Importance of Oral Health During Pregnancy

“Why do my gums bleed so much and so easily?” Oral health is a key component of overall optimal health and wellbeing across a person’s lifespan. During the course of pregnancy, it is very important to obtain treatment for your oral health and it IS safe throughout pregnancy. It is very surprising to find out that 22% of U.S. women reported they never accessed oral health care prior to becoming pregnant, and less than one third of pregnant moms visited their dentist in the postpartum period (between 2 to 9 months postpartum) following the birth of their babies. These statistics were obtained in a 2004 study. Surprising? Yes. Can it be prevented? Absolutely!

Why is oral health so important, especially during pregnancy? The many physiological changes that a woman’s body undergoes during pregnancy can have an undesirable affect on her overall oral health and good oral hygiene. The many hormonal changes that occur in pregnancy can increase the risk of the pregnant mom to be more susceptible to oral infections, such as periodontal disease, and can reduce the body’s ability to repair soft tissues in the mouth. In addition, “pregnancy gingivitis” or mild inflammation of the gums occurs in approximately 60% to 75% of pregnant women. If this condition is left untreated, it can lead to periodonitis, which can lead to bone and tooth loss. Periodontal disease has been associated with cardiovascular disease, stroke, poor diabetes control and adverse birth outcomes. The pain that results from oral disease can also harm nutritional intake and affect a pregnant woman’s self esteem.

While oral health is important to a women’s overall health, her oral health is also important in its relationship to the health of her unborn child. Studies have shown an association between periodontal disease and adverse birth outcomes such as low birth weight, preterm birth and gestational diabetes. More importantly, transmission of bacteria from the mother to her baby is the primary way that children first acquire the disease that causes cavities. Evidence suggests that most infants and most children acquire caries-causing bacteria from their mothers. Cavity-causing bacteria is passed through saliva via activities like sharing utensils, wiping off the baby’s pacifier in the mother’s mouth, and testing food before feeding to your baby. The healthier mom’s mouth, and the longer the initial transmission of bacteria is delayed, the more likely children are to establish and maintain good oral health.

Tips to help promote oral health:
• To help prevent or control tooth decay, brush your teeth with fluoridated tooth paste twice/day, and FLOSS DAILY
• Eat fruit, veggies, whole grain products and dairy products. Limit foods containing sugar to meal times only (watch those carbs!!)
• Drink plenty of water or low-fat/skim milk. AVOID carbonated beverages
• Choose fruit rather than fruit juice to meet the recommended daily intake of fruit (and will have less sugar)
• Obtain necessary oral treatment ideally before pregnancy. Those who have bleeding gums or cavities, should visit a dentist as soon as possible
• Diagnosis (including necessary dental x-rays) and treatment can be provided throughout pregnancy; however, the period between weeks 14 and 20 weeks of pregnancy is the best time to receive treatment.• Delaying necessary treatment could result in significant risk to the mother and indirectly to her baby

If you are dealing with morning sickness or frequent nausea, especially in the first trimester, here are some tips:
• Eat small amounts of nutritious foods throughout the day: the 6 small meals a day rule is important throughout pregnancy, but especially for dealing with nausea
• Chew sugarless or xylitol gum (causes bacteria to lose the ability to adhere to the tooth, stunting the cavity causing process) after meals.
• Rinse your mouth with water and a teaspoon of baking soda (sodium bicarbonate) after vomiting to neutralize acid
• Gently brush teeth with fluoridated toothpaste twice a day to prevent damage to demineralized tooth surfaces
• If you can’t brush your teeth because you feel sick, rinse your mouth with water or a mouth rinse that has fluoride

POSTPARTUM
For mom:
• Maintain good oral health
• Limit foods containing sugar to meal times only (watch sugar intake overall)
• Avoid saliva-sharing behavior, including:
Sharing spoons or other utensils
Cleaning a dropped pacifier or toy by putting it in your mouth

For Baby:
• After the first tooth erupts, wipe your baby’s teeth after feeding with a soft cloth or soft-bristled toothbrush
• Avoid putting your baby to bed with a bottle or sippy cup containing anything other than water
• Ask your baby’s healthcare provider about your baby’s oral health status
• Schedule your baby’s first dental visit for between ages 6 and 12 months

Promoting oral health during pregnancy is the solution to achieving overall health and well-being for pregnant women, their babies and families. Visit your dentist regularly and maintain good oral hygiene.

