Periodontal Disease,
Health Risks, and
Management of
Pregnant Woman
Alice Surine and Mariela Coronado
March 27th 2014
Introduction
Pregnancy influences major physiological transformations in a women’s health, including
changes in the oral cavity. Studies have provided evidence- based findings of many adverse
effects on both the mother and the fetus. Pregnancy induces a greater risk for gingivitis, dental
decay, and periodontal disease. Hormonal imbalances, dietary fluctuations, and other pregnancy
symptoms promotes these dental complications. Having dental disease while pregnant can cause
both maternal and neonatal risks, including Gestational Diabetes Mellitus, preeclampsia and
preterm birth. Research also shows that oral health is key to overall health and well-being [1] and
dental care is essential for prenatal health.
Caries
Pregnant women may have a higher risk of developing tooth decay. Even though there is
no proven relationship between dental caries and pregnancy, hormonal changes may produce a
negative role. [2] Dental decay is an infectious disease that over time causes demineralization and
destruction of a tooth structure. According to A. George et al., the hormones progesterone and
estrogen can increase the permeability of oral blood vessels. [3] The decrease in permeability
decreases the immune response, which increasing the susceptibility of pregnant women to oral
infections. The leading bacteria responsible for metabolizing sugars into acid and causing tooth
decay is mutans streptococci. [2] During pregnancy, there is an increase in appetite and cravings
which can influence frequent snacking. A consistent desire for sugary snacks may lower a
person’s pH in saliva. [3] Mutan streptococci is more likely to adhere to the tooth structure, thus
predisposing the risk of tooth decay. Hormonal changes in the body can also induce the common
side effect of vomiting, can also elevate the amount of bacteria in the oral cavity. [2] Vomit
consists of stomach acids that when in contact with teeth may cause tooth erosion. Tooth erosion
damages and softens enamel which can lead to demineralization. [1]
According to the American Academy of Pediatric Dentistry, modification of the mother's
oral hygiene and diet can have a significant effect on mutan streptococci bacteria levels. [4] A
pregnant women who consumes sugary snacks often can be educated to snack on nutritious
choices like fruits and vegetables; fruits also contain acid, which if consumed frequently may
cause cavities. If morning sickness occurs, rinsing with sodium bicarbonate rinse after vomiting
can neutralize acid. [4] In addition, brushing immediately after vomiting can irritate the enamel
due to the current acid levels. [3] Brushing should be done an hour after vomiting to prevent
erosion. Chewing gum containing xylitol after eating can also help recover salivary flow.
Gingivitis
If bacteria in the oral cavity is not controlled, it can lead to gingivitis. Gingivitis is the
most common oral disease during pregnancy. Pregnancy gingivitis is originated by plaque and
aggravated by endogenous sex steroid hormones. [5] It causes the gum to redden, swell, and bleed
easily. [3] According to research, it affects 36-100% of pregnant women. [4] A study conducted by
Elena Figuero revealed, non-pregnant women had lower mean gingival index (GI) values than
women in their second or third term pregnancy. The lower the GI, the less bleeding and
inflammation recorded in the gums. The study also indicated a lower GI during the first trimester
versus the second or third trimester. [5] The results showed that pregnancy gingivitis usually
occurs during the second or third trimester and can lead to poor pregnancy outcomes.
Periodontal Disease
Periodontal disease is an inflammatory disorder that affects the surrounding and
supporting tissues of the teeth, including the periodontal ligament and alveolar bone. Toxins
produced by the bacteria stimulate a chronic inflammatory response that results in the breakdown
of surrounding bones and tissues. [1] This condition is produced in combination with an increase
in the percentage of anaerobic bacteria, especially Prevotella intermedia, which is caused by the
increase in the serum levels of circulating estrogen and progesterone. [6] By the end of
pregnancy, progesterone levels have increased ten-fold and estrogen levels have increased 20fold over those observed during the menstrual cycle. [6] Studies have indicated that periodontal
pockets serve as a chronic reservoir for the translocation of bacteria (mostly Gram-negative
bacteria, such as Porphyromonas gingivalis). [6] Translocation of bacteria can lead to significant
complications in systemic health, and can also be linked to cause both maternal and neonatal
complications during pregnancy.
