The Impact of Maternal Oral Health During

Pregnancy on the Mother and Her Baby

By Mary S. Haumschild, RDH, RN, MHSc, DHSCM, and Seth C. Holloway, BS, MPH(c

Introduction and/or low birth weight.'' In 2007, Schroeder-Drucks stat-

ed, "pregnant women with periodontal disease have more
The purpose of this project is to create a standardized than seven times the risk of delivering PLBW infants."^
oral health promotion, intervention and educational pro- The theory is that bacteria multiply and may go to
tocol specific to underserved pregnant women for public distant sites, causing a bacteremia, which triggers chemi-
health practice implemented in county health depart- cal events when bioactive substances are released from
ments. the infiamed gingival pockets into the maternal systemic
The literature reflects contradictory findings regarding drculation, initiating the infiammatory cascade.* It is
the assodation between maternal periodontal disease and thought that periodontal disease also releases pro-infiam-
adverse pregnancy outcomes, such as preterm or prema- matory cytokines and the chemical called prostaglandin,
ture low birth weight (PLBW) infants, that have lifelong capable of increasing contractility in the uterus, which can
consequences. Pregnancy is an opportune time to teach induce labor.
mothers about the impact of oral disease, as this is often Preterm birth (less than 37 weeks gestation) and low
the time when they are the most interested in educa- birth weight (less than five pounds, eight ounces) infants
tional and behavioral modifications for themselves and are immature, which contributes to more and extended
the health of their developing baby.' The county health admissions in the neonatal intensive care unit along with
department is often the facility to which indigent, unin- more morbidity and mortality. These infants have an in-
sured or underinsured expectant mothers go to receive creased risk of delayed neurodevelopmental disorders with
care during pregnancy. resulting cerebral palsy, blindness and deafness. Respira-
Adverse pregnancy outcomes, including premature tory conditions such as asthma and chronic lung disease
or low biri:h weight infants, are a major problem in the are more common. In addition, behavioral, cognitive and
United States and internationally because of their eco- learning difiiculties such as attention deficit hyperactiv-
nomic burden, long-term disability and mortality. There- ity disorder are lifelong problems.' These complications
fore, there is a need to create and implement a standard- contribute to a burden on society due to the increase in
ized protocol for serving underserved pregnant women in health care expenditures, with medical costs being 10
county health departments. times greater for PLBW infants compared to full-term
births.^ Lower socioeconomic status, education, income
and access to care have all been associated with poorer
pregnancy events.^
Pregnancy
Many women have the misconception that dental treat-
Mothers should remember that when they are perform- ment during pregnancy will endanger the fetus. In fact,
ing oral hygiene procedures, they are affecting not only one study showed that women who receive periodontal
their own health, but also that of their unborn baby. Most debridement therapy may reduce the risk of PLBW infants
expectant mothers have not thought about the impact by 85 percent.^ Dental insurance is a strong predictor of
of oral health on their own general health and that of dental care utilization, with low-Income minorities hav-
their baby. Oral diseases such as dental caries, gingivitis ing been shown to have a greater prevalence of dental
and periodontitis are infectious diseases that can have disease and less access to care than more affiuent popula-
long-term consequences for the mother and her offspring. tions. Medicaid covers approximately one-third of al! births
These diseases are interrelated and all result from the ef- in the United States with inconsistent coverage among
fects of the dental biofilm matrix on the oral cavity. states. In fact, pregnancy is the only time that most Med-
icaid programs provide dental coverage for low-income
Maternal oral flora is transmitted to the newborn, which
women.-
predisposes the infant to caries later in life.^ The first-
ever Surgeon General's Report on Oral Health in 2000 Currently, there is no standardization of programs for
discussed eliminating oral health barriers and disparities, pregnant women available in the state or county health
and David Satcher, MD, PhD, identified treatment of oral departments. The protocols may vary widely from county
disease as very important to improve maternal and infant to county and state to state. There is a need to support
health during pregnancy. The report also associated ad- educational and therapeutic programs for all pregnant
verse pregnancy outcomes with maternal oral health and females, regardless of their sodoeconomic status or ability
stated that periodontal treatment can improve maternal to access health services, due to the substantial health
and infant general health.^ benefits and economic burdens that will otherwise result.
When indigent, uninsured or underinsured expectant In 2005, Boggess and Edelstein extrapolated from their
mothers go to the county health department to receive findings the suggestion that "[18 percent] of the PLBW
pregnancy-related care, they may receive collaborative infants born annually might be attributable to periodontal
prenatal care, dental care and nutritional suppori: through disease, and thus account for a significant proportion of
the Women, Infants, and Children (WIC) program. One in the $5.5 billion annual costs associated with the care of
10 babies born in the United States is considered preterm PLBW infants."^

