Critical Issues in Dental Hygiene Improving Oral Health Outcomes from through Infancy

Lori Rainchuso, RDH MS Introduction Abstract Oral health plays a crucial role in Purpose: The purpose of this paper is to provide an overview the overall health and well-being of of current professional guidelines regarding oral health care a pregnant woman and her newborn through pregnancy and infancy stages, and to include risks as- child.1-3 The 2000 Surgeon Gener- sociated with treatment, as well as health care providers’ beliefs al’s oral health report called for the and attitudes surrounding treatment of these specific popula- elimination of oral health disparities. tions. Although dental treatment during the second trimester is The report drew attention to the im- ideal, there is no indication that preventive or restorative dental portance of changing attitudes and treatment during any trimester of pregnancy can cause harm beliefs among health care providers, to the mother or developing fetus. Despite these recommenda- as well as in the community. In ad- tions, routine dental care is often voluntarily avoided or post- dition, the importance of oral health poned for the duration of pregnancy. Post-delivery, preventive treatment during pregnancy is high- oral care is typically postponed for a child until 3 years of age, lighted as an important strategy to years after the first tooth has erupted. While most health care potentially improve maternal and in- professionals agree on the importance of good oral health in fant health.4 every stage of life, it is not being addressed. Whether it is based on misconceptions or lack of knowledge, health care providers Pregnancy is not the time to defer are performing inadequate oral care for these patients. dental examinations and necessary Recommendations to increase health care during pregnancy treatment. Dental care can be ren- and infancy should include improved advocacy of the estab- dered safely throughout the preg- lished oral health care guidelines within each professional or- nancy, though experts agree that ganization. In addition, curriculum revision should occur at the due to first trimester morning -sick university level, to ensure future health care professionals will ness, and the third trimester level have a strong oral health foundation. Lastly, a collaborative ef- of comfort and risk of postural hy- fort needs to occur between all health care providers to better potension, the second trimester of treat the patient’s overall health, not only the specifics of one the gestational period is most ide- professional discipline. As health care professionals we are all al.3,5,6 According to a study utilizing responsible for the complete well-being of our patients, and an oral health data from the Centers for interdisciplinary approach will better ensure we accomplish this Disease Control Pregnancy Risk As- task. sessment Monitoring System, many Keywords: pregnancy, oral health, infant oral health, oral dis- women do not receive dental care ease prevention, anticipatory guidance, dental home, interdis- during their pregnancy.7 In addition, ciplinary collaboration only half of the women who report- ed actually having a dental problem This study supports the NDHRA priority area, Health Promo- during their pregnancy were seen by tion/Disease Prevention: Assess strategies for effective com- a dental professional.7 munication between the dental hygienist and client.

Despite numerous research publi- cations, professional guidelines and government re- is recommended that all health care professionals ports regarding the importance of good oral health who serve pregnant women provide the following: throughout pregnancy, health care professionals an oral health risk assessment, counseling of etiol- from both the medical and dental spheres contin- ogy and transmission of cariogenic bacteria to their ue to under-treat women during pregnancy.5,6,8 It newborns, referral to an oral health provider for a

