Pregnancy and Women’s Oral Health Clinical Case #1

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1. Question
Estella, a 32 year old Hispanic woman, presents to your office for a first prenatal visit. She is excited to be 7 weeks pregnant. She quit smoking recently because she heard from her sister who had a preterm delivery that smoking can contribute to preterm labor. She wants to know if there is anything else she can do to reduce her risk of a preterm birth. She has struggled to care for her teeth. She has not seen the dentist in several years because few dentists in your area take her Medicaid insurance. As part of the visit you perform an oral examination and discover that she has periodontitis (see photo):

ICHOP

Which of the following is true?
- Treating her periodontitis during pregnancy will decrease her risk for preterm labor. Recent randomized controlled trials (RCTs) have refuted previous evidence based on weaker study methods that treating periodontitis in pregnancy reduces preterm births. However, four well designed RCTs have demonstrated that periodontal treatment is safe throughout pregnancy. Whether complete control of periodontal disease reduces the risk of preterm labor in subsequent pregnancies has not yet been studied.
- Treating her periodontitis during pregnancy will decrease her child’s risk for caries. Treating maternal caries and implementing caries preventive strategies reduces the mother’s oral bacterial load, and reduces the transmission of those caries-causing bacteria to her child. However, there is no evidence that treating periodontitis alone reduces an offspring’s risk of acquiring caries. However, treatment of periodontitis is safe throughout pregnancy.
- There are no prenatal benefits to treating her periodontitis during pregnancy. You should advise her to wait and see the dentist after delivery. While recent RCTs have shown that the treatment of periodontitis during pregnancy does not lower the risk of preterm birth, treatment is safe throughout pregnancy.
- Treating her periodontitis is safe at any time during her pregnancy.
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Question 2 of 3

2. Question
Estella returns two weeks later concerned about a rapidly growing lesion in her mouth. She has never had anything like this before. It bled last night after eating corn chips. Her sister says she had a similar lesion once when she was on birth control pills. Her doctor told her not to worry about it and it eventually went away on its own.

Brad Neville, DMD

What would be the best advice for Estella?
- Don’t listen to her sister. There is no way she had the same condition on birth control pills. Pregnancy granuloma is indistinguishable from a pyogenic granuloma. It is a rapidly growing, tumor-like lesion. It is an erythematous, non-painful, smooth or lobulated mass that often bleeds easily when touched. Increasing estrogen and progesterone levels during pregnancy exacerbate the condition. Birth control pills can also lead to these lesions, as can trauma, poor hygiene and irritation from an overhanging restoration. It most frequently develops on the gingiva. It typically appears in 2nd to 8th month of pregnancy.
- The lesion should be removed immediately in case it is something serious. Pregnancy granulomas excised during pregnancy recur more frequently than those excised in the non-pregnant state. If possible, excision if necessary should be delayed until after delivery.
- The lesion should be left alone. With brushing, flossing, and good oral care it will likely resolve after pregnancy.
- Encourage her to bite on the lesion in the hopes that will speed its resolution. Since pregnancy granulomas develop in response to local irritation, biting on the lesion will only irritate it further and, if anything, lead to enlargement rather than resolution.
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Question 3 of 3

3. Question
Estella returns to see you for a routine prenatal visit at 32 weeks of gestation. Dental treatment for her periodontitis went well and she is happy to have her mouth feeling good again. The dentist mentioned that because of her history of cavities, she should consider taking measures towards the end of her pregnancy to reduce her oral bacterial load to reduce her child’s risk of cavities. Estella is skeptical and asks your opinion.

Which of the following would be the best advice for Estella?
- There is good evidence that methods to control oral bacterial levels in expecting and new mothers such as xylitol gum, dietary changes, or chlorhexidine rinses can reduce caries levels in their children. She should speak with her dentist about which approach is best for her.
- The evidence supporting dietary fluoride supplement use during pregnancy is much stronger than that for xylitol gum so she should start fluoride tablets instead. Studies show that the use of dietary fluoride supplements during pregnancy does not change the caries risk of offspring.
- Chlorhexidine mouth rinse is safe for long term daily use and would be a good choice for her to use in the next year. Chlorhexidine is best used for short periods of time in conjunction with monitoring of oral bacteria levels. After suppression of bacterial levels patients can be maintained through nutrition methods (limited sugar containing snacks and drinks), good oral hygiene, topical fluorides and the use of xylitol gums.
- There is not enough evidence to show that the use of caries preventive strategies in mothers reduces caries risk in children. Her money and time would be better spent paying for dental care for her child after birth. There is good evidence that preventing bacterial transmission from mothers to infants or up to 2 years of life reduces the child’s caries risk. Therefore interventions that include xylitol, chlorhexidine, and home oral hygiene are very important interventions.
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Pregnancy and Women’s Oral Health

Pregnancy and Women’s Oral Health Clinical Case #1

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