Assalamo-Alaikum and Good morning ladies and gentle men, my name is Muhammad Haseeb and today I will present few of my cases on the topic which is unfortunately overlooked both by patients and doctors
I will try to enable the participants to understand few important consideration for the management of pregnant patients
The increased levels of estrogen and progestrone hormones in pregnancy does a lot to the body system A low response of lymphocytes in pregnancy weakens the body defense system and alters the host immune-modulatory response to bacterial pathogens
Oral cavity harbors a lot of bacterial species, pregnancy not only affects the response of bacteria but also favors the growth of certain bacterias. P. intermedia is a Vit K dependent bacteria and the structure of estrogen resembles that of vit K so the bacteria utilizes the estrogen as a substrate. The increased amount of hormones also causes an increased fluid flow to gingiva Inflammation of gingiva is termed as gingvitis which is quite common in pregnancy Other manifestation which can appear in pregnancy is pregnancy granuloma, tooth erosion and tooth mobility
These myths are common as well and were also documented in older literature. Probably you might also have listened atleast one of them.
But the fact is that there is scientific evidence behind them.
Important to note here is that plaque causes gingivitis, pregnancy causes a hypersensitive response to plaque microorganisms. In the absence of plaque, pregnancy wont itself cause the disease
This patient exhibits swollen gingiva in buccal and palatal aspect
In this case you can appreciate the gingival hyperplasia, the picture was taken after scaling was done.
Same patient, the picture shows hyperplasia on lingual aspect as well.
Patient is instructed to maintain the oral hygiene, professional scaling and polishing is mandatory along with root planing and curettage to remove the irritants that is plaque and calculus
Second trimester is generally considered safe for all elective dental treatment, but scaling and polishing can be done in all trimesters with equal safety.
About 10% of pregnant patients get effected by pregnancy granuloma, the etiology is the irritation from toxins produced by plaque microorganisms. The granuloma is of purple red color due to stasis of blood in it.
This is a fairly large pregnancy granuloma, Pedunculated and originating from the interdental area.
The same patient after resection of pregnancy granuloma using Electrocautery.
There are some other lesions which mimic pregnancy granuloma, so you need not to label every person as pregnant with similar presentation What this can be ? Similar in presentation but the patient is not pregnant
Another case in a male patient
Hyperplasia in another patient
The word pyogenic is misleading because there is no pus associated with it. Pyogenic granuloma usually present in females owing to increased hormone levels both in pregnancy as well as due to use of oral contraceptive drugs.
The problem with pregnancy granuloma is to decide whether to resect or not, because if resected it can recur and if not resected it can harbor bacteria and can cause periodontal disease apart from compromising speech and mastication.
Till now I have been discussing with you the effect of pregnancy on oral cavity, now I would like to reveal you the facts of periodontal disease on pregnancy outcome. The preterm birth and low birth weight have been shown as possible adverse out come of periodontal disease
This flow chart shows the sequele of effect of periodontal disease in causing preterm birth. Release of interleukins from the periodontal tissues and increased levels of prostaglandin E can possibly cause uterine contraction and cervical dilation.
What we mean by preterm birth is the delivery of a new born before 37th week of gestation. Low birth weight refers to the weight of a new born less than 2.5 kg Increased rate of Preterm birth in America is also attributed to high consumption of alcohol and tobacco.
It would be quite surprising for most of you that Bidirectional relationship in adverse pregnancy outcomes and periodontal disease has also been documented. Treatment of periodontal disease during pregnancy can reduce the chances of preterm birth.
This is really important to note. Usually it is a prevailing concept not only in Pakistani population but also in American population that dental treatment can harm the fetus which is absolutely wrong.
The truth is that dental treatment is safe and scaling and polishing should be advised to pregnant women atleast two times in pregnancy Getting a radiograph specially for diagnostic purpose is safe as well.