26 FEB 2010 access

Bacltground is a follow-up by the successor surgeon general, Richard Car-
mona, MD. This report, issued in 2003, recommends expanding
Case-control and cohort studies from 2006 showed a rela- programs for a partnership of public and private organizations to
tionship between both acute gingival infections (gingivitis) and reduce health disparities for vulnerable and special needs popu-
chronic periodontal infections (periodontltis) with abnormal lations. The movement is for enhanced oral health, which leads
pregnancy outcomes.^ Potential confounding risk factors include to better general health and awareness of the integral relation-
the mother's age, height, weight, socioeconomic status, ethnic- ship of certain adverse pregnancy outcomes."'
ity, smoking, alcohol use, cervical competency, diet, hyperten-
sion, history of previous PLBW infant and presence of infection.^
Periodontal disease, characterized by episodes of exacerbation The Standardized Protocol for Treatment of Pregnant
and quiescence or remission, usually worsens during pregnancy.^ Women at a County Heaith Department

Collecting and Analyzing Data

Review of the Literature _ .
The science supporting dental treatment before, during and
Lopez, Smith and Gutierrez found that periodontal disease after pregnancy to reduce dental caries and periodontai disease
was an independent risk factor for PLBW infants.'° The authors transmission is strong. Pregnancy is an opportune time to teach
state that infectious diseases like periodontal disease can and mothers about the impact of oral disease, as this is the time
should be treated prior to and during pregnancy. While many that they are the most interested in educational and behavioral
recent studies report that maternal oral disease may be an inde- modifications for themselves and the health of their developing
pendent risk factor for abnormal pregnancy outcomes, including baby. Dental diseases are highly preventable and manageable
PLBW infants, preeclampsia and mortality, causality has not yet with early and regular dental care; however, the second trimes-
been established, and there is disagreement in the literature ter is considered the best time for restorative intervention,^
about an assocaition.^ As an example, the most recent study The treatment plan should be individualized to each patient's
concluded that there were no significant differences between needs and may include non-surgical periodontal scaling and root
pregnant women in the periodontat treatment group and the planing with local anesthesia when necessary, and the use of
control group and that periodontal therapy did not reduce the ultrasonic and hand instrumentation." In addition, education
incidence of preterm delivery." about avoidance of high sugar intake, smoking cessation, oral
hygiene procedures, sealants, fluoride supplementation, caries
While many recent studies report that maternal prevention and parafunctional habits such as thumb sucking are
important measures to maintain oral health in both mothers and
oral disease may be an independent risk factor for their offspring.' More emphasis should be placed on vulnerable,
abnormal pregnancy outcomes, including PLBW high-risk populations in need of dental care.'^
infants, preeclampsia and mortality, causality has Research conducted in the mid-2000s demonstrates a bi-
not yet been established, and there is disagreement directional relationship between periodontal disease and adverse
pregnancy outcomes. Oral health may be indicative of what is
in the literature about an association. going on in the rest of the body. Improvement in the periodontal
status may also ameliorate other systemic diseases. Educa-
Although there are conflicting results, most of the clinical tion should be offered when the mother is receptive to learning
studies from the 2000s show a positive correlation between about what to expect after the baby is
periodontal disease and PLBW infants, and more research will be
needed to refute them definitively/ Pregnancy gingivitis com-
monly occurs at interproximal sites in the anterior area of the Implemen tation
mouth. The current edition of Carranza's Clinical Periodontology
includes the opinion that periodontal disease in mothers results The maternal oral health program is implemented with a
in abnormally high levels of inflammatory mediators, and that workshop for physicians and nurses from the maternity clinic,
the translocation of bacterial endotoxins from the inflamma- dentists and dental hygienists from the dental clinic, and the
tion may foster premature labor and PLBW infants.'^ To address manager from the Women, Infants, and Children (WIC) clinic.
the potential for poor birth outcomes in dentally underserved Afterward, a review of the literature, with key articles from
populations. Healthy People 2010 aims to increase access for journals from each discipline, (e,g.. Obstetrics & Gynecoiogy,
improved oral health by decreasing barriers such as lack of den- Journal of the American Dentai Association, Journal of Dentai
tal insurance and public programs because oral health tends to Hygiene and Maternal and Chiid Heaith Journai) is presented
vary on the basis of sociodemographic factors. Oral health initia- and discussed. Lastly, 60 days later, there is a follow-up two-
tives, collaborations and partnerships need to occur to increase hour workshop for program analysis with feedback and problem
oral health literacy to explore new ways to improve access for all solving.
Americans.'^ The World Oral Health Report 2003 (WHO) found
The methodology for pregnant women who visit the materni-
that oral diseases qualify as a major public health problem due
ty clinic at the county health department is referral to the dental
to their high prevalence and incidence, with the greatest burden
clinic after signed medical clearance.^" The conceptual frame-
falling on disadvantaged populations.'''
work includes the proposed standardized protocol for treatment
Oral Health in America also states that oral health is essential in the dental clinic at all county health departments that begins
to general health and well-being and should be achieved by all at the first appointment with an assessment by the dental
Americans. Oral disease disproportionately affects our most vul- hygienist, followed by an examination by the dentist. This initial
nerable populations: children, the elderly, and racial and ethnic visit includes blood pressure and pulse measurement, orai can-
minorities," The National Call to Action to Promote Orai Heaith cer screening, nutritional counseling and full-mouth periodontal

