7 questions about treating pregnant patients answered

December 6, 2021

Help future mothers maintain good oral health. Both proper home and professional oral care, combined with regular check-ups and safe treatments are essential for a future mother’s well-being, and that of her baby.

According to the European Federation of Periodontology (EFP), the oral cavity being in a good state is directly connected with an optimal course of pregnancy, and even plays a significant role in decreasing the risk of adverse pregnancy outcomes – especially in women who are at high risk of such issues. The importance of oral health during pregnancy cannot therefore be underestimated. Below are seven important questions about treating pregnant patients, answered with practical information based on clinical studies, the most recent EFP guides, and the experience of dental professionals.

1. How should you evaluate the oral health of woman of childbearing age?

It is commonly omitted, but knowing the pregnancy status of your female patients of a fertile age is very important for deciding the next steps in their dental care. Oral-health professionals should always ask whether a patient is either pregnant or trying/planning to have a baby. At all times, pregnancy status should be considered before recommending any oral-health intervention.

“If women have periodontal inflammation or caries, the ideal approach is to treat these conditions before pregnancy.”

All women, especially those who plan a family, should be informed about the importance of oral and periodontal health during pregnancy, as well as the relevance of adequate therapy to treat existing periodontal diseases before becoming pregnant.

What oral health professionals should pay attention to during check-ups of pregnant patients

According to EFP guidelines

  • Identify the stage of pregnancy
  • Confirm a medical history – with an emphasis on any history of adverse outcomes from previous pregnancies, hypertension, diabetes, cardiovascular disease, etc. – along with details of medications taken
  • Assess risk factors, including smoking status
  • Perform a comprehensive oral evaluation including a periodontal examination, which should include evaluation of plaque accumulation, gingival inflammatory status (bleeding on probing), and periodontal probing. Depending on the result of this periodontal examination, a periodontal diagnosis of “healthy”, “gingivitis”, or “periodontitis”should be identified and specific measures should be implemented. 

The ideal scenario is when optimal oral health is achieved before the patient becomes pregnant. Dr Tatia Rokhvadze, President of the Georgian Association of Periodontology, emphasises the importance of solving dental issues while planning a pregnancy. “If women have periodontal inflammation or caries, the ideal approach is to treat these conditions before pregnancy.” Besides the above mentioned issues, also third molars with constant pericoronitis caused by the impossibility of maintaining a good oral hygiene in the area, should be extracted before a patient gets pregnant.

2. What is different in the mouth of a pregnant woman?

Latest findings show that the microbiome differs between pregnant and non-pregnant women. The microbial changes present during pregnancy may be seen as a natural consequence of a healthy pregnancy. However, according to Balan et al., imbalances in the oral microbial composition that are associated with a poor oral health status, may predispose pregnant women to a higher risk of developing periodontal diseases.

The same study confirmed that the oral bacterial community showed a higher abundance of pathogenic taxa during a healthy pregnancy than when compared to non-pregnant women – despite similar gingival and plaque index scores.

There is a higher abundance of pathogenic taxa during a healthy pregnancy than when compared to non-pregnant women.

 

 It is common that women who suffer from periodontitis or gingivitis prior to conceiving will see the condition worsen during pregnancy – mainly due to chemical and hormonal changes in her body, but often also due to neglected oral care.

It has been shown that oral microbial dysbiosis combined with periodontal inflammation leads to adverse outcomes of pregnancy, including low birth weight, preterm birth, preeclampsia, and miscarriages. The mechanism behind this connection is assumed to be the direct translocation of the oral microbes from the oral cavity to the intrauterine cavity through the bloodstream (hematogenous route). This mechanism probably works thanks to pregnancy-induced gingival vascularization, vascular permeability, and changes in the oral microbiome, as those increase the risk of dental bacteremia. The other observed mechanism is the transmission of oral pathogens via oro-genital sexual intercourse between partners. Considering this second mechanism, in the terms of dental treatment, it is important to include not only pregnant woman, but also her partner.

3. Why is it important to take special care of pregnant women in the dentist’s office?

There are many dental issues that frequently and significantly worsen during pregnancy. The most common are gingivitis, periodontitis, tooth sensitivity, gingival enlargements (pregnancy epulis), and extensive gum bleeding and itching. Periodontitis affects about 40% of pregnant women. It is common that women who suffer from periodontitis or gingivitis prior to conceiving will see the condition worsen during pregnancy – mainly due to chemical and hormonal changes in her body, but often also due to neglected oral care.

