Dental Considerations in Pregnancy – A Systematic Review

Background: Good oral health during pregnancy can not only improve the health of the pregnant mother, but also potentially the health of her child. There is inconclusive and contrasting nature of evidence regarding the effect of pregnancy on oral health. So the purpose of this study was to systematically review the dental considerations during Pregnancy for further investigation. Methods: For the identification of the studies included in this review, we devised the search strategy for each database. The search strategy used a union of controlled vocabulary and free text terms. The main electronic database used to access the studies were PubMed, PubMed Central, Cochrane Review, Embase and Google Scholar. Results: A total of 28 articles fulfilled the criteria and were selected for the review. Some prenatal oral health conditions have adverse effects on the child. Periodontitis is associated with preterm birth, low birth weight infants and high level of cariogenic bacteria in pregnant mother can lead to increased risk of dental caries in the infant. Oral lesions such as gingivitis and pregnancy tumours are benign in nature and require only reassurance and monitoring. Conclusion: It has been suggested that some oral conditions may have adverse consequences on their children awareness related to oral health during pregnancy. Oral health care services should be routinely integrated with prenatal care services for all the pregnant women and specific preventive oral health care program should be made an integral part of antenatal care. Systematic Review Bashir et al.; JPRI, 33(40A): 82-100, 2021; Article no.JPRI.71614 83


INTRODUCTION
The mouth is an obvious portal of entry to the body, and oral health reflects and influences general health and well being. Maternal oral health has significant implications on birth outcomes and infant oral health [1]. Pregnancy is a state of physiological condition that brings about various changes in the oral cavity along with other physiological changes taking place throughout the female body [2]. It affects almost all systems and parts of the body including the oral cavity. Due to changes in the hormones, many opportunistic organisms gain access to various parts of the body in the absence of proper care [3]. The oral cavity is also affected by such endocrine actions and may present both transient and irreversible changes as well as modifications that are considered pathological [4].

CAUSES OF POOR ORAL HEALTH DUIRING PREGNANCY
Women are particularly susceptible to poor oral health as result of various factors such as limited medical and dental insurance can leave women unable to obtain oral health care when needed, resulting in the worsening of many conditions and health status [5]. Hormonal changes occurring throughout the lifespan can increase a woman's chance of developing oral diseases [6]. Barriers in obtaining dental care including limited access to affordable dental services and lack of awareness about the importance of maternal oral health [7].

COMMON DENTAL PROBLEMS DURING PREGNANCY
Gingivitis and periodontitis: The most common oral health disease experienced during pregnancy is gingivitis , with over half of all women develop gingivitis during pregnancy, [8] due to decreased immune response, hormonal fluctuations of estrogens and progesterone and changes in normal oral flora [9,10]. The inflammatory changes in gingiva during pregnancy have been termed as pregnancy gingivitis (gingivitis gravid arum), which is most prevalent oral manifestation associated with pregnancy, [11] frequently ranges from 60% to 75% [12].
Dental Caries: One fourth of women of reproductive age have dental caries pregnant women are at higher risk of tooth decay for several reasons, including increased acidity in the oral cavity, sugary dietary cravings, and limited attention to oral health [13]. It may occur due to increased acidity in the mouth from gastric acids from vomiting, greater intake of sugary snacks and drinks secondary to pregnancy cravings, and decreased attention to prenatal oral health maintenance [14]. Children whose mothers have poor oral health and high levels of oral bacteria are at greater risk for developing dental caries compared to children whose mothers have good oral health and lower levels of oral bacteria [15].
Pregnancy Tumor : Pregnancy tumor is a noncancerous gingival hyperplasia usually near the upper gum line. Pregnancy tumors form on inflamed gum tissue and are caused by increased hormone levels, such as estrogen and progesterone, in combination with bacteria [16]. Oral tumors occur in up in up to 10% of pregnant women and often in women who also have pregnancy gingivitis [17]. The likelihood of pregnancy tumors developing usually occurs during the second trimester and usually disappear after delivery. It is indistinguishable from pyogenic granuloma. Management is usually observational unless the tumors bleed, interfere with mastication, or do not resolve after delivery [18].

Mobility of Teeth:
Teeth can loosen during pregnancy, even in the absence of gum disease, because of increased levels of progesterone and estrogen affecting the periodontium (i.e., the ligaments and bone that support the teeth) [19].
Dental erosion: While no one enjoys the taste of vomit during pregnancy. It actually damage the teeth if the pregnant women reach for toothbrush too soon. Due to the presence of gastric acids, which can erode tooth enamel. If brush too soon after vomiting, it can reduce the teeth's natural defences, leaving them more susceptible to cavities, sensitivity and fractures [20].

