the post

partum, so after the baby is born in that point, that can happen, as well. So that top photo here that I have, the signs and symptoms of preeclampsia, you can take a look at some of those, but they can really be identified in the dental office, especially the swelling piece. So significant swelling is really a hallmark of preeclampsia and you know, when the dentist is doing their evaluation, certainly of the mouth, they're looking at the face, is there a lot of swelling around the eyes, and in t

he cheeks, and things like that, but we can also see the patient's hands, are they swollen, and their feet, especially in the summertime, you can see if they're wearing sandals, you know, how all of those fit, and if we're taking blood pressure, which is the standard of care in the dental office, and noting that high blood pressure really begs the question of whether or not that pregnant mom has had that checked by their OB-GYN, and 10 to 15% of maternal deaths can be linked to preeclampsia, so

it's a significant risk for the mother there. And gestational diabetes, I'm just gonna mention this one, as well, because increased sugar in the blood is a problem, it can also increase the risk for preeclampsia that we just talked about, but also stillbirth, high birth weight, and increased number of C-sections. So a lot of risks here for pregnant women, and like I said, again, just really wanna note that some of these can be identified in the dental office, and if you're a clinician listening

to this, make sure that you make that referral, and you talk to the patient about it, because I put the photo here of the feet, they're definitely swollen, and I wanted to make sure that I showed you an example of that, but also because it was kind of an interesting article that I ran across when I was researching for this, but it was from "Business Insider", which I thought it was very unusual for them to do an article on pregnancy, but they almost seem to downplay the risk of swelling in pregn

ant women, and I do think in some cases, they get lulled into this thought of, "Yeah, swelling is normal in pregnancy", and it is to a point. So definitely make sure you tell your friends and your family that they're having that checked when they go to the OB-GYN, because preeclampsia is such a risk to their health and to the baby. All right, moving into some caries statistics here, a little bit of different graphs that I thought were kind of interesting, but percentage of adults with dental car

ies in their permanent teeth, you can see how it changes as the age groups are broken out further. So 20 to 34, overall pretty low in that last time period, 2011 to 2014, then it certainly moves up 35 to 49, and even higher, 50 to 64. So untreated caries really has remained about the same over the last two decades, but we do tend to see that if a patient has untreated decay, it is remaining that way. It is not being treated over years and years and years throughout the different time periods, li

ke what is researched here, and what is shown in this graph. So that's an interesting thing to think about is that not only do they have the experience, but it may not be treated. And then moving to periodontal disease here on the lower, this graph actually isn't reflective of periodontal disease, it's reflective of a complete dentition. So a lot of teeth can be lost to decay, but they can certainly be lost to periodontal disease, as well. And I wanted to point out the really sharp change betwee

n the 20 to 34 age bracket for having all of your teeth, to 35 to 49 goes down significantly there, and even further down, 50 to 64. So you can see tooth loss is really an important thing to think about, as we age. So periodontal disease, 42% of the adult population, but you know, it really is related to smoking. So 75% of smokers have some type of periodontal disease, and like I said before, cigarette smoking has declined, but we have seen an increase in vaping, and e-cigarettes, and all of tho

se things, so we continue to see challenges in the mouth regarding periodontitis, because of that smoking nicotine habit, and the damage it does in the mouth. So adult and pregnancy, the dental recommendations here, definitely need to go to the dentist, and it is safe to go to the dentist when you are pregnant. Elective treatment is best during the second trimester, because that's when the patient tends to be more comfortable but can be performed at any time, but for high-risk pregnancies, you d

efinitely need to have your OB-GYN as part of the care plan there, and hopefully if there are pregnancy complications, that dental team can be part of identifying those. Oral hygiene's, very, very critical, we know a lot of pregnant moms suffer from nausea throughout their pregnancy, not just in the first trimester, so vomiting may be an issue, if they can use mouth rinse, because they can't brush, great, or even swishing with water, definitely doing something to reduce the plaque and the debris

