Supporting Oral Health in Pregnancy
RUSLAN DASHINSKY/ ISTOCK/GETTY IMAGES PLUS
Providing dental care to pregnant patients is both safe and necessary to ensure the health of both mothers and infants.
By Susan L. Vogell, RDH, BS, MBA
After reading this course, the participant should be able to:
1. List the factors that influence oral health during pregnancy, and
those affecting patient comfort while receiving dental care.
2. Identify common oral conditions experienced by pregnant
patients, and the need for preventive care and treatment.
3. Discuss the transmission of cariogenic bacteria from mother to
child, and adjunctive methods for maintaining oral hygiene
4. Explain when national guidelines for oral health care during
pregnancy were issued, and when medical clearance is needed
before providing oral health services to this patient population.
Comprehensive dental care is considered both safe and necessary during
pregnancy and can be crucial to the well-being of pregnant women and their
offspring. Despite this fact, many women do not receive dental care during
pregnancy. Clinical guidelines are available to address misconceptions and
alleviate concerns about treating pregnant women. Oral health professionals
should be familiar with the various guidelines available; be prepared to treat
pregnant women; and be ready to educate them about the importance of oral
health. By improving the oral health of women during pregnancy, the likelihood
of oral diseases can be reduced—both for the soon-to-be mother and her
Increased Risk for Oral
experience an increase in progesterone and estrogen, which exacerbates the
inflammatory response to gingival irritants, such as plaque biofilm.
Simultaneously, changes in the oral microflora favor the pathogens associated
with gingivitis.1 As a result, pregnant women are more susceptible
to gingivitis, pregnancy granuloma, periodontal diseases, and dental caries.
Gingivitis is a common oral condition that affects up to 75% of pregnant
women.1,2 Increased levels of estrogen and progesterone, changes in
the oral flora, and a weakened immune system affect gingival tissue and cause
inflammation. Poor oral hygiene and increased biofilm can exaggerate
the gingival response. Pregnant women may experience gingivitis
beginning in the second month and continuing throughout pregnancy. Although
the severity may improve post-partum, most women who experience gingivitis
during pregnancy will likely have some form of the disease after pregnancy.1,2
FIGURE 1. A pregnancy
granuloma may form as the
result of local irritants, such
as plaque biofilm, due to
poor oral hygiene or
forming on overhanging
AMERICAN ACADEMY OF FAMILY PHYSICIANS
A pregnancy granuloma, sometimes called a pregnancy tumor, may form as
the result of local irritants, such as plaque biofilm due to poor oral hygiene
or forming on overhanging restorations (Figure 1). It is most commonly seen
along the maxillary anterior labial aspect of the interdental papilla. The
color ranges from dark red to bluish purple. It is usually no larger then 2 cm
and bleeds easily. Pregnancy granulomas will often self-resolve. If surgical
excision is required, it is best performed post pregnancy, as recurrence during
pregnancy is possible.1,2
The hormonal changes that occur during pregnancy increase a women's
susceptibility to periodontal pathogens and reduce the body's ability to repair
oral soft tissues.3 Periodontal diseases have been associated with
adverse pregnancy outcomes.4 Studies have shown an association
between periodontal diseases and preterm birth, development of preeclampsia,
and delivery of low-birth-weight infants.3,5–7
Poor periodontal health has been linked to chronic systemic conditions,
including diabetes, cardiovascular diseases, and respiratory diseases.5,8
Pregnant women experience increases in cardiac output and blood volume, and
changes in the respiratory system—all of which increase their risk for these
diseases.7 For pregnant women with diabetes, excellent oral heath is
critical because periodontal diseases can make diabetes more difficult to
control.8 Furthermore, as the degree of uncontrolled diabetes
increases, so does the risk for congenital anomalies in the fetus.9
Changes in the oral environment during pregnancy can increase the risk
for caries.10 Pregnant women tend to crave a diet high in sugar and
fermentable carbohydrates, increasing the risk for caries. In addition, many
pregnant women experience nausea and vomiting, which can compromise oral
hygiene efforts. Vomiting also increases acidity in the oral cavity. At later
stages of pregnancy, the upward pressure from an expanding uterus may cause
acid reflux.11 This type of acidic environment favors cariogenic
bacteria and can also cause erosion. Additionally, cariogenic Streptococcus
mutans passes from mother to infant through vertical transmission.11,12
The bacterium is transferred by sharing utensils or toothbrushes, kissing on
the lips, cleaning a dropped pacifier by mouth, or the prechewing of food.
