Group10: Pregnancy
E-facilitator: Sophie



Pregnancy, hormone change and oral health awareness

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Aims and Objectives

To research and discuss the role of Hormones during each stage of pregnancy. Also highlighting an oral condition that may occur during pregnancy and the treatment planning / dental hygiene care required for its treatment.

Learning outcomes:
Discuss the role of hormones during each stage of pregnancy.
Present a poster on an oral condition that may occur during pregnancy and the treatment plan needs that need to be addressed when providing dental hygiene care.



Introduction

Hormones play an integral part in pregnancy and prenatal development. Hormones initiate and regulate all the stages of pregnancy and are vital for the growth and development of the child. This wiki page attempts to address the various hormones involved in pregnancy, as well as their sources, functions and timing. It also addresses the proposed link between maternal periodontal disease and premature, low birthweight babies.


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Hormones involved with Pregnancy

  • Progesterone
  • Oestrogen
  • Human Chorionic Gonadotropins (HCG)
  • Relaxin
  • Human Placental Lactogen (HPL) or Human Chorionic Somatomammotropin (HCS)
  • Corticotropin Releasing Hormone (CRH)
  • Anterior Pituitary Hormones


Hormones
Secretion by
Main function (effect of hormone)
Progesterone
Chorion after 6 weeks
Corpus Luteum in first 3-4 months
Placenta after 3 months
Maintains lining of uterus for implantation
Prepares mammary glands for lactatio
Stimulates aldosterone secretion from adrenal cortex
Oestrogen
Chorion after 3-4 weeks
Corpus Luteum in first 3-4 months
Placenta after 3 months
Works with progesterone for endometrium maintenance and mammary gland preparation
Increases protein synthesis
Lowers blood cholesterol level
Inhibits action of prolactin on mammary glands
HCG
Chorion directly after implantation
sharp increase -> peaks at 9 weeks -> decreases until birth
Stops degeneration of corpus luteum
Acts as an indication of pregnancy in urine sample pregnancy tests
Allows gonadotropins to enter the foetal blood to premote sexual differentiation of the foetus
Relaxin
Corpus Luteum
Placenta after 3 months
Increases flexibility of pubic symphysis and ligaments of pelvis
Relaxation of Myometrium
Dilates cervix during labour
HPL
Chorion
Allows active transport of amino acids and glucose from maternal to the foetal blood
Makes free fatty acids available for the mother as an energy source
Prepares mammary glands for lactation
CRH
Placenta
Timing of birth
Stimulates adrenal cortex to secrete cortisol and aldosterone
Anterior Pituitary Hormones
Presence of progesterone and oestrogen
Increase prolactin secretion- stimulates milk secretion
Decrease growth hormone secretion
Decreases ACTH and TSH (gonadotropins) secretion

The stages of Pregnancy and Hormone change:

1. First Trimester
Embryo
  • Fertilisation of egg by sperm – becomes zygote
  • 1 week later becomes blastocyst and implants into endometrium
  • Embryo secretes HCG to control mothers reproductive system
  • Endometrium grows over blastocyst and cells differentiate
  • Embryo obtains nutrients from endometrium
  • Trophoblast becomes placenta – provides nutrients, gaseous exchange, disposal of embryos waste
  • Development of bodily organs
Mother
  • Progesterone initiate changes in reproductive system
- Increased mucus
- Growth of maternal part of placenta
- Uterus enlarges
- Cessation of menstrual cycle by means of negative feedback on hypothalamus and pituitary
  • Breasts enlarge and become tender

2. Second Trimester
Foetus
  • Grows to 30cm and very active
  • Hormone levels stabilise as HCG reduces
  • Corpus luteum deteriorates
  • Placenta is in complete control of secretion and production of progesterone
Mother
  • The uterus grows and the pregnancy is visible