in the teeth is gonna be better than doing nothing, but if they can maintain that normal routine of brushing twice a day, flossing once a day, that is always best. Healthy diet, of course, great for the mom, but great for the baby, as well, so fruits and vegetables, avoiding all those sweets and sticky foods, but we know that definitely cravings in pregnancy, and sometimes we see women really turning to those carbohydrates and those sweet foods really can cause damage in the mouth, so important

for them to see the dentist. And one thing I will note though, there are some challenges with finding a dentist. So vast majority of dentists agree that dental care is important and could be safe during pregnancy, but that same majority also says that they need more information and continuing education on that, and statistics vary, but we do agree that probably not all dental treatment that could be provided actually is, so really it is important, you know, as a woman to advocate for yourself,

and if you need dental care to go and get that, and find a dentist that you're comfortable with who is comfortable providing that treatment to you, and making sure your OB-GYN is comfortable with all of that. So now heading into kind of the last part here, so this is menopause and late adults. So the time periods here do blend a little bit from the adult population I was just talking about, because of how long menopause can last, five to 10 years, and fortunately, 30 to 50% of women experience l

ittle to no symptoms. But that means we've got a whole group that does, and certainly there is a percentage of that population that experience very difficult symptoms associated with menopause. But again, we're kind of seeing the same types of things in menopause that we saw before as far as the oral cavity, we may be seeing redness, and swelling of the gums, certainly bleeding and things like that, all of that needs to be treated and looked at by a dentist to make sure that, you know, we're kee

ping the bacterial counts down, decreasing that risk of caries, and decreasing the risk of periodontal disease. But we also start to see other conditions coming in here related to aging that are important for women, so again, I'll point out cardiovascular disease, certainly stroke is a risk, osteoporosis for women we know is a huge concern, but also, you know, dry mouth, dementia, sometimes the onset of arthritis can be an issue here, and arthritis is difficult for maintaining your oral hygiene

routine, and being able to brush and floss effectively. Oral cancer is also a risk, medications, polypharmacy means multiple medications, depression can become an issue here, as well. So all of these have an effect on oral health, and can make oral hygiene very difficult. But over on the right hand side here, the picture that I have, this is actually mucositis from cancer treatment. So very, very unfortunate. You can see how painful this looks for this patient, but very, very hard on the mouth,

hard on the patient, and can be difficult for dentists to manage. So certainly a reason to go in and see the dentist, there are some things that we can do, but you know, important for thinking about nutrition and maintaining optimal overall health, as well. So caries statistics here, a little bit different, but some things that I wanted to bring up as far as the chronic diseases that I talked about, so 80% living with at least one chronic disease when you're over 65 years of age, nearly 70% have

two diseases, so really something that we're seeing a lot of in the dental office that we need to educate our patients on and make sure that we're adjusting our preventive routine to fit with what they need. Physical or cognitive disabilities can also interfere with oral hygiene and self-care, which becomes important for the mouth, sometimes you have to involve caregivers in how they're brushing and flossing, and the maintenance for the mouth, but included the graph over here for untreated dent

al caries, you can see, again, the percentages here, they're really unfortunate, because when these things are not being treated, it goes that way for a very, very long period of time. And if they're older adults, maybe in a nursing home, assisted living facilities, things like that, sometimes these things never get treated. They just simply don't have the transportation to the dental office to have the work done. Periodontal disease, as I mentioned before, becomes a real issue here, three in fi

ve older adults are affected by this, fortunately as women a little less so than men here, but certainly an issue for us, as well, well is root caries. So if the gum tissue has receded, then it's exposing a different part of the tooth that isn't covered by enamel, and that hard enamel is really what keeps those caries from developing, but if the softer root surface is exposed, more caries, and can result unfortunately in tooth loss, which I address here at the bottom. So 17% of older adults comp

letely edentulous, meaning they have no teeth at all, rates are declining, but you can certainly think about how that would reduce the quality of life, ability to speak and eat, comfort level with smiling and socializing, which in a population, especially as we think about our 65 years plus age group, contributes to that loneliness, where the risk is considerable. So we will note that if they have some teeth, definitely less of a negative impact, but still something to think about. Now, dental r

