Oral Health Status among Pregnant and Breastfeeding Women

1. Introduction

Pregnancy is a period of around 41 weeks where women carry the fetus which develops in her womb. These 9 months are critical in the life of a woman and brings diversified changes in the female’s body [1]. These changes are not only physical but also physiological and biochemical in nature. The summary of these changes is depicted in Figure 1 [2]. The different changes in the female body are also reflected in the oral cavity. Oral cavity is closely related to systemic health. The impact of different physiologic changes can be witnessed through the changes in oral cavity. Some of the major changes happening during pregnancy in oral cavity includes gingivitis, oral lesions, tooth mobility and erosion, dental caries, and periodontitis [3].

The pregnancy induced gingivitis is inflammation of gingiva because of dental plaque accumulation, which may worsen to periodontitis. The changes in musculoskeletal aspect of the female body also lead to increased tooth mobility and erosion. The increased prevalence of dental caries during pregnancy has been seen because of increased pH of saliva, intake of junk foods due to pregnancy cravings, and poor awareness toward oral health. Oral lesions like granulomas or pregnancy epulis are common in the anterior gingiva because of increased inflammatory response [4].

Further, women who breastfeed are also prone to risk of dental caries and gingivitis. There is evidence that suggest that during breastfeeding, females lose 5% of bone mass as the calcium from bones goes into the feeding milk. This makes them vulnerable to caries and gingival inflammation [5]. It is imperative to advise the women against these expected changes in the oral cavity for proper management.

2. Changes in oral cavity during pregnancy

Increased level of estrogen and progesterone during pregnancy leads to increased sensitivity of tissues. In oral cavity, gingiva becomes more sensitive to irritations. In addition, the increased prevalence of epulis gravidarum during pregnancy leads to an increased risk of bleeding from gums, that is, gingivitis. These changes are due to increased vascular permeability because of increased progesterone. In addition, lower level of vitamin C also leads to the bleeding gums problem. Changes in color of gingiva to red color of strawberry is a major change due to gingivitis. These can worsen to pregnancy-induced periodontitis [3]. The different studies in previous years have reported the prevalence of pregnancy gingivitis in 40% of pregnant women. Further, the poor oral health is also a reflection of systemic changes or gestational complications [6, 7, 8, 9, 10]. In addition the teeth undergo changes in terms of tooth decay and erosion. It is believed that the requirement of calcium for fetal growth is fulfilled through teeth. Apart from this, the decrease in salivary flow, increased consumption of carbohydrates, and increased formation of plaque worsens the condition of teeth in oral cavity [3]. The changes in oral cavity during pregnancy are represented in Figure 2.

3. Impact on pregnancy outcomes

There have been evidence that suggest that poor oral health like periodontitis is associated with adverse pregnancy outcomes (pre-term birth, pre-eclampsia, gestational diabetes, etc.). A systematic review and meta-analysis suggested twice the odds of gestational diabetes mellitus among women who have periodontitis [11]. Earlier studies have also established the presence of periodontal microbial translocation into the peripheral bloodstream by breaking gingival epithelial barrier [12, 13]. In addition, as known from the pathophysiology of periodontitis, it is a host immunoinflammatory response due to a dysbiotic shift in oral microbiota. A similar response is also elicited in case of genitourinary tract infection, and similar antibodies can be seen as an early identifier in oral cavity, thus preventing low birthweight or abortions [14]. Thus, oral cavity can be an early identifier, and proper preventive strategies can help in reducing the prevalence of adverse pregnancy outcomes.

4. Oral health assessment and role of counseling

Pregnancy could be the right moment to create awareness on the importance of oral health as pregnant women are concerned about the health of the developing baby. The need for counseling and creating awareness arises through the statistics presented in previous literature which highlights that around 56% of pregnant women do not utilize the service of dentist during pregnancy. The same study also highlights that 60% of pregnant women have not utilized dental services for teeth cleaning during pregnancy [15]. The past study has also shown that oral health care during pregnancy improves with counseling [16].

The role of obstetricians is crucial in developing the need for dental care during pregnancy. It is surprising to note that a previous study have highlighted 80% of obstetricians do not have questions pertaining to oral health in the prenatal visit, and around 90% of them do not recommend pregnant women to a dentist for counseling or treatment [17]. During breastfeeding, ignorance toward maintaining oral health can be harmful as Streptococcus mutans can be transmitted to the infants [18]. Focused training programs for obstetricians must be conducted to increase the awareness and uptake of dental care services [19].

