The Importance of Oral Health during Pregnancy: A review

A IMPORTÂNCIA DE SAÚDE ORAL DURANTE A GRAVIDEZ

Vinay Marla Ritesh Srii Deepak Kumar Roy Hardik Ajmera About the authors

ABSTRACT

Pregnancy is a transient physiological state which brings about different hormonal changes in a woman's body. These effects are generalized and there are various oral changes as well. There are a number of especially important alterations in the periodontal conditions within the oral cavity. These changes have important implications as they have been known to cause adverse pregnancy outcomes. Better knowledge about these scenarios among health care professionals and women would go a long way toward avoiding or minimizing these adverse outcomes. Health education is an important tool in creating awareness among pregnant women regarding improvement of their oral health. Awareness among the health professionals and good inter-departmental collaboration would help toward a more efficient treatment of these pregnancy related conditions.

KEYWORDS:
oral health; oral health education; pregnancy

RESUMO

A gravidez é um estado fisiológico transitório que produz uma série de alterações hormonais no corpo da mulher. Esses efeitos são generalizados e incluem várias alterações orais. Uma destas afeta condições periodontais. Essas mudanças têm implicações importantes, pois sabe-se que causam resultados adversos na gravidez. Um melhor conhecimento sobre esses cenários entre os profissionais de saúde e entre as mulheres seria um passo importante para evitar ou minimizar tais resultados adversos. A educação para a saúde é uma ferramenta importante na conscientização das mulheres grávidas em relação à melhoria da saúde bucal. A consciência entre os profissionais de saúde e a boa colaboração interdisciplinar ajudaria a efetivar tratamento mais eficiente dessas condições relacionadas à gravidez.

PALAVRAS-CHAVE:
saúde bucal; educação para a saúde bucal; gravidez

INTRODUCTION

Oral health was recently re-defined by the Fédération Dentaire Internationale (FDI) as being a multi-faceted condition including the ability to speak, smile, smell, taste, touch, chew, swallow and convey a range of emotions through facial expressions with confidence and without pain, discomfort or disease of the craniofacial complex. The definition further states that oral health is a component of health, including physical and mental well-being.11 Glick M, Williams DM, Kleinman DV, Vujicic M, Watt RG, Weyant RJ. A new definition for oral health developed by the FDI world dental federation opens the door to a universal definition of oral health. J Am Dental Assoc. 2016:147(12):915-7. DOI:10.1016/j.ajodo.2016.11.010
https://doi.org/10.1016/j.ajodo.2016.11....
Oral health can be achieved by maintaining good oral hygiene. The importance of maintaining good oral hygiene is not just restricted to preventing dental caries and periodontal problems, but improving the overall general health status of an individual.22 Hein C, Williams RC. The impact of oral health on general health: Educating professionals and patients. Current Oral Health Reports. 2017;4(1):8-13. DOI:10.1007/s40496-017-0124-4
https://doi.org/10.1007/s40496-017-0124-...
Various studies have shown that there is a direct correlation between oral health and general systemic health of an individual.33 Azarpazhooh A, Leake JL. Systematic review of the association between respiratory diseases and oral health. J Periodontol. 2006;77:1465-82. DOI:10.1902/jop.2006.060010
https://doi.org/10.1902/jop.2006.060010...
,44 Mealey BL, Oates TW. Diabetes mellitus and periodontal diseases. J Periodontol. 2006;77:1289-303. DOI:10.1902/jop.2006.050459
https://doi.org/10.1902/jop.2006.050459...
,55 Winning L, Linden GJ. Periodontitis and systemic disease. Association or Causality? Curr Oral Health Rep 2017;4. DOI:10.1007/s40496-017-0121-7
https://doi.org/10.1007/s40496-017-0121-...

Oral health awareness goes a long way toward improving the oral health status of an individual. Maintaining proper oral hygiene and promoting swift treatment of various oral conditions have a positive impact in this regard.66 Arigbede AO, Babatope BO, Bamidele MK. Periodontitis and systemic diseases: A literature review. J Indian Soc Periodontol. 2012;16(4):487-91. DOI:10.4103/0972-124X.106878
https://doi.org/10.4103/0972-124X.106878...
However, special consideration is required in terms of oral health in women. The presence of different physiological states such as puberty, pregnancy and menopause should be given added consideration, because these conditions are known to modify the overall health status in women.77 Kessler JL. A literature review on women's oral health across the life span. Nursing for Women's Health 2017;21(2):108-21. DOI:10.1016/j.nwh.2017.02.010
https://doi.org/10.1016/j.nwh.2017.02.01...
The importance of oral health in pregnant women is of paramount significance, since it not only has a direct effect on the expecting mother but also on the future of the child.88 Laine MA. Effect of pregnancy on periodontal and dental health. Acta Odontol Scand. 2002;60(5):257-64. DOI:10.1080/00016350260248210
https://doi.org/10.1080/0001635026024821...
This review focuses on the importance of oral health in pregnant women.

METHODS & RESULTS

A literature search was conducted over the past 20 years in PubMed and Google using the terms "oral health', "oral health education" and "pregnancy". Over one hundred articles were downloaded based on the search criteria; out of these, 46 articles were primarily selected based on relevance, availability of full text and non-overlapping entries. These articles were reviewed and data extracted. Fifteen articles which showed the prevalence and risk assessment of dental caries in pregnant women were finally selected for discussion. Most of the studies evaluated the Dental-Missing-Filled-Teeth (DMFT) scores in pregnant women; a few evaluated the cariogenic bacterial load and others studied the salivary flow rate. The findings of these articles were summarized in a draft tabular form.