ecommendations here for our older adults, menopausal adults, the management can vary depending on what medical conditions are present. And so really have to look very closely at the conditions in the mouth. Are we seeing that swelling, bleeding and things like that, are we seeing a very dry mouth, because of, you know, the medications that they may be taking, or some of these chronic conditions because all of that, you know, has to take into consideration how many times a day should they be brus

hing, should they be flossing, should they be using a different type of mouthwash, all of these really need to be considered. But overall, dental visits are a great check on some of the medical conditions, especially with the blood pressure, and some of these conditions can show significant signs and symptoms in the mouth. And one thing I would also note here, just so that it doesn't kind of fall off the radar, but since we've talked about tooth loss, that those patients that don't have any teet

h at all, they still need to keep visiting the dentist, at least once a year, should be checking the fit of the dentures, and screening for oral cancer. So as women age, that oral cancer screening becomes very, very important, certainly should be happening, you know, early on in those early adult years, but becomes increasingly important as we age there. And one of the things I had mentioned before, I'll go ahead and mention it again, sometimes you have to include caregivers here, or you have to

be very specific with demonstrating techniques as a clinician to patients to make sure that they understand how to brush effectively. Maybe they need to switch to an electric toothbrush from a manual toothbrush, use some different flossing aids, there are prescription mouth rinses that we can do for a patient that helps keep those bacterial counts down, hopefully keep the caries risk down, as well, and then for those that are suffering with cognitive issues when we're thinking about dementia, A

lzheimer's, sending those materials home written on paper can really be helpful. Sometimes these patients aren't also, they're not really good with looking some of that stuff up on their phone, or on the internet, and things like that, so paper copies may be helpful there. It gives them a little bit of a reminder when they're at home of what they need to be doing for their oral hygiene routine. So that is the end of my presentations, thank you everyone for listening, and you know, definitely tha

nks to Maria and her team with Go Red for Women for inviting me to do this again this year, very happy to get that call, and be able to do this. If you have questions, or you want to see some of the references for the slides, additional research articles, feel free to reach out here, so I give my email address at the bottom if you want to contact me, but I think now at this point, I'm gonna stop sharing my screen, and we will move to questions if there are any. - [Maria] Hi Michelle, it's Maria.

I sent some questions to you in the chat but I'll read them here, as well. So we did get one question is "Where can we find the mouthwash that you referenced in the PowerPoint earlier?" - So I think there were a couple of different mouthwashes in there that I had pictures of. So one is chlorhexidine, so that is a prescription mouthwash, that's something that you would need to talk to your dentist about, but it does help decrease those bacterial levels in the mouth, so it'd be really important i

f you have a high decay rate, or really if you're having a lot of problems with dry mouth, and things like that. But there were a couple of fluoride rinses that I included in there, Act is kind of the typical one that I think of as a dentist, but Listerine also does a version of it, as well, although you have to make sure that it contains fluoride in it, otherwise it's more of just kind of the typical Listerine rinse that you think of. But having that additional fluoride washing over the mouth i

s really important for decreasing the risk of caries. So I have to say it's a mouthwash that I use every night, because you know, I'm brushing and flossing, of course, but I do know that it gives that additional boost, because I tend to be drinking bottled water during the day, as opposed to, you know, community water, which may be fluoridated. So just to get that extra fluoride, that's what I use there. - [Maria] Wonderful. And then we have another one, "How to find a good dentist if you haven'

t had any luck?" - So it can be very, very tricky. I don't know if this is specific to someone who may be pregnant, sometimes that can be hard, and you have to call multiple areas, but I would say if you have insurance, the best place to look is to go on the website for your insurance company, they all have provider locator tools, you can put in your zip code, and you can find dentists in your area that do accept your insurance, but if you're not able to do that, or you don't have dental insuran

ce, whether it's commercial dental insurance, or Medicaid, Medicare, there are some websites online where you can go and take a look, so there's findhelp.org, you can find resources for all types of healthcare, including dental in your area, and sometimes those have sliding fee scales. So if you don't have insurance, you may be able to access dental care at a discounted rate there. Or certainly, you know, a quick Google search dentists in your area, but if you have insurance, it's probably bette

r to use that website, that way you know they do accept the plan that you have. - [Maria] And then we have another one. "Any suggestions for treating burning mouth syndrome?" - So burning mouth syndrome is very tricky. So I would say probably the first thing that I used to do, at least as a dentist is, you know, talk with the physician. So if there are medical conditions that are present where burning mouse syndrome may be tied to that, so particularly I'm thinking of like diabetics, those with

