Patient Education

Maintaining good oral health during perinatal period

Provides oral healthcare professionals with information about how expectant mothers, new mothers, infants and children can maintain good oral health; and Focuses primarily on the prevention of tooth decay, with a few comments about preventing malocclusions.

MAJOR TOPICS

• Pregnancy and Oral Health
• Oral Hygiene
• Fluoride
• Dental Home
• Nutrition
• Oral Habits
• Importance of Baby Teeth

Time periods to consider

Mother

• Expectant mother
• New mother

Developing child before birth

Infant and young child

• Infant before baby teeth
• Infant and children with baby teeth
• Transition from baby teeth to permanent teeth

Changes to oral health of mother during pregnancy

Hormonal changes

• Pregnancy gingivitis

Most common oral disease during pregnancy

Gums more sensitive to dental plaque, which can cause swelling and bleeding

• Salivary changes – excess saliva or dry mouth
• Pregnancy tumors of the gingiva – growth that subsides after pregnancy
• Metallic or sour taste
• Mobile teeth not related to periodontal disease

Nausea and vomiting

• Nausea may cause increased intake of antacids that contain sugar and add to the risk of dental caries.
• Vomiting can produce erosion of teeth, if one brushes too soon after vomiting.

Dietary changes

• Odd cravings may lead to increased consumption of foods with carbohydrates and sugars, adding to the risk of caries.

uDental Caries

• Pregnancy does not weaken teeth
  or necessarily predispose women to tooth decay.
• Pregnancy does not cause minerals to be removed from teeth.
• However, changes in dietary habits, frequent acid challenges and hormonal changes may add to the risk of dental caries during pregnancy.

Dental caries, periodontal disease
and pregnancy outcomes

• Tooth decay and gum disease are bacterial and/or inflammatory diseases.
• Any infection or inflammation during pregnancy can be a concern for the health and safety of the mother and her unborn child.

Dental caries
and pregnancy outcomes

Tooth decay during pregnancy may influence pregnancy outcomes via inflammation pathways and has been associated with:

• Pre-term birth
• Low birth weight babies; and
• Pre-eclampsia

Periodontal disease
and pregnancy outcomes

Gum disease during pregnancy may influence pregnancy outcomes via inflammation pathways and has been associated with:

• Pre-term birth;
• Low birth weight babies; and
• Pre-eclampsia.

A more certain relationship

Keeping your mouth healthy is important for your baby to have a healthy mouth

Poor oral hygiene during pregnancy can adversely effect teeth of newborn

• If an expectant mother has poor oral hygiene, then decay-causing bacteria can multiply.
• When a baby is born, the mother can pass these bacteria from her mouth to the infant, adding to the risk of the infant developing tooth decay.
• Note: If a new mother has help from a caregiver, poor oral hygiene in that caregiver can also put an infant at risk of tooth decay.
• Babies are not born with cavity causing oral bacteria.
• However, if the mother or primary caregiver has high levels of cavity causing bacteria, these can be passed to the baby.
• The higher the level of these bacteria in the mother’s or primary caregiver’s mouth, the more likely her baby will develop dental decay.
• If high levels of cavity causing bacteria are passed to the baby, then once the baby teeth erupt they are susceptible to decay.
• If the level of these bacteria is high enough the baby teeth can start to develop caries immediately.
• Caries can progress very quickly to dental decay and cavities; some parents comment that the decay seemed to appear overnight.

Cavity causing bacteria passed to infant by mother can put baby’s teeth at risk of decay

Good oral hygiene during pregnancy can positively effect teeth of newborn

If a mom takes good care of her oral health during pregnancy, she has less decay-causing bacteria to pass to her newborn, which reduces the risk of the infant developing tooth decay.

Important Messages

If an expectant mother practices good oral health care during her pregnancy, she can improve her oral health and improve the chances of her new baby having good oral health.

Once the baby is born, it is important that the mother continues her own oral health care and institutes appropriate oral health care for her new baby.

Basics of Prevention

• Oral Hygiene
  Brushing
  Flossing
• Fluoride
  Community water with fluoride
  Toothpaste
  Fluoride varnish
  Fluoride supplementation
• Dental Home
  During and after pregnancy
  Finding a dental home

