Pregnancy and Oral Health, Case Study Example

Introduction

Oral health providers and dental hygienists strive to provide education to patients in order to give them the best available information to prevent future dental problems. The importance of providing oral health care for pregnant women cannot be disputed.  “Research and data suggests there is a casual link between good dental hygiene whilst pregnant and good maternal health.” (“Personal Hygiene and Care during Pregnancy”).  Dentists suggest a pregnant mother should not attempt any root planning or scaling procedures until the 14^th-20^th week of gestation. Preventative dental care is the best source for prevention of formation of bacteria which if left unattended to could lead to other serious conditions for the pregnant mother.

An old wives tale states that a tooth is lost for every child. During pregnancy a baby will take calcium from the mother for growth. This calcium is often deprived from the mother’s bones and teeth.   “Studies reveal hormone levels have a profound effect on gingival tissue.” (Ozcelik, 2006).  “Studies documenting the effects of hormones on the oral health of pregnant women suggest that twenty-five (25) to one hundred (100) percent of these women experience gingivitis and 10 percent may develop a bump also known as a Pyogenic Granuloma.” (Jared & Boggess 2008). It is important to note that both women who are not pregnant and men possess this same hormone.  Periodontal disease in pregnant women may be associated with preterm low birth weight and preeclampsia. “Preterm birth is defined as less than 37 weeks gestation and is the leading cause of death in the first month of pregnancy causing 70% of all perinatal deaths.” (Romagura, Gilbert, Malvitz & Gaffield, 2001 ).  Hypertension often arises during pregnancy causing a condition referred to as preeclampsia.  “Pregnancy complications increase the burden to the public by escalating the costs of health care in addition to adding emotional trauma to the family of pregnant women. The estimated increase of medical costs is estimated in the billions of dollars annually.” (Cunningham et.al, 2001).

During pregnancy, changes in hormone levels promote an inflammatory response that increases the risk of developing gingivitis and periodontitis.  “Without changing the dental plaque levels, fifty (50) to seventy (70) percent of all women have the tendency to develop gingivitis during pregnancy. This is typically seen between the second and eighth month of pregnancy.” (Romagura, Gilbert, Malvitz & Gaffield, 2001) “Elevated levels of progesterone and estrogen cause the small blood vessels of the gingiva to become more permeable. “This elevation allows pathogens into the gingiva and tissues become inflamed.” (Ingber, 2009).  “The altered hormone levels affect the immune system and the rate and pattern of collagen production in the gingiva.” (Jared & Boggess 2008) This altered hormone level results in the body’s ability to repair and maintain healthy gingival tissue.

Further studies conducted at the University of Birmingham, Alabama reveals mothers with severe periodontitis have high levels of prostaglandin in their blood and are more likely to deliver preterm babies. “This preliminary data suggests increased levels of prostaglandins may be associated with early uterine contractions and cervical dilation. In turn, increased levels of prostaglandins in the blood may increase sensitivity to irritants, causing additional inflammation in ureto.”  (Roger et. al, 2007).

During pregnancy, prostaglandin levels gradually increase and reach their peak at the onset of labor.  Because gingival infection produces higher prostaglandlin levels, the body may interpret this as a sign to go into labor.  “Women with periodontal disease are at a three to five times greater risk of preterm birth than those who possess sound gingividal health.”  (Jared & Boggess, 2008).

Food cravings associated with pregnancy can result in consuming foods with high sugar content. This consumption is used often to prevent nausea.  The bacteria responsible for carbohydrate metabolism is often not removed resulting in an increased risk of demineralizing the enamel and tooth structure.  Vomiting associated with pregnancy can further cause extensive erosion of tooth enamel. The American Dental Association states the high acid content of the stomach will most often affect the palatal surfaces of the upper anterior teeth.  The remaining dentition is affected as well but not to the same extent of the UA surfaces of the teeth.  “Tooth and dental tubules may result from thinning enamel layers as well as exposed dentin.” (Wolfe, 2006).

Dental Care During Pregnancy

Clearly, given the wide array of problems associated with pregnancy, dental care is an essential practice during pregnancy. There are no evidence based guidelines available that describe the procedures that can be performed during each trimester. Numerous articles have been written in scientific journals, but, for the most part, health care professionals are unsure about dental care during pregnancy. Table 1 from the New York Dental Journal January 2004 suggests procedures that can be done during each trimester of pregnancy.  There is a strong tendency for dentists to postpone treatment until after delivery because of the added risks imposed by taking radiographs and prescribing drugs. “Complications may arise during dental procedures such as syncope, enhanced gag reflex, supine hypotensive syndrome, seizures and gestational hyperglycemia.” (Romagura, Gilbert, Malvitz & Gaffield, 2001).