330 The Journal of Dental Hygiene Vol. 87 • No. 6 • December 2013 comprehensive examination and assistance in the they seldom asked about the pregnant patient’s establishment of a dental home for their infant.2,9 current oral health, inquired about dental visits or Early intervention and guidance during the perina- provided oral health information. In addition, over tal period from all health care providers is impera- a third of the respondents stated that they did not tive for the mother and infant.2 advise patients to see a dentist for routine dental care. The study also revealed that most do not dis- Current Health Care Perceptions cuss pre-planning methods for preventing dental caries in young children (95%, 91%).11 An Oregon study revealed that general practic- ing dentists’ perceptions and perceived barriers had The study asked basic oral health knowledge the strongest direct effect on their not providing questions in which the majority (57%) acknowl- care to patients during pregnancy. Of these barri- edged they were not qualified to recognize symp- ers, the most significant were: perceived time, eco- toms of , and that training in nomic costs and dissatisfaction with reimbursement medical school and residency, on the screening and compensation.10 The greatest perceived barrier was assessment of oral health issues, was non-existent indicated as economic cost: 72.9% of dentists in- or inadequate. Furthermore, most respondents dicated that compensation by insurance companies stated they were not familiar with any oral health was inadequate for time spent counseling pregnant and pregnancy guideline publications.11 In addi- patients.10 tion, the study showed that a majority of OBGYN physicians recognize the importance of good oral The survey revealed that dentists in Oregon have health during pregnancy, yet they do not address a high level of incorrect knowledge about routine it. With improved advocacy and promotion of oral and emergency procedures concerning prenatal health education, OBGYNs may become more com- women. For restorative services, almost one third fortable with assessing and addressing oral health of dentists indicated they would not perform com- with their pregnant patients.11 By assimilating the posite restorations at any stage of pregnancy. Ap- current dental guidelines regarding oral care of the proximately 50% indicated they would not perform pregnant patient into an OBGYN standard of care composite restorations during a dental emergency. practice, improvement of overall health for both For nonsurgical periodontal treatment the survey mother and child could be achieved. revealed that 57% would not provide this service during the first trimester of pregnancy, 22% during Oral Health Care Guidelines the second trimester and 46% would not provide and Recommendations this service during the third trimester of pregnancy, and 69.2% would not provide this service during Pregnancy commonly creates physical effects a dental emergency involving a severe periodontal that may negatively impact routine oral self-care. abscess and infection. More than half of the dentists Women frequently experience nausea which often indicated they were reluctant to perform routine leads to avoiding practices like tooth services during the pregnancy, and three-quarters brushing, increasing the possibility for dental car- were reluctant to perform services to relieve pain or ies. In addition, women may be experiencing fre- swelling associated with a dental emergency. De- quent vomiting, which compounds the risk of tooth spite the established perinatal guidelines attitude erosion and dental caries.1 To counteract the acidity barriers remain, and negatively impact general of the oral cavity after vomiting, and reduce the risk dental practitioners’ current practices.10 Although of tooth erosion, it is recommended to swish with a the research focused on the state of Oregon, this is teaspoon of baking soda dissolved in a cup of water, expected to be a nationwide trend of practice. and to avoid brushing immediately after a vomiting occurrence.2 Once the acid is neutralized, the teeth Dental professionals are not the only ones re- may be brushed using a soft-bristled toothbrush sponsible for the under-treatment of oral health and fluoridated toothpaste.2 care during pregnancy. Research shows that obste- trician-gynecologists (OBGYNs) have not been ad- Furthermore, increased appetite and frequent dressing the oral health needs or conducting oral snacking of cariogenic foods may also contribute health assessments for their pregnant patients. A to caries development. Pregnancy is an ideal time national study, assessing how OBGYNs addressed for dental professionals to conduct a dietary analy- oral health during pregnancy, showed 84% out of sis. Patients should be educated on the importance the 351 respondents agreed that routine dental of eating nutrient dense foods that promote oral care during pregnancy is important.11 Those sur- health. Providers should include a discussion re- veyed also thought periodontal disease could have garding the relationship of frequent snacking on adverse effects on pregnancy outcomes, however, simple carbohydrate foods, sweetened beverages

