Peninsula Health - Community Dental Program Dental Management of Presentation based upon DHSV Clinical Practice Guidelines Presented by Dr Fayed Azouz Clinical Head Peninsula Health – Community Dental Program

1) To inform the Peninsula Health Community Dental clinical staff on the Current DHSV Clinical Practice Guidelines for dental care management of the pregnant woman.

Advise Risks –  Periodontal disease  Importance of OH  Transfer of streptococcus-mutans and lactobacil us (gram +ve bacteria) from • Use CPP-ACP products to reduce bacteria. – GC Tooth Mousse – 3M ESPE Clinpro Tooth Cream (t/paste)  Periodontal disease & effects on fetus  Educate Mothers-to-be on OH for their baby

Any concerns regarding the safety of the pregnancy or impact of the proposed treatment should always be discussed with the responsible lead maternity carer. Discuss & advise on: Associations between poor periodontal health & adverse effects on the pregnancy and fetus • Calcium & Vitamin D Milk, cheese, dried beans, leafy green vegetables Cheese has pH neutralising benefits after meals • Oral Vitamin D supplement if serum levels are low Use of CCP-ACP products • GC Tooth Mousse • Recaldent and/or Xylitol Gum Fissure sealants Plaque & calculus debridement Dental plan during & post-pregnancy Oral hygiene care advice for infants Tooth development & eruption timeline When to first visit dentist Medical, Dental & Dietary History Questions regarding the woman's medical history should include: Any current or previous pregnancy complications Previous spontaneous complications Pernicious vomiting Present or past tobacco use Questions regarding the woman's dental history should include: Any symptoms of pre-existing oral conditions Current oral hygiene homecare practice Previous dental examination and/or treatment Previous radiographic exposures Questions regarding the woman's dietary history should include: Exposure to carbohydrates and acidic foods/beverages related to increased snacking Quantity consumed per day Timing of consumption Frequency of intake Risks associated with Pregnancy Pregnant women who are at risk of infective Endocarditis Primary prophylaxis is with Amoxicillin 2.0g given orally one hour before the procedure. Penicillin-allergic women can be treated with Clindamycin 600mg orally. No increased risk of preterm birth (<37 weeks gestation), spontaneous miscarriage, stil births or fetal abnormalities associated with essential dental treatment. Essential dental treatment is defined as presence of moderate to severe dental caries, fractured or abscessed teeth. No association between maternal general dental care during pregnancy and gestational age, birth weight or neurodevelopment. Most comfortable and safest time to treat pregnant woman is during the 14th to 20th weeks of gestation. Elective dental treatment should be avoided during the 1st trimester. Elective dental treatment should be avoided in the second half of the 3rd trimester as premature birth is a risk. Amalgam restorations are considered safe for pregnant woman and their baby when handled appropriately. Oral manifestations – pregnancy related Pregnancy granuloma Occurs in 5% of pregnancies Most common after first trimester, grow rapidly and recede after birth. Observational management, unless bleeds, interferes with mastication or doesn't resolve after birth. Lesions removed during pregnancy likely recur. Increased levels of progesterone and oestrogen affect the periodontium Can result in mobility of teeth, even in absence of periodontal disease Need to assure these patients that this is temporary mobility and that teeth will not be lost due to this hormonal change. Ptyalism & Perimylolysis Ptyalism (excess saliva) – common during early pregnancy, usually accompanies nausea. Perimylolysis (acid erosion caused by vomiting of gastric contents) - Rinsing with one teaspoon sodium bicarbonate (baking soda) dissolved in water helps neutralise pH & minimise effect on oral environment. Caused by hormonal changes, effects 44% pregnancies. Relief through chewing sugar-free gum or salivary substitutes (GC Dry-mouth Gel, Biotene Gel) Medications – see therapeutic guidelines Smoking – need to discuss impact on pregnancy Drugs & Pregnancy Nitrous oxide (oxygen anesthesia) – not recommended during pregnancy Local anesthetics – What should we be using? Doses of adrenalin used in dental LA are so low that they are unlikely to significantly affect uterine blood flow. The benefits of adrenalin at dental concentrations justify their use. 3% Citanest® with Octapressin® can be used within dosage guidelines of 15mL or (30150mg Prilocaine hydrochloride 3% with felypressin 0.03 IU/mL). Gross overdose of Prilocaine can cause Methaemoglobinaemia – this has been reported for doses exceeding 600mg. Methaemoglobinaemia is the condition that describes abnormally high levels of methemoglobin in the blood. This is a type of hemoglobin which doesn't bind to oxygen and thus less oxygen transportation throughout the body can cause tissue hypoxia. Prilocaine may enter the mothers breast milk, but in small amounts generally no risk to baby. It is not known whether felypressin is excreted in breast milk. General patient care Supine Hypotensive Syndrome Affects 8% pregnancy's Can cause hypotension, nausea, dizziness, fainting, loss of consciousness Treat by rolling pt on left side Prevention – place rolled towel on pt's back (right side) prior to reclining chair Dental Radiography Max dosage to fetus = 1mSv 2x Bw radiographs = 0.0020.004mSv dosage Lead apron with thyroid collar is necessary Increased risk with maxillary occlusal radiographs due to the angle No need to defer dental radiography during pregnancy on the grounds of radiation protection, however if treatment is deferred then radiography should be deferred also. Radiation dose limit to fetus same as general public at 1mSv. Nitrous Oxide use:  Gas detection system required to monitor scatter  Pregnant staff to avoid this area A TLD can be arranged (personal monitoring device) from the radiology department. Please consult your Team Leader to request. Early Childhood Caries (ECC), previously known as bottle or nursing caries Nursing or Bottle caries is now identified as a subset of ECC, not the single cause. ECC = At least one carious lesion in child with full deciduous dentition. SEVERE ECC = Age Dependent <36months old = Smooth surface carious lesion affecting max. ants. DMFT scores relative to child age: 40% of children under 6yo have some dental decay. 60% of these children are untreated. Short-term consequence of untreated ECC are pain and abscess Long-term consequence of ECC are: Disrupted social development Nutritional deficiency Disrupted academic development Sleep deprivation Reduction in general physical health Traumatic experiences Cost of Tx & time off work for parent Stats & Info sourced 27/06/2011: De Silva-Sanigorski et. al. BMC Public Health 2010 10:97 The VicGeneralion study – a birth cohort to examine the environmental, behavioral and biological predictors of early childhood caries: background, aims and methods. Cause: prolonged sucking of dummy, thumb or digit. Protrusion of maxillary incisors Narrowing & lengthening of maxilla Maxillary Anterior Overjet Posterior Bilateral Cross-bite Orthodontic Implications Speech, mastication, social, trauma >risk. WHY? – comfort, unconscious action Removal of dummy Substitution with soft toy, blanket etc. Over the counter ointments (to place on thumb/digit) as deterrent – available from pharmacy. Fixed orthodontic appliances (palatally fixed) to prevent sucking of thumb/digit. Education for parent and child. • Once child is little older & understands consequences of thumb sucking they are more inclined to reduce or stop this behavior. Orthodontic intervention.