3. Third Trimester
Foetus
  • Will grow to 3-4kg and 50cm
Mother
  • Abdominal organs become compressed and displaced
    • Frequent urination
    • Digestive blockages
    • Back strait
4. Labour
  • Labour usually occurs around the 38-40 week mark
  • Prostaglandins, estrogen and oxytocin induce and regulate labour
  • Oxytocin stimulates contractions of smooth muscles of uterus
    • Stimulates placenta to produce prostaglandins to enhance contractions
5. Birth
  • Brought on by strong rhythmic contractions
  • Three stages
    • Opening and thinning of cervix through to complete dilation
    • Delivery of the baby
    • Expulsion of the placenta

Figure 1a)

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The Chorion of the Placenta: Anatomy and Psyiology syllabus: Reproductive system

Figure 1b)
ovary.jpg
Structure of an Ovary: McGraw-Hill Human Sexuality Image Bank



The Relationship Between Maternal Periodontal Disease and Pre-term, Low Birthweight Babies:


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premature_birth.jpg
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Image References: Left: http://webs.wichita.edu/mschneegurt/biol103/lecture22/lecture22.html
Right: http://www.time.com/time/magazine/article/0,9171,1558331-2,00.html

Introduction

In recent years studies have discovered a relationship between pregnant women with periodontal disease and complications with foetal gestation. These complications include premature birth (birth before 37 weeks gestation), low birth weight and foetal growth restriction (i.e. small weight for gestational age) (Armitage 2001). These adverse pregnancy outcomes are an important issue, as they continue to be significant occurrences, despite progress made in prenatal care (Armitage 2001). Premature babies can have underdeveloped organs at the time of birth and have a higher infant mortality rate than those born in full term. Furthermore, the possible long term effects of preterm birth are numerous, and can include heart disease, anaemia and hypoglycaemia (Medline 2006).

Periodontal disease is an inflammatory and infectious disease that affects the gingival and periodontal tissues. It degrades the periodontal attachment and if left untreated, may result in the loss of teeth. The relationship between periodontal disease and adverse pregnancy outcomes is believed to be highly significant. “In fact, pregnant women with periodontal disease may be seven times more likely to have a baby that's born too early and too small” (American Academy of Periodontology 2005).

The Link

Hormones initiate all the stages of pregnancy and are vital for the growth and development of the child. One such group of hormones are the lipid compounds known as prostaglandins. Prostaglandins interact with receptors in a large variety of body tissues, and facilitate functions including smooth and skeletal muscle contraction. In the final stages of pregnancy, the prostaglandins known as PGE2 and PGF2 induce and regulate labour by stimulating contractions in the smooth muscle of the uterus. These hormones play such a significant role in inducing labour, that synthetic prostaglandins are used clinically to induce childbirth, parturition and abortion (Sahelian, R) and are components of the “morning after pill” (American Academy of Periodontology 2005).

Prostaglandin is also present in oral bacteria, especially in those related with periodontal disease. It is believed that these pathogenic bacteria are capable of translocating from the oral environment to the foetus, placenta and decidual tissues by way of the cardiovascular system. The presence of these bacteria and their toxins, including prostaglandin, is believed to precipitate contractions and subsequently lead to premature birth (Offenbacher et al. 2006). It has been shown that “very high levels of prostaglandin are found in women with severe cases of periodontal disease” (American Academy of Periodontology 2005). It is clear from these observations that periodontal disease has an adverse effect on healthy pregnancy and birth. It is therefore important that effective prevention and treatment strategies are implemented to combat this condition.

Treatment/Prevention

Prevention for the Pregnant Patient at Home

You can help prevent gingivitis by keeping your teeth clean, especially near your gum line and:
  • Brush your teeth at least twice a day and after meals when possible.
  • Floss daily.
  • Don’t smoke.
  • If you suffer from morning sickness, repeatedly rinse out mouth with water and brush your teeth as often as possible to neutralize the acid.
  • If tooth brushing causes morning sickness, rinse your mouth with water, brush without toothpaste and follow with anti-plaque fluoride mouthwash.
  • Eat a well balanced diet with plenty of vitamin C and B12.
  • See you dentist for help in controlling plaque and preventing gingivitis.
  • Schedule routine exams and cleaning to maintain good dental health.