DISCUSSION

Pregnancy is a transient physiological state which begins following fertilization and lasts roughly around nine months, which can be further divided into trimesters. Pregnancy causes a variety of generalized changes in a woman's body due to the progressive cycle of hormonal influences.99 Gupta R, Acharya AK. Oral health status and treatment needs among pregnant women of Raichur District, India: A population based cross-sectional study. Scientifica 2016;Article ID 9860. DOI:10.1155/2016/9860387
https://doi.org/10.1155/2016/9860387...
The increased hormonal secretion may result in different signs and symptoms which can alter the person's overall health and perceptions. These would then cause systemic changes including the cardiovascular, hematologic, respiratory, renal, gastro-intestinal, endocrine and genitourinary systems.1010 Hemalatha VT, Manigandan T, Sarumathi T, Aarthi Nisha V, Amudhan A. Dental Considerations in Pregnancy-A Critical Review on the Oral Care. Journal of Clinical and Diagnostic Research : JCDR. 2013;7(5):948-53. DOI:10.7860/JCDR/2013/5405.2986
https://doi.org/10.7860/JCDR/2013/5405.2...
Various localized effects are also seen involving the oral cavity. The effects on the hard and soft tissues of the oral cavity during pregnancy have been well documented.99 Gupta R, Acharya AK. Oral health status and treatment needs among pregnant women of Raichur District, India: A population based cross-sectional study. Scientifica 2016;Article ID 9860. DOI:10.1155/2016/9860387
https://doi.org/10.1155/2016/9860387...
,1010 Hemalatha VT, Manigandan T, Sarumathi T, Aarthi Nisha V, Amudhan A. Dental Considerations in Pregnancy-A Critical Review on the Oral Care. Journal of Clinical and Diagnostic Research : JCDR. 2013;7(5):948-53. DOI:10.7860/JCDR/2013/5405.2986
https://doi.org/10.7860/JCDR/2013/5405.2...
,1111 Shamsi M, Hidarnia A, Niknami S, Rafiee M, Karimi M. Oral health during pregnancy: A study from women with pregnancy. Dental Res J. 2013;10(3):409-10. DOI:10.4103/1735-3327.115134
https://doi.org/10.4103/1735-3327.115134...
The most common are the conditions affecting periodontal health and include gingivitis and periodontitis.88 Laine MA. Effect of pregnancy on periodontal and dental health. Acta Odontol Scand. 2002;60(5):257-64. DOI:10.1080/00016350260248210
https://doi.org/10.1080/0001635026024821...
A reactive growth called 'pregnancy tumor' is commonly seen in the gingiva during pregnancy.1212 Gondivkar SM, Gadbail A, Chole R. Oral pregnancy tumor. Contemporary Clinical Dentistry. 2010;1(3):190-2. DOI:10.4103/0976-237X.72792
https://doi.org/10.4103/0976-237X.72792...
The incidence of dental caries also increases due to changes in dietary habits; also common are erosion of teeth due to frequent episodes of nausea and vomiting during pregnancy.88 Laine MA. Effect of pregnancy on periodontal and dental health. Acta Odontol Scand. 2002;60(5):257-64. DOI:10.1080/00016350260248210
https://doi.org/10.1080/0001635026024821...
Overall, there is an increased incidence of infectious diseases which could have deleterious effects. It should be kept in mind that the pregnancy related effects have a negative impact not only on the mother, but also on the infant if not handled properly.1313 Rainchuso L. Improving oral health outcomes from pregnancy through infancy. J Dent Hyg. 2013;87(6):330-5.

**Pregnancy and periodontal health.*** Periodontal status is one of the most important aspects of oral health to be considered in a pregnant woman. According to a report given by the American Dental Association, around 60% to 75% of pregnant women have gingivitis.1414 Hartnett E, Haber J, Krainovich-Miller B, Bella A, Vasilyeva, A, Lange Kessler J. Oral health in pregnancy. J Obstet Gynecol Neonatal Nurs. 2016;45(4):565-73. DOI:10.1016/j.jogn.2016.04.005.
https://doi.org/10.1016/j.jogn.2016.04.0...
It has been found that pregnancy as such does not cause gingivitis but aggravates it. Pregnancy gingivitis is usually seen in the marginal gingiva and in interdental papillae. Gingivitis is aggravated by increased capillary permeability which is a predisposing factor, because of increased levels of circulating estrogen levels.88 Laine MA. Effect of pregnancy on periodontal and dental health. Acta Odontol Scand. 2002;60(5):257-64. DOI:10.1080/00016350260248210
https://doi.org/10.1080/0001635026024821...
It has also been observed that levels of Bacteroides, Prevotella or Porphyromonas increase during pregnancy.1515 Wu M, Chen SW, Jiang SY. Relationship between Gingival Inflammation and Pregnancy. Mediators Inflamm. 2015;2015:623427. DOI:10.1155/2015/623427.
https://doi.org/10.1155/2015/623427...
Bleeding, swelling and tenderness are usually encountered from the second trimester onward, with peak levels seen around the eighth month.88 Laine MA. Effect of pregnancy on periodontal and dental health. Acta Odontol Scand. 2002;60(5):257-64. DOI:10.1080/00016350260248210
https://doi.org/10.1080/0001635026024821...
The signs are aggravated by poor oral hygiene. The gingival condition can be controlled by effective oral hygiene measures.88 Laine MA. Effect of pregnancy on periodontal and dental health. Acta Odontol Scand. 2002;60(5):257-64. DOI:10.1080/00016350260248210
https://doi.org/10.1080/0001635026024821...
,99 Gupta R, Acharya AK. Oral health status and treatment needs among pregnant women of Raichur District, India: A population based cross-sectional study. Scientifica 2016;Article ID 9860. DOI:10.1155/2016/9860387
https://doi.org/10.1155/2016/9860387...