Sjogren's syndrome, and things like that, then sometimes medical management in collaboration with the dentist is probably the best way to go. So if the medical condition isn't managed, or really isn't controlled, sometimes it can be difficult to overcome even on the dental side, but there are some things as far as different mouth rinses, so even separate from chlorhexidine, there is like a very concentrated mouthwash, which is a combination of a few different things. Usually like there's kind of

an antibacterial component, there is an antiseptic component, but there's also like a numbing component to it, almost an anesthetic type piece that can reduce that burning feeling, so that may be an option for the patient, as well. But like I said, my first step is always collaborating with the physician, making sure we're all on the same page as far as the medical management, and then you know, working through some of the options on the dental side, as well. Sometimes that can mean changing to

othpaste, and things like that as well too, whatever might be a little bit more comfortable, but trial and error too on the dental side, important. - [Maria] And then another one, "I'm experiencing canker every month right before my menstrual period on my tongue. Any recommendations that I can use to help?" Good question. - Yeah, so if they're coming on your tongue, then they probably are those like aphthous ulcers that I mentioned in the PowerPoint, sometimes they can be related to the hormones

, they can also be controlled a little bit with changing the foods around the same time period that you're experiencing these, or that you anticipate seeing those come through, sometimes there can be a little bit, you know, of management, again, as far as mouth rinses, and stuff like that to try to help keep them from being so painful when they do come, but ultimately, it's a little hard to reduce them if they are significant with the menstrual cycle, in some cases, oral contraceptives, they do

decrease that risk a little bit, because the hormones change, but you know, it's certainly something you would wanna talk specifically with your dentist about as far as how many you're getting, and whether they're very large in size, so there are kind of minor aphthous ulcers, and major aphthous ulcers, and the management does change a little bit, can be controlled somewhat medically if they are considered major aphthous ulcers. So that's something, definitely email me if you want a little bit m

ore information in detail on that, because there might be some resources to help you, you can take to your dentist next time, or even to your physician, and go over. - [Maria] And then last question is, "Does the type of toothpaste matter when you are pregnant?" - So the type of toothpaste really doesn't matter, for the most part, it's really that action with the toothbrush that's important for getting everything off the teeth, because we just wanna make sure that any food debris is off, the pla

que, which you know, harbors bacteria and things like that it against the tooth, we wanna make sure all of that is coming off. So a lot of times, it's the manual action, and less about the toothpaste, although we do always recommend a fluoridated toothpaste. There are some toothpaste out there that are not fluoridated, you tend to see that a little bit more with like the organic and natural solutions out there, but the American Dental Association does recommend fluoridated toothpaste for use whe

n you're pregnant, and it can be, and it is safe to use that. So overall, it doesn't matter, although I will say I've had some pregnant patients over time where if they were using a toothpaste that is flavored like a cinnamon flavored, sometimes they can't handle the mint at that point in time, just doesn't taste good, it makes them nauseous, then you can certainly move to other flavorings and things like that. Like I said, even if you're moving towards an organic one, which tend to not have as

many flavorings there, if it doesn't have fluoride, the action of toothbrushing still helps, and is important. But overall, any type of toothpaste is fine, it's really whatever their pregnant mom can use effectively, and it's comfortable, it doesn't make her feel nauseous. - [Maria] And that was the last one. So I just wanted to say thank you so much again to everyone for listening in today, I hope you learned something, I definitely did. A reminder, this is a recording, so we will send it out i

n our follow-up tomorrow, and thank you so much again to Dr. Kohler and everyone on the Delta Dental team, we are so appreciative, and we will send this out tomorrow on a follow-up, so if you have any other questions, let us know, otherwise, I hope everyone enjoys their day. - Thank you, thank you very much for listening, I hope you learned something, and again, see my contact information, and feel free to reach out. Thank you.