The worsening of oral and dental health during pregnancy is commonly linked to the following factors:

  • During the first months of pregnancy some mothers experience strong cravings for certain foods, such as carbohydrates, which both increase bacteria and create acidic environments in the mouth, and toothbrushing can be neglected after they eat these kinds of foods.
  • Pregnant women bleed more readily due to the effects of pregnancy hormones (estrogen, progesterone), and may consequently avoid brushing their teeth when gums are more sensitive and tend to bleed. Due to this, bacterial plaque can more easily develop. 
  • Morning sickness, especially common during the first months of pregnancy, increases the acidic environment in the mouth. After vomiting women may neglect regular toothbrushing, which enables this acidic environment to remain which can in turn lead to gradual tooth decay.
  • Hormonal changes during pregnancy cause saliva flow to decrease. This allows the increased formation of caries during this period due to the decrease of this natural protection.

Other reasons for a decline in oral health during pregnancy are often caused by myths about dental procedures, which are unfortunately widely spread among pregnant woman. Many patients are still not fully aware of the importance of oral health and its connection to overall health, so they tend to avoid dental care and procedures – especially during the sensitive period of pregnancy. With this in mind, every dental professional should focus on constantly educating their patients about the importance of both proper home and professional dental care at all times. Not only for when they are pregnant, but also before and after this period.

According to EFP recommendations, it is likely that periodontal therapy would be more effective in reducing the risk of these outcomes if it were performed before conception. Therefore, oral-health professionals should communicate frequently with women in their fertility years and emphasise the possible benefits of healthy periodontal conditions during pregnancy, and thus the importance of pre-pregnancy treatments to establish this healthy oral state.

4. What types of treatments are safe during pregnancy?

According to EFP guidelines, it is important to emphasise that procedures aimed at the removal of plaque and calculus from tooth surfaces are both safe and important. These measures are highly effective in improving and maintaining oral health.

Non-surgical periodontal therapy (scaling and root surface instrumentation) and extractions are a safe during pregnancy, especially during the second trimester of gestation. Dental x-rays can also be undertaken and local anaesthesia can be delivered without additional risk to the fetus or the pregnant woman.

If there is a strong need for medication, penicillin, erythromycin, and cephalosporins are safe antibiotics to use during pregnancy. However, tetracycline, vancomycin, and streptomycin have adverse effects and are inappropriate to use during pregnancy.

In addition, according to ADA (American Dental Association), ciprofloxacin, benzodiazepines, and barbiturates should be avoided absolutely. Medication should be prescribed to the pregnant woman after communication with her obstetrician.

5. What is the best dental care strategy according to the different stages of pregnancy?

It is also important to divide pregnancy into three stages in the case of dental treatments.

During the first trimester it is generally suggested to avoid any stress-causing dental treatment since the fetus is in the stage of organogenesis and any excessive stress could be harmful for its proper development.

The second trimester is the best time to perform necessary dental procedures – especially those that, if postponed until the end of pregnancy, would be dangerous – such as fillings, canal treatment or tooth extraction.

During the third trimester, it is usually harder for the future mother to bear dental treatments as the position on the dental chair is often uncomfortable.

The second trimester is the best time to perform necessary dental procedures – especially fillings, canal treatment or tooth extraction.

According to Chiodo et al., dentists should pay attention to the fact that if a pregnant woman in the last trimester sits for too long in the dental chair, it may cause inferior vena cava syndrome (supine hypotensive syndrome). If this occurs, it is helpful to turn the mother to the left side in a semi-sloping manner. This manoeuvre will help to relieve the venous circulation. Generally, as with the first trimester, it is recommended to avoid dental interventions during the third/last trimester. More demanding treatments should be done only in emergency cases.

The ideal number of dental checks in the first trimester is two. In the second and third trimester there should be one check for each trimester. After a good evaluation at the first visit, it should be checked whether any oral hygiene treatments will need to be provided in the second trimester and any planned treatment should be performed in this period (e.g. tooth extraction, fillings).

6. How to explain the belief that loss of teeth during pregnancy is caused by a depletion of calcium, caused by the fetus?

Ideally, pregnant women should meet their calcium requirements by taking calcium-rich foods such as milk and dairy products, and green, leafy vegetables. It is necessary for a mother-to-be to take 1200-1500 mg of daily calcium in order to maintain the proper health of her bones and the developing bones of her baby. However, pregnant patients should be informed that there is no scientific basis for the belief that the calcium required for a fetus’ intrauterine growth is obtained from the mother’s teeth, and that as a result, with every pregnancy comes tooth loss.

