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ODONTOLOGÍA PEDIÁTRICA ODONTOL PEDIÁTR (Madrid)
Copyright © 2009 SEOP Y ARÁN EDICIONES, S. L. Vol. 17. N.º 1, pp. 0-0, 2009
Artículo Original
RESUMEN ABSTRACT
La evidencia científica indica que la presencia de enferme- Scientific evidence suggests that periodontal disease in the
dad periodontal en la mujer embarazada puede tener conse- pregnant patient can have adverse effects on the outcome of a
cuencias negativas en el resultado del embarazo. Por otro birth. Moreover, maternal microbial flora is one of the most
lado, la flora oral de la madre es uno de los factores más important caries predictor in a child. Maternal oral health care
importantes de predicción de caries en un niño; con lo cual la must be based on diminishing the bacterial load, so as to
salud oral materna debe basarse en la importancia de dismi- reduce the probabilities of transmission. All preventive pro-
nuir la carga bacteriana para reducir las probabilidades de grammes should include the assessment of pregnant women,
transmisión. Todo programa de prevención de caries debe and it is therefore essential that pediatric dentists have pro-
incluir la asesoría a futuras madres y por ello, es imprescindi- found knowledge of all pregnancy and oral health issues so as
ble que el odontopediatra conozca en profundidad todos los to understand the importance of integrating these patients in
aspectos relacionados con el embarazo y la salud oral, para our practice.
comprender la importancia de integrar este grupo de pacientes The aim of this review of the literature is to describe the
en nuestros programas. most relevant aspects of pregnancy and their relation to oral
Este trabajo de revisión bibliográfica tiene como objetivo health, with special emphasis on the consequences to the
revisar los aspectos más relevantes del embarazo y su relación future baby.
con la salud oral, con especial enfoque en las consecuencias
en el futuro bebé.
PALABRAS CLAVE: embarazo, salud oral, periodontitis, KEY WORDS: Pregnancy. Oral health. Periodontitis. Preterm
parto prematuro, caries precoz en la infancia. birth. Early childhood caries.
Métodos
SALUD ORAL MATERNA Y RIESGO DE Educación sobre desarrollo dental, prevención y
CARIES DEL BEBÉ patología bucal
Demostración de los procedimientos de higiene oral
Como bien sabemos, las bacterias cariogénicas en los en los padres e indicaciones para el futuro bebé
bebés típicamente se adquieren a través de la transmisión Consejos para instaurar actitudes preventivas
directa de saliva de las madres (26). Mientras más tem- Evaluación de la educación, aceptación y las necesi-
prana sea la transmisión y más cariogénica la dieta del dades individuales
bebé, más sustancial será la transferencia. Por esta razón,
las madres con antecedentes de alto riesgo de caries serán Contenido
más propensas a presentar altos niveles de Streptococcus
mutans en su saliva y el contagio vertical a sus hijos será Salud bucal de los padres
más efectivo, poniendo a sus hijos en mayor riesgo de Educación de los padres sobre los procesos de enferme-
desarrollar caries precoz en la infancia (16). dades bucales y sobre higiene oral, para reducir su car-
Debido a que la flora bucal tiende a mantenerse esta- ga bacteriana y el efecto de transmisión al futuro bebé
ble durante la vida, la flora cariogénica de una mujer Motivación de los padres sobre la higiene oral, para
antes y durante el embarazo anticipa su flora durante los mejorar su propia salud y crear unas óptimas condi-
primeros años de vida del niño, así como la probabili- ciones para el nacimiento
dad de transmitir precozmente la infección al bebé. El Discusión sobre los cambios en la salud oral materna:
tiempo entre la infección y la aparición de una cavidad cambios gingivales, riesgo de caries por aumento de
dependerá de otros factores, tales como la higiene oral, carbohidratos, mitos del embarazo y necesidad de tra-
la frecuencia en la ingesta de carbohidratos fermenta- tamiento dental
bles y la exposición a fluoruros (16).