Prenatal Oral Health Care for Expectant Mom

• Oral Hygiene
  Brush teeth with fluoridated toothpaste twice a day.
  If toothpaste causes nausea, a different flavor and/or reduced amount of toothpaste may be used.
  If toothpaste cannot be tolerated, it can be eliminated; but, brushing should be continued without the toothpaste.
  The toothbrush should be replaced every 3 or 4 months, or more often if the bristles are frayed.
  The toothbrush should not be shared with an infant or anyone else.
• Clean between teeth daily with floss or an interdental cleaner.
• Rinse every night with an over-the-counter fluoridated alcohol-free mouth rinse.
• Oral Hygiene
• After eating, the expectant mom can use a xylitol product to enhance oral hygiene by:
  Chewing a xylitol-containing gum; or
  Using other xylitol-containing products, such as mints, which can help reduce bacteria that can cause tooth decay.
• If the expectant mother has morning sickness and vomiting:
  The mom can rinse her mouth with a teaspoon of baking soda in a cup of water to stop acid from attacking her teeth;
  She can then brush her teeth once the acid has been neutralized
• Prevention with systemic fluoride
• Community Water Fluoridation
  The optimal level of fluoride maintained in community water systems is considered safe for both the expectant mother and developing child.
  When an expectant mother drinks fluoridated water it will help prevent her from getting dental decay.
  However, current thinking is that consumption of community fluoridated water by an expectant mom does not directly prevent decay in a newborn.
• Prevention with systemic fluoride
• Fluoride Supplementation – adding fluoride to water to bring the fluoride level to an optimum level
  If the fluoride level in the mother’s water is low, fluoride supplementation may improve her oral health, which as we have seen can help prevent decay in a newborn.
  However, current thinking is that consumption of fluoride supplemented water by an expectant mom does not directly prevent decay in a newborn.
• Prevention with topical fluoride
• Toothpaste
  As mentioned previously, an expectant mom should brush her teeth, at a minimum, twice a day with fluoridated toothpaste.
  Fluoride Varnish – Consult a dentist
  Fluoride varnish may also be used during pregnancy in expectant moms at high risk for dental caries.
  It can also be use to prevent enamel erosion due to frequent bouts of vomiting.
• The American College of Obstetrics and Gynecologists states,… to potentiate general health and well-being, women should routinely be counseled about the maintenance of good oral health habits throughout their lives as well as the safety and importance of oral health care during pregnancy.
• An expectant mom can:
  Call and verify that her dentist provides care during pregnancy;
  Let the dental office know how far along she is and inform office if she is considered a high risk pregnancy;
  Get a clearance form from her OB for dental treatment; some OB’s provide this at first visit; and
  Ask for a referral to a dentist who can provide this care.

Postnatal Oral Health Care for
New Mom

• After delivery of the new baby, a new mom should continue brushing with fluoride toothpaste twice daily and flossing daily.
• This is still a critical time for optimal oral health.
• Good oral hygiene in the mom helps prevent the growth of cavity-forming bacteria in her mouth and diminishes any such bacteria she might pass to her new baby.

Oral Health Care for Infant
Before Baby Teeth

• The time before baby teeth erupt is a critical time.
• Oral hygiene for the baby, before teeth erupt, will help prevent bacteria from colonizing early in the mouth.
• This will help reduce the risk of dental decay developing once the teeth erupt.
• Wiping a baby’s mouth out daily helps to get baby and parent used to cleansing the oral cavity.
• In addition to routine cleaning, cleaning should also be done after each feeding.
• Also, clean the pacifier.
• Oral hygiene for a baby with baby teeth 
• With the eruption of the 1st baby tooth:
  A mom should switch from wiping the baby’s mouth out with an infant washcloth to using a toothbrush for oral hygiene;
  Brush teeth, gums, cheeks and tongue;
  Routine brushing is twice a day – morning and last thing before bed; and
  Also, should try to brush after each feeding.

Oral Health Care for Infant
With Baby Teeth

Oral hygiene for a baby with baby teeth

• A parent should brush a child’s teeth while the child is gaining the manual dexterity to brush on his/her own teeth.
• Children frequently start trying to brush their own teeth at about the same time they start trying to cut their food with a knife and fork.
• Regardless of how soon a child appears to be brushing well, a parent should continue to brush the child’s teeth with fluoridated toothpaste until age 6-7 years.
• Systemic fluoride for a baby with baby teeth 
• Community water fluoridation
• Fluoride supplements
  A dentist can determine if supplementation is necessary.
  Supplementation may continue until the child is aged 16 years and the 3rd molars are finished forming within the bone and gums.
• Topical fluoride for a baby with baby teeth
• Toothpaste
  A smear/rice-size amount of fluoride toothpaste should be used twice a day with brushing. (AAPD)
  This amount of toothpaste will contain enough fluoride to work while not harming the baby when swallowed.
• Fluoride varnish
  The child’s dentist can talk to the mom about the possible use of fluoride varnish for the child, depending on child’s risk for dental caries.
• Dental Home for a baby with baby teeth 
• When and how often should the baby be taken to the dentist?
  Visit the dentist at the eruption of the 1st baby tooth or the 1st birthday, whichever occurs first.
  Appointments should be every six months, unless the dentist recommends a different schedule.

Transition to permanent teeth

• A very common misconception of many parents and caregivers is that:
  “Baby teeth fall out so we aren’t worried about keeping them healthy. Once there are permanent teeth we will focus on these adult teeth…”
• However, keeping baby teeth healthy is important for many reasons, including:
  Dental caries is a multifactorial infectious bacterial disease and children are more likely to have decay in permanent teeth if they had decay in their baby teeth.
  The permanent teeth erupt into the same environment as the baby teeth – nothing magically changes.
  A good diet and oral hygiene habits developed during early childhood will carry over into childhood and adolescence.
• Oral Hygiene
  Newly erupted teeth may be at higher risk of developing caries, especially when there is a high caries risk. (AAPD)
  When the first permanent tooth erupts (between ages 5-7 years, on average) parents should still be brushing for their child, especially at night, with fluoridated toothpaste.
• Visits to a dentist allows the dentist to:
  Evaluate the risk for dental caries;
  Evaluate the need for fluoride varnish;
  Evaluate the need for fluoride supplements;
  Apply dental sealants; and
  Perform a growth and development analysis of the teeth and face.

