THE DENTAL PREGNANT PATIENT

REBECCA B. SINGSON, M.D., FPOGS

Dental problems that may arise during pregnancy are given attention since it may also potentially affect the growing fetus. Here are some facts and problems for the dental pregnant patient to know

ARE DENTAL CARIES CONSIDERED AN INFECTIOUS DISEASE?

Dental caries is considered an infectious disease since it is caused by a bacteria called Streptococcus mutans which can be can potentially be transmitted to the fetus. If a pregnant mother has multiple caries in her mouth, it is not sufficient to do restorations or extractions since it won’t solve the problem. Unless she takes therapeutic measures during her pregnancy to diminish the bacterial load causing caries in her mouth, the baby is at risk of infection through the transplacental route. Vertical transmission of the mutans strep bacteria can occur from mother to child occurs after the eruption of the primary teeth.

WHAT ARE THE COMMON GUM DISEASES?

Normally, millions of microscopic monsters called bacteria make your mouth their home feeding on food particles left on our teeth. These bacteria produce acid as a result of their feasting and it is this acid which eats into tooth enamel creating cavities. If this wasn't bad enough, the bacteria also pour out volatile sulfur compounds creating embarrassing bad breath. Normally bacteria are found within a mesh of mucus and debris known as plaque. Without regular dental hygiene these bacteria will multiply and pour out toxins causing gum inflammation leading to the following conditions:

1. Pregnancy gingivitis can affect quite a number of pregnancies, some authorities saying at least half and other authorities saying even as much as a hundred percent of pregnant women. The changes in the gum are brought about by hormonal changes which alter the rate at which estrogen and progesterone are metabolized in the gums plus the change in prostaglandin synthesis. These affect the pregnant immune system altering the pattern and rate of collagen production in the gums which in turn, reduces the pregnant woman’s ability to repair and maintain gum tissue. Studies have shown that women with chronic gingivitis have an increased risk for preeclampsia, which is a pregnancy complication marked by swelling of the leg due to marked fluid retention, a rise in blood pressure and protein in the urine. The condition may lead to the more serious eclampsia where the pregnant woman goes in to convulsions compromising the fetus in the womb.

2. Periodontitis – a chronic gingivitis may progress to a more serious condition if uncared for, where the infection can go beyond the bone and the tissues supporting it, leading to periodontitis. This can have serious implications on the pregnancy because research has shown that women with periodontitis are seven times more likely to have a premature delivery. Treating the condition can significantly decrease the risk because another research showed that pregnant women with preiodontitis who were treated with plaque & tartar removal called “scaling & planning” had significantly less preterm babies than women who were not treated.

SHOULD I TAKE FLOURIDE SUPPLEMENTS DURING PREGNANCY?

Most clinicians are not prescribing supplemental fluorides to pregnant women due to lack of evidence of efficacy for the unborn child. Also, it is important to note that current scientific evidence has demonstrated that prenatal fluoride supplements are not beneficial in preventing caries in the child's primary dentition, and therefore are not prescribed to pregnant women. It was previously thought that fluoride could not pass through the placental barrier, but studies have shown that it does indeed cross the placental barrier. However, it is still not known how fast fluoride can transfer to the fetus by. Perhaps because fluoride gets diluted in the amniotic fluid, research shows that there is rapid maternal clearance with only a slight increase in fetal blood fluoride concentrations.

Since 1966, the Food and Drug Administration in the U.S.A. has banned the use of advertising and labeling of fluoride supplements for "prenatal use". It has also banned claims that these supplements will prevent or reduce decay in the offspring of women who use them. The ban, however, does not prevent the prescription of fluoride supplements for pregnant women; it just restricts advertising claims until more solid evidence is available.

HOW CAN I CARE FOR MY TEETH DURING PREGNANCY?