Habits During Pregnancy:
Certain ill-habits during pregnancy which has harmful effects during pregnancy are Tobacco consumption, Alcohol ingestion and sedentary lifestyles during pregnancy, the consumption of 10 or more cigarettes per day during pregnancy was associated with greater odds of having a child with hypodontia. Maternal smoking during pregnancy is associated with hypodontia [21].
Alcohol in the mother's blood passes to the baby through the umbilical cord. Drinking alcohol during pregnancy can cause miscarriage, stillbirth, and a range of lifelong physical, behavioural, and intellectual disabilities. These disabilities are known as fetal alcohol spectrum disorders (FASDs) [22].

Myths During Pregnancy:
When it comes to understanding the relationship between pregnancy and oral health, it helps to know fact from fiction. Myths can keep pregnant women from taking smart precautions when they are expecting and prevent there oral health. Women with severe or moderate gum disease are at a higher risk for low birth weights and early deliveries. Women are more prone to tooth decay not because of leaching of calcium from teeth. Vomiting can dissolve tooth enamel and reduce teeth's defences against decay as morning sickness is harmful [20].
History of previous Diseases: Negative health outcomes associated with sedentary behaviour in the general population, also occur in pregnancy, this could have implications for development of cardio metabolic complications such as gestational weight gain, gestational diabetes mellitus and hypertension, as well as mental wellbeing [23].

NEED FOR THE STUDY
Considering the importance of oral health care in pregnancy, It is a mandate to have a proper knowledge about the effect of oral health in pregnancy as it is vital for maternal and foetal health. The inconclusive and contrasting nature of evidence regarding the effect of pregnancy on oral health warrants the need for further investigation into the topic. Hence, review was conducted . Since most of the women are unaware of the potential consequences of neglecting oral health during Pregnancy.

AIM
Research Question: To review the dental health considerations among Pregnant women.
To estimate the unmet need for dental caries, periodontal health, Oral hygiene status and selfcare practices among the population surveyed.  Fig. 1] A manual search was performed of the reference lists for all primary studies to obtain additional relevant publications. The related article links of each primary study in the PubMed database were also assessed. Full-text versions of the papers that appeared to meet the inclusion criteria (described below) were retrieved for further assessment and data extraction. The search strategies for all databases are included in Table 1.

Eligibility Criteria
We included cross sectional studies that assessed the dental considerations among pregnant women as an outcome. The articles published in English dated from the year 2003 to 2020 were included in this review. The search terms for articles were the terms either in the title or abstract. The focus was to include broadly as much relevant existing data as reasonably possible.

Study Selection and Data Collection Process
Initially, we selected the papers by title and abstract and deleted duplicate studies. Full reports were also obtained when there was insufficient information in the title and abstract to make a clear decision. Subsequently, full-text papers were acquired and 2 reviewers classified those that met the inclusion criteria. The following information was recorded for each included study that is authorship and year of publication, methods including study design and setting , outcome of interest and statistical analysis.

Summary Measures and Synthesis of the Results
We conducted data analyses with the following extracted information: author/year, title, country, study design, sample size, characteristics and source of the study population, outcome, and study findings (demographic factors, socioeconomic, psycho-logical, and behavioural factors, and perceived need). Study characteristics and results were tabulated, and statistically significant factors were reported. The explanatory framework for the dental considerations among pregnant were included.

RESULTS
After the removal of duplicates and title screening, 37 papers remained for assessment. Careful reading of full texts led to the exclusion of 9 papers due to the following reasons: the use of dental services was not the main outcome, the target population was not with-in the objectives of the review; a statistical analysis was not included, the study was qualitative and full text was not found. A total of 28 studies were included to analyse the dental considerations in pregnancy. The summary of the results has been provided in [Table1].

