Adopt an active role in the strategic prenatal development of our youngest patients
By Cathy Hester Seckman, RDH
As hygienists, we put a lot of focus on children. Dr. Alfred Fones’ original intent, after all, was for us to work with children in schools.1 We want to catch them early, train them (and their parents) in home hygiene, make sure they have fluoride available, and watch them grow into caries-free adults with healthy mouths.
But did you ever stop to consider how much we can help children toward that goal before they’re even born? Remember that deciduous teeth begin forming in utero, so a mother’s health and nutrition are vital to the proper formation of teeth. By educating mothers-to-be, we can provide their babies, who are also our patients, with the best possible start on lifelong oral health.
Presuming the mother is healthy, you might say the first step toward baby’s oral health is prenatal vitamins, which include important minerals such as folic acid, iron, iodine, and calcium.2 If the mother lacks certain vitamins during pregnancy, here’s what can happen during baby’s tooth development:
- Vitamin A deficiency: enamel hypoplasia and defective dentin formation
- Vitamin C deficiency: gingival hemorrhaging, improper dentin formation, and gingivitis
- Vitamin D deficiency: loss of lamina dura, enamel hypoplasia, cavitated ECC, and white spot lesions3
A lack of minerals during pregnancy can cause these problems for the baby’s teeth:
- Calcium deficiency: increased caries
- Magnesium deficiency: hypoplasia
- Phosphorus deficiency: incomplete calcification, incomplete dentin formation
- Fluoride deficiency: loss of systemic benefits
In contrast, adequate minerals boost cell formation, repair capabilities, and boost collagen synthesis.3
Another essential item during pregnancy is a proper amount of protein in the mother’s diet. A deficiency can result in inadequate bone growth for the baby, which in turn can lead to crowded or rotated teeth. Tooth development could also be interrupted, and there may be permanent damage to the periodontium.3
Smoking is a habit that not only harms mother and baby, but is detrimental to a baby’s oral development. Several studies note correlations between smoking and cleft lip or palate, especially in males. A multivariate analysis done as part of a 2015 Brazil study showed male gender plus maternal smoking resulted in a 2.5 time (gender) and a 1.5 time (smoking) greater chance of having a cleft.4
Research conducted in 2017 at Virginia Commonwealth University was the first to question the safety of e-cigarettes for embryos. When testing several aerosolized e-cigarette liquids in vivo during embryonic development, they found defects including median facial clefts, midface hypoplasia, cranial cartilage and muscle defects, and reduced blood supply to the face, all induced by exposure to the aerosols. They found that nicotine was not the main factor, but it exacerbated the effects of other components of the e-liquids.5
Smoking and deficient nutrition aren’t the only issues that are linked to poor oral development in infants. We can begin here with information about the connection between periodontal disease and preterm low birth weight (PTLBW). Research has shown links between a mother’s periodontal disease and PTLBW babies. One link is prostaglandins.6 High levels of the fatty acids are found in the oral bacteria of women with periodontitis.7 Those same fatty acids are involved with inflammation control and the smooth muscle contractions that induce labor.8
C-reactive protein also plays a role in both periodontal disease and preterm delivery. In one study, pregnant women with periodontitis had 65% higher CRP levels compared to periodontally healthy pregnant women.9 Other known periodontal pathogens include gram-negative (anaerobic) bacteria, which can enhance uterine contractions and be responsible for premature labor.10
However, research results do conflict. A 2013 study published in ScienceDirect, for instance, states that while an association was found between periodontal disease and low birth weight, no association was found between periodontal disease and preterm delivery.11
With pre-eclampsia, a late-pregnancy toxemia characterized by hypertension, edema, albuminuria, and eventual kidney damage, the research is more confusing. Periodontal disease has been found in 64% of pre-eclamptic women and 36% of non-pre-eclamptic women, leading to uncertainty about a significant link. A systematic review found it “questionable whether periodontal disease plays a causal role in the pathogenesis of pre-eclampsia.”12 A later meta-analysis concluded that a mother’s diagnosis of periodontal disease was an “independent predictor” of the toxemia.13
What are the links between PTLBW and infant oral health? A 2015 article in the International Journal of Clinical Pediatric Dentistry states that the short prenatal period of PTLBW babies affects tooth development.
For hygienists to have a positive effect on pediatric oral health, we don’t need to wait until a child’s first dental visit.
One of the problems is that teeth are not remodeled like bone—any developmental damage is permanent. Damaged enamel in PTLBW babies is decreased in thickness, and defects include a rough, granular, and poorly mineralized appearance. Since two thirds of calcium and phosphorus stores are deposited during the last trimester, the teeth of PT babies are compromised. Some studies indicate that damage can occur to permanent as well as primary dentition, and proper timing of tooth eruption may be affected. Neonatal health problems such as infections and respiratory diseases can also cause deficient enamel in permanent dentition.14
Besides ensuring healthy living and a healthy periodontium, there are other steps hygienists can recommend for pregnant women that can help their children’s healthy oral development. For years researchers have studied pregnant women who use a protocol for xylitol gums or mints.
