Oral Health During Pregnancy: The Necessity for Treatment

Good oral health and dental hygiene are important aspects of a healthy lifestyle and strongly linked to overall health at every stage of life, including during pregnancy. Oral diseases are associated with multiple health problems, such as diabetes and cardiovascular disease, and in pregnant women have been associated with preterm delivery and low birth-weight infants.^1,2 Several organizations, including the American Dental Association, the American Academy of Periodontology, and the American College of Obstetricians and Gynecologists, recommend that women who are pregnant or planning to become pregnant should undergo routine dental visits every 6 months, and that appropriate preventive dentistry or therapeutic services should be provided if indicated.^3,4 Despite these recommendations, only about half of pregnant women who experience oral or dental symptoms visit the dentist, and the rate is even lower for pregnant women who do not have oral problems.⁵ Common reasons for not visiting the dentist include lack of access, myths and misperceptions about what is "acceptable" dental health status in pregnancy, and concerns about the safety of dental procedures during pregnancy.^5,6 Therefore, it is important for dental providers to be aware of the oral health conditions that are common in pregnant patients and to be knowledgeable about what medications and procedures can be safely provided during pregnancy, while remaining alert to the concerns these patients may have about their dental care.

Common Oral Health Problems in Pregnancy

The hormonal changes that accompany pregnancy, such as increased estrogen and progesterone levels, have downstream effects on multiple organ systems of the body, including the mouth.^7,8 Prenatal changes that specifically affect the oral cavity include depression of the normal immune response, microbial shift favoring anaerobic flora, increased capillary permeability in the mouth, which can predispose to inflammation, acid reflux caused by hormone-mediated relaxation of the esophageal sphincter, and the nausea and vomiting (ie, "morning sickness") experienced by approximately two-thirds of pregnant women.^7,8 Although prenatal changes often do not lead to periodontal disease, they can result in worsening of preexisting oral health problems.

Periodontal Disease

Gingivitis (inflammation of gingival tissue without loss of supporting soft tissue or bone²) is the most common oral condition in pregnancy. It is estimated to occur in approximately 60% to 75% of pregnant women.⁶ Common symptoms include gingival swelling, bleeding, and pain, which often worsen at or near the final trimester of pregnancy, secondary to hormonal changes. Good oral hygiene, including brushing and flossing twice a day and oral rinsing with saltwater, can help control the inflammation. Without proper care, gingivitis can progress to periodontitis, a loss of bone and soft tissue caused by an inflammatory response to plaque. Periodontitis can lead to loosening of the teeth and may introduce bacteria into the bloodstream, which may result in infection.⁹

Benign Oral Lesions

Pyogenic granuloma (also known as pregnancy oral tumor, or epulis gravidarum) is a benign vascular lesion that occurs in approximately 5% of pregnant women in response to increased progesterone levels and inflammation.^6,9 Typically located on the gingiva, pyogenic granuloma can grow to 2 cm in diameter, and although these lesions are often painless, they bleed easily on contact.⁸ Most of these tumors resolve after pregnancy, and because they tend to recur if they are surgically excised, most cases are managed expectantly and treated only if severe pain or bleeding occurs.

Tooth Mobility

Loose or mobile teeth may be a symptom of advanced periodontitis, but during pregnancy, tooth mobility can also occur in the absence of oral disease. As a response to the increase in hormones, a temporary loosening of the ligaments and bones that support the tooth may occur, which in turn leads to tooth mobility.^6,9 The pregnant patient should be examined, and if no evidence of periodontal disease is observed, the patient should be reassured that this condition often resolves after pregnancy and that no loss of tooth will occur.

Tooth Erosion

Increased exposure of the tooth enamel to gastric acid as a result of frequent vomiting or gastric reflux during pregnancy can lead to gradual erosion. Symptoms include increased tooth sensitivity, cracks, chips, or indentations of the tooth, and discoloration. Tooth erosion can be managed by avoiding brushing the teeth after vomiting and instead rinsing the mouth with a baking soda solution (the sodium bicarbonate in baking soda helps neutralize acid).⁷ The use of a fluoride mouthwash can also help protect the eroded teeth. Finally, the patient should be encouraged to speak to her obstetric provider regarding the use of antiemetics and antacids to manage vomiting or reflux.

Dental Caries

Pregnancy can sometimes cause food cravings, specifically for those with high sugar content, which can increase acidity and poor oral hygiene and lead to dental caries. Studies have also shown that the bacteria that cause caries are transmitted from the mother to the newborn, thus increasing the child's future risk of dental caries.¹⁰ Prevention and treatment of dental caries in pregnant patients is therefore important for the oral health of both the mother and the child. Patients should be advised that one simple measure for the prevention of caries is brushing twice daily with fluoride toothpaste.

