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Premium member Presentation Transcript Slide 1: Assoc Prof Dittakarn Boriboonhirunsarn, M.D., M.P.H., Ph.D. Department of Obstetrics and Gynaecology, Facultyof Medicine Siriraj Hospital, Mahidol University Oral Health and Pregnancy Oral Health during Pregnancy : Oral Health during Pregnancy Oral health is a key component of overall health and well-being for women across the lifespan. Oral Health during Pregnancy : Oral Health during Pregnancy Changes during pregnancy can adversely affect oral health. Oral health can adversely affect pregnancy outcomes. Oral Health during Pregnancy : Oral Health during Pregnancy Assessment of oral health during pregnancy is usually overlooked. Misunderstandings Lack of awareness Outline : Outline Effect of pregnancy on oral health Common oral health problems during pregnancy Periodontal diseases and pregnancy: GDM, Preeclampsia, Preterm and Low birth weight Recommended oral care during pregnancy Slide 6: Effects of Pregnancy on Oral Health Effects of Pregnancy on Oral Health : Effects of Pregnancy on Oral Health Elevated estrogen and progesterone By the end of 3rd trimester, progesterone and estrogen reach peak plasma levels 10 and 30 times the levels observed during normal menstrual cycle Effects of Pregnancy on Oral Health : Effects of Pregnancy on Oral Health Alterations in the immune system Suppression of T-cell activity Decreased neutrophil chemotaxis and phagocytosis Altered lymphocyte response Depressed antibody production Effects of Pregnancy on Oral Health : Effects of Pregnancy on Oral Health During 2nd trimester, although plaque levels remained constant Ratio of subgingival anaerobes-to-aerobes increased, as well as proportions of B. melaninogenicus and P. intermedia Effects of Pregnancy on Oral Health : Effects of Pregnancy on Oral Health During 2nd trimester, although plaque levels remained constant Significantly higher accumulation of estradiol and progesterone in subgingival plaque samples Effects of Pregnancy on Oral Health : Effects of Pregnancy on Oral Health Effects of estrogen on periodontium Increased amount of plaque with no increase of gingival inflammation (Reinhardt 1999) Inhibit proinflammatory cytokines release by human marrow cells (Gordon 2001) Reduce T-cell-mediated inflammation (Josefsson 1992) Effects of Pregnancy on Oral Health : Effects of Pregnancy on Oral Health Effects of estrogen on periodontium Suppress leukocyte production from the bone marrow (Josefsson 1992, Cheleuitte 1998) Inhibit PMN chemotaxis (Ito 1995) Stimulate PMN phagocytosis (Hofmann 1986) Effects of Pregnancy on Oral Health : Effects of Pregnancy on Oral Health Effects of progesterone on periodontium Increase production of prostaglandins (El Attar 1976b, Smith 1986) Increase PMN and PGE2 in the GCF Reduce glucocorticoid antiinflammatory effect (Feldman 1975, Chen 1977) Effects of Pregnancy on Oral Health : Effects of Pregnancy on Oral Health Effects of progesterone on periodontium Altered collagen and non collageneous protein synthesis (Willershausen 1991) Alter periodontal fibroblast metabolism (Nanba 1989b, Sooriyamoorthy 1989b, Tilakaratne 1999 a, b) Increase vascular permeability (Abraham-Inpijn 1996) Effects of Pregnancy on Oral Health : Effects of Pregnancy on Oral Health Clinical and microbiologic changes in the periodontium during pregnancy Increased tendency for gingivitis and larger gingival probing depths (Loe 1963, Silness 1964, Miyazaki 1991, Robinson 1992, Machuca 1999, Soory 2000a) and periodontitis (Robinson 1992) Effects of Pregnancy on Oral Health : Effects of Pregnancy on Oral Health Clinical and microbiologic changes in the periodontium during pregnancy Increased susceptibility to infection (Cohen 1969, Brabin 1985) Decreased neutrophil chemotaxis and depressed antibody production (Sooriyamoorthy 1989b, Raber-Durlacher 1991, Raber-Durlacher 1993) Effects of Pregnancy on Oral Health : Effects of Pregnancy on Oral Health Clinical and microbiologic changes in the periodontium during pregnancy Increased numbers of periodontopathogens (esp P. gingivalis and P. intermedia) (Kornman 1980, Tsai 1995) Increased synthesis of PGE2 (El Attar 1976b) Slide 18: Common Oral Problems during Pregnancy Common Oral Problems : Common Oral Problems Enamel erosions (Perimylolysis) Exposed to gastric acids Vomiting, gastric reflux Common Oral Problems : Common Oral Problems Enamel erosions (Perimylolysis) Dietary and lifestyle changes Antiemetic, antacids Rinsing after vomiting A cup of water with a teaspoon of sodium bicarbonate (baking soda) Common Oral Problems : Common Oral Problems Enamel erosions (Perimylolysis) Avoid brushing immediately after vomiting Use soft bristles toothbrush Fluoride mouthwash Common Oral Problems : Common Oral Problems Loose teeth Even in the absence of gum disease Increased estrogen and progesterone Usually temporary and will not cause tooth loss if not associated with periodontal diseases Common Oral Problems : Common Oral Problems Caries Acidity in oral cavity, sugary diet, lack of attention to oral health Children of mothers with high caries level are more likely to get caries Common Oral Problems : Common Oral Problems Caries Brushing twice daily Fluoride toothpaste Limit sugary diet Common Oral Problems : Common Oral Problems Xerostomia Hormonal alterations during pregnancy Water and sugarless candy and gum may help alleviate this problem Common Oral Problems : Common Oral Problems Ptyalism (Sialorrhea) Relatively rare Usually begins at 2-3 weeks of gestation and may subside at the end of 1st trimester Common Oral Problems : Common Oral Problems Pregnancy oral tumor Up to 5% of pregnant women Increased progesterone level An exaggerated inflammatory response to an irritation (often calculus) Common Oral Problems : Common Oral Problems Pregnancy oral tumor Erythematous, smooth, lobulated, painless, exophytic mass Sessile or pedunculated base extending from the gingival margin or, in most instances, from the interproximal tissues in the maxillary anterior Common Oral Problems : Common Oral Problems Pregnancy oral tumor Common Oral Problems : Common Oral Problems Pregnancy oral tumor Common Oral Problems : Common Oral Problems Pregnancy oral tumor Most common after 1st trimester, grow rapidly, recede after delivery Observation unless with complications Likely to recur if removed during pregnancy Common Oral Problems : Common Oral Problems Gingivitis Most common 60-75% Usually exacerbate during pregnancy Increased in estrogen and progesterone Changes in normal flora Increased