Introduction There are studies that examine the health status of the newborn after birth, in which maternal nutrition and the mother's health before and during pregnancy play a significant role. In the context of overall maternal health, it is especially important to pay attention to oral health issues. During pregnancy, dental hygiene has a major role and the information obtained in a dental-hygiene practice helps preserve the oral and overall health of the mother, but also of the child. Pregnant women still underestimate visits to a dentist and dental hygienist. Today, medicine and the general public have plenty of information about individual pregnancy periods, yet expectant mothers still lack sufficient correct information in the area of oral health. Many do not have enough information about the negative effects on the still developing fetus. A dental hygienist plays a key role in preserving or restoring a mother's oral health in close cooperation with the dentist. To maintain oral cavity health, it is necessary to emphasize the importance of the oral microbiome, which constitutes a distinct organ of the oral cavity with its direct influence on the development of diseases such as dental caries, gingivitis or periodontitis.

Oral cavity microbiome

The microorganisms that make up the oral microbiome are present in different parts of the oral cavity in varying composition depending on the biological and physical properties of each location, such as lips, palate, tongue, cheeks, teeth, gums, and saliva. The resident oral microbiome in a child begins to form and colonize the oral cavity at birth. Its most pronounced maturation occurs during the first three years of life and continues into adulthood. The mode of delivery also plays a significant role in microbiome formation. During vaginal birth, when the child passes through the birth canal, its oral cavity is colonized by microorganisms from the mother's birth passage (Lactobacillus, Prevotela, Veillonella, Neisseria), which forms the basis of the newborn microbiome. Changes in microbiome also occur during tooth eruption, changes in dietary habits, hormonal changes during puberty and pregnancy, tissue aging and functional changes in old age (Kovaľová, Klamárová, 2015), and also shortly after birth by skin saprophytes (staphylococci, micrococci, corynebacteria) from the hands of healthcare personnel, the mother, and relatives. During caesarean delivery, which is performed under strict aseptic conditions, the child's oral cavity is colonized by microorganisms from the environment, gloves and staff hands (Staphylococcus, Corynebacterium, Propionibacterium). Because a healthy resident microbiome plays a key role in defense against external pathogens and significantly influences immune functions, it is advisable to prefer vaginal birth. The microbial spectrum in the oral cavity changes in a child at the start of regular feeding and is gradually supplemented with new bacterial species during milk, mixed and permanent dentition. It follows that in forming a child’s oral microbiome, transfer of microorganisms—first from mother to child, and then gradually from other people with whom the child has contact, as well as from other changing oral conditions—plays a major role. Ultimately, a child's microbiome contains various bacterial species that, under changed environmental conditions in the mouth (increased sugar intake, reduced saliva production, antibiotic use), trigger disease; according to the type, we say the microbiome is either cariogenic or periodontopathogenic. In a cariogenic microbiome, the bacteria cause damage to hard tooth tissues, while in a periodontopathogenic microbiome they cause periodontal diseases. Klamárová (2016) states the basic principle in determining microbiome type and oral disease development: pregnancy does not cause oral diseases but worsens already existing disease. If a woman already had high caries risk before pregnancy, or suffered periodontal diseases (gingivitis, periodontitis), her microbiome is imbalanced and these microbiome changes are easily transferred to her child after birth. That determines what disease burden the mother passes to her child. It is also proven that bacteria responsible for periodontal disease can also cause complications during pregnancy, such as fetal growth delay and infection, and even preterm birth.

Risk factors affecting oral health of pregnant women

Pregnancy is considered one of the most important periods in a woman’s life. Physiological pregnancy lasts on average 280 days, i.e., 10 lunar months. This period is divided into three trimesters, during which the female body is continuously changing and adapting to the needs of the developing fetus (Trnková, 2018).

Care for oral health, however, should be a given for a woman already in preconception planning. The scope of dental care during pregnancy depends on the currently ongoing trimester in which the woman is. The dentist and dental hygienist should focus on each potential mother in their practice because her proper motivation and instruction account for more than half of success in preventing oral diseases in the mother herself and the other half in preventing oral diseases in the child from birth to adulthood. An important part of care is thorough anamnesis, clinical examination of soft and hard oral tissues, and determining risk factors in the woman regarding oral health. During counseling, the woman gradually receives substantial information on risk factors, options for managing possible changes in oral health, individual oral care, and further treatment and prevention. The extent of oral diseases in a future mother depends on the severity she had before pregnancy. Even in pregnancy itself, major hormonal changes occur in the woman's body, which have a marked effect on all organ systems, including the oral cavity.

