Oral Health Care During Pregnancy

INTRODUCTION

Pregnancy is not a reason to defer routine dental care or treatment. Delay in necessary treatment could cause unforeseen harm to the mother and possibly to the fetus. Appropriate and timely dental care can lead to improved pregnancy outcomes as well as greater comfort for the woman. The treatment of periodontitis, as well as the use of local anesthetics, amalgams, and x-ray scans, does not pose an increased risk to the developing fetus and is, in fact, important in contributing to maintaining optimal health for mother and baby. Several organizations have undertaken efforts to promote oral health during pregnancy. The National Center for Education in Maternal and Child Health published Bright Futures in Practice: Oral Health¹ (supported by the Maternal and Child Health Bureau) to promote and improve the health and well-being of pregnant women and infants. The intent of this paper is to provide the relevant information on the oral health problems of the pregnant women. This article can assist oral care professionals in the implementation of oral health care and to achieve and maintain an optimal oral condition in pregnant women.

NORMAL CHANGES DURING PREGNANCY

Cardiovascular changes

Maternal cardiovascular response to pregnancy involves enormous changes. During gestation, plasma volume and cardiac output increase, peripheral vascular resistance decreases, and there is a modest decline in mean blood pressure during mid-gestation. Due to the enlarging uterus from about mid-pregnancy, women in the supine position are at risk for aortic and venal canal compression by the gravid uterus. Thus, avoiding the flat supine position, particularly in a dental chair, by displacing the uterus laterally is important.²

Respiratory changes

As pregnancy progresses, the enlarging uterus assumes a more important role in the alteration of respiratory functions. Conformational changes in the chest (e.g., rise in the diaphragm) may affect sleep patterns. Shortness of breath reflects increased respiratory drive and airway edema.³ Total lung volume and lung capacities are not greatly changed by pregnancy; changes are primarily limited to the functional residual capacity (FRC), which is decreased 15-20% in the woman at term, and tidal volume, which is increased 30-40%.

Gastroesophageal changes

Pregnancy is also associated with pressure on the stomach caused by the enlarged uterus. Heartburn, nausea and vomiting and rapid satiety (feeling of fullness) are common. Heartburn is primarily a result of decreased gastroesophageal junction tone and increased gastric reflux. Stomach acid refluxed up through the esophagus and into the oral cavity is a concern because excessive vomiting can result in enamel erosion.⁴

Hematologic changes

Common hematologic changes during pregnancy include a mild decrease in mean platelet count (gestational thrombocytopenia), mild increases in mean white blood cell counts, and increased iron demands secondary to increased erythropoiesis which requires iron supplementation to maintain hemoglobin level and avoid depletion.⁵

MEDICAL CONDITIONS AND DENTAL TREATMENT CONSIDERATIONS

Hypertensive Disorders and Pregnancy

Hypertensive disorders, including both preexisting or chronic hypertension and gestational hypertension, occur in 12–22% of pregnant women. Oral health professionals should be aware of hypertensive disorders in pregnancy. Uncontrolled severe hypertension may increase the risk of bleeding during dental procedures. Prenatal care providers should be consulted before initiating dental procedures in women with hypertension to classify the type and severity of hypertension and to rule out preeclampsia if indicated.⁶

Diabetes and Pregnancy

It is usually diagnosed after 24 weeks of gestation. Any inflammatory process, including acute and chronic periodontal infection, can make diabetes control more difficult. Poorly controlled diabetes is associated with adverse pregnancy outcomes such as preeclampsia, congenital anomalies, and large-for gestational age newborns.⁷ Meticulous control to avoid or minimize dental infection is important for pregnant women with diabetes. Controlling all sources of acute or chronic inflammation helps control diabetes.