Bacteroides, Prevotella, Porphyromonas Decreased immune response Common Oral Problems : Common Oral Problems Periodontitis Induced bacteremia Cytokines, prostaglandins, interleukins production Adverse effects on pregnancy: preterm, LBW Slide 34: Periodontal Diseases and Health Periodontal Disease and Health : Periodontal Disease and Health Increased risk of Cardiovascular disease: 1.5-1.9 folds Beck JD, Circulation 2005, Spahr A, Arch Intern Med 2006, Holmlund A, J Periodontol 2006 Periodontal Disease and Health : Periodontal Disease and Health Increased risk of Diabetes: 2-3 folds Jansson H, J Clin Periodontol 2006, Al-Shammari KF, J Int Acad Periodontol 2006 Periodontal Disease and Health : Periodontal Disease and Health Increased risk of Community- and hospital-acquired respiratory infections: 9 folds Azarpazhooh A, J Periodontol 2006 Slide 38: Periodontal Diseases and Pregnancy Periodontal Diseases and Health : Periodontal Diseases and Health Many previous studies have associate periodontal diseases and pregnancy complications and adverse pregnancy outcomes Gestational diabetes Preeclampsia Preterm Low birth weight Periodontal Diseases and Health : Periodontal Diseases and Health Periodontal Diseases and Pregnancy : Periodontal Diseases and Pregnancy Gestational Diabetes (GDM) Periodontal Diseases and GDM : Periodontal Diseases and GDM Cross-sectional study (Mittas E, Spec Care Dentist 2006) GDM had higher gingival inflammation Significant increased in mean PI and GI Periodontal Diseases and GDM : Periodontal Diseases and GDM Cross-sectional study (Novak K, J Public Health Dent 2006) NHANES III data Periodontal disease: ≥1 teeth with ≥ 1sites with PD ≥ 1 mm, CAL ≥ 2mm, and BOP History of GDM, current DM Women with prior GDM are at increased risk for more severe periodontal diseases Periodontal Diseases and GDM : Periodontal Diseases and GDM Cross-sectional study (Xiong X, J Am J Obstet Gynecol 2006) NHANES III data Periodontitis 44.8% in GDM vs. 13.2% in normal pregnancy aOR 9.1 Periodontal Diseases and GDM : Periodontal Diseases and GDM Cross-sectional study (Xiong X, Am J Obstet Gynecol 2006) NHANES III data Periodontitis 40.3% in women with DM, 25% in women with prior GDM, and 13.9% in non-DM women aOR 2.8 Periodontal Diseases and GDM : Periodontal Diseases and GDM Cross-sectional study (Dasanayake A, J Dent Res 2008) Clinical, bacteriological, immunological, and inflammatory mediator parameters Periodontitis: ≥1 teeth with PD > 3 mm Significant higher C-reactive protein 50% in GDM vs. 37.3% in normal pregnancy (NS) Periodontal Diseases and GDM : Periodontal Diseases and GDM Case-control study (Xiong X, J Periodontol 2009) GDM vs. non-GDM pregnant women Periodontitis: PD or CAL ≥ 4 mm 77.4% in GDM vs. 57.5% in non-GDM aOR 2.6 Periodontal Diseases and GDM : Periodontal Diseases and GDM Case-control study (Duiz D, Oral Diseases 2011) GDM, T1DM, and non-DM pregnant women GI, GM, PD, CAL, BOP, and MI: significantly higher in GDM and T1DM PI: significantly higher in GDM but similar inT1DM and non-DM Periodontal Diseases and GDM : Periodontal Diseases and GDM Review of evidence (Taylor G, Oral Diseases 2008) Adverse effects of DM on periodontal health Adverse effects of periodontal infection on glycemic control and DM complications Periodontal Diseases and GDM : Periodontal Diseases and GDM GDM and prior GDM seems to be positively associated with periodontal diseases during pregnancy Periodontal Diseases and Pregnancy : Periodontal Diseases and Pregnancy Preeclampsia Periodontal Diseases and Preeclampsia : Periodontal Diseases and Preeclampsia Case-control study (Canakci V, Aust N Z J Obstet Gynaecol 2004) Severe preeclampsia Mean PD and CAL were significantly greater %BOP, sites with PD ≥4 mm and CAL≥ 3 mm was significantly higher Significant association with preeclampsia, adjusted OR 3.5 Periodontal Diseases and Preeclampsia : Periodontal Diseases and Preeclampsia Case-control study (Canakci V, J Clin Periodontol 2007) 18 severe, 20 mild, 21 normal Significant association with preeclampsia Severe: aOR 3.8 Mild: aOR 2.4 Periodontal Diseases and Preeclampsia : Periodontal Diseases and Preeclampsia Case-control study (Canakci V, J Clin Periodontol 2007) Preeclampsia: significant higher level of IL-1β, TNF-α, PGE2 in both serum and GCF Periodontal Diseases and Preeclampsia : Periodontal Diseases and Preeclampsia Cohort study (Shetty M, Acta Obstet Gynecol 2010) Oral health examination at enrollment and 48 hrs after delivery CAL ≥ 3 mm and PD ≥ 4mm Enrollment: 100% vs. 78%, aOR 5.8 After delivery: 100% vs. 86%, aOR 20.1 Periodontal Diseases and Preeclampsia : Periodontal Diseases and Preeclampsia Systematic review (Kunnen A, J clin Periodontol 2010) Observational studies 8 studies: Positive association 4 studies: No association No RTC reported risk reductions after treatment Periodontal Diseases and Preeclampsia : Periodontal Diseases and Preeclampsia Case-control study (Politano G, J Periodontol Res 2011) Significant association with preeclampsia: Adjusted OR 3.7 No correlation with systemic cytokine expression Periodontal Diseases and Preeclampsia : Periodontal Diseases and Preeclampsia Larger RCTs with pre-eclampsia as the primary outcome and pathophysiological studies are required to explore causality and biological mechanisms involved Periodontal Diseases and Pregnancy : Periodontal Diseases and Pregnancy Preterm and Low Birth Weight Periodontal Diseases and Preterm/LBW : Periodontal Diseases and Preterm/LBW Case-control study (Offenbacher S, J Periodontol 1996) Preterm (<37 weeks) or LBW (2,500 g) Significantly worse periodontal infection than control Periodontal Diseases and Preterm/LBW : Periodontal Diseases and Preterm/LBW Cohort study (Jeffcoat MK, J Am Dent Assoc 2001) 1,313 pregnant women Generalized periodontal infection ≥90 tooth sites with attachment loss of ≥3 mm Periodontal Diseases and Preterm/LBW : Periodontal Diseases and Preterm/LBW Cohort study (Jeffcoat MK, J Am Dent Assoc 2001) Increased of preterm birth <37 weeks: adjusted OR 4.5 <35 weeks: adjusted OR 5.3 <32 weeks: adjusted OR 7.1 Periodontal Diseases and Preterm/LBW : Periodontal Diseases and Preterm/LBW Cohort study (Offenbacher S, Obstet Gynecol 2006) Obstetric outcomes of >1,000 pregnant women Moderate-to-severe periodontal infection (≥15 sites with >4 mm PD) Disease progression: ≥4 sites with ≥2 mm increasing PD, with the postpartum PD ≥4 mm Periodontal Diseases and Preterm/LBW : Periodontal Diseases and Preterm/LBW Cohort study (Offenbacher S, Obstet Gynecol 2006) Moderate-to-severe periodontal infection Preterm