Recommendations for Perinatal Oral Health
Oral health education: The perinatal period is an opportune time to educate and perform dental treatment on expectant mothers. Pregnancy offers an opportunity to educate women regarding oral health by providing a "teachable moment" in self-care and future child-care. Early intervention and counseling during the perinatal period from all health care providers (e.g., physicians, dentists, nurses) are essential to ensure good oral health for the mother and infant.
Oral hygiene: Toothbrushing with fluoridated toothpaste and flossing by the mother are important to help dislodge food and reduce bacterial plaque levels. Systematic literature reviews suggest an association between periodontal disease and an increased risk of adverse pregnancy outcomes, including preterm deliveries, low birth weight babies, and preeclampsia. Periodontal infections, which can be a reservoir for inflammatory mediators, can pose a threat to the placenta and fetus which can increase the likelihood of preterm delivery. Mothers with severe periodontitis have high levels of prostaglandin in their gingival crevicular fluid and blood. In turn, these increased levels of prostaglandins may be associated with uterine contractions leading to preterm deliveries. While some research shows that scaling and root planning during pregnancy can reduce the likelihood of preterm deliveries and low birth weight babies, a recent randomized controlled trial did not support that treatment of periodontal disease during pregnancy prevents preterm birth, fetal growth restriction, or preeclampsia. Regardless of the potential for improved oral health to improve pregnancy outcomes, the data on the relationship between maternal and child experience with dental caries is well established. Therefore, comprehensive dental services for pregnant women should be available so that, not only their own oral and general health is safeguarded, but also so that their children's caries risk is reduced.
The effects of pregnancy may negatively affect oral health behaviors among pregnant women. Nausea and vomiting may lead to avoidance of toothbrushing, resulting in an increased caries rate. For a pregnant woman experiencing frequent vomiting, rinsing with a cup of water containing a teaspoon of baking soda and waiting an hour before brushing can help minimize dental erosion. Using a fluoridated toothpaste, chewing sugarless or xylitol-containing gum, and eating small amounts of nutritious food throughout the day can help minimize their caries risk.
Diet: Important components of the mother's diet need to be discussed fully. A healthy diet is necessary to provide adequate amounts of nutrients for the mother-to-be and unborn child. Food cravings may lead to the consumption of foods that increase the mother's caries risk. The caries potential of the mother's diet (i.e., cariogenicity of certain foods, beverages, medicines), as well as its effect on her child, should be addressed. The frequency of consumption of cariogenic substances and resulting demineralization/remineralization process also are important discussion topics.
Fluoride: Using a fluoridated toothpaste and rinsing with an alcohol-free, over-the-counter mouth rinse containing 0.05% sodium fluoride once a day or 0.02% sodium fluoride rinse twice a day have been suggested to help reduce plaque levels and help promote enamel remineralization.
Professional oral health care: Routine professional dental care for the mother can help optimize her oral health. Every pregnant woman should have an oral evaluation, be counseled on proper oral hygiene, and be referred for preventive and therapeutic oral health care. It has been shown that maternal salivary levels of mutans streptococci (MS) are related significantly to MS colonization in plaque as well as dental caries in their children. Removal of active caries with subsequent restoration of the remaining tooth structure is important to suppress maternal MS reservoirs and has the potential to minimize the transfer of MS to the infant, thereby decreasing the infant's risk of developing early childhood caries (ECC). The safest time to perform dental treatment during pregnancy is in the second trimester, or the 14th–20th weeks. The risk of pregnancy loss is lower in the second trimester compared to that in the first trimester, and organogenesis is complete. Even though the second trimester is usually optimal, dental treatment can be accomplished safely at any time during pregnancy.
Treatment options may include diagnostic x-rays, dental prophylaxis, periodontal treatment, and restorations with the administration of local anesthetics containing epinephrine. Amalgam may be considered as a restorative material in pregnant women. There is no evidence that fetal exposure to mercury released from the mother's existing amalgam restorations causes any adverse effects. Since mercury vapor released during removal and placement of an amalgam restoration may be absorbed into the blood stream and cross the placental barrier, the use of rubber dam and high speed evacuation is recommended. Antibiotics and analgesics for treating infection and controlling pain may be administered. Acute conditions, such as pain and swelling, should be treated as soon as possible. Delay in necessary treatment could result in significant risk to the mother and indirectly to the fetus. The consequences of not treating an active infection during pregnancy outweigh the possible risks presented by most of the medications required for dental treatment. Due to patient positioning, comfort is a consideration for treatment during the third trimester. In these cases, elective treatment sometimes is best deferred until after delivery.
Delay of colonization: Reducing maternal MS reservoirs, avoiding or delaying MS transmission, and implementing preventive practices for the child can help delay the colonization process. Maternal MS reservoirs can be suppressed by dietary counseling, reducing the frequency of simple carbohydrate intake, applying topical chlorhexidine and/or fluoride, removing and restoring active caries, and chewing xylitol-containing chewing gum. Evidence suggests that the use of xylitol chewing gum (at least 2 or 3 times per day by the mother) has a significant impact on mother-child transmission of MS and decreasing the child's caries rate. Avoidance or delay of MS transmission can be accomplished by educating the mother or caregiver on behaviors that directly pass saliva to the child (e.g., sharing utensils or cups, cleaning a dropped pacifier by mouth). Routine preventive efforts should include toothbrushing, optimizing the child's fluoride exposure, and limiting the child's frequency of carbohydrate intake.
The American Academy of Pediatric Dentistry (AAPD) recommends:
- All primary health care professionals who serve pregnant women provide education on the etiology and prevention of early childhood caries. Oral health counseling and referral for a comprehensive oral examination and treatment during pregnancy is especially important for the mother.
- The curriculum of all medical, nursing, and allied health professional programs include education in perinatal oral health, including the infectious etiology of early childhood caries, methods of oral health risk assessment, anticipatory guidance, and the need for early establishment of a dental home.
- Parents/caregivers establish a dental home for infants by 12 months of age.
- Legislators, policy makers and third party payors be educated about the benefits of perinatal intervention in order to support efforts that improve access to oral health care for pregnant women, including more frequent and comprehensive services.