• Brush your teeth at least twice daily. If you can brush after every meal and especially after indulging in sweets. An electric toothbrush cleans better than a manual toothbrush. Research shows that more dental plaque is dislodged with an electric toothbrush in 2 mins. than a manual toothbrush removed in 6 mins.
• Floss at least once a day as recommended by the American Dental Association. Flossing removes the bacteria that escape brushing by hiding in the tiny spaces between the teeth. Brushing without flossing is like washing only 65% of your body. The other 35% remains dirty!!
• Rinse with mouthwash or warm salt water. Warm salt water can help to soothe inflamed tissues.
• It is certainly best to visit your dentist regularly for professional teeth cleaning especially if you are contemplating a pregnancy. If you are already pregnant and have not ever seen a dentist, it is never too late. Make sure you tell your dentist you are pregnant and how many weeks of gestation so she may tailor your treatment without jeopardizing the baby.

You may not realize how important dental hygiene is to insure a non-complicated pregnancy. Healthy gums and healthy teeth in a pregnant mom is a vital component in having a healthy baby.

DIABETES IN PREGNANCY: HOW HARMFUL CAN THAT BE?

Rebecca B. Singson, M.D., FPOGS

WHAT IS GESTATIONAL DIABETES?

This is the most common medical complication of pregnancy affecting about 4% of pregnant women who are diagnosed with abnormal blood sugar levels occurring for the first time in pregnancy. Apparently, during pregnancy, certain rises of hormones such as the human placental lactogen, estradiol and progesterone all stimulate the synthesis and release of insulin from the mother’s pancreas. What happens is a state of high insulin levels or hyperinsulinism. If we nature were to allow this, there would be too much fluctuation in the levels of glucose So these same hormones were designed by nature to block the action of insulin to insure a steady glucose supply to the baby, inducing a state of insulin resistance. Furthermore, placental insulinase was also found in the placenta which acts to accelerate the destruction of insulin. All these make it harder for the pregnant woman to utilize insulin, creating a problem called insulin resistance. This condition makes it hard for the mother's body to use insulin. She may need up to three times as much insulin.

HOW WILL I KNOW IF YOU HAVE THIS CONDITION?

If you have a family history of diabetes, screening is done in the first 3 months of pregnancy. If you don’t have a family history, screening for gestational diabetes is routinely done for all pregnant women at 26 weeks. Screening entails a glucose challenge test (GCT) making the woman drink a sweet juice with 50g of glucose then extracting blood one hour later for sugar determination. Any level about 140 mg/dl or 7 g% is suspect and must undergo a more definitive test called the Oral Glucose Tolerance Test using 100 grams glucose and making 4 blood determinations at hourly intervals.

HOW CAN DIABETES AFFECT MY PREGNANCY?

Diabetes may harm the mother as well as the baby because of the following reasons:

1 Women with gestational diabetes have a 15% increased risk for preeclampsia (another complication in pregnancy consisting of hypertension, swelling of the feet & legs & spillage of protein in the urine); women with diabetes even before pregnancy have a 30% risk of preeclampsia

2. Some infections may be more common especially if the diabetes goes undetected or uncontrolled and these may likely become more severe in pregnant diabetic women.

3. Because so much glucose goes to the baby from the mother with high blood sugar, the fetus ends up secreting much insulin which in turn leads to stimulating much larger growth of the fetus. With a larger than usual baby, the mom becomes more prone to operative delivery either by forceps or C-section.

4. If the fetus grows so big as to weigh over 4 kilos, there is a 30% chance that if a vaginal birth is attempted, the baby can get stuck after the head is delivered since the shoulders cannot be delivered, a potentially fatal condition called shoulder dystocia can occur. It thus becomes safer to deliver by large babies by C section rather than risk fetal injury, or worse, fetal death as a result of shoulder dystocia.

5. Hydramnios (excess amniotic fluid) is more common with diabetic pregnancies and in very rare occasions, coupled with fetal macrosomia, may cause cardiorespiratory symptoms in the mother.

6. In the presence of an excessively large fetus, it becomes more difficult for the uterus to contract after delivery. Postpartum hemorrhage, therefore becomes more common.

7. In the absence of excellent diabetes and pregnancy care, death of the baby occurs considerably more compared to the general population.

8. In women who were diabetic with poor control even prior to pregnancy, there is a three-fold increase in major congenital malformations in the fetus. With the widespread use of insulin & good control, the risk of malformations have considerably decreased.