Golden rule of treating a mother-to-be

At all times, be gentle and understanding. Pay attention to your communication. Listen to your patient’s needs and concerns. Try to explain everything important in an understandable way and to answer all their questions. A pregnant woman is undergoing many changes and creating a new life, so she should be treated with respect and in a welcoming atmosphere. Stress is never good for a future mother. 

The phenomenon of high levels of tooth decay and tooth loss amongst pregnant women can instead be explained by dentists as follows: nausea and vomiting are seen in 70% of pregnancies. Vomiting, as with dietary changes caused by cravings, can affect the chemical balance in the mouth which can cause erosion on the maternal enamel layer, and make the patient more vulnerable to tooth loss. Increased oral hygiene habits are normally enough to counteract these effects however, which is another valid reason for proper oral hygiene during pregnancy. With a good diet and adequate home and professional oral health care, there should be no different tooth problems during pregnancy.

7. What personal and professional treatments should be performed during pregnancy?

Regular brushing and tooth care rituals minimise the general build-up of bacteria.
To maintain good oral health during pregnancy, it is essential to take care of the teeth with gentle dental products at least twice a day.

Zanata et al., found a correlation between preventive maintenance procedures performed during pregnancy, and caries prevalence.

The following recommendations for pregnant patients should therefore be provided:

  • Daily oral care should be continued non-stop. Effective dental care should be obtained by using toothbrushes and dental floss at least twice a day, followed by daily use of interdental brushes. Try to emphasise the importance of interdental brushes in particular, as interdental caries are very easily formed when these areas are frequently neglected. 
  • A full oral examination is recommended before gestation to achieve optimal oral hygiene, and to install the necessary habits to maintain it, as there is a direct relationship between hormonal changes during pregnancy and plaque accumulation and gingival diseases. The hormone increase makes the mouth mucosa more sensitive to external factors, especially against bacterial plaques. 
  • Gargling with mouthwashes or warm salty water can be helpful. Warm salty water relaxes gums and reduces gum sensitivity. EFP’s recommendation is to use different chemical plaque-control remedies in the form of dentifrices and rinses, as these have been shown to be safe and effective in reducing gingival inflammation during pregnancy, when combined with appropriate mechanical plaque control. 
  • In case of morning sickness, it is recommended to initially just rinse the mouth effectively with clean warm water, and wait approximately 20-30 minutes before then brushing the teeth with a gentle toothpaste and soft toothbrush. This way, the enamel affected by gastric acids won’t be affected negatively by mechanical cleaning.

According to Dr Tatia Rokhvadze, it is important to explain to all pregnant women the reasons behind the development of diseases spread in the oral cavity. “The main reason is bacteria, which are located in the dental plaque and which can easily be removed with proper home hygiene. This includes mechanical plaque control: brushing the teeth twice a day and using interdental brushes and dental floss. Also visiting their dental professional minimum twice a year can reduce the influence of risk factors (genetics, hormones etc.) on the development of oral diseases. So pregnant women can really have their oral health under their own control.”

Recommended home oral care for pregnant women

Your pregnant patient is now brushing for two. Provide her with all the relevant information and gentle home-care options she needs during this important time.

✅ Soft toothbrush for daily plaque removal. For sensitive and swelling gums during pregnancy the best option is a soft and dense toothbrush, which doesn’t only clean teeth most effectively, but also softly massages the gums. 

☞ We recommend: Curaprox CS 5460 or  12460 velvet toothbrush

✅ The right-sized interdental brushes to take regular care of their interdental spaces. During an appointment, measure the interdental brush size needed for each of their interdental spaces. This is very important for your patient to reap the most out of using soft and effective interdental brushes. Explain that no long brushing is needed with interdentals – all your patient needs to do is simply insert and remove the interdental brush between each tooth. Low effort, great effect guaranteed.

☞ We recommend: CPS Prime

✅ Mild toothpaste. Advise them to use products without aggressive SLS and too many irritating flavourings, but that do have a sufficient amount of fluoride. Incorporated enzymes in a toothpaste that are supportive for maintaining saliva’s natural protection properties are also highly beneficial. Using a paste with low abrasivity is also important.

☞ We recommend: Enzycal 

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