|Year : 2013 | Volume
| Issue : 2 | Page : 118-122
Oral changes in pregnant and nonpregnant women: A case-control study
Santosh R Patil
Department of Oral Medicine and Radiology, Jodhpur Dental College, Jodhpur National University, Jodhpur, Rajasthan, India
|Date of Web Publication||3-Jan-2014|
Santosh R Patil
Department of Oral Medicine and Radiology, Jodhpur Dental College, Jodhpur National University, Jodhpur - 342 001, Rajasthan
Source of Support: None, Conflict of Interest: None
Aim: The numerous changes occurring during pregnancy affect every body system, resulting in localized physical alterations in almost all parts of the body, including the oral cavity. The aim of the present study was to find the incidence of oral conditions seen particularly in the pregnant women than in the nonpregnant women. Materials and Methods: The oral health condition of 120 pregnant women referred to the outpatient department of Jodhpur Dental College General Hospital from a gynecology clinic were examined and compared with 120 nonpregnant women. The pregnant women were divided in a 3 groups of 40 each, according to the stage of pregnancy. The common oral conditions seen during pregnancy were assessed. Results: Pregnant women had a higher incidence of gingivitis and pyogenic granuloma. Gingivitis and erosion of teeth due to vomiting was seen commonly in the 3 rd trimester. The results indicated that pregnancy had an effect on the oral condition, which was mainly due to the hormonal changes seen during this period rather than other factors. Conclusion: Women planning a pregnancy or those already pregnant should be informed about the role of oral health during pregnancy and the possible outcomes of these conditions for the welfare of their foetus. They should be referred to the dental clinician for necessary counselling for preventive oral self-care and treatment, if required.
Keywords: Dental health, gingivitis, pregnancy, pyogenic granuloma
|How to cite this article:|
Patil SR. Oral changes in pregnant and nonpregnant women: A case-control study. J Orofac Sci 2013;5:118-22
| Introduction|| |
Some striking pathological changes have been made in the oral cavity in women during the pregnancy. The role of sex hormones in the vascular changes seen in gingiva during pregnancy has been known for long now. The sex hormones also alter the normal subgingival microflora and the immune response in the oral cavity.  The reasons for these changes have not been established so far. But, these can result in complications during the pregnancy.  Most commonly seen oral changes during pregnancy are pyogenic granuloma and gingivitis.  However, dental caries, tooth mobility, aphthous ulcerations, erosion of tooth surface due to vomiting, and facial hyperpigmentation are also seen. ,,, Pallor of the oral mucosa due to anaemia is also seen, but these are less specific changes associated with the general health of the women. 
The proper knowledge of these conditions is important to prevent and minimize the unseen complications during the pregnancy, until the birth of the child.  The patient awareness regarding these conditions is also equally important. Normal pregnancy does not necessarily contraindicate dental treatment if the stage of gestation and the extent of dental procedures are taken into account. The patient must be counselled about these transient changes, treatment plan, and reassured accordingly. The aim of the present study was to identify such oral changes in pregnant women when compared with nonpregnant women. The awareness regarding these oral conditions was also evaluated.
| Materials and Methods|| |
The oral health condition of 120 pregnant women referred to the outpatient department of Jodhpur Dental College General Hospital attending a gynecology clinic from September 2011 to August 2012 were examined and compared with 120 nonpregnant women. The ages of the patients ranged from 17 to 40 years, with an average age of 23.5 years. The selection of the patients was done by convenient sampling. The pregnant women were divided in groups of three according to the stage of pregnancy. Each group had 40 pregnant women. Ethical clearance was obtained from the Institutional Ethical Committee. They were examined for the oral findings by a dental surgeon and recorded. A written consent was obtained from each patient prior to the inclusion in the study. A complete and detailed case history was recorded. Medical records were used for information about demographic factors and medical and obstetric history. The Community Periodontal Index of Treatment Needs and Decay Missing Filled Treatment (DMFT) scores were also recorded. Gingival bleeding on probing and visible dental plaque was recorded at four sites per tooth for all teeth. The common oral conditions seen during pregnancy were assessed. The lymph nodes were also examined and facial asymmetry, if present was also recorded. The patients were asked regarding the awareness of the conditions that were observed and whether they have visited a dentist or received any treatment for the same. The observations were entered and analyzed using the computer program, SPSS 12 (SPSS Inc. Chicago, USA).
