Oral health

Treatment of periodontal disease improves a woman’s wellbeing and is safe in pregnancy.

16.1 Background

Oral 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.

16.1.1 Oral health in Australia

Access 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
• 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.

16.1.2 Prevalence of periodontal disease in pregnancy

A 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.

16.1.3 Risks associated with periodontal disease in pregnancy

Associations 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 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% vs 9.7%), birth weight (3,450 vs 3,410g) or pre-eclampsia (4.1% vs 3.4%) (n=1,082) (Newnham et al 2009)
• a reduction in the incidence of caries among children whose mothers received oral health advice during pregnancy (1.7% vs 9.6% in the control group) (n=649) (Plutzer & Spencer 2008).

16.2 Providing advice on oral health

Good oral health and control of oral disease is important to 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.

16.2.1 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
• 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:

• rinsing the mouth with a solution of bicarbonate of soda after vomiting, avoiding tooth brushing directly after vomiting as the effect of erosion can be increased by brushing an already demineralised tooth surface
• using fluoridated mouthwash and toothpaste
• eating small amounts of nutritious yet non-cariogenic foods (snacks rich in protein) throughout the day
• chewing sugar-free gum (especially gums containing xylitol or casein phosphopeptide–amorphous calcium phosphate [CPP-ACP]) after meals or high sugar or acidic drinks.

16.3 Practice summary: oral health

When

At antenatal visits.

Who

• Midwife
• GP
• obstetrician
• Aboriginal and Torres Strait Islander health worker
• multicultural health worker.

What

• Discuss oral health with women
  Explain that pregnancy does not cause 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).

16.4 Resources

• 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. 
• 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.