Treatment of periodontal disease improves a woman’s wellbeing and is safe in pregnancy.
10.5.1 BackgroundOral health refers to the health of tissues in the mouth, including mucous membrane, connective tissue, muscles, bone, teeth and periodontal structures or gums (gingiva). Pregnancy itself does not have a negative effect on oral health, but may increase the risk of dental problems (eg frequent vomiting may raise acidity in the mouth and contribute to caries). As well, high levels of hormones increase blood flow to the gums and may cause inflammation and bleeding (gingivitis) (Taanni et al 2003). In the absence of local plaque build up, healthy gums will not show changes during pregnancy but the risk of peridontitis (inflammation and destruction of supporting tissues around the teeth [ADA 1999]) is increased.
Measures to prevent caries and periodontal disease include regular brushing and flossing and regular dental checkups, with teeth cleaning and treatment as required.
Oral health in AustraliaAccess to dental services in Australia varies, with limited services available in rural and remote areas and women in all areas potentially affected by the costs of dental services, which are not covered under Medicare. Data from the Australian Institute of Health and Welfare show that:
- dental care in Australia is largely provided in the private sector, with public dental patients generally being health care card holders and socioeconomically disadvantaged (AIHW 2010);
- adults living outside major cities are more likely to have poorer dental health, such as more tooth loss and untreated decay and less likely to have visited the dentist in the previous 12 months than those in major cities (AIHW 2009); and
- Aboriginal and Torres Strait Islander adults seeking dental care in Australia in 2004–06 had a greater average number of decayed and missing teeth and a lower average number of filled teeth than non-Indigenous adults across most age groups (AIHW 2008).
Prevalence of periodontal disease in pregnancyA multicentre randomised trial (n=3,563) found a prevalence of periodontal disease of 50% during pregnancy (Macones et al 2010). The incidence of periodontal disease has been associated with lower levels of education and socioeconomic status (Machuca et al 1990; Gaffield et al 2001; Taanni et al 2003).
Risks associated with periodontal disease in pregnancyAssociations between periodontal disease and preterm birth (Jeffcoat et al 2003; Lopez et al 2005; Offenbacher et al 2006; Polyzos et al 2009) and low birth weight (Lopez et al 2005; Sadatmansouri et al 2006; Tarannum & Faizuddin 2007) have been suggested. However, a recent cohort study (n=876) found no association between periodontal disease and adverse pregnancy outcomes (Srinivas et al 2009) and a meta-analysis of observational studies (Khadar & Ta’ani 2005) found that treating periodontal disease did not decrease the rate of preterm birth. Controlled trials into treating periodontitis during pregnancy have also found:
- improved periodontal disease and safety of treatment but no significant change in rates of preterm birth, low birth weight or fetal growth restriction (n=812) (Michalowicz et al 2006; Novak et al 2008; Michalowicz et al 2009);
- no significant reduction in the risk of preterm birth (n=824) (Offenbacher et al 2009; Macones et al 2010), although treatment may protect against low birth weight (n=339) (Cruz et al 2010);
- no significant differences between women receiving treatment during or after pregnancy in terms of preterm birth (9.3% versus 9.7%), birth weight (3,450 versus 3,410g) or pre-eclampisa (4.1% versus 3.4%) (n=1,082) (Newnham et al 2009); and
- a reduction in the incidence of caries among children whose mothers received oral health advice during pregnancy (1.7% versus 9.6% in the control group) (n=649) (Plutzer & Spencer 2008).
10.5.2 Providing advice on oral healthGood oral health and control of oral disease protects a woman’s health and quality of life and has the potential to reduce transmission of pathogenic bacteria from mothers to their children (CDAF 2010). Dental treatment can be safely provided at any time during pregnancy (ADA 1999) if the dentist is informed of the pregnancy.