Edition No 3/2010 Prix Fr. 4.50 Guide de santé «Arthrose» Soulager naturellement les problèmes articulaires Avec interview du Prof. Dr méd. Roland P. Jakob et du Dr Matthias Jacobi Avant-proposPour mener une vie épanouie, la mobilité physique est tout aussi im por- tante que celle de l'esprit. Un seul regard sur l'anatomie humaine en fait la démonstration: 143 articulations assurent un vaste spectre de mou-vements nous rendant capables de réaliser d'étonnantes performances. Pour que le corps puisse utiliser convenablement cet appareil locomoteur, les éléments servant à l'articulation de levier, charnière et amortisseur doivent être fonctionnels. Malheureusement, ce n'est trop souvent plus le cas. Différentes causes peuvent être à l'origine d'une réduction ou perte de la mobilité: les blessures, surcharges, mauvaises positions, maladies infl ammatoires telles que la poly arthrite ou des troubles du métabolisme comme la goutte, ainsi que le processus naturel du vieillissement.

Genetic Use Restriction Technologies: Good for Seed Companies and Bad for Farmers? Luca Lombardo Variety level GURTs The term "Genetic Use Restriction Technologies" (GURTs), The molecular construction described in the patent U.S. coined in 1999 by the Subsidiary Body on Scientific, 5,723,765 provides the use of (i) a lethal gene, (ii) a repressor