During the forty plus years that I have been in practice, I have been amazed at how few physicians view dental health as part of overall health. Even though the inflammation from periodontal disease has been linked to other chronic illnesses such as heart disease, diabetes, and cancer, it seems that the mouth and teeth are often ignored as part of the dialogue. Dentistry is truly a sub specialty of the medical field and should be viewed as such. Diagnosis and treatment of diseases within the oral cavity and those that manifest symptoms there need to be part of the larger conversation in every wellness plan. This is never more crucial then when a woman is pregnant. Yet you rarely see a dentist as part of the pre-natal team.
I have found that even OB/GYN’s are not as knowledgeable at times regarding the unique changes that occur in the oral cavity during pregnancy. In addition, there are varying opinions about what procedures, medications, anesthetics, etc. are safe for their patients. When I have encountered this, I try to make it a point to be a resource for the physician as well as an advocate for my patient. In addition, it is an opportunity for practice growth by showing, knowledge, patience and empathy. Never is a woman more motivated to take care of herself and her family.
Pregnancy creates huge shifts in the body’s mechanisms in order to accommodate the growing fetus. The hormonal and physiological changes are evidence of the extra stress on the mother as the host. We know that these complex hormonal and physiological changes create an increase in the inflammatory process in the mouth as evidenced by the prevalence of Pregnancy Gingivitis and Pyogenic Granulomas. There is a debate, about whether periodontal disease can cause pre-term birth. It is a multifactorial dilemma. Conflicting literature aside, it is a known fact that the bacteria from plaque once released into the circulation can cross the placenta. Informing patients of this fact is a motivating factor to begin to have better habits regarding their home care.
When a woman experiences the significant rise in hormones, she is frequently nauseated. Expectant mothers suffer from varying degrees of morning sickness and, in my opinion it is a misnomer since many women feel sick all day when they are pregnant. (Ask me how I know…) If vomiting occurs on a regular basis, their teeth are being bathed in stomach acid and erosion is a concern. While this tends to ease up after the first trimester, the prevalence of acid reflux throughout the nine months will cause the same deleterious effect.
We also know that daily nutritional requirements increase to support the growth of the fetus. Pregnancy usually causes an increase in hunger, more frequent meals, and sometimes cravings of sugary foods and drinks. While women are most likely instructed by their doctor about eating right for the health of the baby, they need to also be counseled about the effect frequent consumption of sugar and refined carbohydrates have on their teeth. It is not that eating the sugar is so bad, particularly if they have good oral hygiene. They need to know that the more frequently they are eating these foods, the more frequently they are giving their teeth a sugar bath.
The American Dental Association, the American Congress of Obstetricians and Gynecologists and the American Academy of Pediatrics all have made statements encouraging women to get dental care while pregnant. There are varying opinions on what procedures should be performed and what should be postponed until after delivery. Topical anesthesia is considered very safe however there seems to be some confusion about lidocaine with and without epinephrine. A study published in the August 2015 issue of the Journal of the American Dental Association1 followed a group of pregnant women who had procedures that used anesthetics like lidocaine shots and a group that did not. The study showed these treatments were safe during pregnancy, as they cause no difference in the rate of miscarriages, birth defects, prematurity or weight of the baby. In addition, dental radiation, particularly digital imaging is very low. You can reassure your patient of this fact and make sure you use a lead apron to cover their abdomen as well as a thyroid collar.
Hyperventilation, dyspnea, and hypoxia may occur due to increased requirements for maternal- fetal oxygen, airway edema and upward displacement of the diaphragm by the developing baby. This may make it difficult for the patient to breath when placed in a supine position in the chair. The weight of the fetus and the uterus in the supine could also compress the vena cava causing orthostatic hypotension. Tilting the patient on her left side will relieve the pressure on the vena cava. Consideration for the patient’s need to urinate more frequently should be addressed as well.
Some dentists struggle with what is safe and appropriate dental treatment for a pregnant patient. Understanding the essential guidelines is of paramount importance. Oral Health Care During Pregnancy: A National Consensus Statement was published in 20122 by the National Maternal and Child Oral Health Resource Center at Georgetown University. The statement provides detailed guidance for both prenatal and oral health professionals encouraging preventive, diagnostic, and restorative dental treatment throughout pregnancy. They stress that it is safe to have dental care and urge focusing on the need for improvement and maintenance of oral health. They also recommend providing oral hygiene instructions, and education on healthy eating. Included in these guidelines are indications and contraindications for analgesics, antibiotics, anesthetics, and antimicrobial agents.3,4
Make sure you have a place on your medical history where a patient can indicate if they are pregnant. A mother to be will most likely have a heightened interest in oral health and it is important to maximize this teachable moment. This will present an opportunity for your dental team to discuss optimal self-care and appropriate use of dental services for both herself and her infant. By consulting with her physician, you are opening the door to collaborate with a multidisciplinary array of pre-natal healthcare professionals and a chance to achieve a better outcome for your patient. In addition it creates referral opportunities.
- “Pregnancy Outcome After In Utero Exposure to Local Anesthetics as Part of Dental Treatment: A Prospective Comparative Cohort Study” by Dr. Aharon Hagai and colleagues (Hagai A, Diav-Citrin O, Shechtman S, Ornoy A. JADA. 2015;146[8]:572-580) to be an important addition to the literature.
- Oral Health Care During Pregnancy Expert Workgroup. Oral Health Care During Pregnancy: A National Consensus Statement. Washington, DC: National Maternal and Child Oral Health Resource Center; 2012.
- Gaffield ML, Gilbert BJ, Malvitz DM, Romaguera R. Oral health during pregnancy: an analysis of information collected by the pregnancy risk assessment monitoring system. J Am Dent Assoc. 2001;132(7):1009-1016.
- Steinberg BJ, Hilton IV, Iida H, Samelson R. Oral health and dental care during pregnancy. Dent Clin North Am. 2013;57(2):195-210.