Dental caries is a multifactorial disease of hard tooth tissues. It is the demineralization (decalcification) of hard tooth tissues by bacterial acids. The initial lesion begins in enamel and appears as a dull white spot. At this stage, dental caries can still be fully treated. After enamel demineralization, dentin is progressively attacked and dissolved, and a cavity develops. If dental caries is not treated, the cavity content spreads into the pulp, from where infection can spread by blood vessels through the whole body (Kovaľová, Klamárová, 2015). Dental caries is the most common chronic childhood disease and appears very early after tooth eruption. Studies show it is possible to inoculate even a toothless child. Transmission from parents (caregivers) to child is called “vertical transmission.” Horizontal transmission between siblings or spouses is also proven. Transmission of the cariogenic bacterium Streptococcus mutans between unrelated children in schools has also been documented (Kovaľová et al., 2017).

Cariogenic bacteria are part of the oral microbiome located on tooth surfaces, and caries develops when changes in their levels alter pathogenicity. Changes occur under favorable life conditions such as low pH acidic environment and consumption of sugar-rich foods (especially hidden sugars). During sugar metabolism, acids are formed that dissolve dental enamel; extracellular polysaccharides support plaque formation and intracellular polysaccharides support formation of reserves for periods of sugar deficiency. Before caries develops, bacterial acids must act on tooth surfaces for a sufficiently long time. After each meal, pH in the mouth drops below 5.5. Enamel demineralization occurs. Through salivary buffering systems, pH rises within 30 minutes, at which point remineralization begins and the demineralized enamel surface is resealed. Caries develops only when demineralization time exceeds remineralization time (Kovaľová, Klamárová, 2015).

If a dental hygienist wants to identify caries risk factors in a pregnant woman, after clinical examination and plaque detection using indices, saliva analysis, she also performs an analysis of dietary habits using a Nutrition Protocol. Through it, she can determine the frequency and composition of consumed foods and beverages. However, the occurrence of dental caries also depends on additional factors: tooth position, tooth anomalies, tongue activity, occupation, social status, as well as use of fluoride products in individual oral hygiene. Preventive check-ups with a dentist and dental hygienist are also essential for identifying caries risk. Predisposing factors increasing caries risk in pregnancy are shown in Figure 1.

Figure 1 Occurrence of risk factors during pregnancy

(Source: Kovaľová, Klamárová, 2015, p. 15)

Untreated and unrepaired dental caries can endanger the course of pregnancy and maternal health, because infection spreads through dentin blood supply to the entire body. It is proven that in pregnancy women's cellular immunity is reduced, so dental caries must be definitively treated. The most suitable time for caries treatment is the 1st and 2nd trimesters of pregnancy.

Tooth erosion is the loss of hard tooth tissues without bacterial involvement through chemical damage. Its development is also promoted by consumption of erosive drinks and foods. Most commonly these are juices, fruit juices (pH drop to 3.0–3.7), lemon juice (pH 2.7–3.0), vegetable juices (pH 4.0–4.2), sodas (pH 4.0–4.2), cola (pH 2.6–3.0), carbonated mineral water (pH drop to 5.5), drinking water (pH 7.0), milk (pH 6.6–6.8), black tea (pH 6.5–7.0), coffee (pH 5.2–5.6), and others.