DISSCUSSION
Pregnancy causes a variety of generalized changes in a woman's body due to the progressive cycle of hormonal influences [11]. The increased hormonal secretion may result in different signs and symptoms which can alter the person's overall health and perceptions [52]. The pregnancy related effects have a negative impact not only on the mother, but also on the infant if not handled properly [53]. At the same time, oral health is key to overall health and well-being. Preventive, diagnostic, and restorative dental treatment is safe throughout pregnancy and is effective in improving and maintaining oral health. In addition to providing pregnant women with oral health care, educating them about preventing and treating dental caries is critical, both for women's own oral health and for the future oral health of their children. Evidence suggests that most infants and young children acquire caries-causing bacteria from their mothers. Providing pregnant women with counseling to promote healthy oral health behaviors may reduce the transmission of such bacteria from mothers to infants and young children, thereby delaying or preventing the onset of caries [54].
It was observed by Patil et al. [ 55] that nearly 63.3% of pregnant women had dental caries, while in the non -pregnant group, the percentage of caries was around 44.5%. and the difference came out to be statistically significant (P = 0.0001). Moreover, it was found that 71.9% of pregnant women had caries in comparison to 60.5% among non -pregnant women. while as according to Rachanok et al. [28] pregnant women were more likely to have dental caries while compared to non-pregnant women they observed that three-quarter of pregnant women had dental caries, while in the non-pregnant group the percentage of caries was around 50.0.Thus, significant differences were revealed between pregnant and non-pregnant women with regard to dental caries.(P<0.001).While as Ingle et al. [33] observed that the mean number of decayed, missing, and filled teeth were 3.42 ± 2.66, 2.91 ± 2.01, and 3.01 ± 1.98, respectively, and was well formed among the pregnant group. The mean scores for self-reported Oral Hygiene Score, among pregnant group was 64.38 ± 5.59 for decayed teeth and non -pregnant group was 65.81 ± 5.36.
Gingival changes in Pregnancy were described as early as late 1800, even before any knowledge about hormonal changes in pregnancy was available. Pregnancy gingivitis is very similar to the gingivitis that occurs outside of pregnancy and can include a mild inflammation of the gums due to plaque buildup, with red and sore gums that bleed when probed. Pregnancy affects the severity of previously inflamed areas but does not alter healthy gingiva. Tooth mobility, pocket depth, and gingival fluid are also increased in pregnancy. Taani et al. [33] observed that probing pocket depth scores were higher in females pregnant for the first time than the females with multiple pregnancies (P<0.005) While as Amin et al. [34] observed in a study that Periodontal index tended to be significantly higher (P<0.001) in pregnant women (0.737±0.476) than that in non-pregnant women (0.378±0.401).It is also evident from studies that there is a relationship between maternal periodontal disease and low weight birth. Ardakani et al. [56 ] in the year 2013 observed that maternal periodontal disease can be a potential independent risk factor for Low birth weight of newborns.
Oral mucosal lesions are influenced by hormonal changes that occur during pregnancy which in some cases exacerbate or ameliorate minor pathologies such as vascular epulis and apthous ulcer. Annan et al. [26] observed in a study that Vascular epulis along with apthous ulcer was present in pregnant women when compared with All preventive methods and measures are necessary in order to improve oral hygiene among pregnant women.
Annan BDRT, Nuamah K, [26] To find out if any oral condition was particularly prevalent in the pregnant women but not in the nonpregnant women.

Case-control Study
The incidence of vascular Epulis was 3% in pregnant women and absent in nonpregnant. One pregnant women had apthous ulcer and severe gingival bleeding. TMJ symptoms were 7% among the pregnant women and 17% among the nonpregnant women.
Pregnancy has an effect on the oral health status. However this effect is more likely due to the physiological changes associated with pregnancy than any other specific factors.
Thomas JT, Middleton PF, Crowther CA [27] To Assess knowledge and experiences of dental health in pregnancy and to examine the self-care practices of pregnant women in relation to their oral health. To motivate the patient toward oral health and implement the needed prophy--lactic measures.

pregnant women 18-35 Years
Longitudnal study The practice was poor regarding oral health care during pregnancy in pregnant women belonging to different socioeconomic groups.
Intensive oral health education during pregnancy leads to drastic improvement in knowledge attitude and Practice.

Rajesh KS, Ashif A, Hedge S, MS Kumar A [42]
To assess the knowledge and awareness of pregnant women about periodontal health and its effect on pregnancy.

pregnant Women 21-25 Years Crosssectional Study
Majority 79% of the patients didn't know how to prevent gum disease and that swelling of gums can occur during pregnancy. About 75% of participants were not aware about the importance of dental check-up during pregnancy and 48% of them fear that dental treatment can affect the health of newborn. 72% of participants were not aware about the oral health practices to be considered during pregnancy.
Awareness and knowledge level of periodontal health among pregnant women was found to be very low.
Kateeb E , Momany E [43] To assess the dental caries experience of Palestinian pregnant women and examined its relationships to their oral health knowledge, beliefs, behavior, and access to dental care.

Pregnant women Not Mentio--ned
Crosssectional study Mean Decayed, Missing,filled,Teeth(DMFT) in this sample was 15.5 ± 4.5 and an average DMFS of 31.8 ± 21. Age, level of education, providers, advice on utilizing dental care during pregnancy, and the belief that a woman can lose a tooth just because she is pregnant explained 22% of the variation in DMFT scores.
Women had a high prevalence of dental diseases and knew little about dental care during pregnancy. Faulty beliefs about dental care during pregnancy among women and health care providers were major factors in the high levels of disease. Naorungroj S, Hunsrisakhun J, Talungchit S [44] To determine oral hygiene status, self -reported oral malodour, oral hygiene practices, oral health knowledge, and the differences across educational levels in a group of Muslim Thai

Pregnant women 26-27 years
Cross-Sectional study 61% pregnant women reported bad breath experience. 41% were not sure or able to detect an odour when they were asked for oral malodour self-testing by smelling their breath in the cupped hands. The pregnant women had moderate levels of gingival inflammation.
Poor self-reported compliance with regard to oral health and oral health knowledge were in evidence among these pregnant women. To improve oral health status, effective oral health promotion including oral health education and intervention programs are needed.

