Understanding the Dental Need and Care During : A Review

WC Ngeow, FDSRCS*, W L Chai, BDS**, *Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Universiti Kebangsaan Malaysia, Jalan Raja Muda Abdul Aziz, 50300 Kuala Lumpur, **Department of Conservative Dentistry, Faculty of Dentistry, University of Malaya, 50603 Kuala Lumpur

Introduction A. Pregl'lcmcy Associated lesions

As early as 1928, the importance of prenatal dental care Various oral and dental lesions have been found in has been recognised. However, dentists were warned to pregnant women. This may be a sign of pregnancy treat pregnant women only if an emergency condition associated conditions like anaemia or may be an entity was present. Nowadays, while it is common to that is more prone to occur in pregnant women due to encourage postponement of elective dental treatment the hormonal changes of pregnancy. Certain lesions like until after the baby is born, this should not be dental caries has been blamed on loss of calcium from interpreted to mean that pregnant women should avoid the teeth. The following is a review on some common dental care. In fact, pregnant women need more pregnancy associated lesions and manifestation that is prenatal dental attention; not less or only whenever seen in the oral cavity, namely anaemia, epulis, necessary. This is because they are more prone to , tooth mobility and dental caries. It is hoped develop certain pregnancy associated lesions. that medical practitioners may find some useful information from this review to educate their pregnant This paper reviews the commonly occurring pregnancy patients. associated lesions. The advantage of the trimester approach in managing these patients is highlighted. I. Anaemia The importance of good preventive dental care even Pallor of the oral mucosa may be detected during preg­ before pregnancy is emphasised. The significance of nancy. This is an indication that the mother is suffering prescribing fluoride supplements and the use dental from anaemia, most probably due to iron deficiency. radiography during pregnancy are also discussed. Iron deficiency anaemia is a consequence of the

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increased iron requirement for the formation of foetal IV Teeth Mobility red blood cells. The iron requirement usually increases In addition to the gingival changes, generalised teeth by 1000 mg during pregnancy 1 and this can be met by mobility can be observed '. This is possibly caused by giving the patient iron supplements. The role of the some qualitative changes in the fibrous portion of the dentist is more towards detecting this condition and periodontal ligament 7. This does not contribute to making the appropriate referrals. severe periodontal problems with lots of mobile teeth, provided the pregnant patient maintain good oral II. Pregnancy Epulis hygiene. This condition normally settles after delivery. There is an increase in frequency of pregnancy epulis/tumours in pregnant women, mostly during the V Dental Caries second trimester '. Pregnancy epulis histologically There has been claims that there is an increased incidence of caries during pregnancy. However, this is mimics a '. It happens as a more of an .indirect result of pregnancy. For example, result of exaggerated inflammatory response to local due to gingival tenderness, the patient is prevented from irritation ,. It presents as a painless exophytic swelling maintaining good plaque control. This will ultimately on the gingival margin or interproximal spaces. It is cause increased caries formation due to the accumulation usually found in the canine-premolar region. Pregnancy of plaque '. epulis bleeds easily during rooth brushing or when disturbed. Some pregnant women are prone to develop morning sickness. The regurgitation of gastric acids may lead to Excision is indicated when pregnancy epulis interferes enamel demineralisation '. Besides, mothers are often with chewing, tooth brushing or advised to eat frequent, smaller amounts of carbohy­ procedures. It can be removed easily using surgical drate-containing food to compensate for the decreased blades or laser but the patient must be cautioned that it stomach capacity. This leads to more frequent exposure may recur. Otherwise, it will normally subside after to acid challenges '. In addition, some pregnant women delivery. have a craving for specific foods. These may be sour foods which contain high level of acid or sticky food Ill. Pregnancy Gingivitis with a high concentration of sucrose. Pregnancy gingivitis is common during pregnancy even in those with good oral hygiene prior to pregnancy 3. It Oral hygiene procedures and frequent water rinses will has been suggested that this is due to hormonal changes help prevent decalcification due to morning sickness or during pregnancy 4. The increased level of certain exposure to lots of acidic food 1. If vomiting continues, hormones like progesterone and oestrogen causes the the dentist is able to provide daily topical application of gingiva to swell up 5.6. Plaque may get trapped fluoride gels that will help reduce enamel decalcifica­ underneath the swollen area because of this. Routine tion. Otherwise, flexible mouthguards can be fabricated oral hygiene care will be more difficult. It has also been for the application of neutral sodium or stannous fluo­ suggested that there is an accentuated response to ride gels 1. during pregnancy '. g, Treatment Plannil"lg

