Oral Health & the Pregnant Patient

June 13, 2019

 

As an orthodontist in my final weeks of pregnancy, I felt it fitting to round up some information regarding oral healthcare and pregnancy. I am the first to admit that I experienced my own bout of pregnancy-induced gingivitis, which was quite frustrating! My gums bled when brushing and flossing daily, peaking in the early-mid second trimester. Upon exam and a professional cleaning, my dentist put me on a one-month recall to return for cleanings. Fortunately, this protocol has seemed to put my gingivitis in its place, and my gums are looking much healthier. I recognize that pregnancy is a crazy time, and I myself was culpable of waiting too long to see the dentist! My main takeaway if you don't read through this entirely is, please see your dentist regularly! Pregnant or not; however, it is common that the hormonal fluctuations due to pregnancy may cause a few dental-related matters to flare up. Prevention is always the best route to healthcare! So in this vein, I am going to offer some recommendations in terms of oral healthcare, hygiene, dental treatment and pain management in relation to pregnancy.

 

The first trimester is the most sensitive time in terms of development. Smoking may increase risk of spontaneous abortion, low birthweight, perinatal mortality and SIDS. Alcohol and drug abuse is also risky. In terms of nutrition, don’t skimp out on iron, calcium, folate. I will review these more in a bit.

 

I will try to summarize pregnancy cardiovascular physiology briefly, AKA what is changing in our bodies. There is increased blood volume by 30-60%; cardiac output also increases by 30-40%. These changes can exacerbate a pre-existing heart murmur, so this may be worth discussing with your doctor. Blood pressure often may decrease and increased blood volume may lead to varicose veins and/or edema (fluid build-up usually in extremities). 

 

 

Morning sickness is one of the most characteristic pregnancy symptoms, especially in the first trimester. What exactly causes morning sickness? First there’s increased oxygen demand and intake. Then there is decreased digestive tract mobility, alongside increased gastric acid production and decreased gastroesophageal sphincter activity. A recipe for…? If you do end up vomiting, which may be frequent, it’s important to note: do NOT brush your teeth immediately after vomiting. This can burnish the acid into your teeth and cause erosion. You may rinse your mouth with a teaspoon of baking soda mixed with water to help neutralize the acid (or water alone works well, too). Generally speaking, I don’t recommend brushing your teeth immediately after consuming anything acidic for this same reason. In terms of morning sickness, which is also a misnomer as it may occur 24/7(!), I noticed that nibbling smaller meals as well as simpler foods helped me with this symptom.

 

 

Anyway, on to the teeth! In terms of oral healthcare; it IS SAFE to get cleanings, and if necessary in the case of emergency the use of radiographs (x-rays), pain medication and local anesthesia are also safe. Remember to tell your dentist that you are pregnant! Dental visits should be regularly maintained, as in every 6 months at minimum, and so hopefully a routine visit may be fit in prior to becoming pregnant. Practicing good oral hygiene, a balanced diet and attending prenatal classes will all be helpful. Remember to replace your toothbrush head every 3 months, or when the bristles are frayed! And do not share it. Don’t forget to floss, either. Xylitol-containing gum is okay to use during pregnancy and may reduce oral bacteria. Maintaining proper oral hygiene is important for your baby as well; most infants and young children acquire bacteria that cause decay from their mothers!

 

In contrast to routine dental checkups and treatment of active dental disease, comprehensive and elective dental treatments, such as implants or crowns should ideally be performed after pregnancy. Generally speaking, the second trimester is the most ideal time for a routine dental visit. On the other hand, emergency visits are not to be delayed. If necessary, during any dental treatment in the third trimester make sure to keep your head higher than feet due to that hypotensive tendency I mentioned earlier. You may lay on your side and keep a pillow between the hips, as well. 

 

 

I’ll review some dental changes that may occur during pregnancy in particular. What induces pregnancy gingivitis? That increase in the hormone progesterone leads to decreased gingival repair, and other sex hormones also promote bacterial growth. A decrease in mast cells leads to decreased immune system functioning. Increased folate metabolism may also indirectly contribute to gum disease, as it is needed for healthy gingival tissues. It’s important to control gingivitis so it doesn’t progress into periodontal disease. Periodontal disease increases the risk of low weight or preterm births by 2.8x, as well as increasing the risk of pre-eclampsia. The ADA notes it IS SAFE to treat periodontal disease during pregnancy.

