Oral health during pregnancy

American Family Physician, April 15, 2008 by Hugh Silk, Alan B. Douglass, Joanna M. Douglass, Laura Silk

Oral health care in pregnancy is often avoided and misunderstood by physicians, dentists, and patients. Evidence-based practice guidelines are still being developed. Research suggests that some prenatal oral conditions may have adverse consequences for the child. Periodontitis is associated with preterm birth and low birth weight, and high levels of cariogenic bacteria in mothers can lead to increased dental caries in the infant. Other oral lesions, such as gingivitis and pregnancy tumors, are benign and require only reassurance and monitoring. Every pregnant woman should be screened for oral risks, counseled on proper oral hygiene, and referred for dental treatment when necessary. Dental procedures such as diagnostic radiography, periodontal treatment, restorations, and extractions are safe and are best performed during the second trimester. Xylitol and chlorhexidine may be used as adjuvant therapy for high-risk mothers in the early postpartum period to reduce transmission of cariogenic bacteria to their infants. Appropriate dental care and prevention during pregnancy may reduce poor prenatal outcomes and decrease infant caries.

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Comprehensive prenatal health care should include an assessment of oral health, but this is often overlooked. (1) Only 22 to 34 percent of women in the United States consult a dentist during pregnancy. Even when an oral problem occurs, only one half of pregnant women attend to it. (2) This problem is compounded by a lack of national clinical guidelines for the management of common oral conditions in pregnancy. The American Dental Association and the American College of Obstetricians and Gynecologists provide only advisory brochures on oral health for pregnant patients. New York recently became the first state to create an evidence-based prenatal oral health consensus document. (3) In the absence of practice guidelines, fear of medicolegal action based on negligent or substandard treatment of oral conditions during pregnancy abounds, but it is largely unfounded. (4)

In addition to a lack of practice standards, barriers to dental care during pregnancy include inadequate dental insurance, persistent myths about the effects of pregnancy on dental health, and concerns for fetal safety during dental treatment. (5) Patients, physicians, and dentists are cautious, often avoiding treatment of oral health issues during pregnancy.

Nevertheless, pregnancy is a time when women may be more motivated to make healthy changes. (3) Physicians can address maternal oral issues, potentially reducing the risk of preterm birth and childhood caries through oral disease prevention, diagnosis, early management, and dental referral.

Common Oral Problems in Pregnancy

ORAL LESIONS

During pregnancy, the oral cavity is exposed more often to gastric acid that can erode dental enamel. Morning sickness is a common cause early in pregnancy; later, a lax esophageal sphincter and upward pressure from the gravid uterus can cause or exacerbate acid reflux. Patients with hyperemesis gravidarum can have enamel erosions. (6) Management strategies aim to reduce oral acid exposure through dietary and lifestyle changes, plus the use of antiemetics, antacids, or both. Rinsing the mouth with a teaspoon of baking soda in a cup of water after vomiting can neutralize acid. (3) Pregnant women should be advised to avoid brushing their teeth immediately after vomiting and to use a toothbrush with soft bristles when they do brush to reduce the risk of enamel damage. Fluoride mouthwash can protect eroded or sensitive teeth. (7)

CARIES

One fourth of women of reproductive age have dental caries, a disease in which dietary carbohydrate is fermented by oral bacteria into acid that demineralizes enamel (8) (Figure 1). Pregnant women are at higher risk of tooth decay for several reasons, including increased acidity in the oral cavity, sugary dietary cravings, and limited attention to oral health. (9) Early caries appears as white, demineralized areas that later break down into brownish cavitations. Fillings or crowns are a sign of previous caries. Untreated dental caries can lead to oral abscess and facial cellulitis. Children of mothers who have high caries levels are more likely to get caries. (10) Pregnant patients should decrease their risk of caries by brushing twice daily with a fluoride toothpaste and limiting sugary foods. Patients with untreated caries and associated complications should be referred to a dentist for definitive treatment.

[FIGURE 1 OMITTED]

PREGNANCY ORAL TUMOR

Pregnancy oral tumor (Figure 2) occurs in up to 5 percent of pregnancies and is indistinguishable from pyogenic granuloma. This vascular lesion is caused by increased progesterone in combination with local irritants and bacteria. Lesions are typically erythematous, smooth, and lobulated; they are located primarily on the gingiva. The tongue, palate, or buccal mucosa may also be involved. Pregnancy tumors are most common after the first trimester, grow rapidly, and typically recede after delivery. Management is usually observational unless the tumors bleed, interfere with mastication, or do not resolve after delivery. Lesions surgically removed during pregnancy are likely to recur. (11)

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Oral health during pregnancy

American Family Physician, April 15, 2008 by Hugh Silk, Alan B. Douglass, Joanna M. Douglass, Laura Silk

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