Posts Tagged ‘gingivitis’
Tuesday, June 22nd, 2010
We all love to watch an adorable baby sucking on a bottle, but breast fed babies, although less likely to develop cavities compared to formula fed babies, can develop baby bottle syndrome when feeding is done on demand.
Until recently, a child would only visit the dentist after dental disease occurs. Sadly, some children with decay developed pain, infections, abscesses, chewing difficulties, malnutrition and low self esteem. Others experienced malocclusion, poor growth, difficulty in speech, bruxism (grinding) and decay of the permanent teeth. Delayed treatment was expensive and often children required general anesthesia and/or frightening restraint for needed repairs.
As if these outcomes were not terrible enough, many people have had to endure mouthful’s of fillings, crown’s and bridges later in life as the conditions worsened over time. I suppose this all may seem better than the infamous wooden teeth of the George Washington era, but honestly, not by much.
Now that dentistry has, thankfully, shifted to prevention of cavities by proper oral hygiene and treatment with antibacterial and tooth protecting substances, I thought it would be important to write an article focused on oral care guidelines for the newborn infant. This very new information, based upon many years of research, will crown my series of blogs focused on dental guidelines focused on pregnant mothers (and how to avoid gingivitis and periodontal disease and their possible associations of poor obstetrical outcomes). Now it’s time to turn to the babies.
But my baby has no teeth yet!
Not true! Although a baby is born without visible teeth, development of two sets of teeth has begun in earnest by the 6th week of gestation. By the time the baby is born, both the primary and permanent teeth are present below the gums in an early developmental stage.
Now that you understand that all your baby’s teeth are “in there”, it’s clear why early preventative care will help prevent traumatic dental care issues from cropping up any time during life.
What will a good dentist do?
Believe it or not, children should be visiting the dentist by 1 year of age and be seen twice a year after that. Dentists should discuss diet, provide oral hygiene instructions and detailed directions for fluoride intake. They should also offer behavioral recommendations including the use of pacifiers, the ramifications of thumb sucking and the prevention of baby bottle syndrome.
Will my baby’s diet affect her teeth?
Nutrition continues to play an important role in prevention of tooth decay. Cariogenic foods such as crackers, teething biscuits, fruits and fruit juices, sweetened and acidic soft drinks should be limited. Carbohydrates, broken down by the enzymes in saliva along with bacteria in the mouth leave acid residue that dissolves the tooth enamel. Gums and newly erupted teeth should be cleaned after eating these types of foods. Dairy foods, especially aged cheese, can be protective.
Is flouride good or bad for my baby?
Fluoride use, which prevents tooth decay by increasing the density of the enamel, helps the teeth resist acid dissolution and is recommended after birth to limit cavities (caries).
Fluoride content of water should be tested and fluoride given by 6 months of age if the water is not supplemented or if the supplementation is less than .6 parts per million. Excessive intake of fluoride is not recommended because it produces mild dental fluorosis. This can also occur when children swallow large amounts of toothpaste that is supplemented with fluoride.
Fluoride use during pregnancy is controversial, with broadly divergent opinions.
The opinions range from “absolutely not” to “absolutely, positively yes” based on studies, some of which are interpreted to find that there is great benefit provided by the use of fluoride supplements during the pregnancy, to commencing fluoride use with the eruption of the infant’s teeth, to those who express the greatest concern about the generation of fluorosis and other undesirable or even dangerous conditions. Please consult your physician and your dentist for the recommendation in your individual case. Be sure to tell those you ask whether you live an an area that has a fluoridated water supply or well water.
Pacifiers and Thumb Sucking
Pacifiers have both advantages and disadvantages. Pacifiers, which exert less abnormal pressure on the teeth than a thumb or other fingers, might prevent thumb sucking and thereby reduce the risk of developing severe malocclusion (overbite) and abnormal growth patterns of the structures that support the teeth (the maxilla and the mandible). If thumb sucking continues after the permanent teeth have erupted, it has an even higher probability of causing permanent damage. Pacifier use can be controlled in a child in contrast to an appendage such as a thumb. Pacifiers have also been associated with a reduced incidence of SIDS.