Se ha comprobado que el xilitol y la clorhexidina dis- Salud bucal del niño
minuyen la carga bacteriana en la flora materna y redu- Desarrollo del bebé, incluyendo aspectos orales y
cen el riesgo de transmisión bacteriana si se utilizan en generales que pueden afectar su salud bucal
los últimos momentos del embarazo o en el periodo Efectos del estilo de vida sobre el bebé: hábitos, abu-
post-parto (3). Tomando en cuenta que los últimos estu- so de sustancias, ingesta de azúcares, dieta materna,
dios en preescolares en España indican que casi el 20% flúor prenatal y lactancia
de niños a los 3 años (27) y el 40% a los 5 años (28) pre- Periodo postnatal: erupción dental, patrones erupti-
senta caries, sería interesante sugerir estas medidas a las vos, nutrición, hábitos de succión no nutritiva y
pacientes embarazadas. momento de la primera visita al odontopediatra
4 C. PALMA ODONTOL PEDIÁTR
6. Hey-Hadavi JH. Women’s oral health issues: sex differences dings from a cohort of young minority women in New York.
and clinical implications. Women’s Health Prim Care 2002; 5: Eur J Oral Sci 2001; 109: 34-9.
189-99. 19. American Academy of Periodontology statement regarding
7. American Dental Association Council on Access, Prevention periodontal management of the pregnant patient. Task force on
and Interprofessional Relations. Women’s oral health issues. periodontal treatment of pregnant women, American Academy
American Dental Association, November 2006. Disponible en: of Periodontology. J Periodontol 2004; 75: 495.
http://www.ada.org/prof/resources/topics/healthcare_womens.p 20. Sibai BM, Gordon T, Thom E, Caritis SN, Klebanoff M, McNe-
df llis D, et al. Risk factors for preeclampsia in healthy nulliparous
8. Lieff S, Boggess KA, Murtha AP, Jared H, Madianos PN, Moss women: a prospective multicenter study. The National Institute
K, et al. The oral conditions and pregnancy study: periodontal of Child Health and Human Development Network of Mater-
status of a cohort of pregnant women. J Periodontol 2004; 75: nal-Fetal Medicine Units. Am J Obstet Gynecol 1995; 172:
116-26. 642-8.
9. Agueda A, Ramón JM, Manau C, Guerrero A, Echeverría JJ. 21. Boggess KA, Lieff S, Murtha AP, Moss K, Beck J, Offenbacher
Periodontal disease as a risk factor for adverse pregnancy out- S. Maternal periodontal disease is associated with an increased
comes: a prospective cohort study. J Clin Periodontol 2008; 35: risk for preeclampsia. Obstet Gynecol 2003; 101: 227-31.
16-22. 22. DePaola DP, Faine MP, Vogel RI. Nutrition in relation to dental
10. Offenbacher S, Katz V, Fertik G, Collins J, Boyd D, Maynor G, medicine. En: Shils ME, Olson JA, Shike M, editors. Modern
et al. Periodontal infection as a possible risk factor for preterm Nutrition in Health and Disease. 8th ed. Philadelphia: Lea &
low birth weight. J Periodontol 1996, 67(Suppl. 10): 1103-13. Febiger Ed.; 1994. p. 1007-28.
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Lawrence HP, et al. Potential pathogenic mechanisms of perio- health guidelines for pregnant women, infants, and children. J
dontitis associated pregnancy complications. Ann Periodontol Am Diet Assoc 1998; 98: 182-6.
1998; 3: 233-50. 24. Hudson R, Distel H. The flavor of life: perinatal development
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prospective study. J Am Dent Assoc 2001; 132: 875-80. 25. Fassman D. Prenatal fluoridation: a literature review. NY State
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14. Davenport ES, Williams CE, Sterne JA, Murad S, Sivapatha- of infectivity. J Dent Res 1993; 72: 37-45.
