International Journal of Dental and Health Sciences Review Article Volume 02,Issue 03

ORAL HEALTH STATUS AND TREATMENT NEEDS FOR PREGNANT WOMEN: A REVIEW Mamatha.B1,R. Rekha2,G. Radha3,SK Pallavi4 1.Post Graduate Student,Department Of Public Health Dentistry,V.S Dental College & Hospital,Bengaluru 2.Professor & Head ,Department Of Public Health Dentistry,V.S Dental College & Hospital,Bengaluru 3.Reader,Department Of Public Health Dentistry,V.S Dental College & Hospital,Bengaluru 4.Reader,Department Of Public Health Dentistry,V.S Dental College & Hospital,Bengaluru

ABSTRACT: is a special state for a woman, which is associated with a myriad of emotional and physiological changes in different parts of body including oral cavity and dental health. Thus the present review was undertaken to summarize the available information regarding oral health status and treatment needs of pregnant women in various parts, across the world and to discuss possible dental treatment needs during this period. The study was a systematic review of English-language articles indexed in PUBMED and GOOGLE SCHOLAR which was published from the year 2000-2015 with Medical subject heading (MeSH) terms linked with the maternal oral health like Pregnancy and Oral health etc. Of 179 citations, 11 studies met study criteria and were reviewed. Keywords: Pregnancy, Oral health, Treatment needs.

INTRODUCTION: and physical changes in a pregnant woman.[2] The main systemic changes occur Pregnancy is a special state for a woman, in the cardiovascular, hematologic, which is associated with a myriad of respiratory, renal, gastrointestinal, emotional and physiological changes in endocrine, and genitourinary systems. different parts of the body including oral cavity and dental health.[1] The progressive Pregnancy is accompanied by changes in physiological changes that occur during the oral cavity that affect the hard and soft pregnancy are essential to support and tissues of the mouth.[3] Most pregnant protect the developing fetus and also to women change their eating habits to more prepare the mother for parturition. frequently eating foods rich in Pregnancy involves complex hormonal carbohydrates and acids. This situation is interactions, which cause profound exacerbated by the decrease in salivary pH physiologic changes. The changes that associated with frequent nausea and occur are the result of increasing maternal vomiting. Pregnant women who do not and fetal requirements for the growth of comply with regular and careful oral the fetus and for the preparation of the hygiene often suffer from erosions of tooth mother for delivery. These increased enamel and develop new dental caries. hormonal secretion and fetal growth induce several systemic, as well as local physiologic

*Corresponding Author Address: Dr. Mamatha.B Email: [email protected] Mamatha.B. et al, Int J Dent Health Sci 2015; 2(3):619-627 Oral tissues are also known to be affected and poorer health behaviour.[13] Though by pregnancy with the most frequent and studies were available in past literature greatest changes occurring in the gingival regarding the oral health status of tissue.[4] They may be more susceptible to pregnant women, no such review were since higher made. Hence the present review was concentrations of oestrogen and undertaken to summarize the available progesterone can induce hyperaemia, information regarding oral health status edema and bleeding in periodontal tissues, and treatment needs of pregnant women increasing the risk of bacterial infections. in various parts, across the world and to The incidence of periodontal disease has discuss possible dental treatment needs been positively correlated with lower during this period. educational achievement and lower socio- METHODS: economic status.[5-7] In addition to gingival changes, the other manifestations A thorough literature review was made associated with pregnancy include which engaged most of the articles chloasma (bilateral brown patches in the published in peer reviewed journals relating midface), facial telangiectasia, sialorrhea, to maternal oral health among various tooth surface loss usually related to vomit- populations across the world. The review ing when severe (hyperemesis gravidarum), itself began with the search of relevant increased mobility of teeth, changes in the Medical subject heading (MeSH) terms like severity of oral aphthae. [8] pregnancy, Oral health etc and non-MesH terms like Treatment needs in various The reasons for this likely changes are search engines including PUBMED, multi-factorial and include inadequate oral PUBMED CENTRAL & GOOGLE SCHOLAR. hygiene, limited access to oral health care, Articles published in English language only medical co-morbidities that increase oral were included in the review. The spotlight disease risk, and limited knowledge of the of the present review will be oral health relationship between oral and general among pregnant women, and its dental health among prenatal care providers and management will be discussed. Articles their patients. [9,10] published between the years 2000 to 2015 Apart from the effects of hormonal were only reviewed. Finally of 179 citations, changes, other factors such as HIV 11 studies met study criteria and were infection, lack of dental care, poor oral reviewed. hygiene, smoking, low educational level, DISCUSSION: low employment status, increased age and ethnicity contribute to a worsened Pregnancy is a dynamic physiological state periodontal condition during which is evidenced by several transient pregnancy.[11,12] changes. These can develop as various physical signs and symptoms that can affect Pregnant women with low health literacy the patients’ health, perceptions and also have less pregnancy-related knowledge 620