 

 

Another quirky dental change you may notice or wonder: what is this giant red growth in my mouth? This may be a “Pregnancy” (pyogenic) granuloma or sometimes commonly known as “pregnancy tumors”. It’s totally safe, don’t let this nickname scare you. It’s a little round growth connected to the gums/gingiva, developing due to hormonal changes, and most commonly in the second trimester. They may look raspberry-like in appearance and will bleed very easily. Usually they will regress after the baby is born. However, they can be removed or evaluated if you are concerned. They unfortunately are recurrent, if excised to be sent for a biopsy for example.

 

I'll briefly review a few points in terms of a balanced diet. I would recommend getting in those greens (especially because they contain folic acid!). Some of these veggies and fruits include asparagus, broccoli, lettuce, spinach, legumes, avocados, oranges, strawberries, bananas as well as fortified-grains. Whole-grain products are recommended over anything processed or refined. Fish with omega-3 fatty acids such as salmon may help in brain development. Go wild/organic, if possible! However, it’s also recommended to avoid fish that are high in mercury such as tuna or mackerel. Sushi/raw fish? Jury is still out, and I will admit I’ve had my fair share as I’ve been craving salmon eggs this whole time! Foods that are high in refined sugar are generally not recommended; nor salty foods especially in that third trimester, as it may support swelling. Dairy or other foods fortified with calcium are important for the baby’s developing teeth, bones and gums (as well as yours!). Hydration is super important, throughout, and helps with minimizing swelling or Braxton Hicks contractions. Sometimes smaller meals may help with nausea or indigestion. Fiber is also important, as constipation is another common pregnancy symptom due to poor digestive mobility.

 

I will conclude by discussing drugs/pharmaceuticals during pregnancy and breastfeeding. There are numerous benefits to breastfeeding for your baby's growth and development, which you may review in my other blog post here

 

In terms of drug administration in general, the potential benefits to the patient must outweigh the potential harms to the fetus. There are different categorizations made by the FDA on drugs for use in pregnancy. Category A seems to present no risk to the fetus in human controlled studies, while Category B do not indicate fetal risk in animal studies (as there are no human studies, which is most often the case). Category C demonstrates a risk in animal studies, while Category D shows evidence of human fetal risk; however, may be used in certain situations despite the risk. Finally, Category X presents a positive present of human fetal risk and this risk outweighs any benefits of the usage. You can look up FDA categorizations of drugs, and if possible try to limit to Category A and B, if possible.

 

 

When considering pain management (i.e. in relation to dental treatments), acetaminophen is the safest to use. If being prescribed this for a dental (or medical) procedure with codeine or oxycodone, it is “ok” when maintaining limited use. NSAIDs such as Aspirin and ibuprofen are usually avoided. Regarding antibiotics, never take tetracycline, which can permanently stain the baby's developing teeth! Penicillin-family drugs are ok. In addition, avoid ciprofloxin, quinolones, clarithromycin.

 

Furthermore, drug usage should also be limited if one is breast-feeding. Consult with your doctor, as prescriptions may need to be modified especially for drugs with a long half-life or known toxicities. There is a database called LactMed with up-to-date data on drugs and breastfeeding compiled by the NIH: http://toxnet.nlm.nih.gov feel free to check this out; this site may also offer alternate drug recommendations. For example, codeine-family drugs and hydrocodone can reach high levels in breast milk and may cause sedative effects, cyanosis, and bradycardia in the baby. Oxycodone has been shown to depress central nervous system active in 20% of exposed infants during breastfeeding. Other narcotics such as pentazocine (Talwin) and meperidine (Demerol) are also not recommended.

 

What narcotics may be used? Oral morphine, hydromorphine (Dilaudid) or butorphanol, again, in the lowest/shortest dosage indicated. Non-narcotics such as ibuprofen, acetaminophen, naproxen, low-dose aspirin are okay to use when breastfeeding. 

  

There is limited information on herbal treatments. Nursing women are generally “not” recommended to use chamomile, black cohosh, blue cohosh, echinacea, chastetree, gingseng, ginkgo biloba, valerian, and St. Johns wort.

 

I hope this is helpful information - please take care of your teeth and make no hesitation to see your dentist when pregnant! Here are a few websites that I referenced if you'd like to scope out more details:

 

https://www.nnoha.org/nnoha-content/uploads/2013/11/Oralhealthpregnancyconsensusmeetingsummary.pdf

 

https://www.ada.org/en/member-center/oral-health-topics/pregnancy

 

https://www.mouthhealthy.org/en/pregnancy/concerns

 

 

 

 

 

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