Pregnancy and

Oral Health
A Review and
Recommendations
to Reduce Gaps in
Practice and Research

Abstract
This article presents a review of the research relevant
to oral health during pregnancy and includes nursing
practice recommendations for referral of women to a
dentist for safe and effective dental care during pregnan-
cy. In recent years, research linking periodontitis to the risk
for adverse birth outcomes has resulted in increased interest
in the topic of oral health during pregnancy. The achievement
of optimal oral health in pregnant women as its own benefit, how-
ever, has in the past been hampered by myths surrounding the safety
of dental care during pregnancy. Many women also lack access to dental
care and dental insurance, which interferes with their ability to receive ade-
quate oral care during pregnancy. Intraoral changes that occur with preg-
nancy because of hormonal changes, combined with lack of routine exams
and delays in treatment for oral disease, place pregnant women at higher
risk for dental infections.
Key Words: Pregnancy; Oral health; Teeth; Infection.

32 VOLUME 33 | NUMBER 1 January/February 2008


Stefanie L. Russell, DDS, MPH, PhD,
and Linda J. Mayberry, PhD, RN, FAAN
T
he purposes of this article are to (1) review
aspects of oral health that are related to preg-
nancy, (2) call attention to gaps in research
and practice concerning oral care of pregnant
women, (3) present suggestions for needed
research related to oral health during pregnancy and post-
partum, and (4) present current practice considerations for
nurses regarding the oral care of women during pregnancy.
The oral health of pregnant women has received much
attention in the last decade, particularly in relation to the
potential for increased risk for adverse birth outcomes, in-
cluding preterm birth, low birthweight, and pre-eclampsia
in women with periodontitis (Xiong, Buekens, Fraser, Beck,
& Offenbacher, 2006a). Unfortunately, however, certain
subgroups of women (including racial and ethnic minorities
and low income women) who are uninsured or lack access
to dental care are likely to miss out on dental care during
pregnancy. Paradoxically, although some groups without
insurance coverage may lack dental care, some women may
actually have expanded coverage for dental procedures dur-
ing pregnancy. In Utah, for example, the 2006 Utah Legis-
lature cut dental benefits for adults but decided to pay for
basic dental needs, such as a check-up, a cleaning, and fill-
ings for pregnant women on Medicaid (Utah Department
of Health, 2007). Importantly, although investigations have
found that insured women seek dental care during pregnan-
cy at similar rates to women who are not pregnant (Timo-
the, Eke, Presson, & Malvitz, 2005), low-income women
who are covered by Medicaid may have difficulty finding a
dentist who accepts Medicaid as payment for treatment.
Other underinsured, working pregnant women who do not
January/February 2008
qualify for Medicaid might have no dental benefits
provided by their employer.
Because we know that pregnant women may be
more likely to refrain from or reduce health-damag-
ing behaviors (such as smoking) (Herzig et al.,
2006) in order to reduce harm to the developing fe-
tus, helping women to enhance their oral health (and
potentially the health of their children) by improving
their dental care is an important concept. Oral health
efforts aimed at pregnant women are likely to prevent
complications from dental disease during pregnancy and
have the potential to improve the systemic and dental
health of both mother and child.
Oral Health in the United States
It is important to note that despite public health efforts
aimed at prevention (e.g., school dental health programs,
public water fluoridation, and the widespread availability of
dental treatment in the United States), untreated dental dis-
ease is still common. The two major diseases of the oral cavi-
ty, dental caries and periodontal disease, remain highly preva-
lent: 91% of adults have experienced dental caries (Beltran-
Aguilar et al., 2005) and just about 1 in 5 U.S. adults has
some irreversible periodontal destruction (Borrell, 2005). It
has been well established that like many diseases, caries and
periodontal diseases disproportionately affect members of
racial-ethnic minority groups and those of lower socioeco-
nomic means (Beltran-Aguilar et al., 2005). Mexican Ameri-
cans and non-Hispanic blacks have rates of untreated tooth
decay that are twice as high as whites (35.9% and 41.3%
versus 18.4%), and persons with family incomes more than
200% above the federal poverty level have one-half as much
untreated tooth decay than individuals with lower family in-
comes (Beltran-Aguilar et al., 2005).
Effects of Pregnancy on Oral Health
The oral changes that occur because of the complex physio-
logic alterations that accompany pregnancy are believed to
be related to fluctuations of the sex hormones (estrogen and
progesterone), which can lead to an increase in oral vascula-
ture permeability and a decrease in host immunocompe-
tence, thereby increasing susceptibility to oral infections
(Barak et al., 2003). In general, effects of pregnancy on the
oral cavity seem to be largely limited to the soft tissues. The
popular belief that pregnancy weakens women’s teeth as a
result of calcium depletion is a wholly unsupported hypoth-
esis (Scheutz, Baelum, Matee, & Mwangosi, 2002). Tooth
calcium is stable and not available to the systemic circula-
tion to supply a calcium demand for the fetus.
Intraoral Pyogenic Granulomas
Intraoral pyogenic granulomas may occur during pregnancy
as an inflammatory reaction to dental plaque that is exacer-
MCN 33
bated by hormonal fluctuations of pregnancy. These pain-
less, benign “pregnancy tumors” occur in approximately