Dental Care During Pregnancy

Dental care providers are often hesitant to perform dental procedures during pregnancy for fear of causing harm to the fetus. However, there is no evidence that routine dental care causes harm to either the pregnant patient or the fetus.^8,10 Most pregnant patients defer nonurgent treatment to the second trimester, although there is no evidence that routine medications used in the standard dental practice are associated with birth defects.⁸ The first national evidence-based guidelines, released in 2012 and created in collaboration with the American College of Obstetricians and Gynecologist and the American Dental Association, states that dental care can be safely provided throughout all trimesters of pregnancy.⁴ Consultation with an obstetric provider is recommended in specific situations, eg, use of intravenous sedation or general anesthesia, use of nitrous oxide, and in patients with specific comorbidities (diabetes, hypertension, pulmonary or cardiac disease, bleeding disorders).⁴

Medication Use

According to the National Consensus Statement, most commonly used analgesics are safe to use in pregnancy; a table detailing pharmacological considerations for pregnant women can be seen at aegisdentalnetwork.com/go/idh-pregnancy-medications on the eighth page of the document.⁴ Nonsteroidal anti-inflammatory drugs such as ibuprofen and naproxen should be avoided in the first and third trimesters, and during the second trimester their use should be limited to a 48- to 72-hour window. If opioids are necessary for pain control, they can be safely prescribed for the shortest duration needed. Local anesthetics, including those that include epinephrine, can be safely used in pregnancy. Commonly used antibiotics (eg, penicillin, amoxicillin, cephalosporins, clindamycin, and metronidazole) are also safe, but fluoroquinolones, clarithromycin, and tetracycline should be avoided. Antimicrobial mouth rinses can be safely used in pregnancy.

Radiographs

Use of radiographs is safe throughout pregnancy, as highlighted in the 2012 consensus statement.⁴ With the routine use of an abdominal shield, the radiation exposure is minimal and has not been shown to cause harm to the fetus.

Dental Procedures

Several studies have reported that pregnant patients who received dental procedures such as dental fillings, extractions, and root canal treatment during the second trimester did not experience any adverse pregnancy outcomes.^8,11 Urgent dental care can be performed at any stage of pregnancy, given that delayed treatment could lead to additional complications. When in doubt, consultation with the obstetric provider is recommended.

Patient Comfort

Some simple adjustments can be undertaken to make the dental visit more comfortable for the pregnant patient. The patient should be asked what time of the day she prefers for the appointment; in patients who have significant nausea and vomiting in the morning, for example, dental procedures should be avoided during this time of day to prevent aggravating symptoms. Tips for comfortable positioning include keeping the head higher than the feet and placing a small pillow under the right hip to avoid postural hypotension.⁴ If the patient feels dizzy, turn her on her left side; this will relieve the pressure that the uterus places on the systemic circulation.

The Breastfeeding Patient

As with pregnant patients, most medications can be safely used and most dental procedures safely performed in patients who are breastfeeding. Examples of procedures and medications that are safe in breastfeeding patients include radiography, topical anesthetics, nitrous oxide, most antibiotics, and analgesics (although acetaminophen with codeine and tramadol should be avoided because these agents can cause drowsiness and central nervous system depression in breastfed infants¹²). The advice to "pump and dump" is often unnecessary and distressing to the patient who is trying to exclusively breastfeed her child. The LactMed database (a free online database) and InfantRisk Center Helpline (1-806-352-2519) are two excellent resources for checking if a specific medication is safe to use in the breastfeeding patient.

Conclusion

Routine dental care, when provided according to evidence-based guidelines, can be safely performed throughout pregnancy. Dental hygiene and care during pregnancy are not only important to the patient's overall health but may also decrease the risk of pregnancy-related complications. The future oral health of the child is also affected by the mother's dental care during pregnancy. It is the responsibility of both obstetric and dental providers to reassure their pregnant and breastfeeding patients that dental care is safe at this time in their lives and to emphasize the importance of oral health during all stages of pregnancy.

References

1. Corbella S, Taschieri S, Del Fabbro M, Francetti L, Weinstein R, Ferrazzi E. Adverse pregnancy outcomes and periodontitis: A systematic review and meta-analysis exploring potential association. Quintessence Int. 2016;47(3):193-204.

2. Clothier B, Stringer M, Jeffcoat MK. Periodontal disease and pregnancy outcomes: exposure, risk and intervention. Best Pract Res Clin Obstet Gynaecol. 2007;21(3):451-466.

3. Task Force on Periodontal Treatment of Pregnant Women, American Academy of Periodontology. American Academy of Periodontology statement regarding periodontal management of the pregnant patient. J Periodontol. 2004;75(3):495.

4. Oral Health Care During Pregnancy Expert Workgroup. 2012. Oral Health Care During Pregnancy: A National Consensus Statement. Washington DC: National Maternal and Child Oral Health Resource Center. https://www.mchoralhealth.org/PDFs/OralHealthPregnancyConsensus.pdf. Accessed May 29, 2021.

5. Ressler-Maerlender J, Krishna R, Robison V. Oral health during pregnancy: current research. J Womens Health (Larchmt). 2005;14(10):880-882.

6. Silk H, Douglass AB, Douglass JM, Silk L. Oral Health During Pregnancy. AFP. 2008;77(8):1139-1144.

7. Hemalatha VT, Manigandan T, Sarumathi TS, Aarthi Nisha V, Amudhan A. Dental Considerations in Pregnancy-A Critical Review on the Oral Care. J Clin Diagn Res. 2013;7(5):948-953.

8. Steinberg BJ, Hilton IV, Iida H, Samelson R. Oral Health and Dental Care During Pregnancy. Dental Clinics. 2013;57(2):195-210.

9. Oral health care during pregnancy and through the lifespan. Obstet Gynecol. 2013;122(2 Pt 1):417-422.

10. Boggess KA. Society for Maternal-Fetal Medicine Publications Committee. Maternal oral health in pregnancy. Obstet Gynecol. 2008;111(4):976-986.

11. Michalowicz BS, DiAngelis AJ, Novak MJ, et al. Examining the safety of dental treatment in pregnant women. J Am Dent Assoc. 2008;139(6):685-695.

12. Drugs and Lactation Database (LactMed). Bethesda, MD: National Library of Medicine (US); 2006.