Women's Health and Dental Hygiene Care

• Discusses Women's Health and Dental Hygiene Care, specifically Principle of Dental Hygiene 2

Objectives

• Describe hormonal effects and oral health risk factors relating to the menstrual cycle
• Describe and assess the oral care needs of pregnant patients
• Assess oral and gingival changes linked to hormonal shifts
• Apply information to patient management
• Students systematically review, document outcomes, provide on-going feedback in dental hygiene process
• Describe hormonal impacts and oral health risks related to puberty, menses, contraceptives, and menopause
• Describe importance of infant oral health
• Describe components and skills of infant oral exams
• Describe Early Childhood Caries (ECC)

Menstrual Cycle

• Hormone level rise and fall controls the cycle
• Rising estrogen decreases in first half of cycle without conception
• Gingival response to biofilm may increase
• Gingival response may mirror pregnancy if on oral contraceptives

Fetal Development

• Key terms include Fetus, Gestation and Teratogenic
• Divided into three trimesters
• Gestation lasts about 40 weeks
• Early embryo development relies on the mother's overall health and hereditary traits
• 1st Trimester: all organs form, and by week 12 the fetus moves and swallows
• 2nd Trimester: period of growth and ideal for dental treatment
• 3rd trimester: rapid growth and weight change, hormone levels reach maximum in month 8

Expectation vs Reality of Pregnancy

• Pregnancy is unique
• There are misconceptions about pregnancy and oral health
• Professional guidelines suggest early oral health professional referrals
• The American Academy of Periodontology advocates for periodontal evaluation and needed treatment for women seeking pregnancy
• Healthy pregnancy (with or without well-controlled HBP), controlled preeclampsia, diet-controlled gestational DM = ASA II
• Uncontrolled Preeclampsia, uncontrolled gestational DM/high insulin needs, or thrombophilia needing anticoagulation = ASA III

Common Misconceptions Related to Pregnancy and Oral Health

• "You must avoid dental care during pregnancy due to potential harm to the baby"
• "You may not use any products or medicines during pregnancy"
• "Taking x-rays during pregnancy may be harmful to the developing fetus"
• "Having a baby sucked all the calcium out of my teeth and now I have cavities"

Factors That May Harm The Fetus

• Infections correlate with periodontal infections and adverse pregnancy outcomes
• Most drugs cross the placenta impacting the fetus
• Tobacco, alcohol and substance use severely affect the fetus
• Herbal Supplements are not reviewed for safety before release

Use of Herbal Supplements of Pregnancy: Pregnancy and Lactation Labeling Rule

• Herbal and dietary supplements are not FDA regulated
• Women should take a combination of prenatal vitamins by ob/gyn recommendation
• Any use during pregnancy needs ob/gyn consultation
• Use of Echinacea, long-term use with immunosuppression, Valerian to sedate, insomnia, and stress should be considered

"You May Not Use Any Products or Medicines During Pregnancy"

• Most dental medications can be used without fetal harm
• May be used in pregnancy: Acetaminophen, Codeine, Aspirin and Amoxicillin
• Should be avoided: Ciprofloxacin, Clarithromycin and Levofloxacin
• Never use: Tetracycline

Dental Care During Pregnancy

• Avoiding dental care during pregnancy may cause emergency need later
• No evidence suggests any harm to developing fetus or mother from dental or dental hygiene treatment
• Hygiene treatment can happen at any point, 2nd trimester is ideal

dental X-Rays

• The ALARA principle applies
• Dental radiographs are safe and do not harm the fetus throughout pregnancy
• Precautions include lead apron with thyroid collar
• Risks of untreated dental infections or stress are greater than harm to mother/fetus

Why Pregnancy and Oral Health Are Related

• Hormonal storms cause physiological changes, including the oral cavity
• Increased estrogen and progesterone
• Exaggerated response to dental biofilm
• Altered immune function weakens the mother’s cell-mediated immune defense
• Diet and nutrition changes meet growing fetus demands
• Immunologic response weakens mother's cell-mediated immune response
• Pregnancy itself does not cause oral disease
• Hormonal changes are first visible in the oral cavity; existing oral diseases may worsen

Common Oral Findings During Pregnancy

• Hormone changes leading to gingivitis
• Gingival enlargements
• Periodontal infections
• Enamel erosion

Gingivitis From Sex Hormones

• Most common oral condition during pregnancy ("Pregnancy Gingivitis")
• Common characteristics: BOP, enlarged interdental papilla/marginal gingiva and bright red/smooth/shiny
• Predisposing factors include maternal immunologic response, biofilm buildup, hormonal changes, increased presence of certain oral microbiota P. Gingivalis, Prevotella nigrescens, Camplylobacter rectus, and Aggregatibacter actinomycetemcomitans

Gingival Enlargement

• Gingival hyperplasia appears
• The Oral pyogenic granuloma includes a “pregnancy tumor”, benign growth that grows rapidly, painless, color varies, form of hyperplasia with source of bacterial growth and attachment

Periodontal Infections

• Pregnancy-related immunologic changes suppress the mother's cell-mediated response and neutrophil function
• There is a relationship between periodontal infections and preeclampsia/low birth weight
• Untreated Periodontal treatments may worsen if left untreated
• Nonsurgical periodontal treatments are safe during pregnancy