Nutrition: Breastfeeding

• Benefits:
  Reduces cavity formation up to age 12 months;
  Protects against malocclusion in primary dentition.
• Risks:
  Nocturnal breastfeeding puts an infant at elevated risk of dental caries;
  Prolonged breastfeeding, longer than 12 to 24 months, puts a child at an elevated risk of dental caries.

Nutrition for Infant
Before Baby Teeth

• Feeding with Breast Milk or Formula

The AAP recommends that for the first 6 six months, the baby should be fed only breast milk and formula.

The baby’s mouth should be wiped out with a infant washcloth after each feeding.

• Bottle feeding

The mother should avoid bottle propping or putting the baby in bed with a bottle.

Only breastmilk or formula should be used in the bottle, unless other liquids are prescribed by the physician​​​.

Wipe out baby’s mouth daily with an infant washcloth and after each bottle feeding.

Nutrition for Infants and
Young Children

• Bottle feeding
• American Academy of Pediatrics (AAP) guidelines for phasing out the bottle state that,

Bottles should be phased out between 12 and 24 months of age.

• Sippy cups
  Babies are encouraged to drink from a cup starting at 6 months of age, according to the AAP.
  Practice with only water – do not get baby used to sweetened beverages in a cup.
  Juice is not recommended for babies younger than 1 year of age, unless specifically instructed by pediatrician.
  A toddler only needs to drink when thirsty or with meals.
  If a toddler holds on to a cup most of the day like a security blanket, they may end up overdrinking (and need more frequent diaper changes).
  Sippy cups are for transition from bottle feeding to drinking out of regular cups.
  Frequently drinking milk, juices or sodas, which contain sugars, can lead to tooth decay because teeth are continually being bathed in sugary liquids that help bacteria grow.
  The child should not go to bed with a bottle or sippy cup
  Good rule: In between meals, a sippy cup should only contain water. The child should be offered the daily suggested servings of milk and juice at mealtime.
  The mom should keep track of sippy cup use
• Solid Foods
  American Academy of Pediatrics (AAP) guidelines for bottle feeding include to:
  Introduce solid foods around 6 months of age;
  Expose baby to a wide variety of healthy foods; and
  Offer a variety of food with different textures.
  6 months: Introduce solid foods.
  9 months: Introduce 2-3 healthy snacks per day.
  Healthy snacks, such as appropriate portions of fruits, vegetables, and cheeses are much preferred over high-sugar non-nutritive snacks.
  Even with good parenting, a child will often be exposed to unhealthy snacks by others and start to want these.
  However, parents should be reminded that frequent consumption of snacks consisting of sugar rich simple carbohydrates is a high caries risk behavior.
• Liquids
  Good rule –
  The child should be offered the daily suggested servings of milk/formula and juice at mealtimes only.
  Caution –
  Soda often has sugar and/or caffeine.
  Gatorade has sugar.
  Note: Only liquids without sugar and without caffeine are hydrating.

WIC guidelines follow these recommendations …

ORAL HABITS

• Drinking and eating are essential activities for the development of a child.
• However, eating and drinking unhealthy foods can become a habit, which can pose a risk to the child.
• Also, the inappropriate use of bottles, pacifiers and sippy cups can become a habit and also put the child at risk.
• Bottle feedingIf a infant/child continues to bottle feed too long, then the toddler may:
  Skip meals if he/she knows the bottle is available;
  Be exposed to nutritional deficiencies; and/or
  Experience childhood obesity, dental caries, as well as less than optimal craniofacial growth

Thus, it is very important to wean a baby off the bottle.

• High frequency consumption of sugars by bottle-feeding, sippy cup use, or between meal consumption of sugars increases the risk of early childhood caries.
  AAP recommends weaning from the bottle between 12-24 months old.
  Prolonged use of a bottle containing anything but water may lead to early childhood caries.
  Prolonged use of a bottle may lead to poor adaptation of solid foods into the diet.
• Pacifiers
  In general, the use of a pacifier should be discontinued by 36 months of age.
  Extended use of pacifiers may pose a risk to the normal development of teeth and the face and might contribute to:
  Anterior open bite;
  Protruded upper permanent front teeth; and
  Narrow upper dental arch and/or crossbite.
• Sippy Cups
• High frequency consumption of sugars by bottle-feeding, sippy cup use, or between meal consumption of sugars increases the risk of early childhood caries.
• Foods
  Avoid processed foods high in sugars and carbohydrates in between meals.
  Fruit snacks, fruit roll-ups, gummy snacks, sticky candies, crackers, chips, pretzels are all high in sugars/carbohydrates.
  Promote healthy snacks such as appropriate servings of fruits, vegetables and cheeses.
• Liquids
  Offer sugar-free/caffeine-free liquids (WATER) in between meals.

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