9. The infant may inherit the risk of developing diabetes as well.

HOW WILL MY DOCTOR TREAT MY DIABETES DURING PREGNANCY?

Your doctor will definitely place you on a diabetic diet and make you determine your blood glucose several times a day. If diet alone is capable of controlling the blood sugar, there will no be no need for further therapy. However, if the blood sugar remains uncontrolled, insulin treatment needs to be started to reduce the chances of delivering a macrosomic baby. Exercise appropriate for pregnancy is also encouraged both for weight control and for improvement of glucose metabolism.

DO I NEED TO BE DELIVERED BY C-SECTION?

There is no data to support a policy of Cesarean delivery purely on the basis of gestational diabetes. However, when the estimated fetal weight is greater than 4.5 k, prolonged labor or arrest in the descent of the head of the baby is an indication for C-section. If sugar control is poor and the baby or mother appears to be at risk, earlier delivery may be contemplated. However, when there is good sugar control and the weight of the fetus does not appear too large, a normal delivery may be attempted when the patient goes into labor.

Diabetes may be a dreadful complication in pregnancy when it goes unrecognized and uncontrolled. However, with good pre-natal care, one may greatly minimize the risks and have a normal pregnancy and a healthy baby.

MICRONUTRIENT SUPPLEMENTATION IN PREGNANCY

Rebecca Singson, M.D., FPOGS

Pregnancy is in the only time in the life of a woman when another human being becomes a parasite to her, depending on her body to provide the nutrients the fetus needs in order to grow. It is thus a critical time to be equipped with the necessary micronutrients to prevent damage to the growing fetus as well as to the mother herself. Nature protects the fetus so much that if the baby needs a nutrient that the mother does not have enough of for herself and her baby, the nutrient will be preferentially directed to the baby even to the detriment of the mother.

In this generation when we no longer plant our food the way our forefathers did, the nutrition we get from eating fastfood, bottled, canned, frozen food have become devoid of the nutrients we need to keep our bodies healthy, much less to support a healthy pregnancy. We need to insure ingesting at least the following nutrients to begin working towards an uneventful pregnancy.

FOLIC ACID. Folic acid can be found in foods such as spinach, parsley, broccoli, lettuce, lima beans, turnip greens, asparagus and beef liver. Folic acid supplementation is best taken even before planning your pregnancy since there is strong evidence that folic acid can reduce certain birth defects of the brain and spinal cord by more than 70 percent. These birth defects are called neural tube defects (NTDs). NTDs happen when the spinal cord fails to close properly.The most common neural tube defect is spina bifida which occurs when part of the baby's spinal cord remains outside the body. The baby may have paralyzed legs and, later, may develop bladder and bowel control problems. The most serious neural tube defect is anencephaly when baby is born without part of its skull and brain, and eventually dies. For all childbearing ages, the Center for Disease Control in the U.S. recommends that all women of childbearing age take at least 400mg of folic acid daily but for all pregnant women, 1mg/day is recommended. Women with a history a child with neural tube defect should take 4 mg of folic acid 1 month prior to conception and and all throughout the first trimester.¹

IRON. According to the Cochrane review, rron supplementation appears to prevent low haemoglobin at birth or at six weeks post-partum.² The availability or iron for our bodies to use depends on the food source. Heme iron, which is found only in meat, poultry, and fish, is two to three times more absorbable than non-heme iron, which is found in plant-based foods and iron-fortified foods ^3.4. The bioavailability of non-heme iron is strongly affected by the kind of other foods ingested at the same meal. Enhancers of iron absorption are heme iron (in meat, poultry, and fish) and vitamin C; inhibitors of iron absorption include polyphenols (in certain vegetables), tannins (in tea), phytates (in bran), and calcium (in dairy products)^5.6 . Vegetarian diets, by definition, are low in heme iron but can certainly be increased by careful planning of meals. The CDC recommends taking or low dose 30 mg/day) supplements of iron at the first prenatal visit. In the presence of anemia, treatment involves prescribing an oral dose of 60-120 mg/day of iron.⁷.