Enamel Erosion

• Occurs from nausea, vomiting, and acid reflux during pregnancy with hyperemesis gravidarum
• Demineralization happens on palatal surfaces of maxillary teeth
• Results include chronic exposure to gastric acids
• Nutritional counseling
• Recommend 1 tsp sodium bicarbonate and cup of water to rinse with for vomiting and encourage non-abrasive fluoride products/xylitol gum after meals

Dental Hygiene Appointment Planning With The Pregnant Patient

• Every pregnancy is different
• Common characteristics include fatigue, frequent urination, general discomfort, dizziness, and gagging
• Recommended oral health care is early and often during pregnancy
• Routine dental hygiene care does not require Physician approval
• Underlying health conditions may need physician consult
• The goal is to optimize health for mother and fetus
• Adapt modifications to each woman's symptoms
• Supine positions place direct pressure on inferior vena cava and is contraindicated in the 3rd trimester
• The patient should turn to their left side
• Placing a small pillow or blanket to elevate the right hip

Patient Education During Pregnancy

• Maintenance frequency that depends upon patient's biofilm control/gingival assessment
• Educate on increased gingival inflammation and pregnancy
• Education on early infant care
• Help expectant mothers what’s coming!

Dental Caries Control and Pregnancy

• Carries risk assessment is necessary to complete
• Includes caries clinical indicators/risk/protective factors
• It is a misconception that pregnancy causes cavities
• Poor oral health relates to poor oral health during pregnancy
• High cariogenic bacteria makes it likely mothers will pass this bacteria to the baby after birth

Fluoride Use and Pregnancy

• 5% NaF Varnish is safe and effective for caries prevention during pregnancy
• The level of caries risk determines need and frequency of use
• Studies on use limited, 38% SDF has no contraindications for pregnant women
• Self-applied fluorides safe for home use includes fluoridated water, OTC dentifrice and low potency/high frequency mouth rinse
• No research suggests increased fluoride intake via supplements lowers caries after birth

Infant Care

• Oral cavity: sterile upon birth
• Anticipatory guidance: Patient education anticipates oral and systemic issues
• Share appropriate children’s health info to prepare parents, and should start in prenatal appointments
• Teething signs in babies include chewing on hard items, excess drooling, swollen sensitive gums, light rash, extra fussiness, slight fever, and refusal to eat

Feeding Patterns: 1st Year of Life

• Cariogenic foods/beverages and frequency of consumption are key
• Caries risk ups with infant sleeping with milk
• With eruption, breastfeeding and bottle feeding can pose risks
• Avoid sweetened beverages/at will-feeding
• Wean from bottle around age 1.5

Education for New Parents/Caregivers

• Teething causes irritability, increased salivation, and low-grade fever
• OTC teething products containing benzocaine are not recommended, because of Methemoglobinemia
• Homeopathic teething products/gels are not recommended
• Infants need first dental apt. by 12 months OR within six months of first tooth eruption
• Anticipatory guidance covers oral hygiene, fluoride, sucking habits, speech development, and injury avoidance

Birth to 6 Months vs 6 Months to 12 Months

• Eruption of first tooth, pattern, feed rules and risk for dental caries
• Prevention: transfer bacteria from caregiver to infant, brush or wipe with water only.
• Explain fluoride for dev. teeth, what F source do they have?
• Use a car seat
• Discuss if supplements needed/fluoride levels
• Highest rate trauma: 1-2 years old.
• Teething, non-nutritive sucking, scheduling visits and explain why

Infant Daily Oral Hygiene

• Start brushing/wiping at tooth eruption
• Recommend use of smear of fluoridated toothpaste (grain of rice) up to age 3
• Brushing the cervical third needs lifting lip
• Fluoride supplementation starts at 6 months and xylitol is recommended for caregiver

Early Childhood Caries

• One or more decayed/missing/filled primary tooth in child less than six
• Severe-ECC includes smooth surface decay in child under three

Feeding Patterns Related to Early Childhood Caries

• Breastfeeding helps dental caries protection
• Fluoridated water for formula
• Discourage liquids at bed after eruption
• Avoid fruit juice and sweetened beverages and wean at 18 months

Components of Infant Dental Visit

• Crying normal for first appointment with a Complete caries risk assessment
• Risk factors include diet, oral hygiene, fluoride intake and maternal dental health (microbiota exchange from caregiver to infant)
• Seat clinician and parent knee to knee, child head in clinician lap/caregiver stabilizes gently
• Treatment involves gauze removal and fluoride varnish (> 1yr old)

Menopause

• Ovaries exhibit irreversible hormone and reproductive change
• Menstruation will cease
• Average about age 51 with symptoms lasting years

Oral Symptoms of Menopause

• Burning mouth
• Salivary changes, xerostomia
• Gingival changes

Burning Mouth Syndrome

• Includes burning sensation and symptom variations
• Conditions like lichen planus, candidiasis, and viral infections should be ruled out prior to diagnosis
• Mucosa looks normal

Xerostomia

• Varies based on estrogen status
• Is aging's highest complaint and reason for Hormone Replacement Therapy (HRT).
• Consider dental hygiene recommendations and caries risk

Periodontal Health

• Hormones change inflammatory mediators
• Estrogen receptors predispose inflammation = destruction
• Osteopenia/osteoporosis poses periodontal risk

Documentation

• Document hormonal changes
• Age/gender
• Status changes