Especially during the 1st trimester, pregnant women are at risk of tooth erosion during nausea and frequent vomiting. In later stages, increased intra-abdominal pressure and upward displacement of the stomach due to the growing uterus increase the risk of gastroesophageal reflux. Progressive erosive processes cause hypersensitivity (increased tooth sensitivity). Many women experience an unpleasant sensation in the mouth after vomiting or reflux, which then leads to brushing their teeth and entire oral cavity. This is, however, a serious mistake because it further damages already softened enamel through mechanical toothbrushing, especially with abrasive toothpaste, leading to even greater loss of hard tooth tissue. The result is erosive-abrasive damage. Abrasion is also defined as loss of hard tooth tissues due to mechanical damage. The rate of tissue loss also depends on dental aids used, tooth-cleaning technique and pressure used when brushing. As part of anamnesis, clinical examination and diagnosis (degree of erosion), dietary habits must be analyzed: frequency and amount of acidic food and beverage intake, duration of eating and drinking, and method of drinking from a bottle or glass. Through this analysis, the dental hygienist can determine the 24-hour pH value and curve, the so-called Stephan curve—Figure 2.

Figure 2 Stephan curve

(Source: Kovaľová, Klamárová, 2015)

Kovaľová et al. (2015) define gingivitis as an inflammatory condition of the gingiva in which clinical manifestations do not extend into the deeper periodontal structures. This state arises as a result of irritation by microbial plaque (catarrhal gingivitis induced by plaque) and without alveolar bone involvement. Inflammation is caused not by the bacteria themselves, but by their metabolic products (enzymes, antigens, toxins) that penetrate the tissue. Clinical signs include gingival redness, swelling, bleeding on provocation or spontaneously, and gingival sulcus depth changes to a pocket deeper than 3 mm. Gingivitis is the most common oral disease in pregnancy, occurring in 60–75% of pregnant women, and in most pregnant women only worsening of pre-existing inflammation occurs. Hormonal changes can cause overgrowth of periodontopathic oral microbiota. Significant factors in gingivitis development during pregnancy are also changes in maternal immune response. Accumulation of microbial plaque due to reduced oral hygiene in pregnant women is another major risk factor. Gingivitis usually appears in the 2nd month of pregnancy, when estrogen and progesterone increase. Its intensity peaks around the eighth month, then gradually declines, and after delivery returns to pre-2nd-month pregnancy levels (Bird, Robinson, 2015; Kovaľová, Klamárová, 2015).

Periodontitis is a chronic inflammatory disease affecting the entire tooth-supporting apparatus (periodontium), where resorption (dissolution) of alveolar bone already occurs, which is an irreversible state of periodontal tissue loss. Without adequate treatment, complete loss of the supporting apparatus that holds the tooth in bone may occur, followed by tooth loss. The cause of periodontitis is bacteria in the biofilm and their metabolic products, similarly to gingivitis. The development of periodontitis depends on the quantity of pathogenic microorganisms, their ability to penetrate tissues, and the body's readiness to respond to infection. The bacterium Actinobacillus actinomycetemcomitans is a typical predominant organism especially for the aggressive form of periodontitis. The gingiva is highly inflamed, and inflammation is localized mainly around central incisors and first molars (premolar-molar region). Aggressive periodontitis has a so-called family occurrence (family clustering), with marked vertical transmission of bacteria especially during oral colonization. Later, factors such as smoking, health status, medication use, or poor oral hygiene contribute to worsening. In non-aggressive periodontitis, tissue damage proceeds over many years; speed of loss depends on external and internal factors as well as the diversity of the oral microbiome. Hormonal changes during pregnancy alter oral microbiome composition, increasing growth of periodontopathic bacteria (Porphyromonas gingivalis, Campylobacter, Prevotella intermedia). In periodontitis, the affected tissue surface can reach 15 to 72 cm², resulting in bacteremia—the presence of bacteria in the bloodstream—and production of inflammatory mediators (cytokines, prostaglandins, interleukins), which can adversely affect the course of pregnancy (Kovaľová et al., 2015, 2017; Ferko, Pukluš 2015; Petraninová, 2016).

Epulis gravidarum (Figure 3), also known as pregnancy tumor, occurs in about 5% of pregnancies in the period from the 2nd trimester. It is not a malignancy, but an excessive inflammatory reaction to local irritation—plaque or food remnants. It manifests as marked gingival tissue enlargement due to increased levels of steroid hormones, local irritation and increased bacterial plaque in the setting of inadequate oral hygiene. The lesion is red, with smooth or lobulated surface, and is usually located in the anterior dentition region. It usually diminishes after delivery and sometimes disappears completely. If removed during pregnancy, it often grows back. Surgical removal during pregnancy is performed only if it is traumatized, bleeding, or ulcerated on the surface (Kovaľová, Klamárová, 2015).