Similarly, the increased circulating hormonal levels exacerbate the pre-existing periodontal conditions. According to different reports it has been found that the prevalence of pregnant women suffering from periodontal diseases ranged from 30% to 100%.99 Gupta R, Acharya AK. Oral health status and treatment needs among pregnant women of Raichur District, India: A population based cross-sectional study. Scientifica 2016;Article ID 9860. DOI:10.1155/2016/9860387
https://doi.org/10.1155/2016/9860387...
Various studies conducted worldwide have shown that there is an association between periodontitis and adverse pregnancy outcomes.1616 Han YW. Oral Health and Adverse Pregnancy Outcomes - What's Next? J Dent Res. 2011 Mar;90(3):289-93. DOI:10.1177/0022034510381905
https://doi.org/10.1177/0022034510381905...
One of the earliest reports suggested periodontitis to be a potential risk factor for pre-term birth.1717 Offenbacher S, Katz V, Fertik G, Collins J, Boyd D Maynor G, et al. Periodontal infection as a possible risk factor for preterm low birth weight. J Periodontal. 1996;67(10):1103-13. DOI:10.1902/jop.1996.67.10s.1103
https://doi.org/10.1902/jop.1996.67.10s....
An association of pregnancy with low birth weight has also been made.1616 Han YW. Oral Health and Adverse Pregnancy Outcomes - What's Next? J Dent Res. 2011 Mar;90(3):289-93. DOI:10.1177/0022034510381905
https://doi.org/10.1177/0022034510381905...
A systematic review has suggested that a woman's chance of having a preterm birth is significantly reduced by scaling and root planing during pregnancy.1818 Shanthi V, Vanka A, Bhambal A, Saxena V, Saxena S, Kumar SS. Association of pregnant women periodontal status to preterm and low-birth weight babies: A systematic and evidence-based review. Dental Res J. 2012;9(4):368-80. These findings were further affirmed by a meta-analysis conducted on seven randomized control trials.1919 Polyzos NP, Polyzos IP, Mauri D, Tzioras S, Tsappi M, Cortinovis I, et al. Effect of periodontal disease treatment during pregnancy on preterm birth incidence: a meta-analysis of randomized trials. Am J Obstet Gynecol. 2009 Mar;200(3):225-32. DOI:10.1016/j.ajog.2008.09.020.
https://doi.org/10.1016/j.ajog.2008.09.0...
However, a case-control study evaluating the relationship of periodontal disease and preterm birth weight suggested that there was no association between them.2020 Vettore MV, Lamarca GA, Leão AT, Thomaz FB, Aubrey S, Leal MC. Periodontal infection and adverse pregnancy outcomes: a systematic review of epidemiological studies. Cad Saude Publica. 2006;22:2041-053. DOI:10.1590/S0102-311X2006001000010.
https://doi.org/10.1590/S0102-311X200600...
Other adverse pregnancy outcomes related to periodontitis include stillbirth, miscarriage, intra-uterine growth retardation and pre-eclampsia. These findings have been described comprehensively in the Oral Conditions and Pregnancy (OCAP) cohort study conducted in the United States.88 Laine MA. Effect of pregnancy on periodontal and dental health. Acta Odontol Scand. 2002;60(5):257-64. DOI:10.1080/00016350260248210
https://doi.org/10.1080/0001635026024821...
A case of perinatal death in relation to periodontitis has been described in a report from Australia.2121 Shub A, Wong C, Jennings B, Swain JR, Newnham JP. Maternal periodontal disease and perinatal mortality. Aust NZ J Obstet Gynaecol. 2009;49:130-6. DOI:10.1111/j.1479-828X.2009.00953.x
https://doi.org/10.1111/j.1479-828X.2009...

Two theories have been put forward to explain the association of adverse pregnancy outcomes with dental problems. The first suggests that periodontal diseases causes abnormal immunologic changes which result in various complications during pregnancy. The second hypothesis suggests that oral bacteria colonize the placenta which leads to an inflammatory response, hence resulting in the adverse outcomes related to pregnancy. It was also found that this oral-uterine transmission of bacteria was related to periodontal pathogens as well as normal commensals of the oral cavity.2222 George A, Dahlen HG, Blinkhorn A, Ajwani S, Bhole S Ellis S, et al. Measuring oral health during pregnancy: sensitivity and specificity of a maternal oral screening (MOS) tool. BMC Pregnancy and Childbirth 2016;16:347. DOI:10.1186/s12884-016-1140-4
https://doi.org/10.1186/s12884-016-1140-...