It has been shown that long term use of pacifiers can cause dental problems. Misalignment of the teeth or malocclusions have been reported when infants use them beyond the age of 4. There is also a higher risk of otitis media with their continuing use. Limiting the use of pacifiers to the first 6 months or limiting their use to sleep times is recommended. Continuous use of pacifiers may also stunt speech development.
There is little evidence that orthodontic pacifiers are any better than conventional ones.
Choose pacifiers made of a more durable substance like silicon rather than latex, and be sure that the pacifier is made in one piece to avoid smaller parts from being detached and swallowed.
Pacifiers have not been associated with cavities but pacifiers should not be coated with sweets. Contrary to popular belief, pacifiers do not shorten the duration of breast feeding.
What is Baby Bottle Syndrome?
This syndrome that results from excessive baby bottle use is characterized by the development of severe tooth decay with pain and infection leading to extractions and extensive dental treatment. Bacteria in the mouth use milk and other sweetened beverages for metabolism and create an acidic environment in the mouth causing the destruction of tooth enamel and creating cavities. Children suffering from baby bottle syndrome feed poorly and often fail to thrive. The damage initially appears as white lesions on the teeth and then later progresses to brown or black discoloration. When the damage is severe, the crowns break down and permanent teeth may also be damaged. Malnutrition, with deficiencies in calcium and Vitamin D, may also lead to tooth enamel defects which predisposes the teeth to caries. The overall incidence of baby bottle syndrome varies from 3% to 6% in the general population but can go up to 72% depending upon the population. The teeth most affected are the maximally and mandibular primary incisors followed by the primary molars.
Breast fed babies, although less likely to develop cavities compared to formula fed babies, can develop baby bottle syndrome when feeding is done on demand. Breast milk does not support the growth of bacteria, doesn’t lower the acidity in the mouth and is therefore not as destructive. This is another reason why all mothers should be encouraged to breast feed their infants. Proper use of nipple gels, such as the Beauté de Maman Nipple Gel, will heal the chapped, sore breasts that often prevent women from continuing breast feeding.
Summary of DOs and DON’Ts of Proper Infant Dental Care
Things to Do
- Mouth cleaning in infancy should be part of a daily routine.
- Clean gums, newly erupted teeth, (after 6 months of age) and tongue, with clean washcloth, piece of gauze, or very soft moist toothbrush after feedings and before bed.
- Clean mouth with toothbrush or washcloth after giving sweetened medications.
- Introduce solid foods after 6 months of age and avoid cariogenic foods.
- Bottles should only contain plain water if being given for naps, bed or pacifier.
- Schedule first dental visit after the first year of life.
- Encourage breast feeding, especially for the first 6 months of life when fluoride is not recommended.
Things NOT to Do
- Do not allow the infant to sleep or nap with a bottle filled with juice or milk.
- Do not dip pacifiers in sweet or sweetened foods such as honey, sugar, or juice—sugars will feed bacteria in the gums, causing tooth decay even before teeth have erupted. Do not give fluoride supplementation till 6 months of age-the American Dental Association does not advocate use of fluoride at this age because there is an increase of fluorosis (white spots on the teeth) in infants who are supplemented.
Like so much about having a new infant in the house, dental care may seem daunting. My advice to new parents is to find yourself a reputable dental professional, carefully follow the advice given, and then watch your baby’s teeth arrive sparkling, white and pain free.
Monday, June 14th, 2010
I’m terribly sorry if anyone is offended by this photo of a horse with a bad set of choppers, but because a whopping 30% of pregnant women get periodontal disease, I simply couldn’t risk losing your attention. As they say, you can lead a horse to water, but you can’t make it brush its teeth.
While periodontal disease may seem like a boring and unglamorous topic for us to be discussing, it’s so important that I even decided to post two articles in a row about proper dental care during pregnancy.