0.2% to 9.6% of pregnant women, most often in the gingi-
va (Torgerson, Marnach, Bruce, & Rogers, 2006), and they
appear most commonly near the end of the first trimester of
pregnancy. These hyperplastic lesions are composed of capil-
laries and connective tissue fibroblasts and seem to arise in
response to intraoral trauma. Pregnancy tumors usually dis-
appear after the birth of the child; however, they have been
known to recur with subsequent pregnancies.
Pregnancy Gingivitis
Pregnancy gingivitis, an inflammatory response to the intra-
oral plaque, has been shown to occur in anywhere from
30% to 100% of pregnant women as a result of increased
progesterone levels that result in changes in the oral mi-
croflora to a more pathogenic composition (Barak et al.,
2003). In general, the increased gingivitis seen in pregnant
women is a transient condition, because in most individu-
als, the inflammation of the gingiva associated with preg-
nancy subsides after childbirth (Barak et al., 2003).
Dental Caries
Although there is little evidence that dental caries increases
more rapidly during pregnancy than at other times in a
woman’s life, some have suggested that changes in the oral
environment during pregnancy may predispose to an in-
creased incidence of caries in women during pregnancy (Lit-
tle, Falace, Miller, & Rhodus, 1997). To date, however, no
studies have explored whether the purported combination of
oral changes thought to occur during pregnancy (including
dietary changes, such as increased consumption of carbohy-
drates, increased acid in the mouth from vomiting, and de-
creased salivary production and/or increased acidity of the
saliva) combine to increase the risk of dental caries in preg-
nant women. Evidence to the contrary shows that women’s
nutrition improves during pregnancy (Cuco et al., 2006).
Ptyalism and Perimylolysis
Ptyalism, which is excess saliva production during early
pregnancy in women who experience nausea, seems to sub-
side when the nausea improves—at approximately 12 to 14
weeks’ gestation. Nausea and vomiting are very common in
pregnancy and seem to affect anywhere between 50% and
85% of pregnancies (Davis, 2004). Vomiting of the gastric
contents may lead to decreased pH in the oral cavity. Per-
imylolysis (acid erosion of tooth enamel), which has been
found to occur in patients who have bulimia nervosa (Little
et al., 1997), theoretically may occur during pregnancy if
the gastric contents or the frequency and duration of vomit-
ing are excessive (Bartlett, 2006). A case was reported in
the literature of a patient with a gastrinoma that caused in-
tractable vomiting, which resulted in severe dental enamel
34 VOLUME 33 | NUMBER 1
erosion over the course of two pregnancies (Harper,
McVeigh, Thompson, Ardill, & Buchanan, 1995).
Gestational Diabetes
A well-known complication of pregnancy that is likely to
affect the long-term periodontal health of the mother is ges-
tational diabetes, which is currently estimated to occur in
up to 4% of pregnant women (Dabelea et al., 2005). To
date, only one study has examined the relationship between
gestational diabetes and dental health. This population-
based investigation found that women with gestational dia-
betes were more than 9 times more likely to have periodon-
tal disease (ORadj = 9.11, 95% CI 1.11-74.9), adjusting for
multiple potential confounders (Xiong, Buekens, Vastardis,
& Pridjian, 2006). Because the relationship between dia-
betes and periodontal disease is well established (Mealy &
Oates, 2006) and because there is there only one published
study on the oral health of pregnant women with gestation-
al diabetes (Xiong, Buekens, Vastardis, & Pridjian, 2006),
this is an area that could benefit from further study.
“One Tooth, One Child”
One recent survey performed in the United States in a low-in-
come population of women found that 1 out of 5 women
surveyed believed in the old wives’ tale “one tooth for a ba-
by,” meaning that every time a woman gives birth, she loses a
tooth (Al Habashneh et al., 2005). Few studies have systemat-
ically explored the association between parity (i.e., number of
children) and tooth loss. Several studies have found that
women with higher levels of parity had fewer teeth, compared
to women with lower parity (Christensen, Gaist, Jeune, &
Vaupel, 1998; Russell, Ickovics, & Yaffee, 2005), periodontal
disease (Hildebolt et al., 2000; Russell et al., 2005), and den-
tal caries (Russell et al., 2005; Walker, Dison, & Walker,
1983). Other studies, however, have found no association be-
tween parity and dental disease (Scheutz et al., 2002).
Patterns of dental treatment are often altered for women
who are pregnant (Pistorius, Kraft, & Willershausen, 2003;
Gaffield, Gilbert, Malvitz, & Romaguera, 2001). In the United
States, the American Dental Association (ADA) (2006) has
suggested that “elective” dental care be avoided during the first
trimester and the last one-half of the third trimester. Dentists
may either delay care or offer alternative treatment plans to
women who are pregnant (Pistorius et al., 2003), and access to
dental care may be restricted to women during the postpartum
period because of limited time available to women are busy
caring for their infants (Redford, 1993). However, with the re-
cent publication of a large clinical trial that found that peri-
odontal care was safe and effective during pregnancy
(Michalowitz et al., 2006), the head of the National Institutes
of Dental and Craniofacial Research stated that dental care
during pregnancy has long been an issue dominated more by
caution than data (National Institutes of Health, 2006).
January/February 2008
Figure 1.
Consultation form from the New York State Practice Guidelines for Dental Care in Pregnancy