birth <37 weeks: adjusted RR 2.0 Disease progression Preterm birth <32 weeks: adjusted RR 2.4 Periodontal Diseases and Preterm/LBW : Periodontal Diseases and Preterm/LBW Cohort study (Moore S, Br Dent J 2004) No relationship between multiple periodontal parameters and preterm birth Mean PD, % PD ≥4 mm, % BOP, and % CAL ≥2 or 3 mm Periodontal Diseases and Preterm/LBW : Periodontal Diseases and Preterm/LBW Case-control study (Buduneli N, J Clin Periodontol 2005) No differences in periodontal infection between preterm and term birth Increased risk for preterm birth if P. gingivalis or C. rectus were found in subgingival plaque Periodontal Diseases and Preterm/LBW : Periodontal Diseases and Preterm/LBW Metaanalysis (Vergnes JN, Am J Obstet Gynecol 2007) 17 studies Maternal periodontal disease significantly increased risk of Preterm birth: pooled OR 2.83 Periodontal Diseases and Preterm/LBW : Periodontal Diseases and Preterm/LBW Metaanalysis (Corbella S, Odontology 2011) 17 case–control studies Maternal periodontal disease significantly increased risk of Preterm birth: OR 1.78 LBW: OR 1.82 Preterm LBW: OR 3.0 Periodontal Diseases and Preterm/LBW : Periodontal Diseases and Preterm/LBW Metaanalysis (Chambrone L, J Clin Periodontol 2011) 12 case-control studies Maternal periodontal disease significantly increased risk of Preterm birth: RR 1.7 LBW: RR 2.11 Preterm LBW: RR 3.57 Conflicting Results : Conflicting Results Variations in definitions Clinical markers may be late manifestations of infections Potential confounders Differences in population Publication biases Periodontal Diseases and Pregnancy : Periodontal Diseases and Pregnancy Biologic Plausibility Biological Plausibility : Biological Plausibility Bacterial spreading and invasion The possible dissemination of oral bacteria through blood circulation to the amniotic fluid Biological Plausibility : Biological Plausibility Bacterial spreading and invasion The deeper periodontal pockets are, the greater the exchange surface between bacteria biofilm and blood circulation (15-20 cm2 in the most severe cases) Biological Plausibility : Biological Plausibility Bacterial spreading and invasion Direct colonization in the placenta, causing localized inflammatory responses, resulting in prematurity and other adverse outcomes Immune suppression in the placenta allows the bacteria to proliferate freely Biological Plausibility : Biological Plausibility Bacterial spreading and invasion Organisms exclusively associated with periodontal infection have been cultured from amniotic fluid and neonates Biological Plausibility : Biological Plausibility Bacterial spreading and invasion Placental colonization by both F. nucleatum and P. gingivalis has been associated with intrauterine infections in humans (Han, 2009, 2010; Katz, 2009) Biological Plausibility : Biological Plausibility Bacterial spreading and invasion P. gingivalis could infect trophoblasts, decidual cells, and amniotic epithelial cells and promotes inflammatory process (Kotz, J Dent Res 2009, Arce, Placenta 2009) Biological Plausibility : Biological Plausibility Bacterial spreading and invasion A case-report in 2010 (Han, et al. Obstet Gynecol) A stillbirth caused by F. nucleatum from the mother’s mouth Biological Plausibility : Biological Plausibility Periodontal disease causes systemic abnormal immunological changes, leading to pregnancy complications Biological Plausibility : Biological Plausibility Hematogenous dissemination of inflammatory products Increase secretion of several cytokines: PGE-2, TNF-α, IL-6 or IL-1β (AndukhovJ Periodontol 2011, Casarin, J Periodontol Res 2011) Analysis of amniotic fluid of preterm birth shows elevated levels of inflammatory cytokines (Pressman, Am J Obstet Gynecol 2011) Biological Plausibility : Biological Plausibility Hematogenous dissemination of inflammatory products High crevicular fluid PGE-2,IL-1β,or IL-6 have been associated with their elevated levels in amniotic fluid (Offenbacher, Annals Periodontol 1998, Dortbudak, J Clin Periodontol 2005) Periodontal Diseases and Pregnancy : Periodontal Diseases and Pregnancy Effects of Periodontal Disease Treatment Periodontal Disease Treatment : Periodontal Disease Treatment Earlier studies Reduced the risk of preterm birth and LBW (Lopez NJ, J Periodontol 2002, Jeffcoat MK, J Periodontol 2003, Lopez NJ, J Periodontol 2005, Offenbacher S, J Periodontol 2006) Periodontal Disease Treatment : Periodontal Disease Treatment Recent studies Reduced the risk of preterm birth (Radnai, J Dent Res 2009, Novak, Fetal Diagn Ther 2009) No significant risk reduction of preterm birth and LBW (Michalowicz, NEJM 2006, Tarannum, J Periodontol 2007, Offenbacher, Obstet Gynecol 2009, Newnham, Obstet Gynecol 2009, Macones, Am J Obstet Gynecol 2010, Oliveira, Clin Oral Investig 2010) Periodontal Disease Treatment : Periodontal Disease Treatment Metaanalysis (Xiong X, BJOG 2006) 44 studies Maternal periodontal treatment reduced the risk of Preterm LBW: pooled OR 0.53 Periodontal Disease Treatment : Periodontal Disease Treatment Metaanalysis (Polyzos NP, Am J Obstet Gynecol 2009) 7 RCTs Maternal periodontal treatment significantly lowered Preterm birth: OR 0.55 LBW: OR 0.48 Periodontal Disease Treatment : Periodontal Disease Treatment Metaanalysis (Polyzos NP, BMJ 2010) 11 RCTs Maternal periodontal treatment did not significantly lowered Preterm birth: pooled OR 0.93 LBW: pooled OR 0.85 Periodontal Disease Treatment : Periodontal Disease Treatment Metaanalysis (Uppal A, J Am Dent Assoc 2010) 10 RCTs for preterm, 8 RCTs for LBW Maternal periodontal treatment significantly lowered Preterm birth: OR 0.59 LBW: OR 0.72 Not significant in high-quality studies Periodontal Disease Treatment : Periodontal Disease Treatment Metaanalysis (George A, Int J Evid Based Healthc 2011) 10 RCTs Maternal periodontal treatment significantly lowered Preterm birth: OR 0.65 LBW: OR 0.53 Periodontal Disease Treatment : Periodontal Disease Treatment Metaanalysis (Chambrone L, J Clin Periodontol 2011) 8 RCTs Maternal periodontal treatment did not significantly lowered Preterm birth: RR 0.88 LBW: RR 0.78 Preterm LBW: RR 0.52 Periodontal Disease Treatment : Periodontal Disease Treatment Metaanalysis (Baccaglini L, J Am Dent Assoc 2011) 11 RCTs Maternal periodontal treatment did not significantly lowered Preterm birth (pooled OR 0.79) and LBW Periodontal Diseases and Pregnancy : Periodontal Diseases and Pregnancy Pre-pregnancy Treatment? Periodontal Disease Treatment : Periodontal Disease Treatment Pre-pregnancy treatment More intensive treatment than during pregnancy