Sheila Wolf, RDH wrote in 2004 Pregnancy and Oral Health which contains vital information for mothers-to-be concerning oral health. Certain special considerations are recommended for pregnant women while rendering treatment. These include short let appointments and having the patient change positions often in order to keep blood flowing to the patient and unborn child.  “Treatment that warrants extensive surgical procedures should be delayed until after delivery, if possible. As with all patients, regarding the use of radiographs, it is advisable to use high-speed films, filtration, and collimation with a lead apron.” (Gajendra and Kumar, 2004).

Recommended Timetable (Treatment Protocol) for the Management of Oral Health During Pregnancy

1st Trimester: Treatment may be limited due to morning sickness. Only emergency treatment should be rendered during this period.

2nd Trimester: This is the safest period to perform any necessary dental treatment.

Pregnant women should be advised to consult their prenatal care providers about the use of anesthetics and medications.

3rd Trimester: Professional evaluation is necessary. Treatment may be impeded due to increased physical discomfort.

“Professional and home care is important in all three trimesters of pregnancy.” (“American Dental Association”). Preventive dental cleanings and annual exams during pregnancy are deemed safe and recommended.  The rise in hormone levels during pregnancy causes the gums to swell, bleed, and trap food causing increased irritation to the gingiva. Preventive dental work is essential to avoid oral infections such as gum disease. Gum disease has been linked to premature births. Dental work such as cavity fillings and crowns should be treated to reduce the chance of infection. If dental work is done during pregnancy, the second trimester is the ideal time to do such work. Once the third trimester is reached, it may be very difficult for the patient to lie on her back for an extended period of time. However, sometimes emergency dental work such as a root canal or tooth extraction is necessary. In this case the patient would have to bear the uncomfortable positions for the safety of the mother and unborn child’s health.  Elective treatments, such as teeth whitening and other cosmetic procedures, should be postponed until after the birth. It is best to avoid exposing the developing baby to any risks, even if they are minimal.

Currently, there are conflicting studies about possible adverse effects on the developing baby from medications used during dental work. Lidocaine is the most commonly used drug for dental work. Lidocaine (Category B) crosses the placenta after administration. If dental work is needed, the amount of anesthesia administered should be administered minimal or enough to keep the patient comfortable.  If pain is experienced, additional anesthesia is deemed acceptable as long as the patient is not administered more than a minimal dose.  When the patient is comfortable, the amount of stress is reduced. Dental work often requires antibiotics to prevent or treat infections. Antibiotics such as penicillin, amoxicillin, and clindamycin, which are considered category B drugs, are deemed safe to administer during pregnancy. A pregnant woman may consume such a drug from this category without worry as long as the drug is taken according to prescription. Although Category A drugs are deemed the safest drugs to used during pregnancy months. Category X drugs are sure to cause harmful effects to the unborn fetus and should be avoided totally.

X-Rays Used in Dental Work During Pregnancy

Routine x-rays, usually taken during annual exams, can usually be postponed until after the birth. X-rays are necessary to perform many dental procedures, especially emergencies. According to the American College of Radiology, no single diagnostic x-ray has a radiation dose significant enough to cause adverse effects in a developing embryo or fetus. Fetal organ development occurs during the first trimester hence it is best to avoid all potential risks including the use of X-rays during this time. If non-emergency dental work is needed during the third trimester, it is usually postponed until after the birth. This is to avoid the risk of premature labor and prolonged time lying on a pregnant patient’s back.

Suggestions for addressing dental needs during pregnancy:

• The American Dental Association (ADA) recommends that pregnant women eat a balanced diet, brush their teeth thoroughly with an ADA-approved fluoride toothpaste twice a day, and floss daily.
• Have preventive exams and cleanings during pregnancy.
• Inform the dental team of pregnancy.
• Postpone non-emergency dental work until the second trimester or until after delivery, if possible.
• Elective procedures should be postponed until after the delivery.
• Maintain healthy circulation by keeping legs uncrossed while sitting in the dentist’s chair.