Pregnant women with untreated caries have high levels of S. mutans in their
saliva and are thus likely to pass the bacteria onto their offspring. Children
who acquire the bacterium at an early age have a greater risk of developing
early childhood caries.11,12
In 2006, the
New York State Department of Health released evidence-based prenatal oral
health guidelines.13 In 2010, the California Dental Association,
together with the American College of Obstetricians and Gynecologists, revised
their guidelines.11 In 2012, national guidelines were released in a
collaboration between the federal Health Resources and Services
Administration's Maternal and Child Health Bureau, American College of
Obstetricians and Gynecologists, and the American Dental Association.14
These guidelines, Oral Health Care During Pregnancy: A National Consensus
Statement, provide information designed to improve oral health services to
women during pregnancy. They clearly state that providing preventive,
diagnostic, and restorative oral care during pregnancy is safe, effective, and
The new guidelines seek to strengthen interprofessional collaboration
between prenatal and oral health professionals. The prenatal health
professional typically sees the pregnant patient first, and is often the only
clinician to see the patient. During the first prenatal visit, women should be
encouraged to schedule an oral examination. Prenatal practitioners should
provide an oral assessment and make the necessary referrals to oral health care
The success of any guidelines depends on consistent implementation and
adherence by all clinicians, and an ongoing, collaborative relationship between
prenatal and oral health professionals. Barring any significant health issues,
there is no need to obtain medical clearance from a prenatal practitioner
before providing oral care to a pregnant patient. In an effort to facilitate an
easier referral process, however, prenatal health professionals can give
patients a written "communication" form to bring to the dental office.11
This serves as both a referral form and tool to facilitate information sharing
among all caregivers. After treatment is rendered, the form can be completed by
the oral health care team and faxed back to the prenatal clinician. Click here to view a sample oral health clearance form for pregnant women.
BARRIERS TO CARE
importance of oral health during pregnancy, approximately 22% to 34% of women
seek care during pregnancy.10 One reason is that the provision of
oral health care during pregnancy is often misunderstood by patients, as well
as prenatal and oral health professionals. As a result, medical practitioners
may not refer patients for oral care. In addition, dental teams may choose to
delay treatment until after delivery due to concerns about the safety of dental
procedures.11,15 Kloetzel et al15 noted that less than
half of the women surveyed about perceptions of dental care said their
obstetricians had advised them to seek dental care during pregnancy.
Although the most common reason cited for not seeking care is lack of
perceived need, research shows access to care also plays a role.11 The
likelihood of low-income and uninsured women receiving such care is even lower.
A California study found that fewer than one in five pregnant women enrolled in
Medicaid received dental services.11 For many low-income women,
pregnancy is the only time they may have dental coverage. Oral health coverage
for pregnant women varies by state, although states must cover
pregnancy-related services. This means Medicaid-eligible pregnant women must
receive oral health services if the oral condition is exacerbated by the
pregnancy or could negatively impact the pregnancy.16
Moreover, pregnancy is a time when women tend to be motivated to make
healthy choices. Compared to uninformed patients, women who are educated about
oral health needs during pregnancy are more likely to establish improved oral
care habits for themselves and their offspring.16
Access to care may also be hindered by low oral health literacy and
language barriers. All health professionals should ensure patients understand
the information presented and are given the opportunity to ask questions.14
Health Care During Pregnancy: A National Consensus Statement declares that
comprehensive oral care—including necessary radiographs and use of approved
local anesthesia—are beneficial during pregnancy and pose no fetal or maternal
risk.14 Furthermore, treatment can be safely rendered any time
during pregnancy, although pregnant women may be most comfortable being treated
in the second trimester. Pregnant women may experience nausea and vomiting in
the first trimester and any manipulation of oral tissues may worsen the
During the third trimester, women experience increased cardiac output,
which, along with a growing uterus, may compress the inferior vena cava,
especially when in the supine position.7 Consequently, pregnant
patients may experience heart palpitations, dizziness, nausea, or hypotension,
known as supine hypotension syndrome. To prevent supine hypotension syndrome, the clinician
should keep the patient's head at a higher level than her feet. Additionally,
having the patient tilt slightly to her left and placing a pillow or rolled
towel under her right hip can help prevent hypotension.7
As with any patient, a thorough medical and dental history should be
taken, including the use of tobacco, alcohol, and drugs. Assessments should
include a complete head, neck, and intraoral examination; caries risk
assessment; and a periodontal exam. Radiographs should be taken when indicated,
following the As Low As Reasonably Achievable principle of minimizing radiation
exposure, and using a lead apron with a thyroid collar.14 Digital
radiographs offer the least amount of radiation, which can be further reduced
with a rectangular collimator.14 Based on the clinician's
assessment, a comprehensive treatment plan that includes preventive,
restorative, and periodontal treatment can be formulated.