Vol. 87 • No. 6 • December 2013 The Journal of Dental Hygiene 331 (including juices) and caries development. up towel, to elevate the right hip and displace the uterus to the left. Having the patient lean to their Untreated dental caries in mothers increases the left side releases uterine pressure off the inferior risk of caries development among their children, as vena cava, and promotes oxygenation. Semi-su- maternal transmission and early childhood caries pine position may also be advised for patient com- (ECC) has been established.5,12 The vertical trans- fort. These simple positioning modifications can mission of Streptococcus mutans, from mother to prevent dizziness, nausea and supine hypotensive child, has been well documented. Mothers with syndrome. In addition, dental appointments should poor oral health and high levels of cariogenic bac- be short in duration (Table I).2,5,13 teria are at a greater risk for infecting their children with the bacteria and increasing their children’s Guidelines for dental radiographs during preg- caries risk at an early age.13,14 Therefore, decreas- nancy have been established. Recommendations ing the maternal cariogenic bacterial load is vital advise that dental radiographs are safe throughout to the prevention or delaying of the infant devel- pregnancy, and that x-ray exposure for a diagnos- oping ECC.3,5,12,15 The cariogenic bacteria is trans- tic procedure does not cause harmful effects to the ferred by way of exchange through various developing embryo or fetus.22 Dental professionals behaviors such as cleaning the infant’s mouth with should follow the ALARA (As Low as Reasonably a saliva-moistened cloth, sharing of eating utensils Achievable) principles to minimize the patient’s ex- or cleaning a dropped pacifier or teething toy via posure to radiation. The number and types of ra- the parent’s mouth.3,5,12,15 Oral health counseling diographs will depend upon the clinical conditions during the perinatal stage can be beneficial in the and patient’s health history. As standard practice, prevention of ECC development. precautions should be taken, therefore, protective aprons and neck shields should be worn.23 Strategies that will decrease mother-to-child transmission of cariogenic bacteria include the Fluoride therapy during pregnancy can be ad- treatment of the mother’s present dental caries, vantageous in the strengthening of enamel and the improved oral self-care, dietary counseling, fluo- prevention of dental caries. Professional fluoride ride and xylitol. Xylitol supplementation has shown varnish application for caries prevention has been benefits in reducing maternal levels of cariogenic endorsed by the American Dental Association.16 bacteria.3,5,16 Xylitol is a naturally occurring sugar Since it has not been cleared for marketing by the alcohol that has been shown to lower Mutans strep- U.S. Food and Drug Association for this purpose, tococci levels in biofilm and saliva, resulting in re- it remains an “off-label” use of the product. There duced dental caries.17 Evidence suggests that the are many benefits to using fluoride varnish, such use of xylitol sweetened chewing gum (at least 2 as time efficiency, patient acceptance and compli- to 3 times a day by the mother in dosages of 5 to ance over other professional fluoride methods.16 10 grams) has a significant impact on mother-child Additionally, pregnant women should be advised to transmission of Mutans streptococci and decreas- use a fluoridated toothpaste and over-the-counter ing the child’s caries rate.14,17-20 One study showed mouth rinse containing 0.05% sodium fluoride once that mothers who chewed xyilitol gum (at least 2 a day or 0.02% sodium fluoride rinse twice a day to 3 times a day on average, starting at the sixth for enamel remineralization and caries prevention.2 month of pregnancy, and continued for 13 months) had children significantly less likely to show Mutans Routine prophylaxis and periodontal scaling and streptococci colonization than the control group root planing may be provided during pregnancy. children ages 9 to 24 months. The children whose According to the American Academy of Periodon- mothers did not chew xylitol gum acquired Mutans tology, “For pregnant women, proper periodontal streptococci 8.8 months earlier than those whose examination and treatment, if indicated, can have mothers did chew the gum. The study suggested a beneficial effect on the health of their babies.”24 that maternal xylitol gum chewing may show ben- Furthermore, advanced periodontal treatment may eficial effects to reducing transmission of cariogenic be rendered safely, during the beginning of the sec- bactiera.21 ond trimester. To ensure the health of both mother and child, the American Academy of Periodontology Rendering of Dental Care during Pregnancy urges for the prompt treatment of acute periodon- tal infections during any stage of pregnancy.24 Patient positioning modifications during the third trimester of pregnancy should be considered. Lying Professional guidelines regarding pregnancy back in the dental chair can be uncomfortable in the advocate for continuation of restorative care.3,5,6 final weeks of pregnancy. Due to the increased size Restorative therapy to remove carious lesions to of the uterus, it is advised to use a pillow or rolled improve the mother’s oral health and reduce the