An Australian survey of women who had recently given birth (n=388) (Thomas et al 2008) found that most were knowledgeable about oral and dental health but only a small percentage knew about periodontal disease. Lack of knowledge about oral and dental health was strongly linked to lower educational achievement and lower socioeconomic background. Over half of respondents had not attended a dentist in the previous 12 months, and only 30% attended during their most recent pregnancy.
Nausea and vomiting
Nausea and vomiting have the potential to affect oral health:
- frequent snacks and soft drinks/carbonated drinks and cravings for particular foods (often sweet) can increase risk of tooth decay;
- excessive vomiting brings teeth into contact with strong stomach acid; and
- repeated reflux and vomiting can damage tooth enamel and increase the risk of decay.
Measures to reduce the impact of nausea and vomiting on oral health include (Morgan et al 2008; CDAF 2010; Rogers 2011):
- waiting for at least an hour before brushing teeth after vomiting or rinsing the mouth with a solution of bicarbonate of soda;
- using fluoridated mouthwash and toothpaste;
- eating small amounts of nutritious yet non-cariogenic foods (snacks rich in protein) throughout the day; and
- chewing sugar-free gum (especially gums containing xylitol or casein phosphopeptide – amorphous calcium phosphate [CPP-ACP]) after meals or high sugar or acidic drinks.
Recommendation - Grade B29. At the first antenatal visit, advise women to have oral health checks and treatment, if required, as good oral health protects a woman’s health and treatment can be safely provided during pregnancy.
10.5.3 Practice summary — advising women about oral healthWhen — At antenatal visits
Who — Midwife; GP; obstetrician; Aboriginal and Torres Strait Islander health worker; multicultural health worker; pharmacist
- Discuss oral health with women — Explain that pregnancy does not causes dental problems but may make them more likely. Advise women to have their oral health checked and to tell the dentist that they are pregnant.
- Provide advice on oral health to women experiencing nausea and vomiting — Explain that vomiting exposes teeth to acid and give tips on how to reduce the impact (see above).
10.5.4 ResourcesCDAF (2010) Oral health during pregnancy and early childhood: evidence-based guidelines for health professionals. California Dental Association Foundation, American College of Obstetricians and Gynecologists. J Calif Dent Assoc 38(6): 391–403, 405–40.
NACOH (2004) Healthy Mouths Healthy Lives: Australia’s National Oral Health Plan 2004-2013. Adelaide: National Advisory Committee on Oral Health, Australian Health Ministers’ Advisory Council.
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10.5.5 ReferencesADA (1999) American Dental Association: International workshop for classification of periodontal disease and conditions. Ann Periodontol 4: 1–112.
AIHW (2008) The Health and Welfare of Australia’s Aboriginal and Torres Strait Islander Peoples. ABS Cat No 4704.0, AIHW Cat No IHW 21. Commonwealth of Australia.
AIHW (2009) Geographic Variation in Oral health and Use of Dental Services in the Australian Population 2004–06. Cat. no. DEN 188. Canberra: AIHW.
AIHW (2010) Australia’s Health 2010. Australia’s health series no. 12. Cat. no. AUS 122. Canberra: Australian Institute of Health and Welfare.
CDAF (2010) Oral health during pregnancy and early childhood: evidence-based guidelines for health professionals. California Dental Association Foundation, American College of Obstetricians and Gynecologists. J Calif Dent Assoc 38(6): 391–403, 405–40.
Cruz SS, Costa Mda C, Gomes-Filho IS et al (2010) Periodontal therapy for pregnant women and cases of low birthweight: an intervention study. Pediatr Int 52(1): 57–64.
Gaffield ML, Colley-Gilbert BJ, Malvitz DM et al (2001) Oral health during pregnancy: an analysis of information collected by the Pregnancy Risk Assessment Monitoring System. J Am Dent Assoc 132: 1009–16.
Jeffcoat MK, Hauth JC, Geurs NC et al (2003) Periodontal disease and preterm birth: results of a pilot intervention study. J Periodont 74(8): 1214–18.