Pregnancy Complications and Periodontitis
Pregnancy is characterized by complex physical and physiological changes that have
significant impact on almost every organ system of the body, including the oral cavity. [7] Of the
above oral conditions that were presented, periodontal disease have been linked to influence
negative changes to the systemic health of the mother and fetus. The maternal complications
include preeclampsia and gestational diabetes mellitus. The most prominent neonatal
complication related to periodontal disease include preterm birth. Because there are many risks
involved with periodontal infection and pregnancy, management and treatment should be
provided for pregnant women throughout their pregnancy.
Preeclampsia
Preeclampsia is a disorder of worldwide significance and is one of the leading causes of
maternal morbidity and mortality in the western world. [8] It is characterized by abnormal
vascular response to placentation manifesting as generalized vasospasm, activation of
coagulation system, and reduced organ perfusion affecting the kidneys, liver, and brain. [9] Signs
of preeclampsia reveal a blood pressure equal or greater than 140/ 90 mmHg after the week 20 of
pregnancy along with +1 proteinuria (protein) in urine sample. [9] In pregnancy, the immune
response plays a pivotal role in maintaining a healthy equilibrium between the mother and fetal
allograft. Because periodontal disease is also associated with low-grade inflammation, it can be
hypothesized that patients with periodontal disease may have an increased risk of developing
preeclampsia. [8] To test this theory, Dr. Mamatha Shetty et al., conducted a study on 130
pregnant women between 26 and 32 years of age. Measurements of pocket depth, gingival index,
gingival recession, and clinical attachment were observed. The prevalence of periodontitis
among women in the study population between 80- 90% at recruitment and delivery. All of the
women in the preeclampsia group showed signs of periodontitis. Although the findings were
significant, both periodontitis and preeclampsia are multifactorial in etiology and conclusions
regarding causal associated between the two may be premature. [9]
Other studies have also supported the theory that periodontal disease is a factor in
preeclampsia. Dr. Sayar et al., presented a case-control study that consisted of 210 pregnant
women (105 controls and 105 cases). The control group presented a normal blood pressure
without proteinuria, and the case group were defined as having a blood pressure of greater than
140/90mmHg and proteinuria +1. Both groups were examined 48 hours after delivery and
measurements of Plaque Index (PLI), Pocket Depth (PD), Clinical Attachment Level (CAL),
Bleeding On Probing (BOP) and Gingival Recession (GR) were recorded. Results verified that
the preeclampsia cases had significantly greater CAL, GR, and BOP, which are specific factors
of periodontal disease. They concluded that the preeclamptic cases were 4.1 times more likely to
have periodontal disease. [10]
Gestational Diabetes Mellitus
Gestational Diabetes Mellitus (GDM) is defined as the carbohydrate intolerance of
variable severity with the onset or first recognition during pregnancy. [11] Coustan D.R., Lowe
L.P., Metzger B.E., et al. conducted a study in which they found numerous risks neonatal and
maternal risks involved with GDM. Some of the serious risks included macrosomia (excessive
birth weight), primary cesarean delivery, clinical neonatal hypoglycemia, preterm birth,
admission for neonatal intensive care, and preeclampsia. [12]
Dr. Sanz M, Kornman K, et al. suggests that the strongest evidence from both animal and
human studies supports the concept that periodontal infections provide a portal for
haematogenous dissemination (spreading via blood) of oral microorganisms and their products,
which reach the foetal–placental unit. This direct pathway is associated with inflammatory/
immune responses in the foetal– placental unit that induce a range of adverse outcomes, which
are dependent on timing and severity of exposure. [1] Evidence also proposes that sustained
elevated levels of IL-6 and TNF-a (inflammatory mediators) can interfere with carbohydrate
metabolism and consequently cause glucose intolerance, resulting in GDM. [13] These
inflammatory mediators are also found in increased levels in periodontal disease.
Chokwiriyachit A. et al. examine the association between periodontitis and GDM among
non-smoking pregnant females in a case-control study including 50 females who were diagnosed
with GDM and 50 age and hospital matched females without diabetes. Full-mouth periodontal
exams were performed and serum samples were collected to measure the level of inflammatory
mediators existing. Results showed that 50% of the case females had periodontitis compared to
26% of the controls and there was a significant presence of inflammatory mediators in those
cases with periodontal disease. [13] This study strongly suggests that the inflammatory mediators
present in periodontal disease, can have an effect on maternal inflammatory response, inducing
Gestational Diabetes Mellitus.