Patients may find that their gingiva bleeds Triage spontaneously or during tooth brushing. They must be Treatment planning begins with appropriate triage. reassured that there is nothing wrong with their Emergency procedures like the management of severe brushing technique and should be encouraged to odontogenic infection should be performed at any time continue routine dental care without avoiding the with careful planning and care from the medical bleeding area(s). Normally, the gingiva will stop practitioner to minimise adverse effects'. Urgent bleeding when the affected site(s) is/are properly procedures that can be delayed like minor oral surgeries cleaned. following pericoronitis are best performed after the first

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trimester. Completely elective procedures like the C. Radiography removal of benign epulis are best postponed until six Although it has been known that the dental diagnostic weeks postpartum 9. radiograph causes minimal radiation to the foetus, it 1. Trimester Approach should nevertheless be avoided during pregnancy 1.11. The trimester approach recommends that the ideal Usually the most recent films available in the patient's dental treatment should include two visits during the dental chart will be sufficient during the nine months of first trimester, at least once during the second trimester pregnancy 10.

and once during the third trimester 10. Radiographs should only be taken for emergency The first visit should include a clinical examination indications during the first trimester1 • When coupled with review of the most recently available radiographs are essential, a properly shielded and radiographs. Areas that could possibly pose a problem collimated beam and high speed film are required. or discomfort before delivery should be scheduled for Proper collimation and shielding of the equipment' restoration during the second trimester. Emergency restrict the size of the primary beam and reduce scatter treatment and updating history and medications can radiation. The patient's abdomen needs to be shielded also be done at this initial visit. It should also include with a lead apron. prevention counselling. The patient should be educated on the more common dental problems illustrated above D. Preventive Measurement and the appropriate action taken to prevent or treat 1. Plaque Control these problems. Pregnant patients must be taught the role of plaque in causing dental caries and periodontal problems. They The second visit during the first trimester is needed to should be encouraged to develop a good tooth brushing .. check the patient's compliance of home oral hygiene and fiossing habit. Plaque-disclosing tablets can be used instruction, to observe hormone-related tissue changes to highlight the area not properly cleaned. They should discussed above and to reinforce prevention instructions be advised to brush after each snack that contains sugar. if the patient is found to be neglecting it. Oral lavage of acid is required after regurgitation due to

morning sickness. 12. The pregnant patient should be The second trimester is the ideal time to perform dental educated that through the efforts of increased plaque treatment. The patient is usually more comfortable and control alone, most dental diseases associated with is still able to recline in the dental chair. During this pregnancy like gingivitis and caries can be avoided 13. time, dental treatment proceeds as for any other patients, but precautions noted previously should be observed. Some patients may avoid dental treatment altogether during pregnancy out of fear of adverse effects on the A preventive oral care may be scheduled in the early fetus and because of social taboo. For the patient third trimester. Appointments for these patients should receiving regular dental care, this brief absence from the be kept as brief as possible. dental office is not a problem. However, avoiding necessary treatment out of ignorance is unwise. They Il. Reinforcement should be educated regarding the need for dental care For the pregnant patients who require no dental during this period. treatment during the second trimester, a single visit is sufficient. Patients who have no dental disease or home Il. Nutritional Support care deficiencies at this appointment may be excused Nutrition and diet are important areas of preventive

from the third trimester appointmentlO• Postnatal dentistry for the mother and fetus 10. Nutritional dental care for the new-born may be emphasised at this deficiencies can cause hypoplastic enamel in the primary visit. Patients with mild to moderate gingivitis should incisors 14. There are nutritional guidelines that have another scaling procedure. document ideal levels of all nutrients before, during and

