Feature Article
Supporting Oral Health Throughout Pregnancy
©Juliette Reeves 2021
Pregnancy is a critical time in a woman’s life when oral health is of fundamental importance. Maintaining oral health and periodontal health during pregnancy is important both for pregnant women themselves and for their unborn children.
In addition to the effect of increased hormonal activity on the periodontium, associations between periodontal diseases and adverse pregnancy outcomes have been demonstrated. This article reviews our current knowledge of the most common periodontal conditions associated with pregnancy and discusses the nutrition, lifestyle and preventive advice dental professionals can provide during pregnancy.
The main physiological and hormonal changes in the life of a woman occurs during pregnancy[1, and the oral cavity is one of the main areas involved in these changes[2]. Pregnancy-related changes are most frequent and most marked in gingival tissue and include gingival tissue ulcerations, pregnancy granuloma, gingivitis, pregnancy tumors (epulis gravidarum), and xerostomia[3]. Clinical studies have reported an increase in the severity and extension of gingival inflammation during pregnancy[4] with a prevalence rate ranging from 49%[5] to 94%[6] of pregnant women and a self-reported prevalence rate of 46%[7]. The changing hormone levels in pregnancy directly affect gingival tissue, and associated nausea and vomiting can affect the hard tissues causing caries and dental erosion. A number of studies have also reported that increasing levels of oral disease have a negative impact on oral health related quality of life (OHRQoL) and perceptions of well-being among pregnant women[8] [9]
Pregnancy Granuloma
Granuloma gravidarium, is also called pregnancy tumour or pregnancy epulis. It is characterised by a soft tissue swelling or mass at the gingival margin in response to a local irritation. It often has an ulcerated margin and it is usually a solitary lesion that bleeds easily. They most commonly occur at the interproximal sites and are seen more frequently in the anterior maxillary region[10] [11].During pregnancy increased levels of oestrogen and progesterone cause changes in the gingival tissue which could enhance the tissue response to local irritants . It usually appears during the second term of pregnancy and continues growing until delivery when the condition generally resolves . In some cases the granuloma can be removed post-partum if resolution is not complete.
Similar to the case for pregnancy gingivitis, careful oral hygiene, removal of dental plaque and use of soft brushes are essential to treat and prevent its occurrence in pregnant patients.
Pregnancy Gingivitis
Pregnancy gingivitis is characterised by a red gingiva that easily bleeds, enlarged gingival margin, and hyperplasia of the interdental papilla, potentially leading to the presence of pseudo-pockets 1. The clinical appearance of pregnancy gingivitis does not differ from plaque induced gingivitis, except for the tendency to develop severe signs of gingival inflammation in the presence of relatively low amounts of plaque[12]. A systematic review recently concluded that gingival inflammation during pregnancy peaks in the second or third terms, with levels of gingival inflammation returning to first-term values, three months after delivery 4. This suggests that pregnancy gingivitis does not usually imply irreversible damage to the periodontium. It has long been reported that pregnancy gingivitis occurs in women with pre-existing gingivitis and poor oral hygiene in response to increasing levels of oestrogen[13], however, a more recent study from Wu et al[14] demonstrated a significant increase in gingival and bleeding index during the second and third trimester of individuals with excellent plaque control. The most common sites where pregnancy gingivitis appears more marked have been reported as anterior teeth and in interproximal sites10 11
Periodontal Disease in Pregnancy
The onset of periodontitis is governed by a complex set of conditions that affect the oral tissues, the most recognised being the presence of bacterial plaque and the host response or susceptibility to bacterial plaque[15]. Other modifiable risk factors include smoking, stress, obesity[16] and the specific hormonal alterations that occur during pregnancy[17]. Although bacterial plaque precludes the development of periodontitis, the vascular and hormonal changes during pregnancy can amplify the response of the tissues, as demonstrated by pregnancy gingivitis.