and better resolution of periodontal disease Might provide a more definitive conclusion of the association Periodontal Disease Treatment : Periodontal Disease Treatment Pre-pregnancy treatment If the effect is confirmed, improving oral health and treating periodontal disease before pregnancy may lead to a reduction in preterm births and other adverse outcomes Periodontal Disease Treatment : Periodontal Disease Treatment Pre-pregnancy treatment Better understanding of the etiologic pathway and biologic mechanism Pre-pregnancy periodontal treatment would be applicable to many low-or middle-income countries with limited access to preventive or restorative dental care What are the Guidelines? : What are the Guidelines? Slide 97: Guidelines for Oral Care during Pregnancy Guidelines : Guidelines Guidelines : Guidelines AAP Statement 2004 Preventive oral car services should be provided as early in pregnancy as possible. Guidelines : Guidelines AAP Statement 2004 Women should be encourage to achieve a high level of oral hygiene prior to becoming pregnant and throughout their pregnancies. Guidelines : Guidelines AAP Statement 2004 If examination indicates a need for periodontal scaling and root planing or more involved periodontal treatment, these procedures are usually scheduled early in the 2nd trimester. Guidelines : Guidelines AAP Statement 2004 The presence of acute infection, abscess, or other potentially disseminating sources of sepsis may warrant prompt intervention, irrespective of the stage of pregnancy. Guidelines : Guidelines AAP Statement 2004 Diagnosis and treatment Evaluation of periodontal condition Patient education regarding impact of periodontal infection and pregnancy outcomes, and prevention and treatment options Guidelines : Guidelines AAP Statement 2004 Diagnosis and treatment Consultation with caring physician: other risks (GDM, HT), information about periodontal status and treatment Guidelines : Guidelines AAP Statement 2004 Diagnosis and treatment Consideration of pregnancy status, other risks that may influence pregnancy outcomes Periodontal therapy and patient motivation to establish and maintain periodontal health Guidelines : Guidelines Guidelines : Guidelines AAPD 2007 The AAPD recommends that all pregnant adolescents seek professional oral health care during the 1st trimester. Guidelines : Guidelines AAPD 2007 The dental professional should perform a comprehensive evaluation which includes Thorough dental history, dietary history, clinical examination, and caries risk assessment. Guidelines : Guidelines AAPD 2007 During the clinical examination, the practitioner should pay particular attention to health status of the periodontal tissues. Guidelines : Guidelines AAPD 2007 Radiographs should be obtained only when there is expectation that diagnostic yield. If dental treatment must be deferred until after delivery, radiographic assessment also should be deferred. Guidelines : Guidelines Counseling Relationship of maternal oral health with fetal health Individualized preventive plan including oral hygiene instructions, rinses, and/or xylitol gum Dietary considerations Guidelines : Guidelines Counseling Oral changes that may occur secondary to pregnancy Individualized treatment recommendations based upon the specific oral findings for each patient Guidelines : Guidelines Counseling Anticipatory guidance for the infant’s oral health Anticipatory guidance for the adolescent’s oral health Slide 114: General Oral Care during Pregnancy Oral Care during Pregnancy : Oral Care during Pregnancy Screening and prevention Assessment of oral hygiene habits, oral problems Thorough oral examination Particular attention to health status of the periodontal tissues Collaboration between obstetrician and dentist Oral Care during Pregnancy : Oral Care during Pregnancy Plaque control Maintain a good plaque control program to minimize the exaggerated inflammatory response of the gingival tissues Scaling, polishing and root planing whenever necessary Oral Care during Pregnancy : Oral Care during Pregnancy Diagnosis Dental radiography should be delayed until after 1st trimester, unless necessary Teratogenic risk is 1000 times less than spontaneous abortion Oral Care during Pregnancy : Oral Care during Pregnancy Dental treatment Dental procedures should be scheduled during 2nd trimester Te safest and most comfortable time is during 14-20 weeks Problems during 3rd trimester Discomfort, IVC compression Oral Care during Pregnancy : Oral Care during Pregnancy Dental treatment No evidence that the exposure to mercury releases from the mother’s existing amalgam fillings causes any adverse effects Oral Care during Pregnancy : Oral Care during Pregnancy Dental treatment Deferring elective dental treatment during a healthy pregnancy is not justified Deferring treatment after delivery can be problematic Oral Care during Pregnancy : Oral Care during Pregnancy Medications Lidocaine, and epinephrine are safe Sedatives should be avoided 1st-line antibiotics Penicillin, amoxicillin, cephalexin (clindamycin) Anlgesics Acetaminophen, ibuprofen Oral Care during Pregnancy : Oral Care during Pregnancy Caries risk reduction in children Xylitol and chlorhexidine use late in pregnancy and postpartum period A daily rinse of 0.05% sodium fluoride and 0.12% chlorhexidine Xylitol gum Oral Care during Pregnancy : Oral Care during Pregnancy Caries risk reduction in children Lower maternal oral bacteria load and reduce transmission to infants Optimal dose remains controversial (Soderling E, Caries Res 2001, Brambilla E, J Am Dent Assoc 1998) Oral Health and Pregnancy : Oral Health and Pregnancy Conclusion Oral Health and Pregnancy : Oral Health and Pregnancy Evidence have shown possible relationship between unhealthy oral conditions and various adverse pregnancy outcomes Oral Health and Pregnancy : Oral Health and Pregnancy Effective and timely treatment could possibly reduce the risk of adverse outcomes Oral Health and Pregnancy : Oral Health and Pregnancy Timing and patient subgroups that will benefit from appropriate oral care during pregnancy are to be determined Oral Health and Pregnancy : Oral Health and Pregnancy Education Awareness Counseling Collaboration You do not have the permission to view this presentation. 