A tobacco cessation program should be offered to pregnant women who use
tobacco. Women are more apt to quit smoking during pregnancy than during other
times in their lives. Pregnant women who smoke may have an increased risk for
ectopic pregnancy, spontaneous abortion, and low birth-weight/preterm babies.
Infants exposed to second-hand smoke are at higher risk for respiratory
illness, middle ear infections, asthma, and sudden infant death syndrome. A
high incidence of caries in the primary dentition has also been associated with
children who are exposed to second-hand smoke.17
A healthy diet rich in nutrients is necessary for both the pregnant woman
and the fetus. Patients should be advised to eat a balanced diet rich in
folate, protein, calcium, phosphorus, and vitamins A, B6, B12, C, and D.11,18
Pregnant women should be encouraged to take prenatal vitamins, including folic
acid, to reduce the risk of birth defects, such as cleft lip and cleft palate.14
Clinicians should advise these patients to minimize their intake of sugary
foods and starches. When sugary foods and starches are consumed, it is best to
have them with a nutritious meal, as this will help buffer the acidity and
decrease the likelihood of demineralization. Pregnant women should also be
cautioned to limit their consumption of sweetened beverages, such as fruit
juice, sports drinks, and soda, as these drinks can contribute to caries.
Additionally, diet soda should be avoided, as the acidity could cause erosion
and provides a favorable environment for cariogenic bacteria.
Pregnant women should have untreated caries restored because lesions will
likely worsen. Additionally, caries control has the potential to reduce the
mother's cariogenic bacterial load, thereby preventing the transmission of
pathogenic microorganisms from the mother to the infant. Dental
materials—including amalgam, composite, and endodontic material—can be used
safely and effectively.14 A rubber dam and high-speed evacuation
should be used to prevent inhalation of dental material vapor, such as amalgam.14
Periodontal therapies, including scaling and root planing, are safe and
effective during pregnancy.19 The American Academy of
Periodontology recommends periodontal therapy be provided as early in the
pregnancy as possible to reduce the pathogen load and prevent infections.19
ORAL HYGIENE INSTRUCTION
hygiene is essential during pregnancy. Women should be encouraged to brush
twice daily with fluoride toothpaste, and use floss or an alternative
interproximal cleaning method daily. In addition, pregnant women with high
caries risk should use an alcohol-free, fluoride mouthrinse twice daily.14
Rinsing with an alcohol-free 0.12% chlorhexidine formula and 0.05% sodium
fluoride reduces the cariogenic bacterial load. Using xylitol-containing
products two to three times daily is also recommended.14 Although
women should be encouraged to drink fluoridated water,14 systemic
consumption of fluoridated water chiefly benefits the pregnant mother, as only
trace amounts of fluoride reach the fetus.20
Patients who experience vomiting or gastric reflux should avoid brushing
immediately after these incidents due to increased risk of erosion and caries.
Pregnant women should rinse with a teaspoon of baking soda dissolved in a cup
of water to neutralize the acids before brushing their teeth.10
PAIN CONTROL MEASURES
patients may experience increased anxiety, which may lower their pain
threshold. Therefore, clinicians should manage pain with approved topical and
local anesthetics (Table 1)14 and keep appointments short. A recent
study by Hagai et al21 indicates the use of local dental anesthetics
is safe and poses no risk to the fetus. Because of the risk for hypoxia,
hypotension, and aspiration, however, consulting with the patient's obstetrician
is recommended prior using inhalation analgesics, such as nitrous oxide.14
Providing oral health care during pregnancy is
safe and necessary for the mother and her developing fetus. Seeking care early
will not only help prevent oral health problems, it can also reduce the risk of
systemic diseases. Mothers who have received oral care during pregnancy are
more likely to seek continued care for themselves and their infants.22
Modifying the attitudes and beliefs of patients and health care providers is
essential in the effective promotion of preventive oral care.
