Putting to Rest the Myths

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?

1. 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.
2. 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 caval 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.

Summary:

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.