My pregnancy article last week focused on dental changes, good oral hygiene and recommended dental health guidelines. This week’s pregnancy article will concentrate on the specific risks of periodontal disease. It’s not a pretty picture but please read all the way to the end to make sure you understand what you can do to stay out of the 30% and prevent this ugly and damaging syndrome.
What is periodontal disease?
Periodontal disease begins as gingivitis, or inflammation of the soft tissue that supports the teeth. This inflammation is caused by a specific oral bacteria named gram negative anaerobic bacteria. In combination with the elevated hormones during pregnancy that increase blood volume and capillary fragility, these bacteria give rise to redness, increased sensitivity, bleeding and pain. Left untreated, these conditions can predispose a pregnant woman to more serious problems down the road.
Why can periodontal disease lead to more serious problems during pregnancy?
If left untreated, the inflammation previously described can lead to the formation of pockets around the teeth. Within these pockets potential deep infections can occur and as pregnancy progresses, pocket depth has been shown to increase. These pockets are actually the separation of the teeth from the gums and, if left untreated, these teeth can separate from the surrounding supporting structure, named the periodontal ligament and cementum. This separation can eventually lead to the loss of the affected teeth.
What is the incidence of periodontal disease in pregnancy?
Approximately one third of all pregnant women have periodontal disease. Although the disease is measured differently in varying studies it is generally defined as 15 or more tooth sites with greater than 4 mm loss of attachment when probing.
Why is the presence of periodontal disease so important in pregnancy?
Periodontal disease has been associated with preterm delivery (before 37 weeks), low birth weight (less than 2500 grams), poor obstetrical outcomes, pregnancy loss, late miscarriage and preeclampsia, especially in populations comprised of people who have very limited access to dental care. Preterm birth rate has been reported to be 11.2% in women without periodontal disease compared to 28.6% in women with moderate to severe disease (Offenbacher, 2006). Similarly, progression of periodontal disease is also associated with a higher risk of preterm birth (6.4% vs 1.8% by same author). Most studies confirm these findings although some fail to show this association.
How can you explain this association of periodontal disease with poor obstetrical outcome?
- One explanation is that bacteria or infection from the mouth enter the bloodstream and eventually reach the placental membranes causing inflammation and damage resulting in preeclampsia or labor.
- Other explanations behind the results are that the specific bacteria and toxins identified in periodontal disease (Treponema denticola, Campylobacter rectus, Porphyromonas gingivalis to name a few) cause elevations in “inflammatory factors” or cytokines in the maternal blood (tumor necrosis factor-alpha, interleukin-8 (IL-8) and IL-1B) and it is these factors that have been found to increase the substances that stimulate the uterus to contract, such as prostaglandins (PGE-2), which cause the induction of labor.
- Supporting this theory is the finding that blood from pregnant moms who have an increase in antibodies (reactive substances) to some of these bacteria found in the mouth have also been found to have a higher incidence of preterm birth and low birth weight infants. These same elevated antibodies have been found in amniotic fluid and in fetal cord blood samples of infants delivered preterm or of low birth weight.
- Studies have shown that treatment for periodontal disease, through plaque control, scaling, and daily antibacterial rinsing reduced the risk of preterm births. Some studies however, have not been as consistent.
How does periodontal disease relate to other conditions in life?
After pregnancy, chronic exposure to these inflammatory blood substances from bacteria in the mouth may cause a three to four times greater risk later in life to cardiovascular disease, atherosclerosis, stroke, and diabetes compared to the general population. The mechanism is believed to be due to bacteria, toxins and platelets sticking together, along with circulating inflammatory factors which cause clots to form.
Children exposed to these inflammatory factors may also have added risk of cardiovascular disease and diabetes later in life. Other diseases associated with these inflammatory mediators include Crohn’s disease and Alzheimer’s disease as adults.