| Results|| |
The extraoral and intraoral findings of the pregnant and nonpregnant women are shown in [Table 1]. Pregnant women showed a higher incidence of gingivitis, dental caries, and pyogenic granuloma with 100, 98, and 10 patients, respectively. The difference in the incidence of gingivitis and pyogenic granuloma in the pregnant and nonpregnant women was statistically significant (P < 0.05). However, the difference in the incidence of dental caries was not statistically significant (P > 0.05). Most of the patients with pregnancy gingivitis complained of bleeding gums and halitosis. The incidence of pyogenic granuloma in the pregnant women was 8%. A total of 11 patients showed erosion of the tooth surface due to excess vomiting associated with pregnancy. Only two pregnant women had aphthous ulcer, while five of the nonpregnant women were diagnosed with this condition. Both the patients with aphthous ulcers had history of more severe ulcerations before pregnancy. A total of 9 pregnant women and 12 nonpregnant women had complaints of Temporomandibular joint (TMJ) and myofacial pain. No malignant tumors and other severe pathologies were seen. The distribution of these findings in the pregnant women according to their stage of pregnancy is shown in [Table 2]. Pyogenic granuloma was more commonly seen in the 1 st trimester, while gingivitis and erosion of teeth due to excess vomiting was common during the 3 rd trimester. The mean ± standard deviation of the decayed, missing and filled teeth in all the groups is shown in [Table 3]. The DMFT scores were higher during the 3 rd trimester. Pregnant women showed higher DMFT scores than nonpregnant women. Only 10 patients were aware of their conditions, while rest of the patients were unaware of their oral status [Figure 1].
|Table 2: Distribution of various extraoral and intraoral findings in pregnant women|
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|Table 3: Mean values of decayed, missing, and filled teeth in all the groups|
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|Figure 1: Graph showing the level of awareness of the oral status in pregnant women|
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| Discussion|| |
The changes seen during pregnancy are mainly attributed to the hormonal changes seen in pregnancy. Majority of these alterations revert back to normal postpartum, but specific factors do aggravate a few conditions. The levels of oral microflora, plaque, and local irritants determine the severity and the duration of these conditions.  Estrogen and progesterone are the principle female sex hormones produced and play an important role in the physiological changes seen in women from puberty. These hormones function synergistically, controlling the menstrual cycle, and in the maintenance of pregnancy and the initiation of labor. Estrogen levels may reach 30 times higher and progesterone levels 10 times higher in pregnancy than during the menstrual cycle. Elevated levels of these hormones have a significant influence on the major organ systems, including the periodontium. , Receptors for these hormones are found in the gingiva. , These hormones increase vascular permeability and the flow rate of gingival crevicular fluid. They may also alter the immune system.  Estrogen receptors have also been found in periosteal fibroblasts as well as in periodontal ligament fibroblasts.  Thus, they directly affect the periodontal tissues.
The gingival changes seen during pregnancy were reported as early as 1877. Based on the findings of various studies, the prevalence of pregnancy gingivitis ranges from 35% to 100%.  This wide range of variation may be due to difference in the populations studied and the clinical parameters used during the study. The pregnancy exacerbates the preexisting gingivitis and this is first noticeable during the 2 nd month of pregnancy and peaks in the 8 th month. A definite decrease in gingivitis is generally seen in the last month, and immediately postpartum the gingival tissues return to the earlier state similar to the 2 nd month of pregnancy.  It is seen more commonly in the anterior teeth. Though gingivitis is seen in association with plaque, it is interesting to note that pregnancy gingivitis is not related with the amount of plaque.  These changes are seen due to the alteration in the gingival tissue by estrogen and progesterone. Severe gingival bleeding due to disseminated intravascular coagulation was observed in a study by Annan and Nuamah  which subsided after labor. No such condition was observed in the present study.
The pyogenic granuloma or the pregnancy epulis is a localized, soft hyperplastic lesion which develops in up to 5% of pregnancies.  The reported frequency of pregnancy granulomas varies from 0% to 9.6%.  The present study also showed a prevalence of 8%, which is in line with other similar studies. It may develop at any time during the pregnancy, but most commonly seen in the early stage. It arises from an already inflamed gingival papilla and thus plaque is an important initiating factor for the development of pyogenic granuloma. They bleed readily when touched and have a tendency to recur rapidly. These lesions appear to be an accentuation of the inflammatory reaction of gingivitis in pregnancy, including the hormonal and microbial changes. However, no direct proof exists to support the relation of this vascular lesion with the increased hormonal levels.