The relationship of periodontitis with various systemic diseases has already been established and is based on various studies.44 Mealey BL, Oates TW. Diabetes mellitus and periodontal diseases. J Periodontol. 2006;77:1289-303. DOI:10.1902/jop.2006.050459
https://doi.org/10.1902/jop.2006.050459...
,55 Winning L, Linden GJ. Periodontitis and systemic disease. Association or Causality? Curr Oral Health Rep 2017;4. DOI:10.1007/s40496-017-0121-7
https://doi.org/10.1007/s40496-017-0121-...
,66 Arigbede AO, Babatope BO, Bamidele MK. Periodontitis and systemic diseases: A literature review. J Indian Soc Periodontol. 2012;16(4):487-91. DOI:10.4103/0972-124X.106878
https://doi.org/10.4103/0972-124X.106878...
The association of dental diseases with pulmonary infections had been described as early as the sixties.2323 Ameet M. M, Avneesh H. T, Babita R. P, Pramod P. M. The Relationship Between Periodontitis and Systemic Diseases - Hype or Hope? Journal of Clinical and Diagnostic Research : JCDR. 2013;7(4):758-62. DOI:10.7860/JCDR/2013/4500.2906
https://doi.org/10.7860/JCDR/2013/4500.2...
Periodontitis has been found to show significant association with cardiovascular diseases, diabetes mellitus, respiratory conditions and osteoporosis. These systemic diseases have been primarily attributed to the various pathogens seen in periodontitis.55 Winning L, Linden GJ. Periodontitis and systemic disease. Association or Causality? Curr Oral Health Rep 2017;4. DOI:10.1007/s40496-017-0121-7
https://doi.org/10.1007/s40496-017-0121-...
A relative risk of cardiovascular disease in individuals with periodontitis was described in a meta-analysis.2424 Khader YS, Albashaireh ZS, Alomari MA. Periodontal diseases and the risk of coronary heart and cerebrovascular diseases: a meta-analysis. J Periodontol. 2004;75(8):1046-53. DOI:10.1902/jop.2004.75.8.1046
https://doi.org/10.1902/jop.2004.75.8.10...

Tooth mobility has been observed during pregnancy. This is related to the periodontal status of pregnant women. The change in the microflora from aerobic to anaerobic seems to trigger inflammatory mediators which cause disturbances in the lamina dura resulting in tooth mobility.88 Laine MA. Effect of pregnancy on periodontal and dental health. Acta Odontol Scand. 2002;60(5):257-64. DOI:10.1080/00016350260248210
https://doi.org/10.1080/0001635026024821...
Another lesion commonly encountered during pregnancy is a form of pyogenic granuloma known as "pregnancy tumor". This is a reactive tumor-like growth which arises in response to local irritation factors such as plaques. The hormonal influences resulting in increased angiogenesis leads to the development of these lesions. They are generally encountered during the first and second trimester of pregnancy and may regress after parturition.1212 Gondivkar SM, Gadbail A, Chole R. Oral pregnancy tumor. Contemporary Clinical Dentistry. 2010;1(3):190-2. DOI:10.4103/0976-237X.72792
https://doi.org/10.4103/0976-237X.72792...

**Pregnancy and dentition.*** Pregnant women are predisposed to the development of dental caries. Various factors have been suggested to explain this occurrence. It has been observed that there is an increase in appetite in pregnant women with frequent consumption of cariogenic foods.1313 Rainchuso L. Improving oral health outcomes from pregnancy through infancy. J Dent Hyg. 2013;87(6):330-5. As evidenced by the Miller's experiments, this leads to the fall of oral pH below the critical value leading to the development of caries. The incidence of caries is further enhanced by the occurrence of morning sickness which causes vomiting and reflux leading to erosion of the dental surfaces.2525 Miller WD. The human mouth as a focus of infection. Lancet. 1891;138(3546):340-2. The experience of nausea may also deter routine oral hygiene practices. Another factor which has been suggested is that the hormonal influences causes dryness in the mouth leading to poor washing/buffering effect of the saliva. Consequently, the overall incidence of caries in pregnant women is higher than in normal instances.88 Laine MA. Effect of pregnancy on periodontal and dental health. Acta Odontol Scand. 2002;60(5):257-64. DOI:10.1080/00016350260248210
https://doi.org/10.1080/0001635026024821...

Dental caries during pregnancy should not be just treated as an infection of the teeth. It has been found that good oral hygiene in an expectant mother can go a long way in preventing early childhood caries in children.2626 American College of Obstetricians and Gynecologists Women's Health Care Physicians Committee on Health Care for Underserved Women. Committee opinion no. 569: Oral health care during pregnancy and through the lifespan. Obstetrics and Gynecology 2013;122:417-22. Studies have shown that there is vertical transmission of cariogenic bacteria from the mother to the child. The maternally derived Streptococcus Mutans is a well-known cariogenic bacteria which highlights this type of transmission. Streptococcus Mutans may colonize in an infant's mouth from birth or may be transferred through the saliva and is responsible for initiation of dental caries in an infant.88 Laine MA. Effect of pregnancy on periodontal and dental health. Acta Odontol Scand. 2002;60(5):257-64. DOI:10.1080/00016350260248210
https://doi.org/10.1080/0001635026024821...
Various studies have evaluated the prevalence of caries and associated risk factors in pregnant women. The data showing these findings as observed in different countries around the world has been summarized in Table 1. 99 Gupta R, Acharya AK. Oral health status and treatment needs among pregnant women of Raichur District, India: A population based cross-sectional study. Scientifica 2016;Article ID 9860. DOI:10.1155/2016/9860387
https://doi.org/10.1155/2016/9860387...
), (27-40.)

Table 1
Data extracted from various studies showing the prevalence of dental caries/ risk factors in pregnant women.

**Oral health in pregnancy.*** Oral health is an essential component of maintaining the overall health and well-being of a pregnant woman and her child.4141 Kumar J and Samelson R. Oral health care during pregnancy recommendations for oral health professionals. New York State Dent J. 2009;75(6):29-33. The importance of oral health during pregnancy was highlighted in the 2000 Surgeon General's oral health report and recommendations regarding changing the attitudes and beliefs among health care professionals and patients towards oral health.4242 US Department of Health and Human Services. Oral Health in America: A Report of the Surgeon General. Rockville, MD: US Department of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institutes of Health, 2000.

