Expectant mothers play a key role in ensuring their healthy diet and oral hygiene practices are passed on to their children, says paediatric dentistry consultantAlison Cairns
Many women experience oral health problems when pregnant. Fortunately most of these conditions can be managed with good general oral health advice. Expectant mothers should maintain good oral health by brushing twice daily with a fluoridated toothpaste (1450ppmF), and to cut out snack foods which contain sugar. These habits should be transferred to their baby once born1.
Dental health in pregnancy
Women may often experience problems with their gums, and this is sometimes referred to as pregnancy gingivitis2. Here, the gingivae become red, painful, swollen and bleed on brushing, and although it mainly affects the anterior teeth it can also be widespread.
This occurs largely due to changes in hormone levels and the body's immune response3. Gingivitis can be reduced or eradicated with meticulous oral hygiene involving effective tooth brushing twice daily and once daily use of inter-dental tape or floss. Professional scaling and cleaning of the teeth also helps reduce gingivitis and pregnant women are given free dental care on the NHS. For some women, the act of tooth brushing itself can become difficult due to stimulation of the gag reflex - and this can lead to a decrease in their usual levels of oral hygiene. If gagging becomes a problem, ask the mother to brush on an empty stomach. Changes in the gums brought about by pregnancy subside once the baby has been delivered. Occasionally very florid reactions can occur, leading to gingival overgrowths such as pyogeneic granuloma2 (known as a pregnancy tumour). These overgrowths will regress after delivery. If particularly severe, to the point where it interferes with speech or eating, they may need to be removed during pregnancy. However these will, almost without fail, regrow. Is it safe to use mouthwash? Severe gingival conditions may be controlled in the short term with chemical bacteria control such as a chlorhexidine mouthwash. Regular and prolonged use of chlorhexidine mouthwash is not advocated as it will stain the teeth and can lead to taste disturbance. Foods that lead to staining of the dentition (tea or coffee for example) should be avoided immediately after using this type of mouthwash. The effect of chlorhexidine may be negated by toothpaste and should not be used around brushing times 4. If the mother likes to use any other mouthwash this should be alcohol free.
Morning sickness and teeth
Frequent vomiting can be a problem, and can cause dental erosion. Here the acidic vomit causes demineralisation of the enamel and wears away the teeth. After an episode of vomiting it is important not to brush the teeth as this will increase the wear1. Instead, advise patients to rinse with plain water, eat some cheese or ham to neutralise the acid, or chew sugar free gum for 20 minutes to stimulate the saliva. These activities will bring the pH of the mouth back to normal. It is safe to brush the teeth 20 minutes after the episode of vomiting without further concern. Early in the pregnancy some women may complain of excess saliva and nausea. This tends to disappear later on in the pregnancy. Other women may complain of a very dry mouth and should be encouraged to have regular sips of plain water. Regular sips of flavoured waters or juices, even if they are sugar free, could be detrimental to oral health and should be avoided.
Dental pregnancy myths
Contrary to belief, pregnancy does not remove calcium from the teeth. Pregnant women who eat a balanced diet, with sugar restricted to mealtimes, and who practise good oral hygiene, are at no greater risk of dental caries than usual1. Dental treatment carried out while pregnant is perfectly safe, although protracted or complicated procedures should be avoided until after the baby is born, as lying for long periods of time in a dental chair can lead to pressure on major vessels and problems with circulation. If more complex treatment is necessary, it is, however, safe to go ahead. Dental X-rays, although of no proven risk to the foetus, should be avoided in the first trimester if possible. It is also necessary to avoid certain sedative agents, analgesics and antibiotics, and if needed the dental surgeon is likely to liase with the midwife or obstetrician regarding the need for certain medications. Some women may ask regarding taking fluoride supplements in order to strengthen their developing babies' teeth. Fluoride does not cross the placenta in a dosage sufficient enough to be of benefit to developing teeth and should be avoided 5.
Oral health for newborns
The dental health profession are advocates of breastfeeding and the immunological benefits afforded by this. Breast or infant formula should be the main drink until 12 months of age. However bottle-feeding should be phased out after 12 months as it disturbs the transition to a normal adult swallowing pattern and may become relied upon as a soother. Parents should be advised to register their children with a dental practice by six months of age 5-9.