332 The Journal of Dental Hygiene Vol. 87 • No. 6 • December 2013 cariogenic bacterial load can occur during preg- ment to prevent fluorosis.16 Lastly, dietary educa- nancy.5,6,9 Short term exposure of dental composite tion includes the discussion of the cariogenicity of restorations and sealants suggests no health risks. certain foods and beverages, the consequence from Furthermore, amalgam placement has been reaf- frequent consumption of sugary beverages and firmed as safe, when best practices are utilized.25,26 foods, and the demineralization process. The dental There is no significant data for long term usage of team should discourage parents putting their infant these dental treatments.5 to bed with a bottle containing anything other than water, after the first tooth eruption.9,14 A study reporting the associations between ad- verse pregnancy outcomes and essential dental treatment did not significantly increase the risk of any adverse outcomes to mother or fetus. The Conclusion research included both temporary and permanent When rendering best practices, dental profes- restorations, endodontic therapy and extractions.6 sionals may safely treat women during pregnancy. In addition, dental professionals administered lo- Pregnancy is not a time to postpone preventive or cal anesthesia as deemed appropriate during treat- therapeutic dental care. Pregnancy can be an op- ment. The study was conducted during the gesta- portunistic time when women may be more recep- tional period of 13 to 21 weeks.6 tive to oral health information and treatment, and for women of low-socioeconomic status, may be the Infant Oral Health only time they are eligible to receive dental care coverage.8,15,18,21,28 Oral health promotion during Dental care during pregnancy includes educat- pregnancy will ensure both improved oral health for ing the mother about the importance of infant oral the mother, and encourage a healthier future for the health. An infant should receive a dental exam at oral cavity of the child. In order for optimal care age 6 months, or by the eruption of the first prima- during pregnancy and infancy to occur, the future ry tooth. Parents should establish a dental home for health care model must involve interdisciplinary col- infants by 12 months of age. Early establishment laboration. of a dental home is crucial in ECC prevention and intervention.3,5,9,14,27 Oral health care during pregnancy should be a shared responsibility among the prenatal profes- Anticipatory guidance helps a parent learn what sional, patient and dental team. To increase oral to expect during their infant’s present and future health access to these specific populations, the fol- developmental stages. Oral health preventive lowing must occur: OBGYNs informing patients of counseling should include oral hygiene, fluoride ex- the importance of oral health and disease preven- posure, nutrition and diet, nonnutritive oral hab- tion during pregnancy, increasing patients’ knowl- its (such as pacifier use and thumb sucking), den- edge base to enable self-advocacy and educating tal trauma, and injury avoidance.2,9 Best practice dental professionals about the importance of treat- brushing technique involves lifting the lip away to ing patients during pregnancy and infancy. The expose the cervical one-third portion of the anterior dental community must promote an awareness of teeth. This technique has a 2-fold purpose, to effec- oral health being an essential part of overall care, tively brush at the gumline and examine for early and discourage the belief of oral health as a form of carious lesions. Parents should be advised to brush supplemental care. Improving the communication their child’s teeth twice daily, using a smear layer of health care disciplines, as well as, encouraging of fluoridated toothpaste on a child size toothbrush medical-dental student collaboration and interdisci- is advised for an infant of moderate to high caries plinary scholarship among health professionals, will risk, and a pea-sized amount of fluoridated tooth- ultimately provide mutual patients with better over- paste for children older than 2 years of age. Pa- all health care and well-being. rental brushing from infancy, as well as supervised brushing up to 8 years of age, is recommended for Lori Rainchuso, RDH MS, is an assistant profes- effective removal of biofilm, and to prevent exces- sor and Interim graduate program director, Forsyth sive intake of fluoridated toothpaste.5 All necessary School of Dental Hygiene, MCPHS University in Bos- precautions should be taken during tooth develop- ton.

Vol. 87 • No. 6 • December 2013 The Journal of Dental Hygiene 333 References

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