Whilst the exact mechanism has yet to be defined, it has been suggested that an increase in anaerobic bacteria in the composition of biofilm occurs in response to increased circulating levels of oestrogen and progesterone, in particular Prevotella intermedia and Porphyromonas gingivalis, both indicated in the development of periodontal disease1 [18]. Other possible mechanisms include increased dilation of the gingival capillaries mediated by progesterone 17, which appears clinically as redness and oedema and a reduction in the integrity of the epithelial layer leading to an increased response to bacterial irritants[19]. Other theories suggest changes in the maternal immune system during pregnancy may contribute to a greater susceptibility to develop gingival inflammation[20].
More recently a cross sectional study investigating risk factors associated with periodontitis in pregnant women, found a prevalence rate of 11% with the most significant risk factors being education, family income, smoking, body mass index, and bacterial plaque[21].
A number of studies have recently indicated that periodontitis has been associated with preeclampsia, premature birth and low birth weight[22]. Oral health measures, therefore, are of considerable importance during pregnancy and preconception.
Common Oral Health Conditions in Pregnancy
Adapted from: Silk H, Douglass AB, Douglass JM et al. Oral health during pregnancy. Am Fam Physician 2008; 77: 1139-44.
Adverse Pregnancy Outcomes
Pregnancy complications have significant consequences not only in terms of the health of the affected babies and mothers but also pre-term birth (PTB) survivors are at increased risk of developing neurological and behavioural problems along with a wide range of complications extending beyond childhood, including cardiovascular and metabolic disorders[23]. Other pregnancy complications include include: low birth weight (LBW), pre-eclampsia, and gestational diabetes.
Infection, drugs and alcohol consumption, smoking, previous PTB, stress, diabetes, low or high maternal body mass index are among the risk factors that have been associated with adverse pregnancy outcomes[24] (APOs). Several of these factors involve pro-inflammatory pathways and therefore the possibility of an association between periodontal disease (PD) and APOs has been studied.
The proposed mechanism involves pro-inflammatory pathways, starting with the release of pro-inflammatory mediators from Gram-negative bacterial infections as in periodontal disease. These inflammatory mediators “spill over” into general circulation via the ulcerated and therefore permeable junctional epithelium. These same cytokines (IL-1β, IL-6, and TNF-α) in appropriate quantities, stimulate labour[25], and proinflammatory mediators may cross the placental barrier and cause fetal toxicity resulting in preterm delivery and low-birth-weight babies[26] [27].
A direct causal relationship has however, been difficult to identify. A recent systematic review and meta-analysis of the association between adverse pregnancy outcomes and periodontitis concluded that there may be some association, however, the strength of this association is extremely limited and hampered by the wide range of variables in the studies and the conflicting results and in order to further confirm an association, more research is needed[28].
Providing Periodontal Treatment.
The mainstay of oral health remains the prevention and treatment of periodontal disease and dental caries. Good oral health is particularly important during pregnancy and the research suggests that the provision of non-surgical periodontal treatment (NSPT) during pregnancy is considered safe[29]. Two studies[30] [31]demonstrated that the provision of NSPT during pregnancy did not have a deleterious effects on child development at 24 and 28 months of age and that NSPT and essential dental treatment was not associated with any adverse medical events or APOs 31. Timing of NSPT and dental treatment is important and a recent review suggests the second and third trimester as being safe to provide NSPT, intense oral hygiene instruction and prophylaxis30. The use of systemic antibiotics is advised with caution[32].
The affect of NSPT on APOs is not yet proven and whilst provision of treatment is safe during pregnancy, it does not appear to reduce the incidence of APOs such as PTB and LBW. However, a positive effect of periodontal treatment in decreasing PTB and LBW rates may occur in women that are at high risk of APOs 30. NSPT, however, does improve the periodontal status of the majority of pregnant women with PD, and is successful in reducing gingival inflammation. NSPT should also include an intensive oral-hygiene protocol and this further reduces plaque scores, gingival inflammation, probing depths[33] and levels of pro-inflammatory mediators[34]. This becomes significant when considering the potential effect of periodontal infection and inflammation on the fetal-placental unit and access to treatment may be more effective when provided during the preconception period.