The number of pregnant women utilizing dental treatment facilities worldwide is very low. A study based in the United States suggested that nearly 56% of pregnant did not seek dental treatment during pregnancy and only 35% had any form of dental procedure during the first year following child-birth.2626 American College of Obstetricians and Gynecologists Women's Health Care Physicians Committee on Health Care for Underserved Women. Committee opinion no. 569: Oral health care during pregnancy and through the lifespan. Obstetrics and Gynecology 2013;122:417-22. Another multi-state based study indicated that 50% of the pregnant women had dental problems, but neglected them for various reasons.4343 Gaffield ML, Gilbert BJ, Malvitz DM, Romaguera R. Oral health during pregnancy: an analysis of information collected by the pregnancy risk assessment monitoring system. J Amer Dent Assoc. 2001;132(7):1009-16. DOI:10.14219/jada.archive.2001.0306
https://doi.org/10.14219/jada.archive.20...
According to the pregnancy risk assessment monitoring system, only 23%-43% of pregnant women underwent dental treatment.4343 Gaffield ML, Gilbert BJ, Malvitz DM, Romaguera R. Oral health during pregnancy: an analysis of information collected by the pregnancy risk assessment monitoring system. J Amer Dent Assoc. 2001;132(7):1009-16. DOI:10.14219/jada.archive.2001.0306
https://doi.org/10.14219/jada.archive.20...
Similar findings were found in studies conducted in India and Iran.99 Gupta R, Acharya AK. Oral health status and treatment needs among pregnant women of Raichur District, India: A population based cross-sectional study. Scientifica 2016;Article ID 9860. DOI:10.1155/2016/9860387
https://doi.org/10.1155/2016/9860387...
,1111 Shamsi M, Hidarnia A, Niknami S, Rafiee M, Karimi M. Oral health during pregnancy: A study from women with pregnancy. Dental Res J. 2013;10(3):409-10. DOI:10.4103/1735-3327.115134
https://doi.org/10.4103/1735-3327.115134...

Educating pregnant women regarding general and oral health would go a long way in preventing the adverse outcomes of pregnancy. Present day pregnancy is associated with a change in behavior in women and this provides an excellent opportunity to counsel them regarding the importance of oral health. Pregnant women are receptive to information regarding improvements to their own health as well as the infant's well-being.88 Laine MA. Effect of pregnancy on periodontal and dental health. Acta Odontol Scand. 2002;60(5):257-64. DOI:10.1080/00016350260248210
https://doi.org/10.1080/0001635026024821...
Early health care promotion during pregnancy has been shown to improve overall oral health in children. Along with patient education, oral screening is an essential component which could be adhered to during the initial trimester of pregnancy.2222 George A, Dahlen HG, Blinkhorn A, Ajwani S, Bhole S Ellis S, et al. Measuring oral health during pregnancy: sensitivity and specificity of a maternal oral screening (MOS) tool. BMC Pregnancy and Childbirth 2016;16:347. DOI:10.1186/s12884-016-1140-4
https://doi.org/10.1186/s12884-016-1140-...
In this regard, the SMILE study and the Midwifery Initiated Oral Health (MIOH) trial are extremely effective interventions in reducing the adverse outcomes of pregnancy. A Maternal Oral Screening (MOS) tool was developed which was found to be highly sensitive in identifying dental problems.2222 George A, Dahlen HG, Blinkhorn A, Ajwani S, Bhole S Ellis S, et al. Measuring oral health during pregnancy: sensitivity and specificity of a maternal oral screening (MOS) tool. BMC Pregnancy and Childbirth 2016;16:347. DOI:10.1186/s12884-016-1140-4
https://doi.org/10.1186/s12884-016-1140-...
,4444 Johnson M, George A, Dahlen H, Ajwani S, Bhole S, Blinkhorn A et al. The midwifery initiated oral health-dental service protocol: an intervention to improve oral health outcomes for pregnant women. BMC Oral Health. 2015;15:2. DOI:10.1186/1472-6831-15-2
https://doi.org/10.1186/1472-6831-15-2...

The knowledge and attitudes of the health care professionals towards promoting oral health in pregnant women plays an important role in its achievement. Studies have shown that there is awareness among health care professionals regarding the importance of oral health but lack of judgement on referrals.4545 Morgan MA, Crall J, Goldenberg RL, Schulkin J. Oral health during pregnancy. J Matern Fetal Neonatal Med. 2009;22(9):733-9. DOI:10.3109/14767050902926954
https://doi.org/10.3109/1476705090292695...
The U.S. Department of Health and Human Services, Health Resources and Services, administration (HRSA) stresses the importance of inter-professional oral health care clinical competencies among health care providers.1414 Hartnett E, Haber J, Krainovich-Miller B, Bella A, Vasilyeva, A, Lange Kessler J. Oral health in pregnancy. J Obstet Gynecol Neonatal Nurs. 2016;45(4):565-73. DOI:10.1016/j.jogn.2016.04.005.
https://doi.org/10.1016/j.jogn.2016.04.0...
Nurses, nurse-practitioners and nurse-midwives are encouraged to undertake the assessment of oral conditions and referrals whenever necessary as a part of their routine prenatal practice.4646 Mills LW, Moses DT. Oral health during pregnancy. MCN Am J Matern Child Nurs 2002;27(5):275-80. Collaboration between the obstetric and dental teams might be an effective way of providing quality oral health care to pregnant women.

**Oral health management during pregnancy.*** Management of oral health in a pregnant woman is a complex process and requires sound knowledge of the various physiological events occurring during pregnancy. A step-wise approach is required during each trimester of pregnancy. Inter-professional collaboration involving the medical personnel, nursing staff and dental professionals would be effective.4141 Kumar J and Samelson R. Oral health care during pregnancy recommendations for oral health professionals. New York State Dent J. 2009;75(6):29-33.