Periodontal disease is a curable problem. Treatment may not only help save your teeth, but will support the prevention of perinatal mortality and morbidity. If mothers are educated to realize that there might be a link between preventing periodontal disease and improving the health and well-being of their infant, not to mention their own health, more women will seek preventative dental care during pregnancy. Studies that are more conclusive with controls for socioeconomic status, smoking and study size have yet to be performed. However, even if the associations with these other factors are found not to be a factor in getting the disease, treating periodontal disease in pregnancy is safe and effective and, at the very least, may prevent unpleasant symptoms and appearance. It may also prevent the need for costly treatment and potential tooth loss later in life.
You may want to stick my photo of the gingivitic horse on your refrigerator as a reminder to always take good care of your teeth, especially while you are pregnant. Please share this article with everyone you know who is pregnant or may get pregnant. We have provided some sharing links below.
As I mentioned last week… no one has ever regretted taking good care of their teeth!
Tuesday, June 8th, 2010
Drilling Down the Fear of Dental Care During Pregnancy.
Going to the dentist is probably not at the top of your favorite’s list, but if you are pregnant, don’t think for a minute you can neglect those pearly whites that line your mouth and serve you so well each time you eat or smile.
It’s understandable that teeth and gums may seem unimportant compared to all those other physical, and mental, changes taking over the body and mind of a pregnant woman. Even during a normal pregnancy, one can feel “possessed” and feel too busy dealing with all those other concerns to worry about proper dental care. That’s why so many pregnant women neglect even routine brushing and flossing… and end up with bigger oral problems down the road.
My blog for this week will describe some of the oral changes that occur during pregnancy, the importance of maintaining good oral hygiene and the guidelines of proper dental care during the nine month gestation period. I can not stress enough the importance of reading this information right through to the last paragraph. I promise you, no one ever regretted taking good care of their teeth and I will give you some well-researched advice and how, and when, to do this successfully.
What are some of the oral changes that occur during pregnancy?
The hormonal changes of pregnancy, food cravings and acid regurgitation that commonly occur may make a pregnant mother more prone to poor oral hygiene leading to increased risk of gingivitis and severe periodontal disease with resulting damage to gums and other structures and, ultimately, loss of teeth. Of the highest concern to the pregnant woman is that poor oral hygiene may adversely effect the pregnancy. Therefore, it is imperative that we give this important area serious attention.
High levels of estrogen and progesterone produced by the placenta may effect the gingiva (gums), causing inflammation of the structure that holds the teeth in place causing increased tooth mobility. There is an increase in oral vascularization and a decrease in immune response which may also increase susceptibility to oral infections. The gums will become swollen, inflamed, reddened and bleed readily on tooth brushing or flossing, especially with poor oral hygiene and when plaque is present. Gingivitis occurs in 60–75% of all pregnant women. In addition, hormonal changes may cause excessive saliva production called ptyalism, or less commonly, a dry mouth called xerostomia.
What are some of the specific dental complications that can occur in pregnancy?
- Tooth decay occurs at an increased rate in pregnancy due to acid reflux and excessive vomiting in the first trimester, in combination with bacteria and carbohydrate cravings.
- Pregnancy granuloma, also known as pregnancy tumor, appears like a painless gingival growth rarely more than 2 cm in diameter, often near the end of the first trimester. It is an inflammatory reaction to dental plaque. It appears on the gingiva of the anterior teeth and may also involve the tongue, lips, palate and oral mucosa. It bleeds readily and may be nodular or ulcerated. It is found in up to 10% of pregnant women. Excessive bleeding requiring transfusion from these tumors has been reported. The tumor is generally purplish-red or deep blue in color and may require surgical excision if it causes discomfort or bleeds readily. Most often, it regresses postpartum.
- Gingivitis caused by plaque results in swollen, inflamed gums that bleed readily. It occurs in 60–75% of pregnant women and may range from mild asymptomatic cases to more severe cases with pain and bleeding. Changes are progressive, occurring in the second month and continuing to the eighth month.
- Periodontal disease effects up to 40% of all pregnant women. It is nine times more likely to be found in women with gestational diabetes
- Preterm delivery, low birth weight and preeclampsia have been linked to periodontal disease (more on this in next weeks blog—stay tuned!!!). However, more studies need to be done to determine if this is only an association or if it is a true cause and effect relationship.