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after pregnancy and the patients should be advised to are not needed by those who live in fluoridated refer to them. communities 10 Others suggested that in fluoridated areas, the optimal dosage of fluoride supplements is of It is not true that the mother "loses a tooth for every 1.0 mg fluoride ion (2.2 mg) once daily on an empty child", a notion which stems ftom the mistaken belief stomach from the third month of pregnancy to term 1. that dental caries occurs due to the loss of calcium from In non-fluoridated areas, 1.5 to 2.0 mg daily is the teeth to the growing fetus. Studies have shown that recommended 15.17. calcium is bound to the tooth structure and it cannot be reabsorbed into the circulation like that of the bony skeleton. The pregnant patient should be made aware of Conclusion this fact and advised not to blame pregnancy for their Medical practitioners should encourage all patients of dental caries. childbearing age to seek oral health counselling and examinations by dentists as soon as they are diagnosed to Ill. Fluoride Supplementation be pregnant. This would break the taboo of wtong The value of prenatal fluoride supplementation to belief that dental treatment should not be undertaken prevent future caries in the child has been controversial during pregnancy. They should be made aware of some and not been confirmed. Neither does the American pregnancy associated lesions and the treatment Academy of Pediatrics nor the American Academy available. of Pediatric Dentistry recommend prenatal supplementation 2. Elective dental treatment shol,lld be avoided during the first trimester. When necessary, emergency procedures Some studies have shown that teeth morphology would can be performed any time during pregnancy and have relatively flat occlusal surfaces with no deep pits or elective surgery scheduled during the second trimester. open fissures if prenatal fluoride supplement was given 15. Despite this finding other researchers conclude Dental radiography is safe, but must only be done for that there is no biologic rationale for prenatal fluoride emergency cases. Minor dentoalveolar surgery and administration 16. periodontal therapy can be performed without difficulty during week 13 through 24 and later, depending on the At the moment, there is still no adequate information comfort of the patient. However, consultation with the regarding the efficacy of prenatal fluoride supplementa­ patient's physician is always advisable. tion. There is suggestion that the fluoride supplements

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2. Miller MC The Pregnant Dental Patient. Calif Dent 11. Little Jw, Fallace DA. Dental Management of the AssocJournal1995; 23: 63-70. Medically Compromised Patient (4th ed). St Louis: CV Mosby Co., 1993; 383-9. 3. Gaudie WM. Influences on : 1. Nutritional and Hormonal Factors. J N Z Soc 12. Grier RE, Janes DR. Dental Management of the Periodontal 1988; 66 : 7-14. Pregnant Patient. Dent Clin North Am 1983; 27 419-28. 4. Hugoson A. Gingivitis in Pregnant Women. Odontal Rev 1970; 21 : 1-20. 13. Tilk MA, Meister F. Treatment of Periodontal Disease Associated with Pregnancy. Dent Surv 1978; 54 : 24-6. 5. Poma PA, Zajdzinski CV, Rana N, Edward LC, Webster A, Septo RC Oral Caviry Evaluation. A Part of Prenatal 14. Alfano MC (Guest Editor). Understanding the Role of Care. IMJ III Med J 1979; 155 : 85-8. Diet and Nutrition in Dental Caries. Changing Perspectives in Nutrition and Caries Research. New 6. Grant DA, Stern IB, Everett FG. Orban's Periodontics, a York: Medcom Inc. 1979: 6. Concept-Theory and Practice. St Louis L: CV Mosby Co, 1972. 15. Glenn FB, Glenn WD, Duncan RC Prenatal Fluoride Tablet Supplementation and Improved Molar Occlusal 7. Loe H. Periodontal Changes in Pregnancy. J Periodontol Morphology. J Dent Child 1984; 51 : 19-23. 1965; 36 : 37-44. 16. Thylstrup A. Is There a Biological Rationale for Prenatal 8. Fiese R, Herzog S. Issues in Dental and Surgical Fluoride Administration? J Dent Child 1977; 48 : 123- Management of the Pregnant Patient. Oral Surg Oral 5. Med Oral Pathol1988; 65 : 292-7. 17. Danforth DN.. Obstetrics and Gynaecology (4th ed). 9. Blass NH. Nonobstetric Surgery in the Pregnant Philadelphia: Harper and Row, 1982. Patient. American Society of Anaesthesiology Review 1984; 12 : 25-31.

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