Oral Health Policy and Practice Guidelines for Oral Health Providers Treating Pregnant Women

Management of oral infections, disease control, and providing corrective treatments are essential to maintaining health and well-being during pregnancy.

• For new pregnant patients, take a full medical and dental history and conduct a risk assessment
• For existing patients, update medical and dental history when first seen during pregnancy
• Routine dental care, including dental radiography, is safe and acceptable during all trimesters and should be provided when clinically indicated

Oral health providers who care for pregnant women should be aware of the effects of pregnancy on oral health and systemic health. They should understand the physiologic changes throughout all three trimesters (1^st – through 13 weeks gestation; 2^nd – 14 weeks through 27 weeks; and 3^rd – 28 weeks to birth [40 weeks +/-2 weeks]), as well as potential risks found during pregnancy. Normal physiologic changes include increased blood volume and lower blood pressure in the first trimester. Later in pregnancy, the uterus may put pressure on the vena cava so the patient may need to change position during dental treatment.

About 7% of pregnant women have hypertension during pregnancy, 5–8% have pre-eclampsia, less than 1% have eclampsia, and 7% have gestational diabetes. Medications or drugs can have significant effects on the fetus, so it is important to know what medications a woman is taking, and only prescribe those that are safe. Some pregnant patients are at increased risk for pregnancy complications or adverse birth outcomes, such as teens and women older than 35 years of age, women with multiple pregnancies, and those with systemic disease, such as HIV or Hepatitis C.

General information review should include primary care or OB\GYN provider’s name and contact information, medications taken, the use of tobacco products, alcohol, or drugs, and chief complaint.

Collect prenatal information such as due date, whether receiving prenatal care, name and contact information of prenatal care provider, and complications (e.g., high blood pressure, diabetes, morning sickness, severe or prolonged vomiting, or bleeding disorders).

Ask about social history including employment status, education, current access to social services, cultural status, literacy level, primary language, medical and dental insurance, home stability, members of the household, and history of family/personal violence.

Take an oral health history. Plan to address acute issues at the first visit and work up a comprehensive care plan. Obtain a good understanding of self-care practices and historical access to professional oral health services. Be sure to address the patient’s specific pregnancy-related questions or safety concerns. Document any special needs, including relevant medical, psychological, or physical needs during pregnancy.

Conduct a caries risk assessment with specific questions geared to understanding risk factors such as nausea and vomiting. Review diet, eating, and beverage consumption that contribute to increasing caries risk and use of fluoridated products. Community water system information can be found on the Illinois page of CDC’s My Water’s Fluoride.

• Take blood pressure; immediately consult with prenatal providers for pregnant patients with high blood pressure (>140/90) to determine the need for an immediate referral
• Perform a comprehensive oral examination; note pregnancy-specific oral issues
• Periodontal issues - pregnancy gingivitis, chronic periodontitis, or acute exacerbation of periodontitis
• Dental erosions - secondary to severe or prolonged vomiting or gastroesophageal reflux disease
• Tooth mobility may be increased and is normal due to hormonal relaxation of connective tissue
• Take radiographs as needed based on risk and evidence using ADA-FDA 2012 guidelines

Reassure women on the safety of routine dental care during pregnancy, drinking optimally fluoridated water, taking of radiographs, use of local anesthesia, and restoration of dental cavities. Encourage women with caries or periodontal disease to get treatment as soon aspossible.

Treatment Considerations: Sequence treatment that requires immediate treatment, such as extractions and root canals before they become urgent issues. Reinforce that routine dental treatment is safe and can occur at any time during pregnancy and delaying treatment may result in more complex problems.

Provide anticipatory information about common oral health conditions and changes during pregnancy (e.g., pregnancy gingivitis) and explain how maternal oral health affects their child’s oral health (e.g., the transmission of maternal caries-causing bacteria to infants).

Advise women to receive dental cleaning and treatment for all active dental caries. Effective disease control may require multiple or more frequent treatments to control gingival inflammation or dental caries.

Discuss health promotion and ongoing self-care practices, home oral hygiene, the use of fluoride products, appropriate diet, and nutrition, eating and drinking behaviors, and the importance of professional assessment and preventive dental visits.