The first trimester of pregnancy is the period when embryological development occurs leading to the formation of the fetus. This is a critical time, because any complication can lead to teratogenic effects on the developing fetus. In terms of oral health, it is generally recommended that patients should be assessed for their oral conditions and counselled regarding maintaining oral hygiene.1010 Hemalatha VT, Manigandan T, Sarumathi T, Aarthi Nisha V, Amudhan A. Dental Considerations in Pregnancy-A Critical Review on the Oral Care. Journal of Clinical and Diagnostic Research : JCDR. 2013;7(5):948-53. DOI:10.7860/JCDR/2013/5405.2986
https://doi.org/10.7860/JCDR/2013/5405.2...
Additional counselling regarding transmission of Streptococcus Mutans and dietary considerations should be given. No dental procedures should be performed.2626 American College of Obstetricians and Gynecologists Women's Health Care Physicians Committee on Health Care for Underserved Women. Committee opinion no. 569: Oral health care during pregnancy and through the lifespan. Obstetrics and Gynecology 2013;122:417-22.

The second and third trimester are safe for any elective dental procedure. However, it should be noted that the appointments should be short and the patient positioning should be taken into account especially during the third trimester as the increased uterine pressure may cause dizziness, nausea and supine hypotensive syndrome.4141 Kumar J and Samelson R. Oral health care during pregnancy recommendations for oral health professionals. New York State Dent J. 2009;75(6):29-33. The elective procedures that can be performed include (a) oral prophylaxis and dental restorations; (b) fluoride application and use of chlorhexidine mouth rinses; (c) use of xylitol as a sweetening agent; (d) judicious use of analgesics and antibiotics.4646 Mills LW, Moses DT. Oral health during pregnancy. MCN Am J Matern Child Nurs 2002;27(5):275-80.

**Our experience at Dhulikhel Hospital, Nepal.*** At the Dhulikhel Hospital, Nepal we strive to serve the local communities which have been burdened by health problems primarily due to lack of awareness and accessible health care facilities. The year of 2017 was marked by the opening of a new inter-departmental collaborative effort between the Department of Obstetrics & Gynecology and the Dental Department; the objective is to improve oral health in women. A team of dental doctors routinely visits the wards to educate the pregnant women and instill positive oral hygiene practices. Patients with oral conditions are referred to the Dental Department where elective procedures are performed. Community based dental camps are conducted routinely in the various outreach centers of the hospital where oral hygiene practices are taught to the population.

SUMMARY

Pregnancy is a dynamic state which causes numerous physiological, general and oral alterations. Proper and effective care of mothers is essential not only for her but also for the future of the child to be born. Maintaining good oral health is paramount for preventing adverse pregnancy outcomes and delivering a healthy child.