Mamatha.B. et al, Int J Dent Health Sci 2015; 2(3):619-627 interactions with others in the gingiva.[27] There are two theories for the environment. The patients may not always actions of the hormones on these cells: a) understand the relevance of the Change of the effectiveness of the epithelial adaptations of their bodies to the health of barrier to bacterial insult and b) Effect on their fetuses. A gestational woman requires collagen maintenance and repair. various levels of support throughout this Estradiol can induce cellular proliferation time, such as medical monitoring or while depressing protein production in intervention, preventive care and physical cultures of human pre-menopausal gingival and emotional assistance. fibroblasts. This cellular proliferation During pregnancy, the inflammatory appears to be the result of a specific response to the is increased, population of cells within the parent culture leading to swollen gingiva, which tend to that responds to physiologic concentrations bleed on brushing. The which is of estradiol.[28] caused by the hormonal changes which Sex steroid hormones have also been occur in pregnancy is known as pregnancy shown to increase the rate of folate gingivitis. It is considered to be the most metabolism in oral mucosa. Since folate is common oral manifestation of pregnancy, required for tissue maintenance, increased as it has been reported to occur in up to metabolism can deplete folate stores and 100% of the pregnant women. Pregnancy inhibit tissue repair.[29] gingivitis becomes apparent in the second month of gestation and it worsens as the As an independent risk factor for adverse pregnancy progresses, before receiving a pregnancy outcomes, periodontal disease is peak in the eighth month. In the last month preventable and treatable. Controlling of the gestation, the gingivitis usually plaque by brushing, flossing and decreases and immediately postpartum, professional prophylaxis, including scaling the gingival tissues are found to be and root planning, all help to achieve good comparable to that of normal women. dental health in pregnancy.[30]

Pregnant women are more susceptible to Therefore, improving periodontal status periodontal disease because of female before pregnancy in order to reduce the reproductive hormonal influences. A few occurrence of adverse pregnancy outcomes studies have demonstrated that would be of great importance for public periodontal disease may be associated with health. And understanding the adverse pregnancy outcomes, such as characteristic of periodontal status among [25-26] premature birth and low birth weight. women with childbearing age would play an important role in developing health Sex steroid hormones have been shown to strategies. directly and indirectly exert influence on cellular proliferation, differentiation and Teeth brushing, being the most important growth in target tissues, including oral health behaviour, is still prohibited keratinocytes and fibroblasts in the 621

Mamatha.B. et al, Int J Dent Health Sci 2015; 2(3):619-627 during pregnancy for some people who care professionals need to alter their hold the old Chinese superstition and normal pharmacological armamentarium to gestation reaction such as vomiting would address the patients’ needs versus the fetal make women to reduce the brushing demands. Applying the basics of preventive frequency and time. As a result, poor oral dentistry at the primary level will broaden hygiene leads to the occurrence and the scope of the prenatal care. Dentists development of periodontal disease. should encourage all the patients of the Therefore, it is essential to correct the childbearing ages to seek oral health misleading opinion and reinforce the counselling and examinations as soon as consciousness of oral health behaviour they learn that they are pregnant.[33] among this population.[31] For the first trimester (1-12 weeks) Finally knowledge or awareness to sustain During the first trimester, it is proper during pregnancy is recommended that the patients be very crucial for the wellbeing of the scheduled to assess their current dental pregnant women. Studies have found that health, to inform them of the changes that there was a definite lack of knowledge on they should expect during their the importance of maintaining oral care. and to discuss on how to avoid maternal Failure to attend a dentist on a regular basis dental problems that may arise from these and lack of understanding about the changes. It is not recommended that the importance of maintaining oral hygiene procedures may be done at this time. The may be a cause and it might be because concern about doing procedures during the some women simply cannot afford to first trimester is twofold. First, the maintain an adequate level of dental developing child is at a greatest risk which hygiene or regular dental visits. Educating is posed by teratogens during and motivating women to maintain good organogenesis, and second, during the first oral hygiene and providing affordable trimester, it is known that as many as one dental health care is fundamental in in five pregnancies undergo spontaneous reducing dental disease. Improving dental abortions. Dental procedures which are education may need to become a priority in performed near the time of a spontaneous antenatal care to educate women at risk of abortion may be assumed to be the cause, the importance of maintaining oral which lead to concerns for both the patient health.[32] and the practitioner, as to whether this The dental management of pregnant could have been avoided.[34] patients requires special attention. The current recommendations are Dentists, for example, may delay certain elective procedures so that they coincide 1. To educate the patients about the with the periods of pregnancy which are maternal oral changes which occur devoted to maturation versus during pregnancy. organogenesis. At other times, the dental