Figure 3 Epulis gravidarum

(Source: Kovaľová, Klamárová, 2015, p. 21)

Occurrence of possible complications during pregnancy caused by the impact of oral diseases

With insufficient oral hygiene, bacteria accumulate around the cervical area of the tooth near the gingiva and form a pathogenic biofilm. In practice, however, an absolute plaque-free state in the oral cavity is not achievable; prevention of any biofilm formation on tooth surfaces is unattainable and even non-physiological. Oral health can be maintained by preventing excessive accumulation of microbial film on tooth surfaces. Otherwise, periodontopathogenic bacteria in mature plaque will secrete increasingly more destructive metabolic products that further damage periodontal tissues and subsequently stimulate immune response. The result is the onset and progression of inflammation. A negative consequence is that these bacteria and their products can enter the bloodstream, spread, and trigger infection or inflammatory response anywhere in the body. Kovaľová and Klamárová (2015) state that this condition supports the hypothesis that periodontal diseases may be responsible for pregnancy complications. They further note that many studies indicate a 1.5– to 7.5-fold higher incidence of preterm births or miscarriages in women with periodontitis compared with women without periodontal disease. Lea and colleagues (2021), in their meta-analysis, indicate that treatment of gingival inflammation in pregnancy may positively affect pregnancy outcomes, including increased infant birth weight and reduced numbers of preterm births.

Three mechanisms can influence the development of these complications:

  • Bacteremia. Periodontal bacteria in periodontal pockets trigger local immune response with production of inflammatory products and antibodies against bacteria. If the maternal immune system cannot localize and control this infection (e.g., due to insufficient IgG antibody production by the mother), bacteria and their toxins spread into the blood circulation. If invasive oral procedures are omitted (tooth extraction, treatment of deep periodontal pockets), even routine toothbrushing and chewing can lead to a similar spread of bacteria and products into the bloodstream. Through blood flow, bacteria reach the uterine environment, where they cause infection. Inside the uterus, these pathogens provoke an immune response with formation of inflammatory mediators.
  • Spread of inflammatory products. Similarly to bacteria, inflammatory products from diseased periodontium also spread hematogenously. Analysis of amniotic fluid in preterm infants has shown elevated levels of these inflammatory cytokines. Clinically, their elevated level in sulcular fluid is associated with increased levels in amniotic fluid in utero.
  • Feto-maternal immune response to oral pathogens. The immune and genetic characteristics of the fetus and mother are among the most important factors involved in preterm delivery. It has been shown that in mothers with insufficient IgG antibody production against periodontopathogens, preterm infants produced higher levels of IgM antibodies to maternal bacteria compared with children born at term. Maternal pathogen products and toxins can cross the placenta. Placental infection and inflammation can develop, increasing inflammatory mediators. Consequences may include impaired nutrient exchange between mother and fetus, damage to placental tissue (slower fetal growth and low birth weight). Disturbed placental structure can disrupt normal blood flow between mother and fetus, maternal blood pressure may rise, and preeclampsia may occur. Increased production of inflammatory products from maternal periodontopathogens may also contribute to premature rupture of membranes and uterine contractions, leading to miscarriage or preterm birth (Kovaľová, Klamárová, 2015; Markovská, Janitorová, 2017).

Straka (2016), regarding these complications, also states that the prevalence of preterm birth and low birth weight is also influenced by other factors, such as smoking, maternal age, previous pregnancies, maternal education, and the severity and type of periodontitis. He also states that the more the periodontium is damaged, the higher the risk of oral complications during pregnancy. According to him, two main routes of infection transmission exist, but from our perspective on oral health management, the hematogenous route is the most significant. Without effective periodontal treatment, collaboration between mother, dentist and dental hygienist, and in severe periodontitis, there is indeed a high risk of preterm delivery, low birth weight, or preeclampsia.

