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Am Fam Physician. 2014;89(11):847-853

Original Article: Recommendations for Preconception Counseling and Care

Issue Date: October 15, 2013

to the editor: I applaud the advice given by Drs. Farahi and Zolotor about preconception counseling. In addition, oral health should be part of a comprehensive approach to preconception care, because it can have a major impact on health outcomes for women and their children.

Recently, the American College of Obstetricians and Gynecologists recommended that medical professionals “advise women that oral health care improves a woman's general health through her life span and may also reduce the transmission of potentially caries-producing oral bacteria from mothers to their infants.”1 National consensus guidelines agree with this message, and outline the evidence for treating oral conditions in pregnant women and the safety of such treatment.2

Although there is evidence that periodontitis can affect birth outcomes (e.g., low birth weight, preterm birth), studies also show that interventions to manage the disease during pregnancy (e.g., deep root scaling) do not improve these outcomes. Therefore, dental experts have speculated that treating periodontal disease during pregnancy is too late.3 This is yet another reason for family physicians to focus on oral health screenings, advice, and referrals during the preconception period.

Drs. Farahi and Zolotor discuss preconception counseling for women who are obese or have diabetes mellitus. Evidence indicates that addressing oral health and treating periodontitis can improve glycemic control and reduce obesity rates.4 As part of the patient-centered medical home initiative, we need to integrate oral health screening, hygiene counseling, diet advice, and dental referrals into routine care.5

to the editor: I was surprised that this article did not mention screening women of Ashkenazi Jewish descent for inherited disorders. These disorders are prevalent, and the option for screening should be included in any comprehensive conversation with women of Ashkenazi Jewish descent.

in reply: These letters raise two important points about preconception care. Oral health is an essential part of a woman's overall health, and counseling regarding preventive oral health care and treatment of periodontal disease and dental caries should be part of care for all patients throughout the life span.1 Studies have demonstrated that children of mothers who had interventions to prevent caries developed fewer cavities than children of mothers who did not have interventions.2 Although several studies have shown a link between periodontal disease and pregnancy outcomes,3,4 evidence to demonstrate that preventive oral health care during the preconception period decreases rates of pre-term labor or low birth weight is lacking. We agree with Dr. Silk that prevention and treatment of periodontal disease should be a part of comprehensive care for women with type 2 diabetes before, during, and after pregnancy.

In regard to screening for genetic disorders in women of Ashkenazi Jewish descent, we appreciate Dr. Oppenheim raising this issue. Screening for carrier status of heritable conditions is an important part of preconception care. We recommend family genetic history and targeted screening in women with increased risk.

As Dr. Oppenheim points out, certain heritable conditions are more common among persons of Eastern European (Ashkenazi) Jewish descent; Gaucher disease and Tay-Sachs disease are the most common, affecting one per 900 and one per 3,000 of these persons, respectively.5 A more detailed discussion of screening for heritable conditions based on racial and ethnic risk would also need to focus on other common conditions, such as sickle cell disease (affecting one in 300 African Americans)6 and cystic fibrosis (affecting one in 2,500 persons of European descent, especially French Canadian).7

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This series is coordinated by Kenny Lin, MD, MPH, deputy editor.

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