• Brush teeth twice daily with a soft-bristle toothbrush and fluoride-containing toothpaste, and floss daily to reduce gingival bleeding (some bleeding is normal during pregnancy)
• The use of fluorides in toothpaste, rinses, or water is safe when used appropriately

Provide nutrition advice including:

• Choosing healthy foods and snacks and limiting foods containing added sugar
• Choosing water or low-fat milk; limiting juice sports drinks, sugar-sweetened beverages, and all carbonated beverages
• If experiencing vomiting and nausea, eating small amounts of nutritious foods throughout the day
• Encourage patients to continue dental care throughout the pregnancy and during the post-partum period
• Encourage patients to establish a dental home for themselves and their families. Discuss the recommendation that dental visits for children should begin within six months of the eruption of the first tooth or by age 1

Discuss other oral health topics and recommendations with women, as appropriate:

• Rinse with a cup of water with a teaspoon of baking soda after vomiting; do not brush for one hour after vomiting because stomach acid can cause loss of enamel and dentinal hypersensitivity
• Inform women that chlorhexidine and other non-alcohol mouth rinses are acceptable during pregnancy as needed (limit chlorhexidine duration to avoid staining of teeth)
• Consider recommending xylitol gum or mints in the postpartum period (up to two years) to reduce transmission of oral bacteria to the infant
• Support prenatal health by encouraging the use of prenatal vitamins, attendance at prenatal visits, and breastfeeding

Develop a plan to address immediate issues and comprehensive management during and after pregnancy. Work towards establishing a regular source of oral health care.

Discuss treatment options with the patient; explain the safety of all procedures and medications during pregnancy.

Address possible barriers to oral health care during pregnancy:

• General (e.g., transportation or financial)
• Competing health issues, especially for those with special needs
• Fear and fatalistic attitudes, such as “lose one tooth for each baby.”
• Lack of awareness among other health providers about the importance and safety of oral health care during pregnancy
• Illinois Medicaid benefits include dental examination, dental cleanings, treatments for periodontal disease, dental restorations, extraction of teeth, and additional treatments with prior authorization. A description of dental coverage and help for managed care adults and children members enrolled in Medicaid can be found on the Illinois Department of Healthcare and Family Services Adult Dental Program webpage

Treat and control periodontitis for improved prenatal outcomes; read and follow antibiotic recommendations for pregnancy:

• Use practical tips that can help pregnant patients during visits
• All trimesters – keep the woman’s head higher than the level of her feet; use semi- reclining positions and allow for frequent position changes
• Accommodate patient preferences for appointment times due to pregnancy-related issues, such as morning sickness

Provide comprehensive treatment to address dental caries:

• Restoration, root canals, or extractions as needed
• Avoid temporary material when possible because it may be difficult for pregnant and postpartum women to return in the short term

Provide comfort during pregnancy and ongoing care during and after pregnancy. Place a pillow under the right side to position women slightly on the left side to maximize blood flow return through the vena cava, especially in the third trimester (28 weeks to birth).

• Follow up, reinforce, and provide support for effective self-care
• Determine and schedule individualized follow-up visits
• Complete care in a reasonable time
• Follow up with patients that have discontinued care and address barriers

Consider collaborating with area prenatal providers through a written referral relationship.

For pregnant women with normal pregnancies, medical consultation with prenatal providers is not needed for routine dental care. For patients without a medical home, help them make the connection to a provider.

Consider developing a list of prenatal care resources, such as area FQHCs or other OB/GYN and primary medical care practice locations. Call area offices to determine whether they accept Medicaid, other insurance plans, or have sliding fee schedules for uninsured patients. For women with IllinoisMedicaid coverage, see Illinois Healthcare and Family Services webpage for Pregnant Women and Infants for contact information to help in finding Illinois Medicaid providers.

For high-risk patients, such as those with gestational diabetes, pre-eclampsia, or other complex health conditions, consult with prenatal providers before providing dental care. Update prenatal health care providers with pertinent dental treatment and management plans as requested or needed, especially for high-risk patients.

Collaborate with prenatal providers. For example, give a presentation on oral health topics during inter-professional rounds, do a meet-and-greet with local prenatal providers, review which insurance plans are accepted by your practice, and develop a process for sharing health information and consultation for special cases. Offer to provide information about common oral health conditions encountered during pregnancy, corrective treatment measures to be taken, and oral health care for the newborn and infant. This information can also be shared through group settings, such as prenatal classes or centering pregnancy programs, that are hosted by prenatal providers.