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Oral health and pregnancy 2012 dittakarn Download Post to : URL : Related Presentations : Share Add to Flag Embed Email Send to Blogs and Networks Add to Channel Uploaded from authorPOINT lite Insert YouTube videos in PowerPont slides with aS Desktop Copy embed code: Embed: Flash iPad Copy Does not support media & animations WordPress Embed Customize Embed URL: Copy Thumbnail: Copy The presentation is successfully added In Your Favorites. Views: 564 Category: Science & Tech.. License: All Rights Reserved Like it (0) Dislike it (0) Added: February 06, 2012 This Presentation is Public Favorites: 0 Presentation Description No description available. Comments Posting comment... Premium member Presentation Transcript Slide 1: Assoc Prof Dittakarn Boriboonhirunsarn, M.D., M.P.H., Ph.D. Department of Obstetrics and Gynaecology, Facultyof Medicine Siriraj Hospital, Mahidol University Oral Health and Pregnancy Oral Health during Pregnancy : Oral Health during Pregnancy Oral health is a key component of overall health and well-being for women across the lifespan. Oral Health during Pregnancy : Oral Health during Pregnancy Changes during pregnancy can adversely affect oral health. Oral health can adversely affect pregnancy outcomes. Oral Health during Pregnancy : Oral Health during Pregnancy Assessment of oral health during pregnancy is usually overlooked. Misunderstandings Lack of awareness Outline : Outline Effect of pregnancy on oral health Common oral health problems during pregnancy Periodontal diseases and pregnancy: GDM, Preeclampsia, Preterm and Low birth weight Recommended oral care during pregnancy Slide 6: Effects of Pregnancy on Oral Health Effects of Pregnancy on Oral Health : Effects of Pregnancy on Oral Health Elevated estrogen and progesterone By the end of 3rd trimester, progesterone and estrogen reach peak plasma levels 10 and 30 times the levels observed during normal menstrual cycle Effects of Pregnancy on Oral Health : Effects of Pregnancy on Oral Health Alterations in the immune system Suppression of T-cell activity Decreased neutrophil chemotaxis and phagocytosis Altered lymphocyte response Depressed antibody production Effects of Pregnancy on Oral Health : Effects of Pregnancy on Oral Health During 2nd trimester, although plaque levels remained constant Ratio of subgingival anaerobes-to-aerobes increased, as well as proportions of B. melaninogenicus and P. intermedia Effects of Pregnancy on Oral Health : Effects of Pregnancy on Oral Health During 2nd trimester, although plaque levels remained constant Significantly higher accumulation of estradiol and progesterone in subgingival plaque samples Effects of Pregnancy on Oral Health : Effects of Pregnancy on Oral Health Effects of estrogen on periodontium Increased amount of plaque with no increase of gingival inflammation (Reinhardt 1999) Inhibit proinflammatory cytokines release by human marrow cells (Gordon 2001) Reduce T-cell-mediated inflammation (Josefsson 1992) Effects of Pregnancy on Oral Health : Effects of Pregnancy on Oral Health Effects of estrogen on periodontium Suppress leukocyte production from the bone marrow (Josefsson 1992, Cheleuitte 1998) Inhibit PMN chemotaxis (Ito 1995) Stimulate PMN phagocytosis (Hofmann 1986) Effects of Pregnancy on Oral Health : Effects of Pregnancy on Oral Health Effects of progesterone on periodontium Increase production of prostaglandins (El Attar 1976b, Smith 1986) Increase PMN and PGE2 in the GCF Reduce glucocorticoid antiinflammatory effect (Feldman 1975, Chen 1977) Effects of Pregnancy on Oral Health : Effects of Pregnancy on Oral Health Effects of progesterone on periodontium Altered collagen and non collageneous protein synthesis (Willershausen 1991) Alter periodontal fibroblast metabolism (Nanba 1989b, Sooriyamoorthy 1989b, Tilakaratne 1999 a, b) Increase vascular permeability (Abraham-Inpijn 1996) Effects of Pregnancy on Oral Health : Effects of Pregnancy on Oral Health Clinical and microbiologic changes in the periodontium during pregnancy Increased tendency for gingivitis and larger gingival probing depths (Loe 1963, Silness 1964, Miyazaki 1991, Robinson 1992, Machuca 1999, Soory 2000a) and periodontitis (Robinson 1992) Effects of Pregnancy on Oral Health : Effects of Pregnancy on Oral Health Clinical and microbiologic changes in the periodontium during pregnancy Increased susceptibility to infection (Cohen 1969, Brabin 1985) Decreased neutrophil chemotaxis and depressed antibody production (Sooriyamoorthy 1989b, Raber-Durlacher 1991, Raber-Durlacher 1993) Effects of Pregnancy on Oral Health : Effects of Pregnancy on Oral Health Clinical and microbiologic changes in the periodontium during pregnancy Increased numbers of periodontopathogens (esp P. gingivalis and P. intermedia) (Kornman 1980, Tsai 1995) Increased synthesis of PGE2 (El Attar 1976b) Slide 18: Common Oral Problems during Pregnancy Common Oral Problems : Common Oral Problems Enamel erosions (Perimylolysis) Exposed to gastric acids Vomiting, gastric reflux Common Oral Problems : Common Oral Problems Enamel erosions (Perimylolysis) Dietary and lifestyle changes Antiemetic, antacids Rinsing after vomiting A cup of water with a teaspoon of sodium bicarbonate (baking soda) Common Oral Problems : Common Oral Problems Enamel erosions (Perimylolysis) Avoid brushing immediately after vomiting Use soft bristles toothbrush Fluoride mouthwash Common Oral Problems : Common Oral Problems Loose teeth Even in the absence of gum disease Increased estrogen and progesterone Usually temporary and will not cause tooth loss if not associated with periodontal diseases Common Oral Problems : Common Oral Problems Caries Acidity in oral cavity, sugary diet, lack of attention to oral health Children of mothers with high caries level are more likely to get caries Common Oral Problems : Common Oral Problems Caries Brushing twice daily Fluoride toothpaste Limit sugary diet Common Oral Problems : Common Oral Problems Xerostomia Hormonal alterations during pregnancy Water and sugarless candy and gum may help alleviate this problem Common Oral Problems : Common Oral Problems Ptyalism (Sialorrhea) Relatively rare Usually begins at 2-3 weeks of gestation and may subside at the end of 1st trimester Common Oral Problems : Common Oral Problems Pregnancy oral tumor Up to 5% of pregnant women Increased progesterone level An exaggerated inflammatory response to an irritation (often calculus) Common Oral Problems : Common Oral Problems Pregnancy oral tumor Erythematous, smooth, lobulated, painless, exophytic mass Sessile or pedunculated base extending from the gingival margin or, in most instances, from the interproximal tissues in the maxillary anterior Common Oral Problems : Common Oral Problems Pregnancy oral tumor Common Oral Problems : Common Oral Problems Pregnancy oral tumor Common Oral Problems : Common