Article by Jessie Buerlein, MSW, Project Mgr, presented by Angel J. Miller, MSN, CNM
Quickening, Summer 2009. Volume 40, Number 3
Official Newsletter of the American College of Nurse Midwives

Submitted by the Improving Perinatal and Infant Oral Health Project, a joint effort of the American Academy of Pediatric Dentistry and the Children’s Dental Health Project. For more info please visit http://www.cdhp.org

What Pregnant Women Should Know About H1N1 (formerly called swine flu) Virus

What if I get this new virus and I am pregnant?

It is not known if this virus will cause pregnant women to have a greater chance of getting sick or have serious problems. It is also not known how this virus will affect the baby.

We do know that pregnant women are more likely to get sicker than others and have more serious problems with seasonal flu. These problems may include early (preterm) labor or severe pneumonia. It is not known if this virus will do the same, but it should be taken very seriously.

What can I do to protect myself, my baby and my family?

Take these everyday steps to help prevent the spread of germs and protect your health:
• Cover your nose and mouth with a tissue when you cough or sneeze, or sneeze into your sleeve. Throw the tissue in the trash after you use it.
• Wash your hands often with soap and warm water, especially after you cough or sneeze. Alcohol-based gel hand cleaners are also good to use.
• Avoid touching your eyes, nose or mouth. Germs spread this way.
• Try to avoid close contact with sick people. (If you are pregnant and you live or have close contact with someone who has H1N1 flu, talk to your healthcare provider about medicines to prevent flu.)
• Have a plan to care for sick family members.
• Stock up on household, health, and emergency supplies, such as water, Tylenol® (acetaminophen), non-perishable foods.

*Washing your hands often will help protect you from germs*

Washing with soap and water
• Use warm water.
• Wash for 15 to 20 seconds.

Using alcohol-based gel hand cleaner
• Don’t add water.
• Rub the gel on your hands until dry

What are the symptoms of H1N1?

Symptoms are like seasonal flu and include the following:
• Fever
• Cough
• Sore throat
• Body aches
• Headaches
• Chills and fatigue
• Sometimes, diarrhea and vomiting

What should I do if I get sick?

• If there is H1N1 flu in your community pay extra attention to your body and how you are feeling.
• If you get sick with flu-like symptoms, stay home, limit contact with others, and call your healthcare provider. Your healthcare provider will decide if testing or treatment is needed. Tests may include a nasal swab which is best to do within the first 4-5 days of getting sick. Like regular flu, H1N1 flu may make other medical problems worse.
• If you are alone at any time, have someone check in with you often if you are feeling ill. This is always a good idea.
• If you have close contact with someone who has H1N1 flu or is being treated for exposure to H1N1 flu, contact your healthcare provider to discuss whether you need treatment to reduce your chances of getting the flu.

How is H1N1flu treated?

• Treat any fever right away. Tylenol® (acetaminophen) is the best treatment of fever in pregnancy.
• Drink plenty of fluids to replace the fluids you may lose when you are sick.
• Your healthcare provider will decide if you need antiviral drugs such as Tamiflu® (oseltamivir) or Relenza® (zanamivir). Antiviral drugs are prescription pills, liquids or inhalers that fight against the flu by keeping the germs from growing in your body. These medicines can make you feel better faster and make your symptoms milder.
• These medicines work best when started soon after symptoms begin (within two [2] days), but they may also be given to very sick or high risk people (like pregnant women) even after 48 hours. Antiviral treatment is taken for 5 days.
• Tamiflu® and Relenza® are also used to prevent H1N1 flu and are taken for 10 days
• There is little information about the effect of antiviral drugs in pregnant women or their babies, but no serious side effects have been reported. If you do think you have had a side effect to antiviral drugs, call your healthcare provider immediately

When should I get emergency medical care?