REFERENCES

  • 1
    Glick M, Williams DM, Kleinman DV, Vujicic M, Watt RG, Weyant RJ. A new definition for oral health developed by the FDI world dental federation opens the door to a universal definition of oral health. J Am Dental Assoc. 2016:147(12):915-7. DOI:10.1016/j.ajodo.2016.11.010
    » https://doi.org/10.1016/j.ajodo.2016.11.010
  • 2
    Hein C, Williams RC. The impact of oral health on general health: Educating professionals and patients. Current Oral Health Reports. 2017;4(1):8-13. DOI:10.1007/s40496-017-0124-4
    » https://doi.org/10.1007/s40496-017-0124-4
  • 3
    Azarpazhooh A, Leake JL. Systematic review of the association between respiratory diseases and oral health. J Periodontol. 2006;77:1465-82. DOI:10.1902/jop.2006.060010
    » https://doi.org/10.1902/jop.2006.060010
  • 4
    Mealey BL, Oates TW. Diabetes mellitus and periodontal diseases. J Periodontol. 2006;77:1289-303. DOI:10.1902/jop.2006.050459
    » https://doi.org/10.1902/jop.2006.050459
  • 5
    Winning L, Linden GJ. Periodontitis and systemic disease. Association or Causality? Curr Oral Health Rep 2017;4. DOI:10.1007/s40496-017-0121-7
    » https://doi.org/10.1007/s40496-017-0121-7
  • 6
    Arigbede AO, Babatope BO, Bamidele MK. Periodontitis and systemic diseases: A literature review. J Indian Soc Periodontol. 2012;16(4):487-91. DOI:10.4103/0972-124X.106878
    » https://doi.org/10.4103/0972-124X.106878
  • 7
    Kessler JL. A literature review on women's oral health across the life span. Nursing for Women's Health 2017;21(2):108-21. DOI:10.1016/j.nwh.2017.02.010
    » https://doi.org/10.1016/j.nwh.2017.02.010
  • 8
    Laine MA. Effect of pregnancy on periodontal and dental health. Acta Odontol Scand. 2002;60(5):257-64. DOI:10.1080/00016350260248210
    » https://doi.org/10.1080/00016350260248210
  • 9
    Gupta R, Acharya AK. Oral health status and treatment needs among pregnant women of Raichur District, India: A population based cross-sectional study. Scientifica 2016;Article ID 9860. DOI:10.1155/2016/9860387
    » https://doi.org/10.1155/2016/9860387
  • 10
    Hemalatha VT, Manigandan T, Sarumathi T, Aarthi Nisha V, Amudhan A. Dental Considerations in Pregnancy-A Critical Review on the Oral Care. Journal of Clinical and Diagnostic Research : JCDR. 2013;7(5):948-53. DOI:10.7860/JCDR/2013/5405.2986
    » https://doi.org/10.7860/JCDR/2013/5405.2986
  • 11
    Shamsi M, Hidarnia A, Niknami S, Rafiee M, Karimi M. Oral health during pregnancy: A study from women with pregnancy. Dental Res J. 2013;10(3):409-10. DOI:10.4103/1735-3327.115134
    » https://doi.org/10.4103/1735-3327.115134
  • 12
    Gondivkar SM, Gadbail A, Chole R. Oral pregnancy tumor. Contemporary Clinical Dentistry. 2010;1(3):190-2. DOI:10.4103/0976-237X.72792
    » https://doi.org/10.4103/0976-237X.72792
  • 13
    Rainchuso L. Improving oral health outcomes from pregnancy through infancy. J Dent Hyg. 2013;87(6):330-5.
  • 14
    Hartnett E, Haber J, Krainovich-Miller B, Bella A, Vasilyeva, A, Lange Kessler J. Oral health in pregnancy. J Obstet Gynecol Neonatal Nurs. 2016;45(4):565-73. DOI:10.1016/j.jogn.2016.04.005.
    » https://doi.org/10.1016/j.jogn.2016.04.005
  • 15
    Wu M, Chen SW, Jiang SY. Relationship between Gingival Inflammation and Pregnancy. Mediators Inflamm. 2015;2015:623427. DOI:10.1155/2015/623427.
    » https://doi.org/10.1155/2015/623427
  • 16
    Han YW. Oral Health and Adverse Pregnancy Outcomes - What's Next? J Dent Res. 2011 Mar;90(3):289-93. DOI:10.1177/0022034510381905
    » https://doi.org/10.1177/0022034510381905
  • 17
    Offenbacher S, Katz V, Fertik G, Collins J, Boyd D Maynor G, et al. Periodontal infection as a possible risk factor for preterm low birth weight. J Periodontal. 1996;67(10):1103-13. DOI:10.1902/jop.1996.67.10s.1103
    » https://doi.org/10.1902/jop.1996.67.10s.1103
  • 18
    Shanthi V, Vanka A, Bhambal A, Saxena V, Saxena S, Kumar SS. Association of pregnant women periodontal status to preterm and low-birth weight babies: A systematic and evidence-based review. Dental Res J. 2012;9(4):368-80.
  • 19
    Polyzos NP, Polyzos IP, Mauri D, Tzioras S, Tsappi M, Cortinovis I, et al. Effect of periodontal disease treatment during pregnancy on preterm birth incidence: a meta-analysis of randomized trials. Am J Obstet Gynecol. 2009 Mar;200(3):225-32. DOI:10.1016/j.ajog.2008.09.020.
    » https://doi.org/10.1016/j.ajog.2008.09.020
  • 20
    Vettore MV, Lamarca GA, Leão AT, Thomaz FB, Aubrey S, Leal MC. Periodontal infection and adverse pregnancy outcomes: a systematic review of epidemiological studies. Cad Saude Publica. 2006;22:2041-053. DOI:10.1590/S0102-311X2006001000010.
    » https://doi.org/10.1590/S0102-311X2006001000010
  • 21
    Shub A, Wong C, Jennings B, Swain JR, Newnham JP. Maternal periodontal disease and perinatal mortality. Aust NZ J Obstet Gynaecol. 2009;49:130-6. DOI:10.1111/j.1479-828X.2009.00953.x
    » https://doi.org/10.1111/j.1479-828X.2009.00953.x
  • 22
    George A, Dahlen HG, Blinkhorn A, Ajwani S, Bhole S Ellis S, et al. Measuring oral health during pregnancy: sensitivity and specificity of a maternal oral screening (MOS) tool. BMC Pregnancy and Childbirth 2016;16:347. DOI:10.1186/s12884-016-1140-4
    » https://doi.org/10.1186/s12884-016-1140-4
  • 23
    Ameet M. M, Avneesh H. T, Babita R. P, Pramod P. M. The Relationship Between Periodontitis and Systemic Diseases - Hype or Hope? Journal of Clinical and Diagnostic Research : JCDR. 2013;7(4):758-62. DOI:10.7860/JCDR/2013/4500.2906
    » https://doi.org/10.7860/JCDR/2013/4500.2906
  • 24