access FEB 2010 27

chari:ing for tissue assessment and treatment dassification. Medicaid and Medicare services should expand dental cover-
Routine radiographs would be delayed until after pregnancy to age for pregnant women, as pregnancy provides a teachable
prevent unnecessary radiation exposure to the developing baby. moment for both self-care and child-care to limit intergenera-
If the dentist deddes that a radiograph is necessary, a double tional oral disease. Oral health promotion should begin pre-
lead apron would be used to decrease the exposure as much as conception and continue through birth to include prevention
possible.^^ services with education and referral for additional evidence-
The mother's diet must contain the essential nutrients for her based interventions when dental disease is present.^ An ideal
and also to suppori: the baby's developing teeth and avoid cario- strategy would be for the dental community to partner with the
genic foods that might satisfy unusual cravings. It is important medical community and expand public services so that infants
to dispel any myths about the mother losing calcium from her are safeguarded. The transdisciplinary collaboration framework
teeth while pregnant.'^ Tobacco cessation, avoidance of drugs consisting of physidans, dentists, nurses and dental hygienists is
and alcohol, and domestic violence programs are also important important for optimal communication, and because every preg-
to initiate at the first visit.^° Domestic violence assessment and nant female should be assessed for periodontal disease."
intervention for the affected patient is an important concept
to indude in the dental visit, especially since pregnant women
tend to be more vulnerable to such abuse. An individualized
Medicaid and Medicare services should expand
dental treatment plan and plaque control program with proper
brushing and flossing techniques are explained. A series of short dental coverage for pregnant women, as pregnancy
appointments should be planned with frequency dependent on provides a teachable moment for both self-care and
the needs of the patient to maintain a healthy oral environment. child-care to limit intergenerational oral disease.
Oral care supplies such as a toothbrush, toothpaste and dental
floss should be dispensed at this visit with oral care instruction.
These appointments should involve the obstetrician, nurse, den-
tist, dental hygienist, dietitian and expecting parents to focus on Discussion, Conclusions and Recommendations
optimizing the health of the mother and her developing baby,'^
Depending on the findings, the second visit is scheduled with Periodontal disease is characterized by cycles of exacerbation
the dentist to relieve any conditions causing pain, which might and remission. Researchers have hypothesized that the chronic
require extractions or immediate restorative procedures. Routine burden of endotoxins and infiammator/ cytokines damages gin-
dental treatment is delayed until the second trimester or after gival tissue and may also affect placental infiammation, which
the pregnancy. The county health departments do not have the ultimately produces placental damage. However, disparities in
necessary funds for all the needed dentistry. Therefore, they oral health care accessibility and utilization may also confound
concentrate on relieving pain, which is accomplished by means the understanding of the relationship between maternal oral
of extractions or referral to a lower-cost dental dinic for treat- health and adverse pregnancy outcomes. The data is encourag-
ment if the patient qualifies finandally.^° If the patient is not ing, because periodontal disease is preventable, treatable and
in pain, the second visit should be scheduled with the dental reversible in its eariy stages.
hygienist to begin scalings. The dental hygienist should serve in public health facilities
The last visit for the mother is reserved for polishing and such as maternal and child health clinics within community
more education. This is a good time to talk about the impor- health programs, stressing professional dental care and preven-
tance of breastfeeding, care of the baby's first teeth, impor- tive education during pregnancy. When the periodontal tissues
tance of fiuoride and how to avoid baby bottle decay. A child's are healthy and the patient uses good plaque control procedures
toothbrush and supplies should be dispensed at this visit. After at home, exaggerated adverse responses to gingival infiamma-
the birth, the baby should receive follow-up appointments. tory changes during pregnancy can be abated. Prenatal care
These should take place at six-month intervals to assess for helps the mother to enjoy optimum heaith both during and after
eariy childhood caries, fiuoride varnish applications, nutritional pregnancy, which also gives the child the best chance to be born
counseling, oral hygiene instructions and prophylaxis when the healthy.'^
deciduous teeth are present in the oral cavity. Sealants should Despite medical advances in diagnosing and treating preterm
be applied when the permanent teeth first erupt.^^ All educa- labor, complications are rising. Adverse pregnancy outcomes,
tional materials should be available in English, Spanish and such as neurological sequelae, have an impact beyond the im-
other languages. mediate family, as an economic burden to society, in increased
health care costs," The hypothesized improvement in mater-
nal ora! hygiene could lead to improved general health for the
Outcomes mother and her developing baby, since dental health extends
way beyond the oral cavity. According to Oral Health ¡n America,
The anticipated outcome from this standardized oral health new educational initiatives need to be incorporated to spread
promotion, intervention and educational product for underserved the word about this concept. Many medical professionals do not
know about the research linking periodontal disease and adverse
pregnant women implemented in county health departments
pregnancy outcomes. Formal education strategies regarding
would be better maternal-infant heaith. A review article by Bo-
mouth and body connections need to be implemented in medical
betsis et al, found that some of the published intervention stud-
and dental school curriculums for the practitioners to understand
ies show a significant reduction in PLBW infants afi:er periodon-
the health consequences of poor oral hygiene and the growing
tal therapy; however, the results were not always statistically
body of related research.^"
significant, possibly due to the small sample size and noncom-
pliance.^ The suggestion, which ongoing research will need to Counseling prior to conception should be the cornerstone of
verify or refute, is that the risk of PLBW infants may increase contemporary maternal care. Inflammation should be controlled
with the severity of periodontal disease.^^ with periodontal debridement therapy and oral hygiene instruc-

