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Pregnancy and Oral Health

How to provide safe and effective care for this special patient population.

Pregnancy may have significant effects on oral health and the treatment of pregnant women may require the modification of typical treatment plans. Pregnant women are at higher risk of periodontal diseases, dental caries, and gingival inflammation than the general population. Dental hygienists need to be aware of pregnancy-induced oral health changes, as well as the importance of maintaining meticulous oral self-care during this time to ensure the health of both mother and baby.

Pregnant women may experience hormone-based gingival inflammation, raising their risk of oral bacterial proliferation. As hormones fluctuate during pregnancy, pathogenic bacteria take advantage and thrive in and around the periodontal tissues, causing pregnancy-associated gingivitis. An exaggeration of the inflammatory response subsequently occurs, mainly in the second and third trimesters.1 An oral-systemic link may exist between preterm delivery/low birth weight and the presence of oral inflammation. With the onset of pregnancy, bacterial counts increase within the oral cavity, creating an inviting environment for pathogenic bacteria. If the patient has poor oral hygiene, ginigivitis, or periodontitis, these bacteria can permeate the bloodstream. They then disguise themselves as innocuous inhabitants and move toward the developing fetus. Upon arrival at the placenta, the bacteria may compromise sterility of the amniotic sac, thus creating the potential for preterm labor.2 Unfortunately, many women of childbearing age are unaware of this link and the importance of maintaining oral health throughout their pregnancies. One study surveyed 599 pregnant women and found that 74% received no oral health care during their pregnancies.3 Obstetricians may be aware of the possible link between poor oral health and negative pregnancy outcomes, but many are not advising their patients of the importance of receiving oral health care during pregnancy. In a study that assessed obstetricians’ knowledge of periodontitis as a risk factor for preterm delivery and low birth weight, 49% of respondents rarely or never recommended dental examinations to their pregnant patients, although 84% considered periodontitis an important risk factor in adverse pregnancy events.4 As such, dental hygienists need to educate women of child-bearing age about this link and encourage them to maintain optimal oral health during pregnancy.

Table 1. Possible causes of pregnancy granulomas.7
• Poor oral hygiene
• Trauma
• Hormones
• Viruses
• Misshapened blood vessels

Getting Started Most pregnant patients are generally healthy and do not require medical consultation prior to dental treatment. In the treatment of higher risk pregnant patients, such as those with hypertension, gestational diabetes, or a history of preterm labor, patients’ obstetricians should be consulted before treatment is provided.1 These patients can be identified during the medical history assessment where the status of their pregnancies should be addressed.1 If there are any doubts about health status, the obstetrician should be consulted.

Baseline blood pressure should be taken on all patients, especially pregnant women. Blood pressure should be recorded at every appointment. A patient’s obstetrician should be notified if the patient’s blood pressure is high, especially if it is higher than 140/90 mmHG and is not elevated due to pain or fear.1

Misconceptions of Pregnancy

Pregnant women often have misconceptions about oral health care. Many believe that poor oral health during pregnancy is normal. Research demonstrates that this is not the case.5 Fear is often cited as one of the main reasons pregnant women refrain from visiting an oral health care provider.5 Pregnant women may believe that they or their fetuses could be harmed by dental treatment and consequently do not seek oral health care.5 Dental hygienists are key influencers in the dental setting and they need to educate women that the maintenance of oral health during pregnancy is paramount to their own health and the health of their babies.
In order to help states create effective health promotion and intervention programs to address these problems, the Centers for Disease Control and Prevention (CDC) instituted the Pregnancy Risk Assessment Monitoring System in the late 1980s (see sidebar).6

Caries Prevention

Many pregnant women experience morning sickness or nausea, which can lead to vomiting. Due to the gastric acid entering the oral cavity, pregnant patients may demonstrate lingual enamel erosion on the maxillary anterior teeth. After repeat vomiting, the enamel becomes demineralized and patients are at increased risk of caries.7 Pregnant patients experiencing nausea should be advised to rinse with a teaspoon of baking soda dissolved in a cup of water after vomiting in order to neutralize the acid.7 They should also be discouraged from brushing their teeth after vomiting to prevent erosion. A toothbrush with soft bristles is also recommended to minimize insult to the enamel.7 The use of alcohol-free mouthrinses with fluoride in addition to brushing with a fluoridated dentifrice should be recommended.7 A low-abrasive dentifrice is indicated to reduce scratching of the tooth’s surface. For patients with demineralized enamel, prescription fluoride dentifrices with 1.1% sodium fluoride at 5,000 ppm are advised.
Dental caries is an infectious and transmissible disease.8 Bacteria that cause dental caries, such as Streptococcus mutans, can be transmitted from mother to child.9 Pregnant women should be discouraged from sharing utensils, food, and beverages in order to minimize the risk of developing and spreading opportunistic bacterial organisms that initiate dental caries. The use of sugar-free gums that contain xylitol may help reduce specific cariogenic pathogens (eg, S. mutans) in the oral cavity, thereby reducing the overall risk of developing bacterial-based oral infections.7,10

Periodontal Diseases

Table 2. American Dental Association’s oral health recommendations for pregnant women.17
• Brush teeth twice daily with a fluoride toothpaste.