An initial appointment for Periodontal Treatment and Diagnosis

It is recommended that pregnant patients attend their dental clinic for regular checkups and periodontal exams. The key to treating periodontal disease is early diagnosis, prompt treatment and oral health maintenance. If treatment is required is it best to occur during the 2nd trimester, as during the 1st trimester the major organs are being formed and would be at risk. During the 3rd trimester the mother is significantly larger and carrying a much heavier load. It is uncomfortable for the mother to lie back in a dental chair for a long period. If calculus or periodontal disease is diagnosed, a selection of treatment options are available. Plaque and calculus can be removed both supragingivally and subgingivally through periodontal scaling and root planing.

For more severe existing cases of periodontal disease surgical procedures may be used. These include pocket reduction procedures and soft tissue grafts. These procedures are effective in severe cases, however, when a patient is pregnant it is generally recommended that major treatment is postponed until the completion of the pregnancy. The dental professional may also discuss issues and strategies including home oral hygiene practices and the removal of aetiological factors such as stress and smoking.

A recent study showed a positive relationship between the treatment of a control group through scaling and root planing, when compared to a control. “The intervention statistically significantly reduced the odds of preterm delivery … thus, subjects with periodontal disease at baseline who were in the intervention group were at a significantly lower risk of preterm delivery” (Offenbacher et al. 2006). It is therefore, highly recommended that all women who are pregnant or considering pregnancy attend their dental clinic for regular checkups and periodontal treatment if required.

Summary/Conclusion

Through this poster, the authors have defined adverse pregnancy outcomes, as well as highlighting its prevalence and significance. Studies have determined a strong link between maternal periodontal disease and adverse pregnancy outcomes including premature birth. It is believed that pathogenic periodontal bacteria travel from the site of infection to the foetus and decidual tissues via the bloodstream. These bacteria release toxins into the area, including prostaglandins, that are known to initiate birthing contractions. It has been shown that these bacteria and their toxins can be removed from the oral environment through periodontal instrumentation (scaling and root planing). It is therefore imperative for healthy childbirth that maternal oral health is monitored and maintained, and that periodontal care be regarded as a key component of pregnancy health promotion.

For further information, visit the American Academy of Periodontology: http://www.perio.org/consumer/mothers.htm



Figure 1d)
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Oral Health Treatment During Pregnancy


Special considerations need to be addressed when a practitioner has a pregnant patient, because the practitioner is really treating two patients; the mother and the foetus.
Changes in the pregnant body and the mouth are only exacerbated by elevated hormone levels (estrogen and progesterone)

Treatment Plans that need to be addressed when providing dental hygiene care to a pregnant patient:
  • Prevention of Flurosis to foetus - small amounts regularly
  • Special care when a pregnant patient is in the surgery - can't lie back in the chair too far / might need regualar toilet breaks / appointments should be kept short as possible
  • What we might expect to see in a pregnant patients mouth - elevated hormone levels (estrogen and progesterone) are directly linked to the increase in the plaque levels, leading to swollen and inflamed gums "pregnancy gingivitis", which affects almost 100% of pregnant women during the second trimester. If this is left untreated the gingivitis can lead to periodontits which has been associated with premature births and low birth weights. Other conditons of concern are; pyogenic granuloma, irreversible pulpitis, caries (due to more regular food consumption) and dental infections.
  • Recommendations to make to a pregnant patient with regards to her unborn child's teeth and her own -
  • Treatment planning needs - best to complete any necessary treatment as early into the pregnancy as possible - up unitl the completion of the second trimester. (during the third trimester any elective treatment should be post poned if possible till after the pregnancy. Major treatment should be postponed from being undertaken during the first trimester as the major organs are being developed at this time and would be at risk.
Always check the medical history at every appointment
Dental radiography should be postponed where possible. If extreamly neccessary then a lead apron and thyroid collar should be used to protect the foetus.
Local Anaesthetic without vasconstrictor may be used during pregnancy if absolutely neccessary. But it is preferable to put off dental treatment until after the birth.
Penicillin based antibiotics are considered safe to be prescibed to pregant patients. Any tetracycline based antibiotics are absotultly not recommended.
Amalgam restorations can be placed and removed during the pregnancy safely but should only be completed with rubber dam in place and only in an emergency situation.