28 FEB 2010 access

tions as needed until delivery. Cross-referral is another way to surgeongeneraLgov/topics/oralheaith/nationalcalltoaciian.htm. Accessed Aug.
implement transdiscipiinary protocols for decreasing the ma- 8, 2008,
ternal effects of poor oral hygiene for optimum patient care." 17. Michalowia BS, Hodges JS, DiAngelis AJ, et al. Treatment of periodontal dis-
ease and the risk of preterm birth. N EngI 3 Med. 2006; 355: 1885-94,
There needs to be a paradigm shift to shared responsibility 18, Burakoff R, New York State ieading the way m establishing guidelines for oral
for oral health promotion by direct referral systems, improved care in pregnancy. Grand Rounds in Oral-Systemic Medicine. 2006; î:50-2.
screenings, expanded guidelines for health promotion and pre- 19, LePeau NS, Wilkins EM. The pregnant patient. In: Koger B, Dietz K, ed. Clinical
vention, standardized assessment instruments, implementation practice of the dental hygienist, 10th ed. Philadelphia: Lippincott, Williams &
of evidenced-based intervention protocols and interdisciplinary Wilkins; 2009: 765-77,
20. Pinellas County Health Department. Pregnancy protocol. St. Petersburg, Fla.:
continuing education venues.'^ A standardized protocol should Florida Department of Health; 2005,
be implemented at all county health departments. 21. Jeffcoat MK, Geurs NC, Reddy MS, et al. Periodontal infection and preterm
Additional research is needed to determine whether periodon- birth: results of a prospective study, J Am Dent Assoc 2001; 132: 875-80.
22. Witt 3S, Williams KB, Kelly PJ, Engaging hygienists, nurses and social service
tal interventions completed before conception or early in preg-
professionals in an interdisciplinary model for prevention and early care of orai
nancy might improve pregnancy and birth outcomes. The as- diseases in women of childbearing age. Grand Rounds in Oral-Systemic Medi-
sociation between maternal periodontal disease and premature, cine 2006; 1:40-8,
low birth weight infants should be explored to establish if there 23, Kerpen SJ, Fleischer A. An obstetridan and periodontist translate periodontal-
is a causal or merely associative relationship. More randomized, systemic research to preserve the health of pregnant women at risk for adverse
pregnancy outcomes. Grand Rounds in Oral-Systemic Medicine 2006; 1:28-39.
placebo-controlled, double-blind trials need to be performed to
24, Wilder R, Robinson C, Jared HL, et al. Obstetricians' knowledge and practice
test the strengths of these associations. In the meantime, we behaviors concerning periodontal health and preterm delivery and low birth
know that scalings can be safely performed during the second weight. J DentI Hyg 2007; 8 1 : 1-15.
trimester to help reduce the inflammation. Therefore, since
periodontal disease is both preventable and treatable, it is the
interdisciplinary team's duty to intervene with pregnant females Mary S. Haumschild, RDH, RN, MHSc, is adjunct
faculty in the Schooi of Dentai Hygiene Associate
to help decrease the occurrence of periodontal disease, and pos- program and in the Heaith Services Administra-
sibly PLBW infants, with their public heaith consequences. tion Bachelor's program at St. Petersburg College.
She is a doctoral candidate at Nova Southeastern
University and practices clinical dental hygiene
with Massaro & Massaro in Seminóle, Fla.
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access FEB 2010 29

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