One of the more recent randomized controlled trials was conducted in Japan. Pregnant women with high mutans streptococci (MS) levels used gum containing 1.32g of xylitol four times a day for at least five minutes. This continued for 13 months, beginning in the sixth month of pregnancy. Some 23% of the women showed markedly decreased levels of MS, and at 15 months postintervention, the levels had not increased. It’s easy to see the benefit in this since babies are born without MS and acquire it from their caregivers.15
In a previous study by the same research group, babies of the pregnant women who chewed xylitol gum were less likely to colonize MS. Babies of the control group demonstrated MS colonization nearly nine months earlier than the babies of the xylitol group.15
For hygienists to have a positive effect on pediatric oral health, we don’t need to wait until a child’s first dental visit. As soon as a glowing young woman walks into the office and checks off the “pregnant” box in her health history update, we can give her all the information she needs to make healthy choices for her child’s teeth.
Cathy Hester Seckman, RDH, worked in dentistry 32 years, including 12 years as a pediatric hygienist. Officially retired from clinical hygiene, she still fills in occasionally at the same pediatric practice. She is multi-published in dental magazines, works part-time as an indexer, and is the author of three novels, more than a dozen short stories, and an Arcadia Publishing history of her hometown. Her new book, Ohio Day Trips, will be published by AdventureKEEN on March 1.
3. Stegeman C, Davis JR. 2005. Dental Hygienist’s Guide to Nutritional Care; Elsevier Saunders.
4. Martelli DR, Coletta RD, Oliveira EA, Swerts MS, Rodrigues LA, Oliveira MC, Martelli JH. Association between maternal smoking, gender, and cleft lip and palate. Braz J Otorhinolaryngol. 2015 Sep-Oct;81(5):514-9. Epub 2015 Jul 22.
5. Kennedy AE, Kandalam S, Olivares-Navarrete R, Dickinson AJG. E-cigarette aerosol exposure can cause craniofacial defects in Xenopus laevis embryos and mammalian neural crest cells. PLoS One. 2017 Sep 28;12(9):e0185729.
6. Ahmad Haerian-Ardakani A, Eslami Z, Rashidi-Meibodi F, Haerian A, Dallalnejad P, Shekari M, Moein Taghavi A, Akbari S. Relationship between maternal periodontal disease and low birth weight babies. Iran J Reprod Med. 2013 Aug; 11(8): 625–630.
7. Shanthi V, Vanka A, Bhambal A, Saxena V, Saxena S, Shiv Kuma S. Association of pregnant women periodontal status to preterm and low-birth weight babies: A systematic and evidence-based review. Dent Res J (Isfahan). 2012 Jul-Aug; 9(4): 368–380.
8. Jones RL. Functions of prostaglandins. Pathobiol Annu. 1972;2:359-80.
9. Pitiphat W, Joshipura KJ, Rich-Edwards JW, Williams PL, Douglass CW, Gillman MW. Periodontitis and plasma c-reactive protein during pregnancy. J Periodontol. 2006 May; 77(5): 821–825.
10. Bansal J, Bansal A, Kukreja N, Kukreja U. Periodontal diseases as an emerging potential risk factor for adverse pregnancy outcomes: A review of concepts. J Turk Ger Gynecol Assoc. 2011 Sep 1;12(3):176-80.
11. Yen-Li Wang, Jui-DerLiou, Whei-LinPan. Association between maternal periodontal disease and preterm delivery and low birth weight. Taiwanese Journal of Obstetrics and Gynecology, Volume 52, Issue 1, March 2013, Pages 71-76.
12. Kunnen A, van Doormaal JJ, Abbas F, Aarnoudse JG, van Pampus MG, Faas MM. Periodontal disease and pre-eclampsia: a systematic review. J Clin Periodontol. 2010 Dec; 37(12):1075-87.
13. Huang X, Wang J, Liu J, Hua L, Zhang D, Hu T, Ge ZL. Maternal periodontal disease and risk of preeclampsia: a meta-analysis. J Huazhong Univ Sci Technolog Med Sci. 2014 Oct;34 (5):729-35. Epub 2014 Oct 16.
14. Zaidi I, Thayath MN, Singh S, Sinha A. Preterm birth: A primary etiological factor for delayed oral growth and development. Int J Clin Pediatr Dent 2015;8 (3): 215-219.
15. Shinga-Ishihara CA, Nakai YA, Milgrom PC, Söderling ES, Tolvanen MD, Murakami KA. Xylitol carryover effects on salivary Mutans Streptococci after 13 months of chewing xylitol gum. Caries Res 2012;46:519–522.