Subgingival microbiota changes during pregnancy Some researchers have speculated that the accumulation of progesterone and estrogen in gingival tissues during pregnancy may enhance bacterial growth by providing bacterial growth factors. Species such as P. melaninogenica and P. Intermedia can use these factors rather than Vitamin K for their growth (Kshirsagar and Balamurugan, 2018). Longitudinal changes in subgingival microbiota during pregnancy have been documented, but study populations are small; determining the clinical significance of microbiotic changes requires further investigation. For example, a study of 20 pregnant women aged 18 or older found that although the subgingival levels of bacteria associated with periodontitis do not change over time, the number of individual bacterial species do. The qualitative microbiota changes during pregnancy feature a shift Oral health during pregnancy The assumed link between periodontitis and the risk for adverse birth outcomes (discussed later) has spurred interest in oral health during pregnancy. However, optimal oral health in pregnant patients has, until recently, been impeded by myths surrounding the safety of dental care during pregnancy specifically that dental care may pose dangers to the developing fetus. (Hartnett, et. al., 2016; Muralidharan and Merill, 2019). In addition, the lack of access to dental care for pregnant patients, and possibly the lack of dental insurance, can interfere with the utilization of oral healthcare services. Variations in income levels, lack of education, lack of perceived need and personal circumstances and stressors can all contribute to the lack of oral health care during pregnancy (Hartnett, et al., 2016). Odontogenic infection Pregnant women are at higher risk for dental infections because of hormonal changes, lack of routine dental examinations, and delays in treatment for oral disease. In addition, the maternal immune system is slightly suppressed during pregnancy, with a decrease in cell-mediated immunity and natural killer cell activity (Shah et al., 2017; Kshirsagar and Balamurugan, 2018). As a consequence, odontogenic infections in pregnant women Enamel erosion The pregnant patient is at higher risk of gastric acid reflux due to hormonal and mechanical changes in the gastrointestinal tract (The American Dental Association, 2021). Consequently, the risk of dental erosion is increased. Nausea and vomiting associated with pregnancy can also contribute to erosion. Patients with severe gastric reflux caused by nausea and vomiting during early pregnancy are candidates for fluoride treatment to enhance the remineralization of eroded surfaces and to prevent further progression of dental wear. Topical fluoride is a U.S. Food and Pregnancy gingivitis So-called pregnancy gingivitis occurs in approximately 35% to 100% of pregnant women (Hartnett, et al., 2016; Kashetty, Kumbhar, Patil, & Patil, 2018). This condition usually emerges in the first trimester of pregnancy and peaks during the second trimester. Its cause is most likely related to increased levels of sex hormones (progesterone and estrogen), which trigger an exaggerated gingival inflammatory response to local irritants. Clinically, pregnancy gingivitis is characterized by redness, edema, and tenderness of the interproximal papillae with Periodontitis and adverse pregnancy outcomes The health impact of maternal periodontal disease and caries has generated considerable analysis and debate, particularly regarding the effect on pregnancy outcomes (e.g., premature birth and low birth weight) and early childhood health. Several putative mechanisms have been proposed linking periodontal disease and preterm birth or low birth weight. For example, periodontitis may cause preterm birth by producing low-grade bacteremia concentrated in the decidua and chorioamnion or by releasing an endotoxin into the maternal circulation that triggers
from aerobic or facultative gram-positive species towards an anaerobic gram-negative species (Kshirsagar and Balamurugan, 2018). Patients were followed with increased bacterial counts noted for Neisseria mucosa (p < 0.001), and lower counts were noted for Fusobacterium nucleatum and F. naviforme , Staphylococcus aureus , Streptococcus mutans , and S. sanguinis (p < 0.001). Results from this study suggest that while decreases in the levels of many species occur during a normal pregnancy, other species, such as N. mucosa, increase. These elevated counts were significantly associated with gingivitis (p < 0.001) and bleeding on probing. Machado and colleagues (2016) observed changes in the proportions of oral microflora during pregnancy, most notably a reduction in Prevotella nigrescens . Given the clear links between oral and general health, and between maternal and infant oral health, oral health care should be a goal for all individuals. It has been estimated that only 22% to 34% of women obtain dental care during pregnancy despite an awareness of the importance of maintaining oral health during pregnancy (Vogell, 2017). Some women believe that poor oral health during pregnancy is normal (Muralidharan and Merrill, 2019). In addition, some women may have concerns regarding the impact of dental care while pregnant (e.g., potential harm to themselves or their fetus). If perceptions of oral health during pregnancy are truly viewed differently by women that may be one contributing factor in women’s avoidance of dental treatment while pregnant (Rocha, Arima, Werneck, Moysés, & Baldani, 2018). can more rapidly develop into deep-space infections. For these reasons, it is important to promptly treat odontogenic infections during pregnancy by draining an abscess, extirpating offending pulp tissue, or extracting a tooth. The patient’s obstetrician should be informed of the patient’s status and consulted regarding any course of treatment. Drug Administration (FDA) category B drug, although fluoride taken internally is listed as category C (Prescribers’ Digital Reference, n.d.; see the section on drugs and pregnancy). Please note, however, that the letter categories have been replaced by the Pregnancy and Lactation Labeling Rule (PLLR) as developed by the FDA as of June 30, 2015 (Drugs.com, 2021). The application of a fluoride varnish may be better tolerated than topical fluoride gel, which may cause nausea (ADA, 2017; CVS Pharmacy, n.d.). bleeding on probing. It usually responds to removal of local irritants and improved oral hygiene. A so-called pregnancy tumor (pyogenic granuloma) may occur in some patients and usually is located on the labial surface of the papilla (Figueiredo C, et al., 2017). Local debridement, chlorhexidine rinses, and improved oral hygiene are appropriate interventions for small pyogenic granuloma lesions, although surgery may be required for large lesions. intrauterine inflammation. Inflammatory mediators, such as prostaglandins (PG), interleukins (IL), and tumor necrosis factor, can potentially trigger preterm labor. Alternatively, periodontitis can produce a systemic host response with an upregulation of serum cytokines. Thus, it is possible that periodontal infections can precipitate the birth of preterm low birth weight infants by acting as reservoirs for gram-negative anaerobic organisms and inflammatory mediators (Kawar, Patovi, Hildebolt, McLeod, & Miley, 2016; Lee and Hoerler, 2019; Lohana, Suragimath,
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