IODINE. This is essential for normal fetal thyroid function. If the mother lacks iodine, the baby may develop cretinsm (congenital hypothyroidism) of which mental retardation is a component. Cretins have abnormal looking faces with the tongue sticking out. Acc. to the Cochrane Review, iodine deficiency is the leading preventable cause of intellectual impairment in the world. Supplementation during pregnancy especially in areas with high incidence of cretinism results in reduction of this problem with no adverse side effects.⁸

The use of iodized salt is one way to prevent iodine deficiency. Salmon, tuna and seaweeds are excellent leading sources of iodine from food.

If using seaweeds as an iodine source it is best to use seaweeds that have been found to have a fairly consistent iodine content, such as kelp (kombu) or hijiki. It may be dangerous to consume more than 100g/year (by dried weight) of most seaweeds carries a significant risk of thyroid disorder due to iodine intakes in excess of 1000 micrograms per day.

Nori (the seaweed used to wrap sushis with) is low in iodine and several sheets a day can be eaten without any concern about excess iodine. Frequent addition of small amounts of powdered or crumbled seaweed to stews or curries while cooking, or to other foods as a condiment, is an excellent way to provide adequate iodine (in the absence of other supplementation) . 100g of dried hijiki or 15g of dried kombu or kelp in a convenient container in the kitchen provides one year's supply for one person.

MAGNESIUM. Magnesium supplementation during pregnancy has been associated with fewer pre-term births and less intrauterine growth retardation. ^9.10,11 Magnesium deficiency is associated with pre-eclampsia, and pre-term delivery and possibly with low birth weight.¹² , coagulation defects ¹³, premature delivery^14,15, intrauterine growth retardation ^9.15,and muscle cramping¹⁶ Diets high in magnesium density would contain whole grains, lean meats, low amounts of fats and sugars, abundant fruits and vegetables, and low-fat milk. Diets low in magnesium density would contain refined cereal grains, fatty meats, high amounts of fats and sugars, few fruits and vegetables and sugar-containing soft drinks.

DHA. In the latest researches it has been found that supplementing pregnant mothers with fish oil may benefit brain and retinal development in their offspring particularly if born prematurely. Supplementing from mid-pregnancy to the 34th week was found to be perfectly safe and more importantly, may reduce the incidence of preeclampsia (pregnancy-related high blood pressure).¹⁷ It was found that breastmilk contains DHA whereas formula milk did not. Researchers at the University of Milan report that infants whose formula contains long- chain polyunsaturated fatty acids [especially Docosahexaenoic acid (DHA)] have better brain development than children who do not receive DHA in their formula. The observation supports earlier findings that there is a direct correlation between the DHA concentration in the red blood cells of infants and their visual acuity. The researchers recommend that infants who are not breastfed be fed on a DHA- enriched formula. Nothing is as complete as breast milk since it is already complete with the fatty acids necessary for good brain development.

MICRONUTRIENT INTERACTIONS.

There are some micronutrients that alter the absorption of others. For example, calcium can block the absorption of iron. Vitamin A may also contribute to anemia by interfering with iron although studies have shown that when given together, there is greater reduction in anemia. Iron supplements can also interfere with the absorption of zinc. On the other hand, vitamin C can increase the absorption of and zinc. Zinc in high doses may interfere with absorption of iron or copper. But many studies still document achieving greater benefits with combined, rather than single, micronutrients therapy but many more studies are required to evaluate these interactions in malnourished populations. Because of the possibility that there may be multiple deficiencies in pregnant women in developing countries, UNICEF has concluded that a multivitamin–mineral supplement should be given during pregnancy^19. By simply supplementing, many complications in the mother and infant during and after pregnancy may be avoided.

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⁸Mahomed K , Gülmezoglu AM. Maternal iodine supplements in areas of deficiency. The Cochrane Database of Systematic Reviews 1997, Issue 4. Art. No.: CD000135. DOI: 10.1002/14651858.CD000135
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¹⁹UNICEF (1999) Composition of a multi-micronutrient supplement to be used in pilot programmes among pregnant women in developing countries.