What are some important recommendations for pregnant women to optimize dental health?
- Emphasizing proper nutritionThe following food recommendations should be followed:
- Vitamin A foods—Green leafy vegetables, dark-yellow vegetables, fruits, cereals, egg yolk, liver, fortified milk, dairy products, and breakfast cereals.
- Vitamin C foods—Citrus fruits, strawberries, collard greens, spinach, broccoli, tomatoes, green and red peppers.
- Vitamin D foods—liver, fish liver oil, and eggs.
- Calcium—(for bone formation in the fetal skeleton and tooth bud formation)—found in milk, cheese, yogurt, ice-cream, green leafy vegetables, , and legumes.
- Phosphorous—found in foods rich in calcium and protein.
- Protein—meat, eggs, milk, cheese, poultry, and seafood.
- Encourage sugar free gum and candies.
- Plaque control and caries prevention
- Seek dental care early in the pregnancy and continue preventative cleanings and exams at least every 6 months.
- Continue brushing and flossing twice a day.
- Encourage brushing immediately after vomiting or at least rinsing the mouth with water to avoid acid erosion of the enamel.
- Consider professional prophylaxis which may include coronal scaling, root curettage, and polishing the teeth.
- Prenatal fluoride supplementation and fluoride mouth rinses effectiveness is still equivocal according to the CDC and the American Academy of Pediatrics.
- Consider chlorhexidine mouth rinse that inhibits the development of plaque, tartar, and gingivitis. This will reduce the concentration of Streptococcus mutans which can cause caries.
- Avoid nutritional deficiencies of vitamin C, folic acid, calcium, and zinc which may make pregnant women more susceptible to bacterial plaque which can cause periodontal disease.
- Encourage anticariogenic foods such as cheese and milk products which may increase salivation, and neutralize plaque acids (protein, calcium, and phosphorous content), and enhance remineralization of enamel.
When should a pregnant woman consider treatment for a dental problem?
Dental treatment may be undertaken at any time during the pregnancy. However, if optional, it is advisable to avoid treatment during the first trimester due to risk of teratogenicity (organ malformations in the fetus) with the use of medications during the time of organ formation, and then toward the end of the third trimester—due to risks of preterm labor and hypotensive (low blood pressure) episodes are greater, such as when lying on the back for extending periods of time during treatment in a dental chair.
What special considerations should pregnant women be concerned about when getting treatment?
- Avoid x-rays unless absolutely essential, and then, if unavoidable, careful use of a full leaded apron including a leaded thyroid collar. Radiation exposure from dental radiographs is minimal.
- Take precautions to avoid bacteria entering the blood stream (may need to take antibiotics before or after working in a contaminated area like the mouth.)
- Make sure any medications taken are safe in pregnancy.
- Emergency dental care should be undertaken without hesitation.
- Avoid lying on the back for long periods of time due to vena cava syndrome. This occurs more commonly in the third trimester when the large uterus mechanically blocks the blood flow returning to the heart from the major vessel, the vena cava. A pregnant woman will commonly experience a drop in her blood pressure and faint. Procedures are best done in the semi reclining position with the knees flexed, wedging the body to the side, and doing procedures in stages to avoid reclining over long periods of time.
The majority of pregnant women fail to seek dental care despite the importance of maintaining oral hygiene in pregnancy. In addition, studies have shown that when dental problems occur in pregnancy, less than half the women seek treatment. Mothers seem to have irrational fears of harm to the fetus resulting from dental care or treatment during pregnancy. Health care providers must make every effort to modify these false perceptions. Optimally, women should obtain any extensive treatments prior to becoming pregnant so thorough evaluation by a dentist in the preconception period is advisable. Recommendations during pregnancy should include proper nutrition, plaque control, oral hygiene instruction, and prophylactic maintenance during each trimester of pregnancy. Pregnant patients should be educated about dental infections and preterm labor and all dental problems should be treated. Elective treatments could be deferred to second trimester or wait until the postpartum period.