Introducing a drinking cup
From six months infants should be introduced to a drinking cup. From an oral health perspective, plain tap water (boiled and cooled for those less than six months of age) is the only fluid recommended in addition to breast or formula milk. "No added sugar" diluted drinks or natural fruit juice should only be advised if there is a particular medical need for it - such as constipation. If well-diluted juice is given, it must be restricted to mealtimes only and given in a free flow feeder cup or beaker. Most "baby juices" are high in sugar and should be avoided 5-9.
Soya-based formulas contain sugars, which can cause dental caries. Parents should be advised of this and only use these formulations on medical advice (these are only suitable for infants aged 6+ months)5-9.
First teeth usually arrive at around four to eight months of age, although some completely healthy children still have no teeth by one year (and this is still considered normal). The first teeth to erupt are usually the lower central incisors, followed closely by the other incisor teeth. Next are the first primary molars at around 14 to 16 months; canine teeth from around 17 to 19 months; and finally the second primary molars at two to two and a half years. Tooth brushing twice daily, is recommended as soon as enamel is evident - at least once before bedtime using a soft, small-headed brush and fluoridated tooth paste. After bedtime the child should have no further food or drink, with the exception of plain water. A toothpaste with a strength of no less than 1000ppm fluoride is recommended for twice daily parental brushing 5-9.
Recommended toothpaste amounts
Only a smear of toothpaste should be used for very young children in order to prevent the development of dental fluorosis, affecting the developing anterior permanent teeth. In cases where the primary teeth are still unerupted by nine to 10 months parents can be advised to start gently brushing the gumpads, so that their child gets used to the tooth brushing sensation and routine for when the teeth finally do erupt.
First signs of teething The signs of teething are excessive saliva production, red cheeks and uncomfortable red gingivae. Carers can reduce problems by gently massaging the gums with a clean finger or toothbrush, or a cold teething ring. For babies who become very distressed or pyrexic, an ibuprofen elixir is often the most appropriate medicine as it has anti-inflammatory properties, as well as being an analgesic. Excessive salivation can cause irritation to the lips and skin, so carers should keep the child dry and use a barrier cream to protect the skin 5-9.
If a baby has a particular need to suck, the use of a soother is preferable to the child developing a digit sucking habit. If a soother is used it should be restricted for use in aiding the child to fall asleep. "Orthodontic" soothers, or those made to closely replicate the shape of a breast, are recommended over cherry types. After the age of 18 months to two years, the soother should be discontinued as prolonged use can lead to a variety of different dental malocclusions that may affect speech development, function of the teeth and aesthetics. Parents wishing to stop digit sucking should be advised to completely bind the thumb or finger with an adhesive plaster bandage both day and night until the habit is broken 5-9.
Early childhood caries
Early childhood caries (also known as nursing caries) is most commonly caused by prolonged overnight feeding
10. It usually occurs when a bottle or feeder cup filled with a sweetened liquid is left with the baby or toddler in bed overnight. Under these circumstances even milk can cause caries; the salivary rate is decreased overnight therefore acids produced by bacteria are not buffered or washed away; the frequency of intake can be high as the child takes occasional drinks from the bottle or cup; the child may fall asleep with un-swallowed liquid in their mouth, bathing the teeth. The use of a feeder cup or bottle overnight should also be discouraged due to the risk of choking. Early childhood caries can also be caused when a soother or dummy is dipped in sugared drinks, jam or honey as a comforter. If a mother has already allowed this habit to develop, advise gradual dilution of the milk or juice over a two week period until the child is taking only plain water. Hopefully the child will then become disinterested in this habit and enjoy a better night's sleep.
This is also a reason for the recommended discontinuation of on-demand overnight breastfeeding after one year (in fact, in dentistry terms it is preferable for on demand feeding to cease after the first four-six months). Low/No sugar weaning foods Good weaning foods (from six months) should be sugar-free, or very low in sugar. These include unsweetened rice, non-wheat cereals, pureed vegetables and non-citrus fruits. No sugar, fruit syrup or honey should be added to the food. Sugar-free finger foods include lightly buttered toast, breadsticks and vegetables. Early introduction of sugar to a baby's diet will increase their appetite for sweetened foods, which can cause dental caries 5-9.
Pre-school oral health
Tooth brushing for the preschool child should be initially supervised and then carried out by a responsible adult, as a child does not have adequate manual dexterity to brush their own teeth effectively until around seven years of age. A toothpaste strength of 1000ppmF may still be suitable for some children, but others who are at high risk of developing caries should use a toothpaste between 1350-1500ppmF. Children from the age of three years should have a small pea-sized amount of paste on their brush. Tooth brushing should be done using a dry brush and the child should be encouraged to spit out excess paste.