• Floss daily.

• Limit foods containing sugar to mealtimes only.

• Choose water or low-fat milk as a beverage.• Avoid carbonated beverages.

• Choose fruit rather than fruit juice to meet the recommended daily fruit intake.

• Obtain necessary dental treatment before delivery.

• Chew xylitol-containing gum (four pieces per day).

• Avoid saliva-sharing behaviors that directly pass saliva from mother or caregiver to child.

Many expectant mothers experience a high prevalence of bacterial organisms that initiate inflammation or pregnancy gingivitis. In 2% to 5% of pregnant women, a pyogenic granuloma or “pregnancy tumor” occurs due to increased vascularity, as well as bacterial proliferation.11 The onset is typically in the second or third trimester and it presents as a red-colored lesion of varying size most often found near the maxillary gingival margin. Pregnancy granulomas are prone to bleeding and may create a break in the skin or crust over.7 The etiology of pregnancy tumors is unknown. Table 1 lists possible causes. Women with pregnancy granulomas usually also present with pregnancy gingivitis.7 Treatment is often unnecessary and granulomas typically disappear after the pregnancy is completed. If a patient’s speech or eating ability is compromised, the granuloma may be surgically removed, although the rate of recurrence is approximately 50%.7

Nutritional Deficiency

Most pregnant women understand the need for eating a balanced diet. In addition, they should take a daily prenatal vitamin supplement.12 The diet of expectant mothers has a direct correlation to the healthy growth and development of the fetus.13 If the mother lacks the proper nutrients in her body, the growing fetus will also lack the nutrients during development. The increased frequency of ingesting cariogenic foods can raise the risk of tooth decay and nutritional deficiency for both the mother and fetus. Snacking increases the dentition’s exposure to fermentable carbohydrates and the acids they create while also lowering the oral cavity’s pH level. These factors increase demineralization of the tooth structure.13 Vitamin and mineral deficiencies can have profound effects on the health of the fetus. Not enough folic acid may result in neural tube defects, such as spina bifida, which causes the incomplete development of the brain, spinal cord, and their protective coverings due to the spine not closing correctly during the first trimester.14,15 The CDC recommends that all women of childbearing age take 0.4 mg of folic acid per day.14 Dental hygienists can also recommend patients consume folic-rich food and beverages, such as raspberries, oranges, broccoli, peas, asparagus, and peanuts.14 Iron deficiency anemia is also common among pregnant woman. The fetus gets the necessary iron from the mother, mostly during the last trimester of pregnancy. Anemia during pregnancy can increase the risk of low birth weight and the infant’s propensity for developing iron deficiency anemia.14 Enriched bread and cereal, red meat, dark and dark green leafy vegetables are good sources of iron.14 A lack of calcium is another common nutrition-based deficiency among pregnant patients. Milk and dairy products; green leafy vegetables; fish containing soft bones, such as sardines; and bread and cereal products made with enriched flour are good sources of calcium.13

Dental Appointment Considerations

Dental care is part of ensuring a healthy pregnancy. The American Academy of Periodontology (AAP) advises pregnant women to seek typical preventive oral health care including periodontal evaluation, teeth cleaning, and any necessary restorative treatment. AAP suggests that scaling and root planing be performed early in the second trimester and that infection or abscess should be treated at any time during the pregnancy.16 Professional oral health intervention may be undertaken at any time during pregnancy. However, the period between week 14 and week 20 is considered ideal.17 The first trimester is a delicate time when a significant amount of development is occurring and the third trimester may present comfort issues for pregnant patients.

The final trimester of pregnancy may pose difficulties in positioning and comfort for the patient. Vena caval compression is a risk.18 Patients receiving care in the third trimester should be situated on their left side and repositioned often to increase comfort and reduce risk of vena caval compression.18 Emergency dental procedures should be performed at any point during the pregnancy, however.1 When providing oral health care to pregnant women, a few modifications can make a big difference in terms of comfort. To prevent nausea or dizziness, the patient’s head should be higher than her feet and a pillow can be placed under the right hip, turning the patient slightly to the left.7 Breaks should also be allowed during treatment. Pregnant patients may need to adjust their position or take frequent restroom breaks.