sundram V, Curtis MA. Maternal periodontal disease and pre- 27. Bravo Pérez M, Llodra Calvo JC, Cortés Martinicorena FJ,
term low birth weight: case-control study. J Dent Res 2002; 81: Casals Peidró E. Encuesta de salud oral de preescolares en
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Baylis R, et al. A prospective study to investigate the relations- dra Calvo JC. Encuesta de salud oral en España 2005. RCOE
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me. Br Dent J 2004; 197: 251-8. 29. Kohler B, Andreen I, Jonsson B. The effect of caries-preventive
16. Boggess KA, Edelstein BL. Oral health in women during pre- measures in mothers on dental caries and the oral presence of
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Original Article
RESUMEN ABSTRACT
La evidencia científica indica que la presencia de enferme- Scientific evidence suggests that periodontal disease in the
dad periodontal en la mujer embarazada puede tener conse- pregnant patient can have adverse effects on the outcome of a
cuencias negativas en el resultado del embarazo. Por otro birth. Moreover, maternal microbial flora is one of the most
lado, la flora oral de la madre es uno de los factores más important caries predictor in a child. Maternal oral health care
importantes de predicción de caries en un niño; con lo cual la must be based on diminishing the bacterial load, so as to
salud oral materna debe basarse en la importancia de dismi- reduce the probabilities of transmission. All preventive pro-
nuir la carga bacteriana para reducir las probabilidades de grammes should include the assessment of pregnant women,
transmisión. Todo programa de prevención de caries debe and it is therefore essential that pediatric dentists have pro-
incluir la asesoría a futuras madres y por ello, es imprescindi- found knowledge of all pregnancy and oral health issues so as
ble que el odontopediatra conozca en profundidad todos los to understand the importance of integrating these patients in
aspectos relacionados con el embarazo y la salud oral, para our practice.
comprender la importancia de integrar este grupo de pacientes The aim of this review of the literature is to describe the
en nuestros programas. most relevant aspects of pregnancy and their relation to oral
Este trabajo de revisión bibliográfica tiene como objetivo health, with special emphasis on the consequences to the
revisar los aspectos más relevantes del embarazo y su relación future baby.
con la salud oral, con especial enfoque en las consecuencias
en el futuro bebé.
PALABRAS CLAVE: embarazo, salud oral, periodontitis, KEY WORDS: Pregnancy. Oral health. Periodontitis. Preterm
parto prematuro, caries precoz en la infancia. birth. Early childhood caries.
and oral habits that can lead to the formation of caries in TABLE I
mothers with other risk factors (1).
COMMON CONDITIONS DURING PREGNANCY AND
At a microbiological level it has been proved that THEIR THERAPEUTIC MANAGEMENT
certain bacteria, such as Streptococcus mutans and
Lactobacillus acidofilus, increase during pregnancy Vomiting:
(5). Likewise salivary acidity increases (lower pH) and Mouthwash with a spoonful of sodium bicarbonate
the remineralization potential decreases (lower con- diluted in a glass of water in order to neutralize the
centration of calcium and phosphate) during pregnan- acid
cy (1).
Another factor to be taken into consideration is that Dental sensitivity due to enamel erosion:
inevitably there will be an increase in food consumption Sodium fluoride mouthwash for protecting eroded or
due to a greater energetic need. The increase in quantity sensitive teeth
and frequency of food, and the increase in bacteria and
salivary acidity, as well as the little attention given to Pregnancy tumor:
oral health, may increase the risk of caries of the future These should be observed unless there is interference
mother (1,2,6). On the other hand, a high percentage of with mastication, excessive bleeding or if they persist
women suffer from vomiting during pregnancy and this after the birth. If so, they should be surgically remo-
may cause erosion of enamel, increasing the risk of ved, although they may reappear if removed during
caries and dental sensitivity (1,2). the pregnancy.
With regard to gingivitis, the high increase in hor-
mones during pregnancy, particularly progesterone and Gingivitis/periodontitis:
estrogens, particularly affects the periodontium. The Strict oral hygiene, professional curettage, use of
exact mechanism by which hormones increase gingival chlorhexidine mouthwash.
inflammation is unknown (1). Gingivitis is the most
common oral finding in pregnant women with a preva-
lence of 60-75% (7). In addition, if before the pregnan-
cy the patient has gingivitis, the disease tends to worsen tors at a systemic level, could lead to a premature
during the gestation period (1,6). birth (11).