They should not rinse out with water after brushing their teeth as this will remove fluoride 5-9. Children at high risk of dental caries can receive a professional application of high strength fluoride varnish as often as four times per year 5-9. This treatment can be provided by the child's dental surgeon or on their prescription via public health initiatives such as Scotland's Childsmile scheme 9.
Recommended low sugar snacks
Snacks for this age group should again be sugar-free. Alternatives include fresh fruit (dried fruit, has a high sugar content), bread sticks, rice cakes, Scotch pancakes, biscuits for cheese, blocks of cheese or raw vegetables and savoury sandwiches, etc 5-9. Potato crisps can be recommended in moderation, although they are high in salt and fat so have negative health issues. Plain milk and plain water are the only safe between meal drinks. It is important to emphasise "plain" as many children are offered flavoured water and strawberry milk as their alternatives. Juices, even if they contain no added sugar, are bad for a child's teeth. They should be taken only as an occasional treat, restricted to mealtimes, and should be taken through a straw positioned on the child's tongue, not held in front of the anterior teeth. For children on regular medication, sugar-free formulations should be recommended 5-9. There is research to show that children who take sweetened medication have more caries after six months 10. Even for occasional medicines such as paracetamol and ibuprofen elixirs, it is good practice to recommend sugar-free options. Children suffering from constipation may be taking lactulose, which is also a sugar. There is currently no research to say that this medicine needs to be taken before bedtime, but many GP's still advise this regime. To make this medication safer it should be taken only at mealtimes, and certainly not 20 minutes before going to bed.
Dental neglect is a serious and widespread problem and is a factor when it comes to considering an overall picture of child neglect 11. If parent/carers are aware of the causes and means of prevention, yet their child suffers episodes of pain and the frequent need for treatment involving the use of general anaesthetic, then this should be reported as a child protection issue. Over recent years dental teams have become much more aware of their roles and responsibilities with regard to this and are happy to work within the multiagency dynamics of the child protection system 12. This is a last resort, though, as it is hoped community health professionals can help get the message across to parents about how vital it is for them to look after their child's teeth.
1. Dental advice during pregnancy: NHS Scotland, 2009 www.maternal-and-early-years.org.uk [Accessed August 2011]
2. Amar S, Chung KM. Influence of hormonal variation on the periodontium in women. Periodontol 2000 1994; 6: 79-87
3. Lopatin DE, Kornman KS, Loesche WJ. Modulation of immunoreactivity to periodontal disease-associated microorganisms during pregnancy. Infect Immun 1980; 28(3): 713-718
4. Sheen S, Owens J, Addy M. The effect of toothpaste on the propensity of chlorhexidine and cetyl pyridinium chloride to produce staining in vitro: a possible predictor of inactivation. J Clin Periodontol 2001; 28(1): 26-51
5. Scottish Intercollegiate Guidelines Network (SIGN), number 83. Prevention and management of dental decay in the pre-school child; 2005. http://www.sign.ac.uk/pdf/sign83.pdf [Accessed August 2011]
6. Scottish Dental Clinical Effectiveness Programme. Prevention and management of dental caries in children; 2010. http://www.sdcep.org.uk/index.aspx?o=2332 [Accessed August 2011]
7. Delivering better oral health: An evidence-based toolkit for prevention (2nd edn). Department of Health and the British Association for the Study of Community Dentistry; 2009. http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/ digitalasset/dh_102982.pdf
8. British Society of Paediatric Dentistry: a policy document on oral health care in preschool children. Int J Paediatr Dent 2003; 13: 279-285. http://www.bspd.co.uk/LinkClick.aspx?fileticket=0TcSJAWRVb8%3D&tabid=62 [Accessed August 2011]
9. Childsmile NHS Scotland. A national programme to improve oral health of children in Scotland and reduce inequalities in dental health and access. www.child-smile.org.uk [Accessed August 2011]
10. Shelton PG, Berkowitz RJ, Forrester DJ. Nursing bottle caries. Pediatrics 1977; 59: 777-778
11. Roberts IF, Roberts GJ. Relation between medicines sweetened with sucrose and dental disease. BMJ 1979; 2(6181):14-16
12. Child Protection and the Dental Team http://www.cpdt.org.uk (Accessed August 2011)
Alison M Cairns BDS, MSc, MFDS RCSEd, M Paed Dent, FDS (Paed Dent) RCPSG, Dip Ac Prac, FHEA Senior Clinical University Teacher/ Honorary Consultant in Paediatric Dentistry