I would conclude my talk by highlighting what is needed by the general practitioners and specialist doctors. Please do refer the patients to dentist for mechanical cleaning of teeth. If you have considerations of sterilization of dental equipment, let me tell you that in Fatima memorial hospital dentistry department ensures that all protocols of sterilization and cross infection control are practiced so it is quite safe for your patients to have treatment there.
Dr Muhammad Haseeb Department of Periodontology, Fatima Memorial Hospital College of Medicine and Dentistry.
Outcome: <ul><li>Understand the effects of pregnancy on oral health </li></ul><ul><li>Understand the oral manifestations which can arise during pregnancy </li></ul><ul><li>Understand the importance of Oral health and its effects on systemic health </li></ul><ul><li>Understand the rationale behind some common beliefs </li></ul><ul><li>Understand the importance of referring the patient to a dentist </li></ul>
Systemic changes in Pregnancy <ul><li>Increased progesterone levels </li></ul><ul><li>Increased estrogen levels </li></ul><ul><li>CD4:CD8 ratio may be decreased </li></ul><ul><li>Low response of lymphocytes </li></ul>Mukherjee PM, Almas K. Orthodontic considerations for gingival health during pregnancy: a review. Int J Dent Hygiene 8, 2010; 3–9
Changes in Oral cavity <ul><li>Alteration in micro flora (Prevotella intermedia, Porphyromonas gingivalis, Tannerella sp. dominates) in pregnancy </li></ul><ul><li>Increased gingival crevicular fluid </li></ul><ul><li>Pregnancy gingivitis </li></ul><ul><li>Pregnancy granuloma/epulis/tumor </li></ul><ul><li>Periodontal disease and Tooth mobility </li></ul><ul><li>Tooth surface loss </li></ul>
Old wives tales about pregnancy <ul><li>The baby extracts calcium from the tooth of mother !!! </li></ul><ul><li>You lose a tooth for every pregnancy !!! </li></ul><ul><li>Gums always bleed in pregnancy !!! </li></ul>
Rationale behind the tales <ul><li>There is increased tendency of vomiting in pregnancy which causes stomach acid to erode the tooth surface </li></ul><ul><li>With lack of maintenance of oral hygiene, the periodontal condition gets worsen and leads to increased mobility of teeth </li></ul><ul><li>Gums bleed because of pregnancy gingivitis </li></ul>
Pregnancy Gingivitis <ul><li>Clinical Features: </li></ul><ul><ul><li>Inflammation of gingiva </li></ul></ul><ul><ul><li>Increased swelling of gingiva </li></ul></ul><ul><ul><li>Bleeding from gums while brushing or spitting </li></ul></ul><ul><li>Pathophysiology: </li></ul><ul><ul><li>Primary cause is dental plaque, pregnancy makes it hypersensitive to plaque irritation </li></ul></ul>
Pregnancy gingivitis <ul><li>A 20 year old pregnant woman (7 th Month) presents with gingival hyperplasia on buccal and lingual sides. </li></ul>
Treatment for Pregnancy gingivitis <ul><li>Oral hygiene instructions </li></ul><ul><li>Scaling and root planing </li></ul><ul><li>Curettage </li></ul>
Significance of each trimester <ul><li>1 st Trimester: </li></ul><ul><ul><li>Severity of Gingivitis increases from 2 nd month </li></ul></ul><ul><li>2 nd Trimester: </li></ul><ul><ul><li>Considered safest for the elective dental procedures </li></ul></ul><ul><li>3 rd Trimester: </li></ul><ul><ul><li>Gingival swelling again gets increased in third trimester </li></ul></ul>
Pregnancy Granuloma <ul><li>Pedunculated </li></ul><ul><li>Usually originates from inter dental papilla (part of the gum between two teeth) </li></ul><ul><li>Highly vascularized </li></ul><ul><li>Compromise esthetics </li></ul><ul><li>May compromise mastication or speech </li></ul>
Pregnancy Granuloma <ul><li>A 28 years old woman in her 8 th month of pregnancy presents with a pregnancy granuloma , hanging in the palatal surface between the central incisors </li></ul>