Consultation for Pregnant Women to Receive Oral Health Care

Referred To: Date:

Patient Name: Last First
DOB: Estimated Delivery Date: Week of Gestation Today:
Known Allergies:
Precautions: ❑ None ❑ Specify (If any):

This patient may have routine dental evaluation and care, including but not limited to:
• Oral health examination
• Dental prophylaxis
• Scaling and root planing
• Extraction
• Dental x-ray with abdominal and neck lead shield
• Local anesthetic with epinephrine
• Root canal
• Restorations (amalgam or composite) filling cavities

Patient may have: (Check all that apply)

❑ Acetaminophen with codeine for pain control
❑ Alternative pain control medication: (Specify)
❑ Penicillin
❑ Amoxicillin
❑ Clindamycin
❑ Cephalosporins
❑ Erythromycin (Not estolate form)

Prenatal Care Provider: ___________________________________ Phone: _____________________

Signature: ______________________________________________ Date: ______________________

DO NOT HESITATE TO CALL FOR QUESTIONS

DENTIST’S REPORT
(for the Prenatal Care Provider)
Diagnosis: _________________________________________________________________________________
_________________________________________________________________________________________
Treatment Plan: _____________________________________________________________________________
_________________________________________________________________________________________
Name: _____________________________ Date: ________________ Phone: __________________________
Signature of Dentist: _________________________________________________________________________

Recommendations for Oral
Healthcare During Pregnancy
In reaction to the knowledge that pregnant women may be
receiving limited or inadequate dental care during pregnan-
cy (Gaffield et al., 2001) and in recognition of potential
lack of public information regarding what is appropriate
care during pregnancy, New York State Department of
Health (2006) released practice guidelines for oral health
during pregnancy. In this document, the most important
message to pregnant women and healthcare professionals is
that dental care is safe and effective during pregnancy and
that needed care can be provided throughout a woman’s

