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
E2 ◊Page E1 HYGIENE TRIBUNE Dental Tribune Middle East & Africa Edition | 1/2019 gingivitis, patients should use chlo- rhexidine therapeutically for a short time, best in a concentration of 0.1– 0.2 per cent or 1 per cent. Different meta-analyses have found that chlo- rhexidine can be used with conﬁ- dence during pregnancy. Long-term chemical plaque control is suitable for pregnant women with nausea and poor oral hygiene, particularly in the molar area. Other alternatives, such as tea tree oil and propolis, have not shown any effectiveness in stud- ies. What to keep in mind with periodontal therapy If the practice team has to treat preg- nant patients for periodontitis, nei- ther has any special procedures to be considered ﬁrst. Research shows that non-surgical periodontal therapy is safe and sensible during the second trimester. Scaling and root planing are quite possible during pregnancy. Radiographs can be taken and local anaesthesia can be administered without additional risk to the foetus or the mother. Articaine is the agent of choice in this case. Periodontal therapy does not reduce the occur- rence of negative pregnancy issues. However, it can lower the frequency of negative pregnancy outcomes in women at high risk of pregnancy complications or who respond bet- ter to periodontal treatment. Modern pregnancy prophylaxis Professional tooth cleaning as part of modern bioﬁlm management is an indispensable component of gin- givitis and periodontal therapy in the context of a prophylaxis session. Professional tooth cleaning, in com- bination with oral hygiene products and instructions, clearly reduces moderate or severe gingivitis. The second trimester is therefore best suited for professional tooth clean- ing. At this point, nausea has usually disappeared and the patient can stay lying down for a whole hour. An optimal pregnancy prophylaxis also includes nutrition from a den- tistry point of view. Here patients should not limit themselves, but enjoy their pregnancy. Neverthe- less, patients should forgo acidic foods and beverages. A craving for AD #SayAhh #WOHD19 Prof. Nicole Arweiler, Germany SAYACT ON MOUTH HEALTH A healthy mouth and body go hand in hand. Teach your patients how good oral care contributes to overall health and well-being. DENTAL CHECK-UP Spread the word and share the campaign resources SCAN ME FOR MORE INFO www.worldoralhealthday.org y b d e z n a g r O i s r e n t r a P l a b o G l s r e t r o p p u S Prof. Nicole Arweiler, Germany sour and sweet foods, often in high frequency, also increases the risk of caries or an erosive change in the tooth enamel. In addition, the buff- ering capacity and rinsing function of the saliva is reduced during preg- nancy; the mouth tends to be dry, which promotes the development of dental caries. Even allegedly healthy foods and drinks, like fruits or fruit juices, which are acidic, can quickly damage the tooth enamel. Speaking of erosion, morning sick- ness also leads to the production of gastric acid, which can again lead to dental erosion of varying intensity. Toothbrushing should be avoided after an episode. The pellicle needs 2 hours to reform after vomiting. Helpful means of neutralising are the consumption of milk, cheese and, above all, chewing gum. Instead of brushing right after, antibacterial mouth rinsing solutions and ﬂuo- ride rinsing solutions are suitable ﬁrst. Pregnancy is a major challenge with regard to teeth and gingivae. The main task of periodontal treatment during pregnancy is to improve the periodontal and overall health of pregnant women. Oral hygiene training and nutrition advice reduce plaque and gingivitis and thus peri- odontitis. With respect to affecting negative pregnancy outcomes, in- tervention even before pregnancy may be more effective. If the practice team controls the gingivitis and so avoids periodontitis, it has made its contribution to a problem-free preg- nancy. In all cases, prevention is bet- ter than cure and every tooth counts. Editorial note: A list of references can be obtained from the publisher. This article was originally published in prevention international magazine for oral health, Issue 1/2018.
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Disrupting the cxcle Bacteria can colonize on the teeth, initiating the formation of dental biofilm, but they also adhere to soft tissues in the mouth. From here they recolonize on the surface of teeth that have been brushed, rebuilding the dental biofilm causing diseases to reoccur. Protecting the soft tissues prevents adherence of bacterial biofilm and so protects the soft tissue and hard surfaces from bacterial colonization. Regular fluoride toothpaste* is not enough to achieve Whole Mouth Health - it only protects hard surfaces with fluoride. Regular fluoride toothpaste* does not protect the hard surfaces from repopulating with bacteria harbored in the soft tissues. Whole Mouth Health as the new paradigm for prevention The route to improving Whole Mouth Health is to prevent the build-up of oral biofilm and achieve good bacterial control on all oral surfaces, both hard and soft tissues. 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By recommending new Colgate Total® to your patients, they will have an advanced single solution for better, more complete oral health† If xou would like more information about the clinicallx proven benefits and efficacx of new Colgate Total®, visit our website at: www.colgateprofessional.com References: 1. Nazir MA. Int J Health Sci (Qassim). 2017 Apr-Jun; 11(2): 72–80. 2. Kassebaum, N.J., et al. Global Burden of Untreated Caries. A Systematic Review and Metaregression. Journal of Dental Research. Vol 94, Issue 5, 2015. 3. https://www.efp.org/publications/Tonetti_ et_al-2017-Journal_ofClinical_Periodontology.pdf 4. Perio & Caries Project. Available at: http://www.efp.org/publications/projects/ perioandcaries/ 5. Enhanced in vitro zinc bioavailability through rational design of a Dual Zinc plus Arginine dentifrice, Manus, L et al, J Clin Dent, Submitted August 2018. 6. Prasad & Mateo, July, 2016 internal report. 7. A clinical investigation of a Dual Zinc plus Arginine dentifrice in reducing established dental plaque and gingivitis over a 6-month period of product use, Garcia-Godoy, F et al, J Clin Dent, submitted August 2018. 8. The science of developing appealing flavors to drive compliance, Lee, C et al, J Clin Dent, Submitted August 2018. 9. A clinical investigation of the efficacy of a Dual Zinc plus Arginine dentifrice for controlling oral malodor, Hu, D., et. al., J Clin Dent, Submitted August 2018. * defined as non-antibacterial toothpaste ** after 4 weeks use, 12 hours after brushing † vs ordinary non-anti-bacterial fluoride toothpaste # with continuous use, after 3 weeks www.colgateprofessional.com www.colgatetalks.com
What you say can make a real diﬀ erence. New Colgate Total® with Dual-Zinc + Arginine for Whole Mouth Health. Reinvented to proactively work with the biology and chemistry of the mouth. Protects teeth, tongue, cheeks, and gums NEW Next generation technology • Superior reduction of bacteria on 100% of mouth surfaces, 12 hours after brushing*1 • Weakens to kill bacteria • Creates a protective barrier on hard and soft tissue to protect against bacterial regrowth For better oral health outcomes,† advise your patients about New Colgate Total® *Statistically signiﬁ cant greater reduction of cultivable bacteria on teeth, tongue, cheeks, and gums with Colgate Total® vs non-antibacterial ﬂ uoride toothpaste at 4 weeks, 12 hours after brushing. †Signiﬁ cant reductions in plaque and gingivitis at 6 months vs non-antibacterial ﬂ uoride toothpaste; p<0.001.2 References: 1. Prasad & Mateo, July 2016, internal report. 2. Garcia-Godoy F, et al. J Clin Dent, submitted August 2018.