Risk of Aspiration and Positioning During Pregnancy

Pregnant women have delayed gastric emptying and are considered to always have a “full stomach.” Thus, they are at increased risk for aspiration. After 20 weeks gestation, they should be maintained in a semi-seated position or a pillow should be placed underneath the right side of the body to allow left lateral uterine displacement off the vena cava. This positioning is generally comfortable and will help avoid hypotension, nausea, and aspiration.^8,9

DENTAL CONDITIONS AND CONSIDERATIONS

Tooth Decay

Tooth decay is a chronic bacterial disease that can affect all people across all age groups. Pregnancy impacts oral health in several ways. Changes in the woman’s diet and oral hygiene practices during pregnancy can result in an increase in tooth decay. In addition, nausea and vomiting during pregnancy can cause extensive erosion of the tooth surface and lead to deteriorating oral health status. Treatment of tooth decay in pregnant women cannot only improve the overall health of the mother but also helps decrease the transmission of dental caries causing bacteria from the mother to the infant.¹⁰ Children whose mothers have poor oral health and high levels of oral bacteria are at greater risk for developing dental caries or tooth decay, as compared with children whose mothers have good oral health and lower levels of oral bacteria.¹¹

Pregnancy gingivitis

Periodontal treatment is very important during pregnancy. The hormones that are released in the pregnant woman's body make her more susceptible to plaque and in turn gum bleeding^12,13 (condition known as pregnancy gingivitis). Many pregnant women mistakenly think that gum bleeding is normal during pregnancy and they do not seek dental care.¹⁰ The dentist has to inform the pregnant woman and give her instructions on how to improve her oral health. Furthermore, if necessary, more frequent visits to the dentist should be scheduled.

Pregnancy epulis

A periodontal lesion characteristic during pregnancy is the pregnancy epulis. The lesion is estimated to affect 0.2-5% of pregnant women and is more common in the maxillary gingiva. It is a form of pyogenic granuloma that is hormone related. Lesions may regress spontaneously after birth. If not, they should be surgically removed. If they are bleeding excessively and cause trouble in mastication they may be removed with safety during pregnancy.¹⁴

ROLE OF THE DENTIST

• Explain the importance of oral hygiene and oral health care.
• Explain that oral health care during pregnancy is safe and effective and that it is essential for the pregnant woman and the fetus.
• Tell women that diagnosis (including necessary dental X-rays¹⁵) and treatment for conditions requiring immediate attention are safe during the first trimester of pregnancy.
• Inform women that necessary treatment can be provided throughout pregnancy; however, the period between the 14th and the 20th week of pregnancy is the best time to provide treatment.¹⁶ Advise women that delaying necessary treatment could result in significant risk to the mother and indirectly to the fetus.
• Educate women and encourage behaviors that support good oral health: Brushing teeth twice daily with fluoridated toothpaste, especially before bedtime, and flossing daily. Taking prenatal vitamins, including folic acid to reduce the risk of birth defects such as cleft lip and palate, and eating foods high in protein, calcium, phosphorus and vitamins A, C and D. Chewing xylitol-containing gum or other xylitol-containing products, two to three times a day, after eating.
• Position Pregnant Women Appropriately During Treatment: Keep the head at a higher level than the feet. Place a small pillow under the right hip, or have women turn slightly to the left to avoid dizziness or nausea.
• Consult with the prenatal care health professional when considering the following: Deferring treatment because of pregnancy, Co-morbid conditions or medication use (e.g., diabetes, hypertension, heparin use) that may affect management of oral problems, Intravenous sedation or general anesthesia to complete dental procedures.
• Use the Following When Clinically Indicated: X-rays with thyroid collar, and abdominal apron, Local anesthetic with epinephrine, Appropriate analgesics and/or antibiotics.¹⁷(Refer Table 1), Dental amalgam with proper isolation and high-speed evacuation.^18,19

CONCLUSION

Oral health care in pregnancy is often avoided and misunderstood by dentists, physicians and pregnant women because of the lack of information or perceptions about the safety and importance of dental treatment during pregnancy. Prevention, diagnosis and treatment of oral diseases, including needed dental radiographs and use of local anesthesia, are highly beneficial and can be undertaken during pregnancy with no additional fetal or maternal risk when compared to the risk of not providing care. Good oral health and control of oral disease protects a woman’s health and quality of life and has the potential to reduce the transmission of pathogenic bacteria from mothers to their children.

REFERENCES