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Mamatha.B. et al, Int J Dent Health Sci 2015; 2(3):619-627 2. To emphasize strict oral hygiene question arise about the safety of a instructions and thereby, plaque procedure, particularly if there are special control. circumstances which are associated with the pregnancy.[35] 3. To limit the dental treatment to a periodontal prophylaxis and The current recommendations are: emergency treatments only. 1. Oral hygiene, instructions and 4. To avoid routine radiographs. They plaque control. should be used selectively and only 2. Scaling, polishing and curettage may whenever they are needed. be performed if they are necessary. For the second trimester (13-24 weeks) 3. The control of active oral diseases, if By the second trimester, the organogenesis any. is complete, and the risk to the fetus is low. 4. An elective dental care is safe The mother has also had time to adjust to her pregnancy, and the fetus has not grown 5. Avoid routine radiographs. Use to a potentially uncomfortable size that selectively and when they are would make it difficult for the mother to needed. remain still for long periods. The positioning of the pregnant patients is important, For the third trimester (25-40 weeks) especially during the third trimester. As the The fetal growth continues and the focus of uterus expands with the growing fetus and the concern now, is the risk to the the placenta, it comes to lie directly over upcoming birth process and the safety and the inferior vena cava, the femoral vessels, comfort of the pregnant woman (eg. the and the aorta. If the mother is positioned chair positioning and the avoidance of supine for the procedures, the weight of drugs that affect the bleeding time). It is the gravid uterus could apply enough safe to perform a routine dental treatment pressure to impede a blood flow through in the early part of the 3rd trimester, but these major vessels and to cause a from the middle of the 3rd trimester, condition which is called supine routine dental treatments are avoided. . In this condition, the drops secondary to the impeded The current recommendations are: blood flow, which causes an- asyncopal or a 1. Oral hygiene, instructions and near-syncopal episode. This situation is plaque control. easily remedied by a proper positioning of the patient on her left side and elevating 2. Scaling, polishing and curettage may the head of the chair, to avoid compression be performed if they are necessary. of the major blood vessels. The dental practitioner should not hesitate to consult 3. Avoid an elective dental care during the patient’s obstetrician, should any the 2nd half of the third trimester.

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Mamatha.B. et al, Int J Dent Health Sci 2015; 2(3):619-627 4. Avoid routine radiographs. Use would promote their oral health status. selectively and when they are Nevertheless, pregnancy is a time were needed.[36] women may be more motivated to make healthy changes. So gynaecologists and CONCLUSION: physicians can address maternal oral health Thus it was clearly evident that oral health issues, which would probably reduce the status of pregnant women were poorer risk of adverse pregnancy outcomes with more treatment needs, thus through available preventive measures, establishing a healthy oral environment and early diagnosis, and appropriate maintaining optimal oral hygiene levels management by referring to a dentist.

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Mamatha.B. et al, Int J Dent Health Sci 2015; 2(3):619-627 TABLES: Table 1: Summary of articles published from 2000 - 2015 Authors Year Study Sample Clinical Significant finding Place size parameters Agbelusi GA, 2000 Nigeria 250 OHI-S Increase in OHI-S scores Akinwande JA, CPITN 1ST Trimester OHI-S – 0.72 Shutti YO[14] 2ND Trimester OHI – S – 1.06 3RD Trimester OHI – S – 1.06 DMF – 1.54 Treatment needs Amalgam restoration – 51.72% Extraction – 23.37% Partial denture – 16.38% Rakchanok 2010 Thailand 94 WHO Caries – 74% N, Amporn assessment Gingivitis – 86.2% D, Yoshida Y, Harun-Or-Rashid M, Sakamoto J[15] Karunachandra 2012 Srilanka Rural - DMFT Rural NN, 459 Mean DMFT – 5.4 ± 3 Perera IR, Urban - Urban Fernando G[16] 348 Mean DMFT – 3.69 ± 3.62 Merglova V, Hecova 2012 Czech 142 DMF Treatment need H, Stehlikova Republic 81 – case CPITN Case – 77% J, Chaloupka [17] 61- PBI Control – 52% control Wandera M, 2012 Eastern 713 OHI-S Periodontal problems – 67% Astrom AN, Okullo I Uganda CPITN Poor oral hygiene - 12.1% and Tumwine JK[18] Recent dental visit – 29.8 periodontal symptoms – 65%. Kumar S, 2013 India, 206 DMFT Caries experience – 86% Tadakamadla J, Udaipur WHO Mean caries experience in 1st Tibdewal H , assessment trimester – 3.59 Duraiswamy P, Mean caries experience in 2nd Kulkarni S[19] trimester – 3.59 Cornejo C et al[20] 2013 80 DMFT Gingivitis – 93.75% Gingival Index DMFT - 12.24 +/- 6.48 – Loe & One Missing tooth – 73.3% Sillness Active caries lesion – 92.1% One filled tooth – 53.7% Onigbinde 2014 Nigeria 415 OHI-S OHI – S – 1.26 ± 0.78 O, Sorunke CPI CPI – Women in second trimester M, Braimoh had the highest score, M, Adeniyi A[21] CPI code 2. Amin R & Shetty 2014 India, 153 OHI-S OHI-S and Russel’s periodontal P[22] Karnataka DMFT index were found to be Russel’s significantly higher in pregnant periodontal women when compared to non Index pregnant women Chiga S et al[23] 2015 Japan 20,702 CPI Periodontitis – 32% Basha S, 2015 India, 340 CPI Periodontitis – 41.04% Shivalinga Swamy Karnataka Periodontitis is an independent H, Noor Mohamed risk factor for R[24] poor pregnancy outcome

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