If you have any of these signs, seek emergency medical care right away:
• Difficulty breathing or shortness of breath
• Pain or pressure in the chest or abdomen
• Sudden dizziness
• Confusion
• Severe or persistent vomiting
• Decreased or no movement of your baby
• A high fever that is not responding to Tylenol®

How should I feed my baby?

Flu can be very serious in young babies. Babies who are breastfed do not get as sick and are sick less often from the flu, than do babies who are not breastfed.
Breastfeeding protects babies. Breast milk passes on antibodies from the mother to a baby. Antibodies help fight off infection.

Is it ok to breastfeed my baby if I am sick?

• A mother’s milk is made to fight diseases in her baby. This is really important in young babies when their immune system is still growing.
• Do not stop breastfeeding if you are ill. Breastfeed early and often. Limit formula feeds if you can. This will help protect your baby from infection.
• Be careful not to cough or sneeze in the baby’s face, wash yohands often with soap and water.
• Your doctor might ask you to wear a mask to keep from spreading this new virus to your baby.
• If you are too sick to breastfeed, pump and have someone give the expressed milk to your baby.

Is it OK to take medicine to treat or prevent H1N1 flu while breastfeeding?

• Yes. Mothers who are breastfeeding can continue to nurse their babies while being treated for the flu.

May 2009 Information provided by the CDC, Centers for Disease Control and Prevention

Pregnancy Increases Risk of Severe H1N1 Disease

Pregnant women are at greater risk for severe disease and complications from H1N1 pandemic flu than the general public, researchers said. Pregnant women should be treated promptly with antiviral drugs if the pandemic flu strain is suspected, according to Denise Jamieson, MD, of the CDC, and colleagues. The recommendation is based on an analysis of cases and deaths of pregnant women from the pandemic strain in the early weeks of the U.S. outbreak, Dr. Jamieson and colleagues reported online in The Lancet.

The findings underscore the CDC recommendation that pregnant women with the flu should receive prompt antiviral treatment and may also have implications for the use of a vaccine against the pandemic. “If a pregnant woman feels like she may have influenza, she needs to call her healthcare provider right away,” Dr. Jamieson said in a statement.

In addition, she said, doctors treating/caring for pregnant women need a triage system to screen for influenza-like symptoms “and they should not delay in initiating appropriate antiviral therapy.” Dr. Jamieson said some doctors hesitate to use antiviral drugs in pregnant women “because of concerns for the developing fetus, but this is not the correct approach in this instance. It is critical that pregnant women, in particular, be treated promptly.”

During the first month of the outbreak of the H1Nl virus, from April 15 to May 18, 34 (thirty four) confirmed or probable cases of pandemic H1N1 in pregnant women were reported to the CDC from 13 states, the researchers found. Confirmed cases were those with laboratory evidence of H1N1; probable cases were those in which the victim had an acute febrile respiratory illness and was positive for influenza A, but negative for H1 and H3, Dr. Jamieson and colleagues said. Of the 34 cases, 11 (eleven) — or 32% — required inpatient care, for an estimated hospital admission rate of 0.32 per 100,000 pregnant women, compared with 0.076 per 100,000 in the general population at risk, they said. By June 16, 6 (six) H1N1-related deaths in pregnant women had been reported to the CDC, all in women who had developed pneumonia and subsequent acute respiratory distress syndrome requiring mechanical ventilation (a tube inserted to help the patient breathe.) That was 13% of the 45 deaths reported during that period, the researchers said. Of the six who died, one was in the first trimester, one in the second trimester, and four were in the third trimester ; all were “fairly healthy” pregnant women before their illness, the researchers said. All the women were treated with oseltamivir (Tamiflu) and the time from symptom onset to treatment ranged from six to 15 days, they said.