Khader YS & Ta’ani Q (2005) Periodontal diseases and the risk of preterm birth and low birth weight: A meta-analysis. J Periodont 76(2): 161–65.
Lopez NJ, Da Silva I, Ipinza J et al (2005) Periodontal therapy reduces the rate of preterm low birth weight in women with pregnancy-associated gingivitis’, J Periodont 76(11 Suppl): 2144–53.
Machuca G, Khoshfeiz O, Lacalle JR et al (1990) The influence of the general health and socio-cultural variables on the periodontal condition of pregnant women. J Periodont 70: 779–85.
Macones GA, Parry S, Nelson DB et al (2010) Treatment of localized periodontal disease in pregnancy does not reduce the occurrence of preterm birth: results from the Periodontal Infections and Prematurity Study (PIPS). Am J Obstet Gynecol 202: 147.e1–147.e8.
Michalowicz BS, Hodges JS, DiAngelis AJ et al (2006) Treatment of periodontal disease and the risk of preterm birth. New Engl J Med 355(18): 1885–94.
Michalowicz BS, Novak MJ, Hodges JS et al (2009) Serum inflammatory mediators in pregnancy: changes after periodontal treatment and association with pregnancy outcomes. J Periodont 80(11): 1731–41.
Morgan MV, Adams GG, Bailey DL et al (2008) The anticariogenic effect of sugar-free gum containing CPP-ACP nanocomplexes on approximal caries determined using digital bitewing radiography. Caries Res 42: 171–84.
Newnham JP, Newnham IA, Ball CM et al (2009) Treatment of periodontal disease during pregnancy: a randomized controlled trial. Obstet Gynecol 114(6): 1239–48.
Novak MJ, Novak KF, Hodges JS et al (2008) Periodontal bacterial profiles in pregnant women: response to treatment and associations with birth outcomes in the obstetrics and periodontal therapy (OPT) study. J Periodont 79(10): 1870–79.
Offenbacher S, Beck JD, Jared HL et al (2009) Effects of periodontal therapy on rate of preterm delivery: a randomized controlled trial. Obstet Gynecol 114(3): 551–59.
Offenbacher S, Lin D, Strauss R et al (2006) Effects of periodontal therapy during pregnancy on periodontal status, biologic parameters, and pregnancy outcomes: a pilot study. J Periodont 77(12): 2011–24.
Plutzer K & Spencer AJ (2008) Efficacy of an oral health promotion intervention in the prevention of early childhood caries. Comm Dent Oral Epidemiol 36(4): 335–46.
Polyzos NP, Polyzos IP, Mauri D et al (2009) Effect of periodontal disease treatment during pregnancy on preterm birth incidence: a metaanalysis of randomized trials. Am J Obstet Gynecol 200(3): 225–32.
Rogers JG (2011) Evidence-based Oral Health Promotion Resource. Melbourne: Prevention and Population Health Branch, Department of Health, Victoria.
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Sadatmansouri S, Sedighpoor N, Aghaloo M (2006) Effects of periodontal treatment phase I on birth term and birth weight. J Ind Soc Pedodont Prevent Dent 24(1): 23–26.
Srinivas SK, Sammel MD, Stamilio DM et al (2009) Periodontal disease and adverse pregnancy outcomes: is there an association? Am J Obstet Gynecol 200: 497.e1–497.e8.
Taanni DQ, Habashneh R, Hammad MM et al (2003) The periodontal status of pregnant women and its relationship with socio-demographic and clinical variables. J Oral Rehabil 30: 440–45.
Tarannum F & Faizuddin M (2007) Effect of periodontal therapy on pregnancy outcome in women affected by periodontitis. J Periodont 78(11): 2095–103.
Thomas NJ, Middleton PF, Crowther CA (2008) Oral and dental health care practices in pregnant women in Australia: a postnatal survey. BMC Pregnancy & Childbirth 8: 13.