    Khader YS, Albashaireh ZS, Alomari MA. Periodontal diseases and the risk of coronary heart and cerebrovascular diseases: a meta-analysis. J Periodontol. 2004;75(8):1046-53. DOI:10.1902/jop.2004.75.8.1046
    » https://doi.org/10.1902/jop.2004.75.8.1046
  • 25
    Miller WD. The human mouth as a focus of infection. Lancet. 1891;138(3546):340-2.
  • 26
    American College of Obstetricians and Gynecologists Women's Health Care Physicians Committee on Health Care for Underserved Women. Committee opinion no. 569: Oral health care during pregnancy and through the lifespan. Obstetrics and Gynecology 2013;122:417-22.
  • 27
    Vasiliauskiene I. Oral Health Status of Pregnant Women. Stomatologija. Baltic Dental and Maxillofacial Journal 2003;5:57-61.
  • 28
    Ji Y, Nakai Y, Rodis OMM, Kariya N, Matsumura S, Shimono T. Relationship between caries risk and presence of cariogenic bacteria among Japanese pregnant women. Pediatric Dental J. 2005;15(2):203-6. DOI:10.1016/S0917-2394(05)70054-9
    » https://doi.org/10.1016/S0917-2394(05)70054-9
  • 29
    Rakchanok N., Amporn D., Yoshida Y., Harun-Or-Rashid M., Sakamoto J. Dental caries and gingivitis among pregnant and non-pregnant women in Chiang Mai, Thailand. Nagoya J of Med Sci. 2010;72(1-2):43-50.
  • 30
    Bressane LB, da Silva Costa LNB, Vieira JMR, Rebelo MAB. Oral health conditions among pregnant women attended to at a health care center in Manaus, Amazonas, Brazil. Rev Odonto Cienc 2011;26(4):291-6. DOI:10.1590/S1980-65232011000400003
    » https://doi.org/10.1590/S1980-65232011000400003
  • 31
    Molnar-Varlam C, Molnar-Varlam C, Gabriela B, Tohati A. Risk assessment of caries in pregnancy. Acta Medica Marisiensis. 2011;57(6):685-9.
  • 32
    Merglova V, Hecovaa H, Stehlikovaa J, Chaloupka P. Oral health status of women with high-risk pregnancies. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub. 2012;156(4):337-41.
  • 33
    Vergnes J-N, Kaminski M, Lelong N, Musset A-M, Sixou M, Nabet C. Frequency and Risk Indicators of Tooth Decay among Pregnant Women in France: A Cross-Sectional Analysis. PLoS ONE 2012;7(5):e33296. DOI:10.1371/journal.pone.0033296.
    » https://doi.org/10.1371/journal.pone.0033296
  • 34
    Öztürk LK, Akyüz S, Garan A, Yarat A. Salivary and Dental - Oral Hygiene Parameters in 3rd Trimester of Pregnancy and Early Lactation: The Effect of Education. Marmara Dental J. 2013;1:1-8. DOI:10.12990/MDJ2013127.
    » https://doi.org/10.12990/MDJ2013127
  • 35
    Rahman MM, Hassan MR, Islam MZ, Ahmad MS, Alam MM, Islam KM. Oral Health Status of Pregnant Women attended the Mothers and Children Welfare Center (MCWC) in Bangladesh. City Dent Coll J. 2013;10(2):1-4. DOI:10.3329/cdcj.v10i2.16312
    » https://doi.org/10.3329/cdcj.v10i2.16312
  • 36
    Amin R and Shetty P. Oral health status during pregnancy in Mangalore. Nitte University J of Health Sci. 2014;4 (2):114-7.
  • 37
    Karnik AA, Pagare SS, Krishnamurthy V, Vahanwala SP, Waghmare M. Determination of salivary flow rate, pH, and dental caries during pregnancy: A study. J Indian Acad Oral Med Radiol 2015;27:372-6.
  • 38
    Azofeifa A, Yeung LF, Alverson CJ, Beltrán-Aguilar E. Dental caries and periodontal disease among U.S. pregnant women and nonpregnant women of reproductive age, National Health and Nutrition Examination Survey, 1999-2004. J Public Health Dent. 2016;76(4):320-9. DOI:10.1111/jphd.12159.
    » https://doi.org/10.1111/jphd.12159
  • 39
    Kamate WI, Vibhute NA, Baad RK. Estimation of DMFT, Salivary Streptococcus Mutans Count, Flow Rate, Ph, and Salivary Total Calcium Content in Pregnant and Non-Pregnant Women: A Prospective Study. J Clin Diagn Res. 2017;11(4):ZC147-51. DOI:10.7860/JCDR/2017/24965.9516.
    » https://doi.org/10.7860/JCDR/2017/24965.9516
  • 40
    Shaghaghian S, Malekmakan L, Rahimian V, Savadi N. Dental caries status and its associated factors in pregnant women, Shiraz, Iran, 2014. J Oral Health Oral Epidemiol 2017;6(3):165-72.
  • 41
    Kumar J and Samelson R. Oral health care during pregnancy recommendations for oral health professionals. New York State Dent J. 2009;75(6):29-33.
  • 42
    US Department of Health and Human Services. Oral Health in America: A Report of the Surgeon General. Rockville, MD: US Department of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institutes of Health, 2000.
  • 43
    Gaffield ML, Gilbert BJ, Malvitz DM, Romaguera R. Oral health during pregnancy: an analysis of information collected by the pregnancy risk assessment monitoring system. J Amer Dent Assoc. 2001;132(7):1009-16. DOI:10.14219/jada.archive.2001.0306
    » https://doi.org/10.14219/jada.archive.2001.0306
  • 44
    Johnson M, George A, Dahlen H, Ajwani S, Bhole S, Blinkhorn A et al. The midwifery initiated oral health-dental service protocol: an intervention to improve oral health outcomes for pregnant women. BMC Oral Health. 2015;15:2. DOI:10.1186/1472-6831-15-2
    » https://doi.org/10.1186/1472-6831-15-2
  • 45
    Morgan MA, Crall J, Goldenberg RL, Schulkin J. Oral health during pregnancy. J Matern Fetal Neonatal Med. 2009;22(9):733-9. DOI:10.3109/14767050902926954
    » https://doi.org/10.3109/14767050902926954
  • 46
    Mills LW, Moses DT. Oral health during pregnancy. MCN Am J Matern Child Nurs 2002;27(5):275-80.

Publication Dates

  • Publication in this collection
    2018

History

  • Received
    02 Jan 2018
  • Reviewed
    01 Feb 2018
  • Accepted
    20 Feb 2018
Mavera Edições Técnicas e Científicas Ltda Rua Professor Filadelfo Azevedo, 220, Cep: 04508-010, tel: (11) 3051 3043 - São Paulo - SP - Brazil
E-mail: medicalexpress@me.net.br