The five patients with viable pregnancies had cesarean sections and none of the infants were born with flu. Four have been discharged home in good health, while the fifth — born at 27 weeks gestation — remains in the hospital and is doing well, Dr. Jamieson and colleagues said.

Meanwhile, the issue seems likely to kindle debate over who should get the H1N1 vaccine when it becomes available. “There are two broad goals in using a vaccine,” said Marc Lipsitch, DPhil, of Harvard University, “to protect people who are likely to get severely ill if they are infected, and to slow down transmission by vaccinating the people who are most likely to get infected and pass the virus on.” But the second goal is going to be difficult to reach since current estimates show the vaccine arriving on the scene well after the second wave of the pandemic starts this fall, he said. “Therefore,” Dr. Lipsitch said, “it is very wise to plan to use vaccines mainly to protect those most vulnerable.” But he cautioned that it will be vital to monitor vaccine safety, since pregnant women, and some other potentially high-risk groups, are also at higher risk for other adverse events. “This means that even with a perfectly safe vaccine, there will be (by chance) people who receive the vaccine and then very shortly after experience adverse health events,” he said. To avoid a possible backlash, Dr. Lipsitch said, “it is critical for the public and the health community to understand in advance that adverse events in vaccinated people are expected to happen, and their occurrence is not in itself an indication that the vaccine is unsafe.”

Carlos del Rio, MD, of Emory University in Atlanta, concurred that safety is an important issue. “The vaccine (as far as I can tell) has not yet been tested for safety in pregnancy,” he said. Dr. del Rio said it’s not surprising that pregnancy appears to be a risk factor for severe H1N1 disease. “Pregnancy is also a risk factor for other infectious diseases to be more severe,” he said. “Thus, it makes sense that (pregnant women) should be immunized.”

On the other hand, he said, obesity also appears to be a risk factor for more severe disease, so this group might also be considered as a priority group. The principle that should guide vaccine use is that “limited vaccine needs to go where it will do most good and prevent the most serious cases or deaths,” according to Howard Markel, MD, PhD, of the University of Michigan in Ann Arbor. Pregnant women, the obese, and those with asthma and diabetes appear to be such groups, he said, “but we also need to think of first responders,” including doctors, nurses, police, and fire personnel. “Even the people who keep our power lines, coal, water, electricity, and energy lines going — we don’t want any of these people out in time of a national crisis,” Dr. Markel said.

The CDC’s former director, Julie Gerberding, MD, said vaccinating pregnant women would have a double benefit. It “protects mom and also likely protects newborns until they are old enough to be vaccinated or take antivirals, she said.

The authors noted several limitations of the study including the fact that “ascertainment of women infected with pandemic H1N1 influenza virus was dependent on surveillance and laboratory testing methods used by state public health authorities during the outbreak. These methods varied by state and by the timing during the outbreak.” Other limitations include the fact that that pregnant women might be less likely to be tested than were those who were not pregnant and that “healthcare providers might be more likely to admit a pregnant woman than a nonpregnant person with similar findings, which could lead to an exaggerated admission rate in pregnant women.”

The study was supported by the CDC. Dr. Jamieson and several other authors are employees of the agency. No other potential conflicts were reported.

By Michael Smith, North American Correspondent, MedPage Today
Published: July 29, 2009
Reviewed by Zalman S. Agus, MD; Emeritus Professor
University of Pennsylvania School of Medicine and
Dorothy Caputo, MA, RN, BC-ADM, CDE, Nurse Planner

Primary source: The Lancet
Source reference:
Jamieson DJ, et al “H1N1 2009 influenza virus infection during pregnancy in the USA” Lancet 2009; DOI: 10.1016/S0140-6736(09)61304-0.