Diagnosis ??? <ul><li>This patient is not pregnant </li></ul>
Diagnosis ??? <ul><li>He is a man, cant be pregnant ! </li></ul>
Diagnosis ??? <ul><li>This 20 years old lady is not pregnant </li></ul>
Diagnosis Pyogenic Granuloma <ul><li>It is an over growth of soft tissues due to irritation, physical trauma or hormonal factors </li></ul><ul><li>Pregnancy granuloma is a type of pyogenic granuloma </li></ul>
Treatment for Pregnancy Granuloma <ul><li>Remove the irritating source (plaque/calculus) </li></ul><ul><li>Regresses after pregnancy </li></ul><ul><li>Should better be removed if it is compromising mastication or speech </li></ul><ul><li>Excision </li></ul><ul><ul><li>Surgical </li></ul></ul><ul><ul><li>Electrocautery </li></ul></ul><ul><li>Potential problems with excision </li></ul><ul><ul><li>Profuse bleeding if surgically excised </li></ul></ul><ul><ul><li>Chance of recurrence </li></ul></ul>
Possible Effects of Periodontitis on pregnancy outcome <ul><ul><ul><ul><li>Pre-term Low birth </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Birth Weight </li></ul></ul></ul></ul>Clothier B, Stringer M, Jeffcoat MK. Periodontal disease and pregnancy outcomes: exposure, risk and intervention. Best Pract Res Clin Obstet Gynaecol . 2007;21(3):451–466
Preterm birth and low birth weight <ul><li>Preterm birth refers to the delivery of new born before 37 th week of gestation </li></ul><ul><li>Low birth weight refers a weight equal or less than 2500 grams </li></ul><ul><li>Rate of preterm birth varies with country to country. (1 in 8 births in USA) </li></ul><ul><li>Preterm birth is one of the most common reason for infant mortality </li></ul>MacDormann MF, Mathews TJ. Behind international rankings of infant mortality: how the United States compares with Europe. Int J Health Serv. 2010;40(4):577-88.
Does Periodontal treatment decrease the chances of low birth weight ? S adatmansouri S, Sedighpoor N, Aghaloo M. Effects of periodontal treatment phase I on birth term and birth weight. J Indian Soc Pedod Prev Dent 2006;24:23-6
A Common Misbelief ! <ul><li>Usually women tend to believe that any dental procedures can harm their pregnancy </li></ul><ul><ul><ul><li>One American study showed that women seek dental treatment less during pregnancy period, specially getting a radiograph </li></ul></ul></ul>Peilei Jiang, Eric P. Bargman, Nancy A. Garrett, et al. A Comparison of Dental Service Use Among Commercially Insured Women in Minnesota Before, During and After Pregnancy. J Am Dent Assoc. 2008 Sep;139(9):1173-80.
The truth ! <ul><li>American Dental Association recommends that all dental procedures are safe and can be carried out in pregnancy </li></ul><ul><li>Periodontal scaling and prophylaxis is considered safe in all trimesters. </li></ul><ul><li>ADA endorses at least 2 dental visits during pregnancy </li></ul><ul><li>According to the American Academy of Family Physicians, you would need 50,000 dental x-ray examinations to reach the 5-rad cumulative dose to the fetus. </li></ul>
Recommendations for Family Physicians/Specialists <ul><li>Examine the oral cavity of every pregnant patient </li></ul><ul><li>Educate the patient on maintaining good oral health </li></ul><ul><li>Refer to the dental surgeons specially periodontists for tooth cleaning (scaling) </li></ul>
Take Home Message ! <ul><li>Timely referral to the dentist will save complications like preterm birth and low birth weight babies of your patients which will eventually benefit your practice </li></ul><ul><li>Prevention of preterm birth and low birth weight will reduce the financial burden on part of government and the individual </li></ul>
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