Preterm Birth
Periodontal disease is already perceived to be a risk in maternal health, and it also has
been proposed to correlate with neonatal complications. One of the most prominent neonatal
risks induced by periodontal disease is preterm birth. Preterm birth is defined as having the
delivery before the 37th gestational week and is generally accompanied with a birth weight less
than 2500 g (5.5lbs). [14] Approximately 20% of infant deaths are due to preterm birth, and
survivors experience significant and life- long morbidity. The mechanism of periodontal disease
associated with preterm birth is not clear, but likely involves maternal and fetal inflammatory
and immune response to the infection burden. [15] Many studies have been conducted in order to
find this association.
Offenbacher S, Boggess KA, Murtha AP, et al. found that maternal periodontal disease,
identified either early in pregnancy or progressing during pregnancy, is a risk factor for preterm
and very preterm birth, respectively, independent of other risk factors. The study included 1,020
pregnant women who received both an antepartum and postpartum periodontal examination. This
study suggested that if pre-existing periodontal disease becomes active during the pregnancy, it
may pose a significant linked infectious or inflammatory exposure during the pregnancy, as
would the onset of new disease, causing the preterm birth. [16]
Another study presented by S. Zadeh-Modarres, et al. supported the idea that the
inflammation process in periodontal disease influences preterm birth. In this case-control study,
201 pregnant women without systemic disease or other risk factors for preterm labor were
chosen. Subjects were measured on the frequency of brushing, duration of pregnancy and
probing depth, bleeding index and debris index were also considered. Findings from this study
indicate that the inflammation process and the production of endotoxins induced by Gramnegative bacteria, as is the case in periodontal disease, lead to the production and release of
cytokines and prostaglandins. Such factors in sufficient amounts, can induce delivery. [17]
Management
Pregnancy induces many risks and complications and prenatal care is needed not only the
medical field but also in the dental field. Reports show that only 22.7 to 34.7% of women are
going the dentist during pregnancy.[18] Early intervention and counseling during the perinatal
period from all health care providers (eg, physicians, dentists, nurses) are essential to ensure
good oral health and systemic health for the mother and infant. [4] Many misconceptions of the
safety of providing maternal dental care has been presented, both to dental professionals and to
pregnant women. Pregnant women deserve the same level of care as any other dental patient, and
clinicians now have evidence based verification that shows appropriate dental care as being both
necessary and safe during the perinatal period. [19]
When dental treatment is indicated, standard practice should be presumed, even with a
pregnant patient. Treatment options may include dental prophylaxis and exam, diagnostic
radiographs, periodontal therapy, administration of local anesthetics with epinephrine and
restorations, Rubber dam placement is permitted when implementing composite or amalgam
restorations, to ensure the airway is blocked from debris. Amalgam is a restorative material that
is silver in color and contains mercury. Many misconceptions of mercury poisoning from dental
restorations has prevented patients from receiving treatment. There is no evidence that fetal
exposure to mercury released from the mother’s existing amalgam restorations causes any
adverse effects. [4] Removal of active caries with subsequent restoration of the remaining tooth
structure is important to suppress maternal mutan streptococcus (MS- mutans streptococci;
bacteria found in dental decay) reservoirs. Removal of dental decay has the potential to minimize
the transfer of MS to the infant, thereby decreasing the infant’s risk of developing early
childhood caries. [4]
In addition of treating dental disease, many medications used in dentistry for pain
management, antibiotics and antimicrobials are safe for use. The National Maternal and Child
Oral Health Resource Center presents guidelines for dental practitioner. Antibiotics and
analgesics for treating infection and controlling pain may be used, including acetaminophen,
codeine, and amoxicillin. [4] [19] The consequences of not treating an active infection during
pregnancy out-weigh the possible risks presented by most of the medications required for dental
treatment. [4] 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. [4]
Conclusion
Oral health is a significant component of general health and should be maintained during
pregnancy and through a woman's lifetime. In 2007-2009, 35% of U.S. women stated that they
did not have a dental visit within the past year and 56% of women did not visit a dentist during
pregnancy. [20] Healthy maternal oral hygiene during perinatal period may lower the risk of
possible caries, periodontitis, and gingivitis. It is important to provide dental treatment to
pregnant women due to the risks of complications involved with active dental infection and
disease. In this case, the benefits of receiving treatment out- weigh the risks to the mother and
the fetus.
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