Oral Problems Pregnancy oral tumor Most common after 1st trimester, grow rapidly, recede after delivery Observation unless with complications Likely to recur if removed during pregnancy Common Oral Problems : Common Oral Problems Gingivitis Most common 60-75% Usually exacerbate during pregnancy Increased in estrogen and progesterone Changes in normal flora Increased Bacteroides, Prevotella, Porphyromonas Decreased immune response Common Oral Problems : Common Oral Problems Periodontitis Induced bacteremia Cytokines, prostaglandins, interleukins production Adverse effects on pregnancy: preterm, LBW Slide 34: Periodontal Diseases and Health Periodontal Disease and Health : Periodontal Disease and Health Increased risk of Cardiovascular disease: 1.5-1.9 folds Beck JD, Circulation 2005, Spahr A, Arch Intern Med 2006, Holmlund A, J Periodontol 2006 Periodontal Disease and Health : Periodontal Disease and Health Increased risk of Diabetes: 2-3 folds Jansson H, J Clin Periodontol 2006, Al-Shammari KF, J Int Acad Periodontol 2006 Periodontal Disease and Health : Periodontal Disease and Health Increased risk of Community- and hospital-acquired respiratory infections: 9 folds Azarpazhooh A, J Periodontol 2006 Slide 38: Periodontal Diseases and Pregnancy Periodontal Diseases and Health : Periodontal Diseases and Health Many previous studies have associate periodontal diseases and pregnancy complications and adverse pregnancy outcomes Gestational diabetes Preeclampsia Preterm Low birth weight Periodontal Diseases and Health : Periodontal Diseases and Health Periodontal Diseases and Pregnancy : Periodontal Diseases and Pregnancy Gestational Diabetes (GDM) Periodontal Diseases and GDM : Periodontal Diseases and GDM Cross-sectional study (Mittas E, Spec Care Dentist 2006) GDM had higher gingival inflammation Significant increased in mean PI and GI Periodontal Diseases and GDM : Periodontal Diseases and GDM Cross-sectional study (Novak K, J Public Health Dent 2006) NHANES III data Periodontal disease: ≥1 teeth with ≥ 1sites with PD ≥ 1 mm, CAL ≥ 2mm, and BOP History of GDM, current DM Women with prior GDM are at increased risk for more severe periodontal diseases Periodontal Diseases and GDM : Periodontal Diseases and GDM Cross-sectional study (Xiong X, J Am J Obstet Gynecol 2006) NHANES III data Periodontitis 44.8% in GDM vs. 13.2% in normal pregnancy aOR 9.1 Periodontal Diseases and GDM : Periodontal Diseases and GDM Cross-sectional study (Xiong X, Am J Obstet Gynecol 2006) NHANES III data Periodontitis 40.3% in women with DM, 25% in women with prior GDM, and 13.9% in non-DM women aOR 2.8 Periodontal Diseases and GDM : Periodontal Diseases and GDM Cross-sectional study (Dasanayake A, J Dent Res 2008) Clinical, bacteriological, immunological, and inflammatory mediator parameters Periodontitis: ≥1 teeth with PD > 3 mm Significant higher C-reactive protein 50% in GDM vs. 37.3% in normal pregnancy (NS) Periodontal Diseases and GDM : Periodontal Diseases and GDM Case-control study (Xiong X, J Periodontol 2009) GDM vs. non-GDM pregnant women Periodontitis: PD or CAL ≥ 4 mm 77.4% in GDM vs. 57.5% in non-GDM aOR 2.6 Periodontal Diseases and GDM : Periodontal Diseases and GDM Case-control study (Duiz D, Oral Diseases 2011) GDM, T1DM, and non-DM pregnant women GI, GM, PD, CAL, BOP, and MI: significantly higher in GDM and T1DM PI: significantly higher in GDM but similar inT1DM and non-DM Periodontal Diseases and GDM : Periodontal Diseases and GDM Review of evidence (Taylor G, Oral Diseases 2008) Adverse effects of DM on periodontal health Adverse effects of periodontal infection on glycemic control and DM complications Periodontal Diseases and GDM : Periodontal Diseases and GDM GDM and prior GDM seems to be positively associated with periodontal diseases during pregnancy Periodontal Diseases and Pregnancy : Periodontal Diseases and Pregnancy Preeclampsia Periodontal Diseases and Preeclampsia : Periodontal Diseases and Preeclampsia Case-control study (Canakci V, Aust N Z J Obstet Gynaecol 2004) Severe preeclampsia Mean PD and CAL were significantly greater %BOP, sites with PD ≥4 mm and CAL≥ 3 mm was significantly higher Significant association with preeclampsia, adjusted OR 3.5 Periodontal Diseases and Preeclampsia : Periodontal Diseases and Preeclampsia Case-control study (Canakci V, J Clin Periodontol 2007) 18 severe, 20 mild, 21 normal Significant association with preeclampsia Severe: aOR 3.8 Mild: aOR 2.4 Periodontal Diseases and Preeclampsia : Periodontal Diseases and Preeclampsia Case-control study (Canakci V, J Clin Periodontol 2007) Preeclampsia: significant higher level of IL-1β, TNF-α, PGE2 in both serum and GCF Periodontal Diseases and Preeclampsia : Periodontal Diseases and Preeclampsia Cohort study (Shetty M, Acta Obstet Gynecol 2010) Oral health examination at enrollment and 48 hrs after delivery CAL ≥ 3 mm and PD ≥ 4mm Enrollment: 100% vs. 78%, aOR 5.8 After delivery: 100% vs. 86%, aOR 20.1 Periodontal Diseases and Preeclampsia : Periodontal Diseases and Preeclampsia Systematic review (Kunnen A, J clin Periodontol 2010) Observational studies 8 studies: Positive association 4 studies: No association No RTC reported risk reductions after treatment Periodontal Diseases and Preeclampsia : Periodontal Diseases and Preeclampsia Case-control study (Politano G, J Periodontol Res 2011) Significant association with preeclampsia: Adjusted OR 3.7 No correlation with systemic cytokine expression Periodontal Diseases and Preeclampsia : Periodontal Diseases and Preeclampsia Larger RCTs with pre-eclampsia as the primary outcome and pathophysiological studies are required to explore causality and biological mechanisms involved Periodontal Diseases and Pregnancy : Periodontal Diseases and Pregnancy Preterm and Low Birth Weight Periodontal Diseases and Preterm/LBW : Periodontal Diseases and Preterm/LBW Case-control study (Offenbacher S, J Periodontol 1996) Preterm (<37 weeks) or LBW (2,500 g) Significantly worse periodontal infection than control Periodontal Diseases and Preterm/LBW : Periodontal Diseases and Preterm/LBW Cohort study (Jeffcoat MK, J Am Dent Assoc 2001) 1,313 pregnant women Generalized periodontal infection ≥90 tooth sites with attachment loss of ≥3 mm Periodontal Diseases and Preterm/LBW : Periodontal Diseases and Preterm/LBW Cohort study (Jeffcoat MK, J Am Dent Assoc 2001) Increased of preterm birth <37 weeks: adjusted OR 4.5 <35 weeks: adjusted OR 5.3 <32 weeks: adjusted OR 7.1 Periodontal Diseases and Preterm/LBW : Periodontal Diseases and Preterm/LBW Cohort study (Offenbacher S, Obstet Gynecol 