- Steinberg BJ. Women's oral health issues. J Calif Dent Assoc.
- Steinberg BJ, Hilton IV, Iida H, Samelson R. Oral health and dental
care during pregnancy. Dent Clin N Am. 2013;57:195–210.
- Boggess KA, Edelstein BL. Oral health in women during preconception
and pregnancy: Implications for birth outcomes and infant oral health. Matern
Child Health J. 2006;10(Suppl 1):169–174.
- Lieff S, Boggess KA, Murtha AP, et al. The oral conditions and
pregnancy study: periodontal status of a cohort of pregnant women. J
- Boggess KA, Society for Maternal-Fetal Medicine Publications
Committee. Maternal oral health in pregnancy. Obstet Gynecol.
- Han YW, Oral health and adverse pregnancy outcomes—What's next? J
Dent Res. 2011;90:289–293.
- López NJ, Gómez RA. Dental and medical comanagement of pregnancy. In: Periodontal
Disease and Overall Health: A Clinician's Guide. Genco RJ, Williams RC,
eds. Yardley, Pa: Professional Audience Communication Inc; 2010:250–267.
- Allston A. Improving Women's Health and Perinatal Outcomes: The Impact
of Oral Diseases. Available at: jhsph.edu/research/centers-and-institutes/womens-and-childrens-health-policy-center/publications/oralbrief.pdf.
Accessed January 23, 2017.
- Centers for Disease Control and Prevention. Check Your Knowledge:
Diabetes and Pregnancy. Available at: cdc.gov/features/diabetespregnancy/.
Accessed January 23, 2017.
- Silk H, Douglass AB, Douglass JM, Silk L. Oral health during
pregnancy. Am Fam Physician. 2008;77:1139–1144.
- California Dental Association Foundation, American College of
Obstetricians and Gynecologists, District IX. Oral health during pregnancy and
early childhood: evidence-based guidelines for health professionals. J Calif
Dent Assoc. 2010;38:391–403, 405–440.
- American Academy of Pediatric Dentistry. Guideline on Perinatal Oral
Health Care. Available at:
January 23, 2017.
- New York State Department of Health. Oral Health Care During
Pregnancy and Early Childhood: Practice Guidelines. Available at:
health.ny.gov/publications/0824.pdf. Accessed January 23, 2017.
- Oral Health Care During Pregnancy Expert Workgroup. Oral Health Care
During Pregnancy: A National Consensus Statement. Available at:
mchoralhealth.org/PDFs/OralHealthPregnancyConsensus.pdf. Accessed January 23,
- Kloetzel MK, Huebner CE, Milgrom P. Referrals for dental care during
pregnancy. J Midwifery Womens Health. 2011;56:110–117
- National Health Law Program. Dental Coverage for Low-Income Pregnant
Women. 2012. Available at:
Accessed January 23, 2017.
- American Academy of Pediatric Dentistry, Council on Clinical Affairs,
Committee on the Adolescent. Guideline on oral health care for the pregnant
adolescent. Pediatr Dent. 2012;34:153–159.
- U.S. Department of Health and Human Services, National Institutes of
Health, Office of Dietary Supplements. Nutrient Recommendations: Dietary
Reference Intakes (DRI). Available at:
ods.od.nih.gov/Health_Information/Dietary_Reference_Intakes.aspx. Accessed January 23, 2017.
- Task Force on Periodontal Treatment of Pregnant Women. American
Academy of Periodontology statement regarding periodontal management of the
pregnant patient. J Periodontol. 2004;75:495.
- Patsouri K. Re-Examining the fluoride intake during pregnancy: A
necessity or not for the incoming member. Int J Dent Med Res.
- Hagai A, Diav-Citrin O, Shechtman S, Ornoy A. Pregnancy outcome after
in utero exposure to local anesthetics as part of dental treatment: A
prospective comparative cohort study. J Am Dent Assoc. 2015;146:572–580.
- Curtis M, Silk HJ, Savageau JA. Prenatal oral health education in
U.S. dental schools and obstetrics and gynecology residencies. J Dent Educ.
From Dimensions of Dental Hygiene. February 2017;15(2):46-49.