January/February 2008 MCN 35

Table 1.
Clinical Implications for the Dental Treatment of Pregnant Women
Dental procedure/ Safe during
treatment pregnancy?
Radiographs Yes
Amalgam restorations Yes
Treatment of infection Yes,
Category Ba
Treatment of pain Yes,
Category Ba
Use of local anesthetics Yes,
Category Ba
Use of inhalation anesthesia Use with caution
(nitrous oxide)
aPregnancy Risk Categories A and B are safe to use in pregnancy. Category C medications should be used with caution, if at all, under the direction of the physician and should be given
only if the potential benefit outweighs the potential risk to the fetus. Drugs are classified as Category C when (a) animal studies show adverse effect and toxicity on fetus and (b) no ade-
quate and well controlled studies have been done on pregnant women. Category D and X drugs should be avoided.
pregnancy. This document recognizes that a delay in receiv-
ing necessary dental care could result in significant risk to
the mother and/or the fetus. To coordinate medical and
oral healthcare during pregnancy and facilitate dental treat-
ment, care providers may want to use a consultation form,
an example of which was provided in the New York State
Practice Guidelines (Figure 1), which would best be provid-
ed automatically to pregnant women by their medical care
providers. Women could bring this form to their dentists
when they present for treatment, and follow-up consulta-
tions could occur during the pregnancy by phone.
Other information that could help women and their
providers includes specific aspects of dental treatment
(Table 1). The best time for general dental procedures is
during the second trimester (14-20 weeks’ gestation), when
the risk of pregnancy loss is lower and the woman is gener-
ally most comfortable. Although dental treatment is safe
throughout the course of pregnancy, oral healthcare and
other professionals involved in her care should consider fac-
tors such as gestational age of the fetus, maternal health-
damaging behaviors, and the presence of other medical
conditions (e.g., gestational diabetes, pre-eclampsia) when
developing a treatment plan. Oral healthcare professionals
can play a key role in the care of pregnant women, not on-
ly specifically through oral healthcare, such as relief of pain
36 VOLUME 33 | NUMBER 1
Specific recommendations
for pregnant women
Always use lead apron with thyroid cuff.
Removal of old amalgam restorations should be done with a rubber dam in
place, and with high speed suction.
Category B antibiotics (including penicillin, amoxicillin, cephalosporins, and
clindamycin) are safe, as are erythromycin ethylsuccinate and stearate (except
in estolate form).
Category C antibiotics (including erythromycin estolate, quinolones, and clar-
ithromycin) should be avoided but may be used after physician consultation
when the benefits outweigh the risk to the fetus.
Do not use Category D antibiotics (tetracyclines).
Category B analgesics (including acetaminophen, meperidine, and morphine)
are safe for use during pregnancy; do not exceed recommended dose.
Category C analgesics (including codeine and hydrocodone) may be used with
caution.
Ibuprofen and Naprosyn should be used only after the first trimester, and only
for 72 hours or less.
Category B anesthetics (including lidocaine with epinephrine and prilocaine)
are safe.
Category C anesthetics (including mepivacaine and bupivacaine) should be
avoided.
The use of nitrous oxide should be limited to cases in which topical and local
anesthetics are inadequate and should be administered only after consultation
with the patient’s physician. Adequate precautions should be taken to prevent
hypoxia, hypotension, and aspiration. Note that pregnant women require lower
levels of nitrous oxide to achieve sedation.
and infection, but also through counseling patients on the
harmful effects of smoking, alcohol use, and illicit drug use
during pregnancy. The ADA (2006) recommends that every
pregnant woman see a dentist for a comprehensive oral ex-
amination at some point during her pregnancy.
A list of common procedures performed as part of dental
care is contained in Table 1, as are specific recommendations
for use of these procedures during pregnancy and modifica-
tions in care, when necessary, for pregnant women. Dental ra-
diographs are safe during pregnancy. It has been estimated
that uterine doses for a full, 20-film radiographic series are a
small fraction (<1 mrem) (Matteson et al., 1991) of uterine
doses that are received from naturally occurring background
radiation during pregnancy (75 mrem). Given this minimal
dose of radiation, the benefits of dental radiographs may out-
weigh any negligible risks. Guidelines for dental radiographs
have been published by the ADA in conjunction with the U.S.
Food and Drug Administration (FDA) (ADA, 2004), which
recommend that the health history of the patient and clinical
judgment determine the need for the type and number of
films and that lead aprons and thyroid collars always be used
to minimize exposure. Regarding the use of dental amalgam,
there is no evidence that fetal exposure to mercury from exist-
ing dental amalgams causes adverse effects ( New York State
Department of Health, 2006). In fact, the consumption of fish
January/February 2008
and seafood is a much greater source of mercury exposure
than mercury released from dental amalgams (New York
State Department of Health, 2006). Care should be used
when removing amalgam, and high-speed suction and rubber
dams can greatly reduce mercury vapor inhalation.
Medications commonly used or prescribed by dentists in-
clude antibiotics, analgesics, and anesthetics. The U.S. FDA has
published guidelines for medication use, and all drugs are classi-
fied as one of five pregnancy risk categories (New York State
Department of Health, 2006). Drugs in categories A and B are
safe for use during pregnancy, and drugs in category C may be
used with caution under the direction of a physician when the
benefit to the patient outweighs the risk to the fetus. Drugs clas-
sified as category D or X should be avoided during pregnancy.
Conclusion
Pregnancy is a time when women may be most receptive to
changing health behaviors, such as smoking reduction or ces-
sation, and receiving preventive dental care. Given the review
of research findings presented in this article, increased atten-
tion to oral care during pregnancy is essential to overall health
during pregnancy. It is likely that primary care practitioners,
including nurses and physicians, do not routinely address the
importance of oral care during pregnancy during the prenatal
period. One recommendation is to include a brochure about
the safety of receiving dental care during pregnancy at the first
visit with the obstetrician, midwife, or nurse practitioner. A
mid-pregnancy reminder could be helpful, at which time
women can be queried about any delays in receiving dental
care. To facilitate referral to a dentist, the consultation form
included in this article could be distributed. Nurses should be
proactive in instructing women to contact their provider if
they have any questions regarding oral health during pregnan-
cy or if they need a referral to a dentist. The postpartum visit
may be another opportunity when nurses can address appro-
priate preventive care and any necessary dental care. Nurses
who work in institutions that provide postpartum visits could
initiate the topic and reinforce the need to continue good oral
health practices in preparation for overall optimal health in
subsequent pregnancies. ✜
Stefanie L. Russell is an Assistant Professor, New York Uni-
versity College of Dentistry, New York, NY. She can be
reached via e-mail at stefanie.russell@nyu.edu
Linda J. Mayberry is an Associate Professor, New York
University College of Nursing, New York, NY.
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