To help prevent dental caries and periodontal diseases, dental hygienists should reinforce interproximal cleaning through the use of floss or interdental aids such as flossers, toothpicks, and interproximal brushes.7 Additional oral health recommendations for this population appear in Table 2 as provided by the American Dental Association.19

Conclusion

Pregnant women are part of a special patient population that requires oral health practitioners to use critical thinking to identify risk of periodontal diseases, caries, and nutritional deficiency; they should also educate patients about the oral-systemic link.20 Various barriers may impede women from seeking oral health care during pregnancy. As such, oral health care professionals should work with obstetricians to incorporate a discussion of the importance of dental care throughout pregnancy into routine prenatal care. In the end, the responsibility of oral health lies with the patient. Dental hygienists need to encourage pregnant women to maintain an optimal level of oral hygiene and overall health.21

ACKNOWLEDGEMENT The authors would like to thank Gina Dailey for her assistance with the literature review.

References

  1. Giglio JA, Lanni SM, Laskin DM, Giglio NW. Oral health care for the pregnant patient. J Can Dent Assoc. 2009;75:43-48.
  2. Davenport ES. Preterm low birth weight and the role of oral bacteria. J Oral Microbiol. 2010;2:5779.
  3. Wilder R, Robinson C, Jared HL, Lieff S, Boggess K. Obstetricians’ knowledge and practice behaviors concerning periodontal health and preterm delivery and low birth weight. J Dent Hyg. 2007;81:81.
  4. Boggess KA, Urlaub DM, Massey KE, Moos MK, Matheson MB, Lorenz C. Oral hygiene practices and dental service utilization among pregnant women. J Am Dent Assoc. 2010;141:553-661.
  5. Ressler-Maerlender J, Krishna R, Robison V. Oral health during pregnancy: current research. J Womens Health (Larchmt). 2005;14:880-882.
  6. Pregnancy Risk Assessment Monitoring System. Available at: www.cdc.gov/prams/. Accessed April 27, 2011.
  7. Kimbrough VJ, Henderson K. Oral Health Education. Upper Saddle River, NJ: Pearson/ Prentice Hall; 2006:164.
  8. Caufield PW, Li Y, Dasanayake A. Dental caries: an infectious and transmissible disease. Compend Contin Educ Dent. 2005;26(5 Suppl 1):10-16.
  9. Berkowitz RJ, Jones P. Mouth-to-mouth transmission of the bacterium Streptococcus mutans between mother and child. Arch Oral Biol. 1985;30:377-379.
  10. Caufield PW, Griffen AL. Dental caries. An infectious and transmissible disease. Pediatr Clin North Am. 2000;47:1001-1019.
  11. Paradowka A, Slawecki K, Gwiadzda-Chojak E. Pregnancy tumor—review of the literature. Dent Med Probl. 2008;45:51-54.
  12. Williamson CS. Nutrition in pregnancy. Nutr Bull. 2006;31:28-59.
  13. Palmer CA, Boyd LD. Nutrition, diet, and associated oral conditions. In: Harris NO, Garcia-Godoy F, Nielsen Nathe C, eds. Primary Preventive Dentistry. 7th ed. Upper Saddle River, NJ: Prentice Hall; 2009:287.
  14. Wehby GL, Murray JC. The effects of prenatal use of folic acid and other dietary supplements on early child development. Matern Child Health J. 2008; 12:180-187.
  15. National Institute of Neurological Disorders and Stroke. Spina Bifida Information Page. Available at: www.ninds.nih.gov/disorders/spina_bifida/spina_ bifida.htm. Accessed April 27, 2011.
  16. Task Force on Periodontal Treatment of Pregnant Women, American Academy of Periodontology. American Academy of Periodontology statement regarding periodontal management of the pregnant patient. J Periodontol. 2004;75:495.
  17. Kumar J, Samelson R. Oral health care during pregnancy recommendations for oral health professionals. N Y State Dent J. 2009;75:29-33.
  18. Silk H, Douglass AB, Douglass JM, Silk L. Oral health during pregnancy. Am Fam Physician. 2008; 77:1139-1144.
  19. American Dental Association. Pregnancy. Available at: www.ada.org/3019.aspx. Accessed April 27, 2011.
  20. Jared H, Boggess K. Periodontal diseases and adverse pregnancy outcomes: a review of the evidence and implications for clinical practice. J Dent Hyg. 2008;82:2-20.
  21. South Carolina Takes Action: Oral Health for the Young Child. Available at: www.scdhec.gov/administration/library/CR-009592.pdf. Accessed April 27, 2011.

From Dimensions of Dental Hygiene. May 2011; 9(5): 28, 30, 32.

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