Simple questions like whether pregnant female is facing bleeding gums, pain in gums, or swollen gums can be helpful. In addition, insight into the previous visit and the time since the last visit can help understand the inclination of the pregnant women toward oral care. This can be further used to develop a mechanism to have dental check-ups done for pregnant woman. Role of counseling thus plays a role in breaking these barriers. Understanding the complexities that may arise when the pregnant or breastfeeding female avoids dental treatment is important. The treatment of root canal, tooth extraction, and restoration are not complex. These treatments along with radiological examination with proper shielding and anesthetic administration does not yield any complexities [20]. Midwives and other prenatal care providers have a unique opportunity to offer preventive oral health services, including assessments, education, and referrals [21]. Integrating oral health into prenatal care, particularly among ethnic and racial minority groups, can be beneficial for maternal and infant health [16]. There is a clear need for improved oral health assessment and counseling during pregnancy. Implementing preventive strategies, such as including oral health education in antenatal visits and involving prenatal care workers in disseminating oral health awareness, can significantly benefit the dental health of both women and children [21, 22].

5. Oral health knowledge and awareness

Oral health knowledge, attitude, and awareness among pregnant and breastfeeding women are generally poor, with significant implications for both maternal and child health. Studies across various regions show that pregnant women often lack adequate knowledge about oral health and its importance during pregnancy. In India, a systematic review found that pregnant women had poor knowledge and awareness regarding oral health, with very few subjects (17.1% and 37.5%) feeling the need to visit a dentist during pregnancy [23]. Similarly, a study in Chennai revealed that the majority (72%) of school-educated pregnant women had never visited a dentist [24].

Interestingly, while some studies report poor knowledge, others indicate a more positive attitude toward oral health. For instance, a study in Hyderabad found that the majority of women showed good knowledge and attitude regarding oral hygiene and its relation to pregnancy. However, the same study noted poor compliance with recommended oral hygiene protocols [25]. This contradiction between knowledge/attitude and practice is also observed in a Nepalese study, where 98.2% of respondents had a positive attitude, but 92.1% had insufficient oral hygiene practices during pregnancy [26].

While awareness and attitudes toward oral health during pregnancy vary, there is a consistent gap between knowledge and practice. Factors such as education level, urban/rural residence, and working status significantly influence oral health awareness and practices [27]. The lack of referrals from gynecologists for dental check-ups during pregnancy (only 6.2% in one study) further compounds the issue [24]. These findings underscore the need for targeted oral health education and intervention programs for pregnant women, as well as better integration of oral health care into prenatal services.

6. Integrated services system for better oral health

The obstetrician holds a key role in care giving to pregnant woman. It is essential to utilize change to positive prenatal behavior, a major attributable factor in success of pregnancy. A holistic approach is a better way of ensuring desirable pregnancy outcomes. The integrated service system depicted in Figure 3 is a proposed mechanism toward a better oral health of pregnant and breastfeeding women.

The proposed framework includes the questions related to oral health in the examination sheet of the obstetrician. In addition, referral linkage with a dentist can strengthen the oral health of the pregnant and breastfeeding women. The obstetrician can arrange for the counseling sessions through multi-disciplinary team comprising of obstetrician, dentist, nutritionist and physiotherapist. This will ensure the holistic care delivery to the pregnant women.

The obstetricians can use 5A’s approach to sensitize the patients toward importance of oral health. The 5A’s approach is depicted in Figure 4.

The 5A’s approach comprises of the following as shown in Table 1.

7. Recommendations for improved oral health during pregnancy and breastfeeding

The obstetricians, community members, family members, and women can keep the following points in mind for better oral health [20, 28]:

1. Obstetrician should discuss oral health with each women during pregnancy and after the birth of infant.

2. Awareness on the importance of oral health as a precursor in impacting the systemic health and also the risk of transfer of potentially harmful caries-causing bacteria from mother to infant.

3. Regular oral health assessment is essential.

4. Reassuring patients that diagnosis, treatment, and preventive care for healthy mouth is safe. (List of safe procedures are listed in Table 2.)

5. Dental care may be covered in state’s Medicaid plan. Appropriate referral linkage with dentist can help in advocating importance of healthy mouth.

6. Establishing healthy linkage mechanism between obstetrics and dentists can help.

7. Advocating for better oral health of women before, during, and after pregnancy.

8. Reinforcing healthy oral habits like proper brushing of teeth, flossing, limiting high sugary foods and visit to dentist twice a year will help.

8. Conclusion

The chapter highlights the significance of oral health during pregnancy and breastfeeding, emphasizing the physiological changes that occur during this period and their impact on oral health. Pregnant women experience changes in estrogen and progesterone levels, which increase tissue sensitivity, leading to issues like gingivitis, periodontitis, and oral lesions. The hormonal fluctuations, coupled with lifestyle changes, can increase the prevalence of dental caries and tooth erosion due to increased cravings for sugary foods, reduced oral hygiene practices, and altered salivary pH. It is important to understand the critical role of healthcare providers, particularly obstetricians, in promoting oral health through regular assessments, referrals, and counseling. Ignoring oral health can have adverse effects on pregnancy outcomes, such as preterm birth and gestational diabetes, as poor oral hygiene may lead to the translocation of oral bacteria into the bloodstream, affecting systemic health. Thus, by integrating oral health into prenatal care by educating and advocating for regular dental check-ups, providing safe treatments during pregnancy, and establishing collaborative efforts between obstetricians and dentists.

Conflict of interest

The authors declare no conflict of interest.