Maternal matters

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MED reviews the impact of periodontal disease on pregnancy, and guidelines for the safe treatment of pregnant patients.

Pregnancy affects every aspect of a woman's life, and her oral health is no exception. During the nine-month term, women commonly undergo gingival changes. Any existing oral problems may worsen, and up to 70% of women will develop pregnancy gingivitis.

Increasingly, studies are showing the reach of these periodontal problems stretch far beyond the oral cavity. Oral infections have been linked to gestational diabetes, preeclampsia, premature birth and low birth weighs. With oral health tied to the baby's health, a hygienist's visit should be on all prenatal ‘to do' lists.

Common complaints

Throughout pregnancy, hormones fluctuate. Progesterone and oestrogen reach levels 10 to 30 times those seen in the typical menstrual cycle. This spike is thought to be an underlying cause of pregnancy gingivitis, a condition that occurs in 30 to 70% of pregnancies. An acute form of gingivitis, it is characterised by erythema, oedema, hyperplasia and increased gingival bleeding.

Pregnancy gingivitis usually begins in the second to third month of pregnancy, peaking in severity through the eight month and then decreasing along with the sharp drop in hormone levels after birth.

It's also not uncommon to see pyogenic granuloma develop on the oral tissues of mums-to-be. These large, isolated growths are often referred to as pregnancy granuloma or pregnancy tumours, but are not cancerous.

The growths tend to be associated with areas of irritation; with poor oral health, trauma blood vessel malformations suspected as co-factors. It is thought the increase in hormonal levels seen during pregnancy exaggerates the tissue response.

In many cases, both pregnancy gingivitis and granuloma subside after childbirth. More concerning is the suspected link between periodontal infections and the health of the baby.

Recent papers have shown poor oral health ranks along smoking and alcohol use as a risk factor for babies born too early and too small. Studies have also revealed that less than 50% of women receive dental care during their pregnancy, mainly due to lack of awareness or inability to afford dental care, and fear that dental procedures will harm the pregnancy.

Periodontitis and its consequences

This low take-up of dental treatment among expectant mothers can have serious consequences. A study published in the February edition of the Journal of Periodontology (JOP) revealed maternal periodontal disease to be a risk factor for preeclampsia - a potentially serious complication involving hypertension that often leads to premature delivery.

Researchers examined 130 preeclamptic and 243 non-preeclamptic women in the 26-36 weeks of pregnancy. Chronic periodontitis was more prevalent in the preeclamptic group by more than 63%, compared to 36% in the non-preeclamptic group.

It was also found that the presence of common periodontal microorganisms like Porphyromonas gingivalis, Tannerella forsythia and Eikenella corrodens increased the risk of preeclampsia.

This could be an indictor that these bacteria find a way into the bloodstream of pregnant women. This theory is backed by a second, smaller JOP study, published in July. The paper, which reviewed 26 pregnant women with a diagnosis of threatened premature labour, found P. Gingivalis present in both the oral cavity and amniotic fluid of 30% of the women.

For mothers-to-be, periodontal disease can also mean an increased likelihood of gestational diabetes mellitus. This condition, which arises during pregnancy and usually resolves after birth, can contribute to hypertension, macrosomia (a larger-than-normal baby) and may necessitate a caesarean section.

A paper published in the April edition of the Journal of Dental Research suggested periodontal disease may be a treatable risk factor for GDM. Of the 265 women studied, the 8% who developed gestational diabetes displayed higher levels of periodontal bacteria and C reactive protein levels, a marker for inflammation.

Lead researcher Dr Ananda P. Dasanayake, of New York University College of Dentistry, said it was possible that periodontitis and its associated inflammatory response may exacerbate any pregnancy-related impairment in blood sugar control.

Treating to term

That data is inconclusive as to whether periodontal treatment improves pregnancy outcomes. However, we do know it's safe and improves the oral health of the mother.

Before treating pregnant patients, hygienists are advised to confirm a few key points; namely that the patient is seeing a physician for prenatal care; when the due date is; whether the pregnancy is considered high risk; and if there have been any previous complications in prior pregnancies. The answers to these questions should inform any dental treatment, in conjunction with the patient's physician if necessary.

During a patient's first trimester, a preventive care programme can be initiated. Expectant mothers are likely to be experiencing morning sickness, which can cause damage to the tooth enamel. Advise patients to rinse with water after vomiting rather than brushing, to reduce the risk of toothbrush abrasion.

According to the Journal of Dental Hygiene, prophylaxis is also safe during this time. Studies suggest the safest time to provide dental treatment is weeks 14-20. Scaling and root planing can be provided, and category B local anaesthetics and category B analgesics are considered safe to use.

Radiographs are safe throughout the pregnancy, reports the Journal of Dental Hygiene, as the benefits outweigh any negligible risks. Similarly, emergency dental treatment to remove an infection or bacterial load will aid the mother, and possibly the foetus.

Experts agree that the importance of providing dental care to expectant mothers cannot be disputed. Data suggests oral health impacts on pregnancy health, and studies support the notion that dental care is safe. Mothers-to-be should be urged to maintain regular hygienist visits; they may have a marked impact on both mother and baby's health.

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