Author
Objective Sample size Age group Study type Result Conclusion pregnant women.
Half of the participants stated that they had regular tongue cleaning and had visited a dentist for a dental check-up. Lasisi TJ, Salam RAA [45] To describe pattern of oral health among a cohort of pregnant women.

Pregnant Women 29-30 years
Cross-Sectional study 96.1% never had dental checkup and only 3.9% of participants ever had previous dental checkup. 6.5% of the respondents had dental complaints and the dental complaints elicited included tongue blisters, swollen gums, tooth decay and toothache. There is need of interaction between dental practitioners and gynaecologists / other antenatal care providers to include routine dental checkup as a mandatory element during antenatal visits of pregnant females.
Non-pregnant Females While as according to Ghalayani et al. [30] the level of sex hormones during pregnancy lead to aggression of lesions such as geographical tongue along with presence of other etiological factors such as genetic potential, human leukocyte antigen marker and stress.
Richards et al. [57] observed that patients aged between 10 and 50 years of age with the prevalence of disorders ranging from 0.22% to 31%.The main lesions reported were gingival hyperplasia, morsicatio buccarum (chronic cheek biting), oral candidiasis, pyogenic granuloma and benign migratory glossitis.
Oral health may be considered an important part of prenatal care, given that poor oral health during pregnancy can lead to poor health outcomes for the mother and baby [58]. There is no gain saying the fact that good oral health during pregnancy is important because poor oral health may result in unfavorable pregnancy outcomes [36]. All preventive methods and measures are necessary in order to improve oral hygiene among women. Vasiliauskiene et al. [25] observed that all preventive methods and measures are necessary in order to improve oral hygiene among pregnant women While as according Amin et al. [34] observed that inadequate knowledge of dental health care, and poor dental hygiene practice were two to three times more at risk of developing dental diseases. Naorungroj et al. [44] observed that poor self-reported compliance with regard to oral health and oral health knowledge were in evidence among pregnant women and Rakchanok et al. [28] observed in a study that community awareness programs should be conducted in order to increase the women's awareness regarding oral hygiene practices during pregnancy to highlight the importance of good oral health and health for the mother and her baby. Also according to the "committee on healthcare for undeserved women" the committee stated that improved oral health of the women may decrease transmission of cariogenic bacteria to infants and reduce children's potent future risk of caries. gynecologists and dentists are the most easily accessed health care professional, which creates a unique chance to educate women throughout their lifespan, about the importance of dental care and good oral hygiene [59].

CONCLUSION
It is concluded that pregnant women should be stressed on the association of maternal oral health with foetal health and made aware of the possible risk of pretem low birth weight owing to periodontal infection. Oral health care services should be routinely integrated with prenatal care services for all the pregnant women. Specific preventive oral health care program should be made an integral part of antenatal care by including a dentist or dental hygienist in the antenatal team along with gynaecologist and paediatrician. Their needs should primarily be handled through a prevention-oriented treatment plan that places a greater emphasis on self-care measures, with dental care supplied based on the pregnant trimester.

RECOMMENDATIONS
1. Improvement in diagnostic and therapeutic systems used in antenatal care may reduce the burden of complications of pregnancy. 2. There is a need for the health care professionals to acknowledge the importance of good oral health in ensuring a safe and successful pregnancy. 3. Oral healthcare needs should be a part of the training of medical students, nurses, and healthcare workers so as to enable them to identify the main dental manifestations of pregnancy. 4. There is a need to incorporate oral health education and motivation interventions in the pre and postnatal care programs administered by the ministry of health in public clinics. 5. All women should be encouraged at the first prenatal visit to schedule an oral health examination if one has not been performed in the last six months, or if a new condition has occurred. 6. Future efforts involving oral health and pregnant women in low-income settings should focus on providing tools and resources to maintain dental hygiene, promoting good oral health behaviours and knowledge possibly through contextappropriate cadres of trained communitybased workers, and increasing access to qualified and fully trained dentists to improve the overall oral health of pregnant women. 7. Education about oral health and its effect on pregnancy should be encouraged in all anganwadi centres through pamphlets, power point presentations and group discussion.

CONSENT
It is not applicable.

ETHICAL APPROVAL
Ethical approval was taken from the Institutional Review Board Committee prior to the conduct of the study.