Nutrition and Lifestyle Advice
The Early Nutrition Research project[35] states that nutrition and lifestyle before and during pregnancy, lactation, infancy and early childhood have been shown to induce long-term effects on later health of the child, including the risk of common non-communicable diseases such as obesity, diabetes and cardiovascular disease[36]. Healthy pregnancy outcomes are more likely if women who enter pregnancy are physically active, have a healthy diet, do not smoke, avoid alcohol and have a normal BMI 38. The report encourages healthcare providers to support and provide advice on preconception nutrition, including optimizing adolescent nutrition and health. As many women have an unhealthy lifestyle as they enter pregnancy, often characterised poor quality diet, low levels of physical activity, smoking and excessive alcohol consumption and which remain prevalent around the time of conception, the International Federation of Gynecology and Obstetrics panel has proposed recommendations for healthcare providers in relation to nutritional status before pregnancy Table 2[37].
Table 2
Adapted from: Hanson MA, Bardsley A, De-Regil LM. et al: Int J Gynaecol Obstet 2015; 131(suppl 4):S213–S253.
The guidelines include recommendations for increase in energy intake by no more than about 10% above the recommended energy intake in non-pregnant women, with the focus being on eating a healthy diet with foods rich in critical nutrients, rather than eating more[38]. There is also convincing evidence that folic acid supplementation of 400mcg daily in addition to a folate rich diet, markedly reduces the risk for serious birth defects, in particular neural tube defects (NTDs) and potentially cleft palate disorders[39] [40]. Plant-based foods including green leafy vegetables, cabbage, legumes, whole grain products, tomatoes and oranges are good dietary folate sources, but additional supplementation is strongly advised[41]. Pregnant women should also aim to consume the equivalent of 300mg Omega 3 fatty acids per day, which can be achieved by eating 2 portions of fish per week, with 1 portion of an oily fish such as mackerel, herring, sardines or salmon [42] [43], and consumption of large predator fish (e.g., tuna, swordfish) should be limited. Adequate intake of Vitamin D during pregnancy is essential for maintaining maternal calcium homeostasis and foetal bone development[44]. As vitamin D is primarily synthesised in the skin via exposure to sunlight, this becomes important in dark skin and cultures where the skin in extensively covered. In these cases a supplement of 400 iu per day is recommended 38.
Raw meat products, smoked fish and soft cheeses, unpasteurized milk and products containing unpasteurized milk products, and vegetables and salads should be avoided as they may transfer listeriosis[45]. Raw fruit and vegetables as well as lettuce should be washed well before consumption.
Oral Health Screening
The European Federation of Periodontology advise that oral-health professionals should screen the oral health of all pregnant patients and 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, along with details of medications taken, along with an assessment of risk factors including smoking status. A comprehensive oral evaluation should be provided including a periodontal examination, 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. This includes oral hygiene advice, and NSPT where indicated along with regular monitoring and maintenance of the patients periodontal status[46].
Conclusion
7.6% of live births in the UK are pre-term with 6.8% of births in the UK considered low weight births[47], which can have a significant affect on the growth and development of the child and the risk of further health complications in adulthood. It is widely acknowledged that a focus on preconception health offers an important, newly recognised opportunity for improving the health of future generations[48] .
Good oral health and nutrition before conception are central to a mother’s ability to meet the nutrient demands of pregnancy and breastfeeding, and are implicated in the reducing the risk of adverse pregnancy outcomes. As primary healthcare providers we are in an ideal position to provide our pregnant patients with oral health and nutrition advice at a critical time in their health and the development of a healthy baby.
Bibliography
The European Federation of Periodontology Oral Health and Pregnancy Project:
Petrini M, Gursoy M, Gennai S et al: Biological mechanisms between periodontal diseases and pregnancy complications. A systematic review and meta-analysis of epidemiological association between adverse pregnancy outcomes and periodontitis: an update of the review by Ide & Papapanou (2013). EFP Oral Health and Pregnancy Project Mar 2020.
Bobetsis Y and Madianos P: Treating periodontal disease during pregnancy. EFP Oral Health and Pregnancy Project Mar2020.
Koletzko B,Godfrey K.M, Poston L et al: Nutrition During Pregnancy, Lactation and Early Childhood Ann Nutr Metab 2019;74:93–106 97
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