In the case of periodontitis, the toxins produced Later, other studies (12,13), including one carried out
because of periodontal bacteria stimulate a chronic in Spain (9), found the same statistically significant
inflammatory response. Up to 40% of pregnant women relationship between maternal periodontitis and prema-
have some type of periodontal infection (8) and this can ture birth. It should be mentioned that there are also
lead to unfavorable situations, as will be analyzed fur- studies that have not been able to demonstrate a direct
ther on. Lastly, 5% of pregnant women have a pyogenic relationship between both factors (14,15) and it is there-
granuloma or pregnancy tumor of the gingiva, general- fore still not clear if the relationship between periodon-
ly of the upper incisors. This benign and asymptomatic tal disease and the birth result is causal or whether it
vascular lesion is of unknown etiology, however it is forms part of other maternal factors (16).
related with an increase in progesterone, bacteria and What is clear is the effectiveness of maternal peri-
local irritating factors. Pregnancy tumors generally odontal treatment during the pregnancy as a way of
appear after the first term, bleeding easily and growing reducing premature births and the prevalence of low-
rapidly, reducing or disappearing after the birth (1,3). weight babies. All the studies have shown the absence
Table I shows some of the common oral conditions of any risk from carrying out periodontal treatment, for
during pregnancy and their approach. the mother as well as the fetus (12,17,18). In 2004, the
American Academy of Periodontology recommended
carrying out a periodontal evaluation of all pregnant
women or those planning a pregnancy. Should it be nec-
THE RELATIONSHIP BETWEEN MATERNAL essary preventative and therapeutic care should be giv-
ORAL HEALTH AND BIRTH RESULT en. (19).
PREMATURE BIRTH
Premature birth (birth with less than 37 weeks of ges- OTHER ADVERSE RESULTS
tation), is one of the most important causes of morbidity
and neonatal mortality. In spite of major efforts in the Pre-eclampsia is a serious hypertensive complication
health sector, there has been no reduction in incidence during pregnancy affecting 5% of pregnant women
(9). leading to a great number of fetal deaths (16,20). The
In 1996, Offenbacher et al. (10) reported a poten- etiology of pre-eclampsia is not clear and some authors
tial association between maternal periodontal disease have suggested that periodontal disease could be one of
and preterm and low birth weight babies. The hypoth- the risk factor of this disorder (21). However, the evi-
esis is that periodontal bacteria, particularly gram dence on the role of maternal periodontitis in pre-
negative anaerobes, could encourage an early inflam- eclampsia is not very conclusive and more investigation
matory mediator response, including cytokines and is needed in order to determine if the relationship
prostaglandins. This increase in inflammatory media- between both diseases is causal or associated.
8 C. PALMA ODONTOL PEDIÁTR
CONCLUSSIONS
Fig. 1. All pregnant women should have a diagnosis of their
oral health and they should receive information on correct
Given the close relationship between a person’s oral oral health habits.
hygiene and their general health, oral health as such
should be a right for every individual (16). However,
scientific evidence suggests that periodontal disease in a
mother can be a risk factor in premature births, and edu- the probabilities of transmission to the baby. Likewise,
cation as well as oral hygiene measures should be we should make the most of the opportunity and offer
focused in particular on pregnant women. mothers information on the risk of childhood caries, and
As pediatric dentists we should be aware that the oral hygiene habits should be taught for the first years
effectiveness of preventative programs during infancy of life.
depends largely on the education of future mothers and Taking these factors into account, it is essential that
of health providers (gynecologists, pediatricians, family women consult a dentist before becoming pregnant, and
doctors, etc). If maternal oral flora is one of the most at least once a trimester during the gestation (4) (Fig. 1).
important factors in the prediction of caries in the child Dentists as well as pregnant women should be informed
(26), maternal oral health should be based on the impor- as to there being no risk at all from carrying out routine
tance of decreasing the bacterial load in order to reduce visits and treatments at any point in a pregnancy.