Pregnancy & Women's Oral Health

Question 1

Oral Disease Risk Factors

Answer 1

Individual
* Personal history of caries or periodontal disease
* Low socioeconomic status
* Medications that contain sugar or cause xerostomia
* Chronic disease such as diabetes
* Emotional or physical disabilities

Behavioral
* Poor oral hygiene habits
* High sugar-containing diet
* Lack of routine dental visits
* Alcohol and tobacco use

Environmental/Societal
* Non-fluoridated community water
* Poor access to dental and/or medical care

Race/Ethnicity
* Social injustice and inequity affects overall health and health profoundly through stress and other means
* There are fewer dental providers of colour
* Dental providers may be less accessible in communities of colour (e.g. location, hours, transportation, etc)

Question 2

Adult Oral Anatomy

Answer 2

Anatomy of the Tooth
* Outer protective layer of the tooth is enamel, which is extremely hard.
* Middle layer is dentin.
* Pulp is composed of nerves and blood vessels that exit the tooth via the apices.
* The root connects to alveolar bone via the periodontal ligament.

Adult Dentition
* Permanent teeth begin to erupt around age 6 years and are all present by 21 years of age. Some adults had their third molars (wisdom teeth) or premolars extracted to relieve crowding, or they may not have erupted, so there may be only 24 to 28 teeth in intact-appearing dentition.

However, most adults have 32 teeth, which include:
* 8 incisors
* 4 canines
* 8 premolars
* 12 molars

Question 3

Transmission risk from mother to child of caries

Answer 3

Caries is a transmissible disease!
* Mothers are the main source of passing streptococci mutans, the bacteria responsible for causing caries, to their infants. However, any caregiver can be a potential source of transmission.
* Transmission occurs via saliva contact such as tasting or pre-chewing food.
* If mom’s bacterial level is high, transmission is more likely.
* Transmission can occur even before the first teeth erupt at about 6 months of age.
* Evidence suggests that babies born by caesarean delivery are more likely to have early acquisition of S. mutans. This is possibly due to decreased exposure to maternal microorganisms during birth, which can compete for colonization in the predentate environment.
* If colonization is delayed until after age two, then the child will have fewer caries.
* Caregivers with caries also often pass on bad habits (high sugar intake, poor oral hygiene).
* Message to moms should be BRUSH FOR TWO!
* Bacterial transfer can occur via shared utensils

Question 4

Reducing Caries Risk

Answer 4

Dental caries is the most common chronic disease of childhood. Untreated caries can lead to local and systemic complications, such as:

• Infections (Dental abscess, facial cellulitis, brain abscess)
• Pain
• Nutrition and growth changes
• Sleep dysfunction
• Poor self-esteem

Caregivers can decrease their own caries levels by:
* Receiving regular comprehensive dental care, including during pregnancy
* Limiting the frequency of sugar in the diet
* Maintaining excellent oral hygiene
* Using preventive agents, such as prescribed mouth rinses and Xylitol-containing gums

Question 5

Post Partum Interventions

Answer 5

At postpartum visits with the mother, focus on the following:

Promote breast feeding
* Children who are breast fed are less likely to develop caries than those who are bottle fed, especially if there is ad lib use of bottles and sippy cups.
* Breastfeeding has multiple other proven health benefits.
* The American Academy of Pediatrics recommends that breastfeeding should be exclusive for the first 6 months of life and should continue to at least age 12 months or beyond, as desired by mother and child.

Promote high dose xylitol gum or chlorhexidine rinse programs for mom until child is age two.
* Xylitol can help decrease transmission of caries causing bacteria from mom to child.
* If chlorhexidine is used, use only for brief periods of time (i.e. weeks) to reduce the risk of tooth staining.

Ensure children are not put to bed with a bottle.
* Teeth are at highest risk overnight when saliva levels are low.

• Gently clean infants’ gums and teeth after breastfeeding, then brush twice daily with a smear of fluoride toothpaste once teeth erupt (AAP and AAPD recommendation).
• Recommend children see a dentist at 12 months of age.

Question 6

The Relationship Between Periodontal Disease and Preterm Birth

Answer 6

Numerous studies have documented an association between maternal periodontal disease and preterm birth and low birth weight. Several studies also demonstrate positive associations between periodontal disease, pre-eclampsia, and gestational diabetes. There are several potential explanations for these associations. Periodontal disease may have direct effects on the uterus through bacteremia causing direct infection of the chorioamnion. However, it is more likely that an indirect mechanism mediated by a systemic inflammatory response occurs.

Bacteria: direct mechanism
* Periodontal infection in the mouth may have direct effects on the uterus through bacteremia causing direct infection of the chorioamnion. Some studies have shown higher rates of periodontal pathogens such as P. gingivalis and F. nucleatum within the placental tissues.
* Immunohistochemical and immunofluorescent stains of placental tissues have been used in some studies to support that colonization, as opposed to mere transient bacterial presence, can occur within the placental tissue.

Systemic Inflammatory Response: Indirect Mechanism
* It is postulated that preterm birth results from a systemic inflammatory response to periodontal infection that increases prostaglandins and interleukins and affects labor initiation.
* Inflammatory response may lead to placental blood flow restrictions, placental necrosis, and consequent low birth weight.
* A similar mechanism has been proposed to explain the association seen between periodontitis and increased rates of heart disease and diabetes.

studies do not demonstrate that treatment of periodontal disease during pregnancy improves pregnancy outcomes.

Question 7

Pregnancy Granuloma

Answer 7

Pregnancy granuloma occurs in 5% of pregnant women. It is indistinguishable from pyogenic granuloma, and is a rapidly growing, tumor-like lesion that develops as a response to local irritation such as poor hygiene, overhanging restorations, or trauma. Increasing estrogen and progesterone levels during pregnancy exacerbate the condition.

Symptoms
* Erythematous, nonpainful, smooth, or lobulated mass
* Bleeds easily when touched
* Most frequently develops on the gingiva, but less common locations include the lip, tongue, or buccal mucosa
* May vary in size from a few millimeters to several centimeters in diameter
* Usually appears between second and eighth month of pregnancy

Treatment
* Offer reassurance
* Observe unless lesions are bleeding excessively, interfere with eating, or do not resolve spontaneously after delivery
* Lesions can be treated by conservative surgical excision
* Recurrence is uncommon unless the lesion is incompletely removed or the source of irritation remains
* Lesions excised during pregnancy recur more frequently

Question 8

Hyperemesis Gravidarum

Answer 8

Gastroesophageal reflux and Hyperemesis gravidarum are both common in pregnancy and can cause enamel erosions.

Management
* Rinse with water or bicarbonate to reduce acid in mouth immediately after vomiting.
* Avoid brushing too firmly or immediately following vomiting.