Original Article: AAFP Releases Position Paper on Preconception Care [Practice Guidelines]

Issue Date: September 15, 2016

See additional reader comments at: http://www.aafp.org/afp/2016/0915/p508.html

To the Editor: I read with interest this Practice Guideline on Preconception Care. It is impressive that topics such as emotional abuse and behavioral history were included. It was disappointing, however, not to see any mention of oral health. The American College of Obstetricians and Gynecologists published a Committee Opinion in 2013 encouraging obstetricians to “discuss oral health with all patients” and “advise women that oral health care improves a woman's general health through her lifespan and may also reduce the transmission of potentially caries-producing oral bacteria from mothers to their infants.”¹ The report also discusses the association between periodontitis and preterm birth. Although women with periodontitis experience more preterm births, interventions during pregnancy have not consistently resulted in improved outcomes.² Experts have postulated that preconception interventions for periodontitis may help with prevention.³ It is important for physicians who care for women of child-bearing age to discuss this during preconception care because many women do not seek dental care during pregnancy. According to the Pregnancy Risk Assessment Monitoring System in 10 states, 56% of mothers did not have dental care and 60% did not have their teeth cleaned during their most recent pregnancy.⁴ Additionally, most women (59%) did not receive any counseling about oral health during pregnancy.⁵ A good resource is the Smiles for Life Module 5: Oral Health and the Pregnant Patient (http://www.smilesforlifeoralhealth.org).⁵ Family physicians are in a position to engage their patients in a discussion of oral health before, during, and after pregnancy.

In Reply: We thank Dr. Silk for his comments regarding the lack of inclusion of oral health in the American Academy of Family Physicians (AAFP) position paper on preconception care. There is indeed a role for family physicians to play in improving the oral health of their patients and this includes addressing oral health issues before, during, and after pregnancy. Future iterations of the position paper will address the importance of oral health. The AAFP is committed to oral health and feels that all Americans should have access to age-appropriate dental services.¹ The AAFP supports fluoridation of water supplies to prevent dental caries.² The AAFP also provides resources and continues to work at building partnerships with organizations and programs, such as Smiles for Life, regarding oral health (http://www.aafp.org/patient-care/public-health/oral-health.html).

We feel strongly that addressing oral health must be done in an evidence-based manner and that screenings, as well as interventions, should be supported by patient-oriented, outcomes-based evidence. The primary goal of perinatal oral health care for the infant is to reduce vertical transmission of cariogenic bacteria, which can be prevented.³ This strategy has been helpful in delaying infant colonization of cariogenic bacteria; however, it is also important to note that other factors are associated with this colonization, such as low socioeconomic status and frequent snacking.⁴ Furthermore, studies suggest that children with severe early childhood caries have less maternal genotypes of cariogenic bacteria and higher rates of colonization from horizontal transmission from children of similar ages such as siblings or other children in day care.⁵

Although some studies have suggested links between poor maternal oral health, preterm birth, and low birth weight, most studies are of limited quality and there is significant heterogeneity. Additional evidence and studies are needed to identify appropriate oral health screenings and interventions as part of primary care for all patients and for preconception care. We applaud Dr. Silk's commitment to advancing oral health and recognize the immense value the Smiles for Life curriculum has for our members, residents, students, and patients.