There are no significant data to indicate that the incidence of dental caries increases during pregnancy. As the dental caries usually takes several years to develop, the possible increase in caries incidence during pregnancy is difficult to estimate. Increased levels of Mutans streptococci and Lactobacilli are seen in late pregnancy and during lactation.  The regular consumption of sugary snacks and drinks to satisfy cravings or to prevent nausea and sickness during early pregnancy may result in an increased incidence of dental caries. This can be further complicated if the pregnant woman is unable to maintain good oral hygiene as tooth brushing is compromised owing to the nausea and sickness.  The DMFT scores in the present study were higher in the pregnant women particularly during the 3 rd trimester. This finding is in accordance with the results of Al-Nuaimy and Al-Doski  However, various studies have shown that there exists no relation between dental caries and any complications during and after pregnancy due to dental caries. 
Aphthous ulcerations have shown reduced incidence during pregnancy as is evident in the present study. These can occur either as single or multiple ulcers that tend to recur. Dietary factors and altered immune response may be related with these ulcers; however, no particular mechanism has been suggested so far. The ulcerations severe during the luteal phase of the menstrual cycle. 
Tooth surface loss, mainly by acid-induced erosion, is seen if there has been nausea and repeated vomiting during pregnancy. This was recorded in 11 pregnant women in the present study. This was more common during the 2 nd and 3 rd trimesters. The cause in these cases was very much evident. Annan and Nuamah  showed a lower incidence of pregnant women with erosion of teeth (three pregnant women) when compared with the present study. They presented with a complaint of sensitivity. This was found as dentine was subsequently exposed due to erosion. The most affected are the palatal surfaces of the upper incisors and canines. 
Increased tooth mobility has been detected in pregnancy even in periodontally healthy women. It has been associated with the presence of a hormone, relaxin that helps in the preparation of the birth passage way. It may also relax the periodontal fibers.  The upper incisors are most mobile during the last month of pregnancy.  Development of such mobility is possibly due to mineral shifts in the lamina dura and not to modification of the alveolar bone. The degree of periodontal disease present and disturbance of the supporting attachment tissues are also thought to contribute to this mobility, which usually resolves postdelivery. 
Temporomandibular joint disorder symptoms get severe mainly during the immediate postpartum period due to the stress. They are rarely reported during pregnancy. The patients should be counselled for stress management and reassured accordingly. A total of 7.5% of the pregnant women and 10% of the nonpregnant women had TMJ and myofacial pain. This finding is in line with the results of Annan and Nuamah,  who reported an incidence of 7% in pregnant women and 17% in nonpregnant women. However, it has been reported that 90% of patients in USA with TMJ pain are females.  This difference needs to be studied further.
Hyperpigmentation has also been well-documented in the literature.  Increase in the salivary flow has also been shown to be associated with pregnancy. It is most commonly related to the nauseous sensation experienced during pregnancy, rather than the actual increase in the flow rate.  Given the considerable effect of pregnancy on oral health, the impact of periodontal disease on pregnancy outcome is also equally considered nowadays. There has been a well-documented association between periodontal disease and adverse pregnancy outcomes such as preterm birth, low birth weight, miscarriage, and preeclampsia. 
The present study indicates that oral healthcare should be an integral part of the routine check up of the pregnant women. Visits to a dentist every 3 months during pregnancy should be encouraged, for consultation and prophylaxis. It is also suggested that a dental clinician should be in attendance to the outpatient department of maternity hospitals. Obstetricians and prenatal healthcare workers are the first to become aware of the developing oral conditions and can provide appropriate information, advice, and reassurance, followed by referral to a dental clinician for examination, treatment, and monitoring. Therefore, an effective communication should be present between the dental and medical professionals to ensure that pregnant women receive the best possible oral, obstetric, and general healthcare.
| Conclusion|| |
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. They should also be able to advise pregnant women on how to maintain good dental health. This will aid in bridging the gap between the obstetricians and the dental clinician to provide an effective healthcare to the pregnant women and prevent the associated complications.
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[Table 1], [Table 2], [Table 3]