Gingivitis occurs in 60% to 75% of pregnant women



Summary / Conclusion

It has been shown in this wiki page that hormones initiate all the stages of pregnancy and are vital for the growth and development of the child.

The role of hormones during pregnancy also plays a significant role in the health of both the mother and the unborn child. Hormonal fluctuations in pregnancy can increase the mother's susceptibility to conditions such as gingivitis. Furthermore, the presence of maternal periodontitis may lead to premature, low birthweight deliveries.

Pregnancy, its related hormones and its oral health implications, should be a key focus of all dental practitioners working with pregnant patients. Pregnancy can cause significant changes to dental and general health and it is important that the practitioner can anticipate these changes, and work with the patient to help make this period as healthy and risk free as possible.



Reference list

Armitage, GC 2001, ‘Periodontal Disease and Pregnancy: Discussion, Conclusions and Recommendations’, Ann Periodontal, vol. 6, no. 1, pp. 189-192.

Campbell NA, Reece JB, 2005, Biology , 7th Edition, Pearson Education Inc, USA

Hassel , TM, Wolf, HF 2006, "Color Atlas of Dental Hygiene: Periodontology", Thieme, Stuttgart, New York.

Jennett S, 1989, Human Physiology , Churchill Livingstone, Glasgow

Marieb EN, 2004, Human Anatomy and Physiology , 6th Edition, Pearson Education Inc, USA
Medline plus 2006, Premature infant, The U.S National Library of Medicine and The National Institutes of Health, Viewed 27th September 2007,
< http://www.nlm.nih.gov/medlineplus/ency/article/001562.htm >.

Offenbacher, S, Lin, D, Strauss, R, McKaig, R, Irving, J, Barros, SP, Moss, K, Borrow, DA, Hefti A & Beck, JD 2006, ‘Effects of periodontal therapy during pregnancy on periodontal status, biologic parameters, and pregnancy outcomes: a pilot study’, Journal of Periodontology, vol. 77, no. 12, pp. 2011-2024.

Sahelian, R, Prostaglandin by Ray Sahelian, M.D. (nutrition information), viewed 27th September 2007,
< http://www.raysahelian.com/prostaglandin.html >.

The American Academy of Periodontology, 'AAP Offers Mothers-To-Be Advice with Just-in-Time Delivery for Mother's Day', The American Academy of Periodontology, viewed 2nd September 2007, < http://www.perio.org/consumer/mothers.htm >.

The American Academy of Periodontology 2005, 'Baby steps to a healthy pregnancy and on-time delivery', The American Academy of Periodontology, viewed 2nd September 2007, < http://www.perio.org/consumer/pregnancy.htm#4 >.




Websites to visit for more information on Dental Care during Pregnancy:


http://www.pregnancy-info.net/dental_care.html
http://www.expectantmothersguide.com/library/connecticut/ECThormones.htm
http://www.marthajefferson.org/modules/pregnancy/hormone.htm
http://www.healthinsite.gov.au/topics/Hormones_and_Pregnancy
http://www.britannica.com/eb/art-19648/Major-structures-and-hormones-involved-in-the-initiation-of-pregnancy
http://www.perio.org/consumer/mothers.htm>.
http://www.perio.org/consumer/pregnancy.htm#4
American Academy of Periodontology
Studies in the //Journal of Periodontology//
http://www.perio.org/consumer/procedures.htm
http://www.perio.org/consumer/procedures.htm
http://www.dentalgentlecare.com/pregnancy_and_gingivitis.htm


Contributors:
Julia Matthews
Chantelle Nowicki
Nicholas Watts

E-facilitator:
Sophie Karanicolas (thakyou for the direction and encouragement)