PUBLISHED IN DUBAI www.dental-tribune.me January-February | No. 1, Vol. 9 Gain a child, lose a tooth? By Prof. Nicole Arweiler, Germany The most important physiological, hormonal and perhaps also most beautiful changes in a woman’s life occur during pregnancy. And the mouth is one of the main areas in- volved in these changes. Although gingival inflammation during preg- nancy tends to increase—even with correct oral hygiene—pregnancy gingivitis does not normally cause lasting damage to the periodontium. In the post-partum phase, even women with periodontitis who did not receive periodontal treatment during their pregnancy show an im- provement in all clinical periodontal parameters. So all is well, right? Un- fortunately not. The research agrees: pregnant women require special oral hygiene instructions, owing to hormonal changes, in order to avoid periodontitis. This is because periodontal treatment can be nerve- racking, time-consuming and bad for their health. How important is periodontal health for pregnancy really? Its significance is actually increasing with current re- search findings. Pregnancy gingivitis is one of the most important peri- odontal diseases. Like other forms of gingivitis, untreated it can lead to periodontitis. No specific type of periodontitis is linked to pregnancy, but periodontitis seems to be a po- tential risk factor for negative preg- nancy outcomes. But how strong are the connections between peri- odontitis and negative pregnancy outcomes like premature birth, low birthweight and pre-eclampsia re- ally? More on that later. The legislature has already known for decades about the importance of periodontal health for expectant mothers. The maternal health pass- port guides women in Germany and Austria through pregnancy. Federal committees and health insurance companies also require that gynae- cologists and dentists speak about the importance of oral hygiene for mother and child in the last trimes- ter as needed. Unfortunately, the reality is that only 5–10 per cent of pregnant women worldwide see a dentist during pregnancy. Certainly, socio-economic status, fear and per- haps also apathy mean that many patients avoid the dentist. Many expectant mothers say they do not have time to go to the dentist several times. “Gain a child, lose a tooth,” as your grandmother used to say. (pregnancy What is pregnancy gingivitis? Various periodontal diseases, includ- ing pregnancy gingivitis, granuloma gravidarum tumour, also epulis gravidarum) and peri- odontitis, affect the (oral) health of pregnant women. Pregnancy gingi- vitis is therefore among the classic gingival diseases. Besides plaque- induced gingival disease, pregnancy gingivitis ranks among the diseases altered by systemic factors. This Prof. Nicole Arweiler, Germany includes hormonal influences, like puberty, menstruation, pregnancy and diabetes mellitus or even blood disorders. In appearance and form, pregnancy gingivitis does not differ from clas- sic gingivitis, but it does differ in prevalence. Already in 1933, Ziskin et al. spoke of a 30–100 per cent occur- rence.1 In more recent studies,2–4 this varied between 38 per cent and 93.7 per cent. Gingivitis has been found to correlate with hormone level and plaque. In the second and third tri- mesters, pregnant women generally notice an increase in gingivitis and bleeding, since the body produces the steroid hormones progesterone and oestrogen more strongly. The more plaque, the higher the risk of gingivitis. The causes of pregnancy gingivitis, however, seem to be more com- plicated than previously believed. Even small quantities of plaque in pregnant women lead to an exces- sive inflammatory reaction in the susceptible tissue. Not only does the immune system change, but so do blood circulation and the cell system. The entire oral mucosa prepares for the birth. The practice team must therefore pay particular attention to the dental biofilm. Progesterone and oestrogen directly promote the pathogens Prevotella intermedia and Porphyromonas gingivalis. In- directly, the soft tissue is more sen- sitive to bacteria that reach the oral cavity. Does pregnancy gingivitis lead to premature birth? Generally, science assumes that periodontal inflammation plays an important role in pregnancy com- plications. Periodontitis as a chronic inflammation is ultimately caused by a bacterial infection and thus represents a potential source of circulating inflammatory biomark- ers. These inflammatory mediators spread throughout the entire body and are related to possible negative pregnancy outcomes. In studies on periodontitis in pregnant women, the occurrence of the disease varied between 0 per cent5 and 61 per cent.3 Clinical studies further suggest that bacteria, like P. gingivalis, Treponema denticola, Tannerella forsythia and Fusobacterium nucleatum, from the oral cavity colonise the foetus and the placenta, with blood being the most likely transfer medium. These periodontal pathogens may there- fore represent a risk factor for nega- tive pregnancy outcomes, including low birthweight, premature birth and pre-eclampsia (high blood pres- sure). Actually, there is still no clear proof to support the connection between periodontitis and negative pregnancy outcomes. Some studies indicate that there could be a link. Further studies are needed, however, to understand the complex biologi- cal processes. Three facts remain. First, a pre-existing periodontal con- dition in the woman can exacerbate periodontitis during pregnancy. Sec- ond, after the birth, the periodontal status of women with periodontitis improves without active periodontal therapy. However, the disease does not disappear and can even worsen after the birth. Third, pregnancy gin- givitis alone does not lead to nega- tive pregnancy outcomes. Treatment and prevention Whether the mouth is healthy, has gingivitis or even periodontitis, nowadays, organisations and re- searchers recommend that pregnant women make three visits to the den- tist, ideally once per trimester. This way, dentists can advise them com- prehensively in the first trimester. The second trimester is suitable for a professional tooth cleaning and periodontitis treatment. The practice team should use the third trimester for consultation on the dental health of the baby. Ideally, prophylaxis should begin for the child during pregnancy. Different studies show how important it is to educate wom- en during pregnancy and right after the birth in order to reduce the risk of caries in children. In the dentist’s office, pregnant pa- tients should learn everything im- portant about the development of dental caries, routes of infection and nutrition; however, the emphasis here is not just on the information, but also on targeted, preventative therapy. Expectant mothers who become enthusiastic about prophy- laxis pass this experience on to their children. This way, prophylaxis for the child, the first primary prophy- laxis even before the birth, becomes the focus of dentistry. Mechanical and professional plaque control Mechanical plaque control has al- ways been the focus of pregnancy prophylaxis. Brushing with a tooth- brush with soft bristles and fluoride toothpaste, and using instruments for interdental care and, if necessary, chemical plaque control are key in- struments for the prevention of gin- givitis and periodontitis even before pregnancy. That is why, for example, Oral-B recommends electric tooth- brushes with oscillating rotations. At the same time, every system of mechanical plaque control is suit- able in principle, whether manual or electric, as long as the correct tech- nique is used regularly and with per- sistence (120 seconds). In the case of gingivitis, toothpastes with antibacterial agents such as stannous fluoride are beneficial, and mouth rinsing solutions are suit- able as additional therapy. For acute ÿPage E2