Dental Medications Whilst Nursing a Newborn

When nursing your baby it is considered safe to take dental medications for dental services “because the amount of medications excreted into the milk of the mother to the newborn is in the range of 1-2%.” Studies suggest this amount is unlikely to affect your newborn. (“How Pregnancy Affects your Oral Health”).

Conclusion

There are some minimal risks involved with dental work during pregnancy but these risks can be eliminated if precautions are taken.  A pregnant woman’s physiological and psychological changes should be considered when deciding whether to administer dental care during pregnancy.  The American Academy of Periodontology Journal of Periodontology (Supplement) 2000 urges health care providers to motivate patients to treat periodontal infections during pregnancy through referral to the patient’s dentist or periodontist. This treatment is to eliminate further problems that could result from minimal problems and cause issues with the pregnancy and unborn child such as premature birth.  Dentists and dental hygienists should take a proactive role in encouraging all patients of childbearing age to seek oral health care. Good communication should be established between the dental care providers and prenatal care providers. Often to-be mothers misinterpret oral health as a personal concern and do not realize their oral health is dependent upon the health of their future newborns health.  It is imperative that dental health providers educate pregnant women on the importance of caring for their dental needs whilst pregnant. The safest course of action is to postpone all unnecessary dental work until after the birth of the newborn child unless there is an infection or gum disease that could lead to complications for the mother or the unborn child. The pregnant mother should be seen by a dental care professional in order to have her individual situation accessed for her and her unborn child’s safety. The health professional is better educated to advise the patient when to have dental procedures and if some procedures are considered emergency or could wait until after the birth of the child. The use of medications should be only used under the strictest advice of the dental care provider to ensure the health of the pregnant mother and the unborn child.

References

American College of Radiologists (2009) Retrieved December 21, 2009 from,  http://www.acr.org/

American Dental Association (1998) Retrieved December 21, 2009 from, http://www.agd.org/consumer/oralhealthtopics.html and American Dental Association

American Dental Association (2009) Retrieved December 20, 2009 from,  http://www.ada.org/

Carey, C. (2001) Planning Your Pregnancy and Birth Third Ed. The American College of Obstetricians and Gynecologists, New York: Rawlings Limited Press. Ch. 7.

Cunningham, G.  (2007) William’s Obstetrics Twenty-Second Ed. The American Gynecological Society, New York: Peakson Publishing, Ch. 41.

Gajendra, S. and Kumar, J. (2004) Oral Health and Pregnancy: A Review Retrieved December 21, 2009 from, http://www.nysdental.org/img/pdf_files/JrnlJ04Gajendra.pdf

How Pregnancy affects your Oral Health (2009) Retrieved December 22, 2009 from, http://www.simplestepsdental.com/SS/ihtSS/r.WSIHW/st.31848/t.35020/pr.3.html

Ingber, A. (2009) Retrieved December 21, 2009 from, http://www.springerlink.com/content/j47281k485l5h231/

J Am Dent Assoc (2001;132;1009-1016) Raul Romaguera, Colley Gilbert, Dolores M. Malvitz, Mary Lyn Gaffield, Brenda J.:New England, 2009.

Jared, H. and Bogess, K. (2008) JADHA Supplement to Access Retrieved December 20, 2009 from,  http://www.med.unc.edu/obgyn/annual-report/MFM_annual-report/publications

Personal Hygiene and Care during Pregnancy (2007) Retrieved December 21, 2009 from, http://www.brooksidepress.org/Products/Obstetric_and_Newborn_Care_1/lesson_7_Section_1A.htm

Ozcelik, O. (2006) The Effects of Anabolic Androgenic Steroid Abuse on Gingival Tissues Retrieved December 21, 2009 from, http://www.joponline.org/doi/abs/10.1902/jop.2006.050389

Pregnancy and Swollen Gums (2009) Retrieved December 19, 2009 from, www.americanpregnancy.org/pregnancyhealth/swollengums.html.

Reynolds, B. (2009) Breaking News and It’s Effect on Healthcare Fibroblastic, (1) 1, p. 2-6

Wolfe, D. (2006) Ouch! Dental Hypersensitivity Revisited Retrieved December 21, 2009 from, http://www.dentalofficemag.com/display_article/272459/56/none/none/Feat/Ouch!-Dentinal-Hypersensitivity-Revisited

Zachariasen RD. (1993) The Effect of Elevated Ovarian Hormones on Periodontal Health: Oral Contraceptives and Pregnancy. Women Health; 20:21-30.