Counseling for pregnant women according to the problem

  • Frequent vomiting (erosion prevention)—the tooth surface is softened; it is necessary to neutralize the acidic environment in the mouth and strengthen teeth. Before vomiting, it is advisable to rinse once with mouthwash containing aminfluoride, stannous fluoride, and sodium fluoride for 15 to 30 seconds. After vomiting, rinse the mouth 2 to 3 times with clean water or once with a solution prepared from 1 teaspoon of sodium bicarbonate dissolved in 200 ml of lukewarm clean water. Thereafter, it is necessary not to brush the teeth for at least one hour. The teeth should be coated with calcium-phosphate preparations. In erosions with progressive hard tissue loss and exposure of cervical tooth areas, increased tooth sensitivity occurs (Byrtusová, 2017). In this case, desensitizing toothpastes are also appropriate.
  • Frequent intake of acidic foods (erosion prevention)—after consuming acidic foods and beverages it is not suitable to brush immediately; instead, it is better before intake. Before each acidic meal or drink, use mouthwash with aminfluoride, stannous fluoride and sodium fluoride for 15 to 30 seconds, so that a protective film can form on enamel with active saliva participation. After eating or drinking acidic items, rinse only two to three times with clean water, preferably non-carbonated mineral water, to allow neutralization of oral pH. Trnková (2022) states that fruit juices in hydration regimens should be diluted with water.
  • Frequent intake of sweets (caries prevention)—after breakfast, brush teeth with fluoride/aminfluoride toothpaste and, for medium to high caries risk, rinse with fluoride mouth rinse. After every sugary meal, it is advisable to rinse with clean water, so that pH in the mouth normalizes faster and saliva can promote enamel remineralization more quickly. If clinical assessment by the dental hygienist identifies increased to high caries activity, dietary habits must be adjusted by limiting acidic and sweet foods and beverages. The pregnant woman may be advised to chew xylitol candies or xylitol gum to reduce the number of cariogenic bacteria and thus prevent their transmission to the child after birth and the formation of a cariogenic microbiome in the child. Increased fluoridation (individual and professional) is also appropriate.
  • Periodontitis, gingivitis (prevention of periodontal damage)—with high inflammatory activity, visits to the dentist and dental hygienist are needed every two to three months. During acute inflammation, chlorhexidine rinses are recommended for 7 to 10 days, followed by anti-inflammatory mouthrinses, for example with essential oils, LAE, or stannous ions.

Examinations in dental practice and dental-hygiene services

A future mother must keep in mind both her own health and that of her child. Dental hygiene during pregnancy depends on the condition of each future mother’s dentition. If she has healthy gums and teeth, no morning sickness, and no significant dietary changes, the oral-hygiene routine does not change. The foundation remains mechanical plaque removal with interdental brushes, dental floss, and toothbrush, using regular fluoride toothpaste in the morning after breakfast and at bedtime. Interdental devices should be used at least once a day, preferably in the evening. If gingival inflammation is already present, bleeding occurs during brushing, gums are swollen, or oral malodor of any intensity is present, it is essential that the future mother visits a dental-hygiene clinic promptly and follows the dental hygienist’s recommendations.

Table 1 Content of dental care for a pregnant woman during individual trimesters

Source: own processing based on Kovaľová and Klamárová, 2015; Kovaľová et al., 2017.

Conclusion

The main preventive measure that can reduce the risk of transmission of infection to young children is reduction of cariogenic and periodontopathogenic bacteria from people in contact with them. The later a child is “infected” with cariogenic and periodontopathogenic bacteria, the fewer experiences it will have with dental caries and periodontal damage. Preventive measures for dental caries should begin with the pregnant woman and continue with the mother and child as the child ages. Despite unrestricted internet access and a wealth of information, there remains a great need for the correct information. A well-informed, truthfully educated, actively cooperating expectant mother can prevent errors that could threaten her health and the health of her unborn and expected child, as also indicated by study results by Bushehab et al. (2022). The authors emphasize that inadequate awareness of pregnant women about oral diseases, especially periodontal ones, adversely affects the course of pregnancy. Regular visits to dental and dental-hygiene practices are associated with comparatively higher awareness among pregnant women and women planning pregnancy.

Authors: PhDr. Bc. Ľudmila Andraščíková, PhD., MBA, MPH MUDr. Tatiana Klamárová, PhD. Prešovská univerzita v Prešove, Fakulta zdravotníckych odborov

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