2006) Obstetric outcomes of >1,000 pregnant women Moderate-to-severe periodontal infection (≥15 sites with >4 mm PD) Disease progression: ≥4 sites with ≥2 mm increasing PD, with the postpartum PD ≥4 mm Periodontal Diseases and Preterm/LBW : Periodontal Diseases and Preterm/LBW Cohort study (Offenbacher S, Obstet Gynecol 2006) Moderate-to-severe periodontal infection Preterm birth <37 weeks: adjusted RR 2.0 Disease progression Preterm birth <32 weeks: adjusted RR 2.4 Periodontal Diseases and Preterm/LBW : Periodontal Diseases and Preterm/LBW Cohort study (Moore S, Br Dent J 2004) No relationship between multiple periodontal parameters and preterm birth Mean PD, % PD ≥4 mm, % BOP, and % CAL ≥2 or 3 mm Periodontal Diseases and Preterm/LBW : Periodontal Diseases and Preterm/LBW Case-control study (Buduneli N, J Clin Periodontol 2005) No differences in periodontal infection between preterm and term birth Increased risk for preterm birth if P. gingivalis or C. rectus were found in subgingival plaque Periodontal Diseases and Preterm/LBW : Periodontal Diseases and Preterm/LBW Metaanalysis (Vergnes JN, Am J Obstet Gynecol 2007) 17 studies Maternal periodontal disease significantly increased risk of Preterm birth: pooled OR 2.83 Periodontal Diseases and Preterm/LBW : Periodontal Diseases and Preterm/LBW Metaanalysis (Corbella S, Odontology 2011) 17 case–control studies Maternal periodontal disease significantly increased risk of Preterm birth: OR 1.78 LBW: OR 1.82 Preterm LBW: OR 3.0 Periodontal Diseases and Preterm/LBW : Periodontal Diseases and Preterm/LBW Metaanalysis (Chambrone L, J Clin Periodontol 2011) 12 case-control studies Maternal periodontal disease significantly increased risk of Preterm birth: RR 1.7 LBW: RR 2.11 Preterm LBW: RR 3.57 Conflicting Results : Conflicting Results Variations in definitions Clinical markers may be late manifestations of infections Potential confounders Differences in population Publication biases Periodontal Diseases and Pregnancy : Periodontal Diseases and Pregnancy Biologic Plausibility Biological Plausibility : Biological Plausibility Bacterial spreading and invasion The possible dissemination of oral bacteria through blood circulation to the amniotic fluid Biological Plausibility : Biological Plausibility Bacterial spreading and invasion The deeper periodontal pockets are, the greater the exchange surface between bacteria biofilm and blood circulation (15-20 cm2 in the most severe cases) Biological Plausibility : Biological Plausibility Bacterial spreading and invasion Direct colonization in the placenta, causing localized inflammatory responses, resulting in prematurity and other adverse outcomes Immune suppression in the placenta allows the bacteria to proliferate freely Biological Plausibility : Biological Plausibility Bacterial spreading and invasion Organisms exclusively associated with periodontal infection have been cultured from amniotic fluid and neonates Biological Plausibility : Biological Plausibility Bacterial spreading and invasion Placental colonization by both F. nucleatum and P. gingivalis has been associated with intrauterine infections in humans (Han, 2009, 2010; Katz, 2009) Biological Plausibility : Biological Plausibility Bacterial spreading and invasion P. gingivalis could infect trophoblasts, decidual cells, and amniotic epithelial cells and promotes inflammatory process (Kotz, J Dent Res 2009, Arce, Placenta 2009) Biological Plausibility : Biological Plausibility Bacterial spreading and invasion A case-report in 2010 (Han, et al. Obstet Gynecol) A stillbirth caused by F. nucleatum from the mother’s mouth Biological Plausibility : Biological Plausibility Periodontal disease causes systemic abnormal immunological changes, leading to pregnancy complications Biological Plausibility : Biological Plausibility Hematogenous dissemination of inflammatory products Increase secretion of several cytokines: PGE-2, TNF-α, IL-6 or IL-1β (AndukhovJ Periodontol 2011, Casarin, J Periodontol Res 2011) Analysis of amniotic fluid of preterm birth shows elevated levels of inflammatory cytokines (Pressman, Am J Obstet Gynecol 2011) Biological Plausibility : Biological Plausibility Hematogenous dissemination of inflammatory products High crevicular fluid PGE-2,IL-1β,or IL-6 have been associated with their elevated levels in amniotic fluid (Offenbacher, Annals Periodontol 1998, Dortbudak, J Clin Periodontol 2005) Periodontal Diseases and Pregnancy : Periodontal Diseases and Pregnancy Effects of Periodontal Disease Treatment Periodontal Disease Treatment : Periodontal Disease Treatment Earlier studies Reduced the risk of preterm birth and LBW (Lopez NJ, J Periodontol 2002, Jeffcoat MK, J Periodontol 2003, Lopez NJ, J Periodontol 2005, Offenbacher S, J Periodontol 2006) Periodontal Disease Treatment : Periodontal Disease Treatment Recent studies Reduced the risk of preterm birth (Radnai, J Dent Res 2009, Novak, Fetal Diagn Ther 2009) No significant risk reduction of preterm birth and LBW (Michalowicz, NEJM 2006, Tarannum, J Periodontol 2007, Offenbacher, Obstet Gynecol 2009, Newnham, Obstet Gynecol 2009, Macones, Am J Obstet Gynecol 2010, Oliveira, Clin Oral Investig 2010) Periodontal Disease Treatment : Periodontal Disease Treatment Metaanalysis (Xiong X, BJOG 2006) 44 studies Maternal periodontal treatment reduced the risk of Preterm LBW: pooled OR 0.53 Periodontal Disease Treatment : Periodontal Disease Treatment Metaanalysis (Polyzos NP, Am J Obstet Gynecol 2009) 7 RCTs Maternal periodontal treatment significantly lowered Preterm birth: OR 0.55 LBW: OR 0.48 Periodontal Disease Treatment : Periodontal Disease Treatment Metaanalysis (Polyzos NP, BMJ 2010) 11 RCTs Maternal periodontal treatment did not significantly lowered Preterm birth: pooled OR 0.93 LBW: pooled OR 0.85 Periodontal Disease Treatment : Periodontal Disease Treatment Metaanalysis (Uppal A, J Am Dent Assoc 2010) 10 RCTs for preterm, 8 RCTs for LBW Maternal periodontal treatment significantly lowered Preterm birth: OR 0.59 LBW: OR 0.72 Not significant in high-quality studies Periodontal Disease Treatment : Periodontal Disease Treatment Metaanalysis (George A, Int J Evid Based Healthc 2011) 10 RCTs Maternal periodontal treatment significantly lowered Preterm birth: OR 0.65 LBW: OR 0.53 Periodontal Disease Treatment : Periodontal Disease Treatment Metaanalysis (Chambrone L, J Clin Periodontol 2011) 8 RCTs Maternal periodontal treatment did not significantly lowered Preterm birth: RR 0.88 LBW: RR 0.78 Preterm LBW: RR 0.52 Periodontal Disease Treatment : Periodontal Disease Treatment Metaanalysis (Baccaglini L, J Am Dent Assoc 2011) 11 RCTs Maternal periodontal treatment did not significantly lowered Preterm birth (pooled OR 0.79) and LBW Periodontal Diseases and Pregnancy : Periodontal Diseases and Pregnancy Pre-pregnancy Treatment? Periodontal Disease Treatment : Periodontal Disease Treatment Pre-pregnancy treatment More intensive treatment than during pregnancy and better resolution of periodontal disease Might provide a more definitive conclusion of the association Periodontal Disease Treatment : Periodontal Disease Treatment Pre-pregnancy treatment If the effect is confirmed, improving oral health and treating periodontal disease before pregnancy may lead to a reduction in preterm births and other adverse outcomes Periodontal Disease Treatment : Periodontal Disease Treatment Pre-pregnancy treatment Better understanding of the etiologic pathway and biologic mechanism Pre-pregnancy periodontal treatment would be applicable to many low-or middle-income countries with limited access to preventive or restorative dental care What are the Guidelines? : What are the Guidelines? Slide 97: Guidelines for Oral Care during Pregnancy Guidelines : Guidelines Guidelines : Guidelines AAP Statement 2004 Preventive oral car services should be provided as early in pregnancy as possible. Guidelines : Guidelines AAP Statement 2004 Women should be encourage to achieve a high level of oral hygiene prior to becoming pregnant and throughout their pregnancies. Guidelines : Guidelines AAP Statement 2004 If examination indicates a need for periodontal scaling and root planing or more involved periodontal treatment, these procedures are usually scheduled early in the 2nd trimester. Guidelines : Guidelines AAP Statement 2004 The presence of acute infection, abscess, or other potentially disseminating sources of sepsis may warrant prompt intervention, irrespective of the stage of pregnancy. Guidelines : Guidelines AAP Statement 2004 Diagnosis and treatment Evaluation of periodontal condition Patient education regarding impact of periodontal infection and pregnancy outcomes, and prevention and treatment options Guidelines : Guidelines AAP Statement 2004 Diagnosis and treatment Consultation with caring physician: other risks (GDM, HT), information about periodontal status and treatment Guidelines : Guidelines AAP Statement 2004 Diagnosis and treatment Consideration of pregnancy status, other risks that may influence pregnancy outcomes Periodontal therapy and patient motivation to establish and maintain periodontal health Guidelines : Guidelines Guidelines : Guidelines AAPD 2007 The AAPD recommends that all pregnant adolescents seek professional oral health care during the 1st trimester. Guidelines : Guidelines AAPD 2007 The dental professional should perform a comprehensive evaluation which includes Thorough dental history, dietary history, clinical examination, and caries risk assessment. Guidelines : Guidelines AAPD 2007 During the clinical examination, the practitioner should pay particular attention to health status of the periodontal tissues. Guidelines : Guidelines AAPD 2007 Radiographs should be obtained only when there is expectation that diagnostic yield. If dental treatment must be deferred until after delivery, radiographic assessment also should be deferred. Guidelines : Guidelines Counseling Relationship of maternal oral health with fetal health Individualized preventive plan including oral hygiene instructions, rinses, and/or xylitol gum Dietary considerations Guidelines : Guidelines Counseling Oral changes that may occur secondary to pregnancy Individualized treatment recommendations based upon the specific oral findings for each patient Guidelines : Guidelines Counseling Anticipatory guidance for the infant’s oral health Anticipatory guidance for the adolescent’s oral health Slide 114: General Oral Care during Pregnancy Oral Care during Pregnancy : Oral Care during Pregnancy Screening and prevention Assessment of oral hygiene habits, oral problems Thorough oral examination Particular attention to health status of the periodontal tissues Collaboration between obstetrician and dentist Oral Care during Pregnancy : Oral Care during Pregnancy Plaque control Maintain a good plaque control program to minimize the exaggerated inflammatory response of the gingival tissues Scaling, polishing and root planing whenever necessary Oral Care during Pregnancy : Oral Care during Pregnancy Diagnosis Dental radiography should be delayed until after 1st trimester, unless necessary Teratogenic risk is 1000 times less than spontaneous abortion Oral Care during Pregnancy : Oral Care during Pregnancy Dental treatment Dental procedures should be scheduled during 2nd trimester Te safest and most comfortable time is during 14-20 weeks Problems during 3rd trimester Discomfort, IVC compression Oral Care during Pregnancy : Oral Care during Pregnancy Dental treatment No evidence that the exposure to mercury releases from the mother’s existing amalgam fillings causes any adverse effects Oral Care during Pregnancy : Oral Care during Pregnancy Dental treatment Deferring elective dental treatment during a healthy pregnancy is not justified Deferring treatment after delivery can be problematic Oral Care during Pregnancy : Oral Care during Pregnancy Medications Lidocaine, and epinephrine are safe Sedatives should be avoided 1st-line antibiotics Penicillin, amoxicillin, cephalexin (clindamycin) Anlgesics Acetaminophen, ibuprofen Oral Care during Pregnancy : Oral Care during Pregnancy Caries risk reduction in children Xylitol and chlorhexidine use late in pregnancy and postpartum period A daily rinse of 0.05% sodium fluoride and 0.12% chlorhexidine Xylitol gum Oral Care during Pregnancy : Oral Care during Pregnancy Caries risk reduction in children Lower maternal oral bacteria load and reduce transmission to infants Optimal dose remains controversial (Soderling E, Caries Res 2001, Brambilla E, J Am Dent Assoc 1998) Oral Health and Pregnancy : Oral Health and Pregnancy Conclusion Oral Health and Pregnancy : Oral Health and Pregnancy Evidence have shown possible relationship between unhealthy oral conditions and various adverse pregnancy outcomes Oral Health and Pregnancy : Oral Health and Pregnancy Effective and timely treatment could possibly reduce the risk of adverse outcomes Oral Health and Pregnancy : Oral Health and Pregnancy Timing and patient subgroups that will benefit from appropriate oral care during pregnancy are to be determined Oral Health and Pregnancy : Oral Health and Pregnancy Education Awareness Counseling Collaboration