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Orthodontic considerations for gingival health duringpregnancy: a review Authors' affiliations: Abstract: Gingivitis is caused by several known systemic Padma M. Mukherjee, Division of and local factors. Among systemic factors, the role of Orthodontics, Department of Craniofacial hormonal changes during pregnancy is well established.
Sciences, University of Connecticut School of Dental Medicine, Farmington, CT, USA While presence of fixed orthodontic appliances alone may not Khalid Almas, Division of Periodontology, cause gingivitis, factors such as pregnancy and poor oral University of Connecticut School of Dental hygiene combined together could precipitate acute gingival Medicine, Farmington, CT, USA inflammation that may progress to a periodontal condition in Correspondence to: a patient receiving orthodontic therapy. There has been an Dr Padma M. Mukherjee increase in the number of adult patients who are receiving Division of Orthodontics orthodontic treatment. Orthodontic appliances could act as a Department of Craniofacial Sciences University of Connecticut School of Dental potential plaque retentive source and aggravate inflammatory reactions that are seen during pregnancy. There is a lack of 263 Farmington Ave awareness regarding oral healthcare issues among patients Farmington, CT 06030, USA who are pregnant and choose to seek orthodontic treatment.
Tel.: +1 860 679 3625 Fax: +1 860 679 1920 In addition, there is a need in the literature to outline management guidelines for patients who want to receive orthodontic treatment during pregnancy, with or without pre- existing gingival conditions. This review focuses on the aetiology of pregnancy gingivitis and the management of orthodontic patients during pregnancy. Our emphasis is on patient education, oral hygiene maintenance, preventive and treatment strategies for the management of gingival health in orthodontic patients during pregnancy. We also highlight some of the possible complications of initiating orthodontic treatment during pregnancy.
Key words: gingiva; oral hygiene; orthodontics; pregnancy Accepted 11 February 2009 To cite this article: Int J Dent Hygiene 8, 2010; 3–9 Mukherjee PM, Almas K. Orthodontic consider- ations for gingival health during pregnancy: Gingivitis is one of the most common causes of periodontal dis- ease. Aetiological factors of gingivitis can be broadly classified  2009 John Wiley & Sons A ⁄ S into local and systemic causes. Local causes may include Int J Dent Hygiene 8, 2010; 3–9 Mukherjee and Almas. Gingival health during pregnancy microorganisms, food impaction, certain drugs and some iatro- Vascular and hormonal changes may increase the gingival genic factors like faulty restoration (rough surfaces or crowns, crevicular fluid and aggravate response to plaque (8, 11).
marginal overhangs) and orthodontic appliances. Most of these local factors act as plaque retentive areas and when Oral health care during pregnancy coupled with poor oral hygiene maintenance leads to gingival inflammation. Systemic causes include disorders like diabetes, It has been reported that in the United States, over 6 million haematological disorders, nutritional imbalance and hormonal women get pregnant each year (22). Less than a quarter of changes including pregnancy (1–5).
these women receive any dental care during pregnancy (23, Local factors of gingival inflammation include calculus, 24). Studies have also reported that an important factor that defective restorative margins and orthodontic appliances.
determines if pregnant women seek dental care is their socio- These factors act as plaque retentive factors causing constant economic status and subsequently the type of oral hygiene gingival irritation and leading to inflammation. Here, we will methods used (25). Women with lower socio-economic strata discuss presence of orthodontic appliances and gingival inflam- tend to avoid visiting dental offices during pregnancy. In addi- mation in more detail. It is known that orthodontic appliances tion, there is a lack of awareness among women about the could compromise the maintenance of optimum oral hygiene potential risk of poor pregnancy outcomes and periodontal dis- even in the most conscientious patient (6). Although in most ease (24, 26, 27). Thus dental care visits are reduced during children undergoing orthodontic therapy, with no previous his- pregnancy and some choose to wait until after delivery to tory of loss of attachment or periodontal disease, the only con- address any oral healthcare needs (28). Studies have shown a sequence of wearing orthodontic appliances is a transient mild correlation between periodontal disease and increased risk of gingivitis caused by plaque. After completion of orthodontic preterm low birth weight babies. In addition, there is research therapy, this problem usually resolves because of ease in the to support that treatment of periodontal disease could reduce access of inter-dental cleaning. However, during pregnancy, preterm births (29–33). There have been reports that support because of the presence of established gingivitis in some the association of periodontal disease with pre-eclampsia patients, the condition usually can progress to an irreversible during pregnancy (34).
breakdown of the periodontium.
It is therefore not surprising that several studies have been Systemic factors that cause gingival inflammation can be conducted to investigate dental care seeking behaviour during broadly classified into genetic, haematological, hormonal, meta- pregnancy. Most of them show that at the most only 35–50% bolic and environmental factors. Gingivitis and gingival hyper- of women visit the dentist during pregnancy (23, 35). Another plasia have been associated with hormonal changes as seen interesting area to discuss at this point is the behavioural during puberty, pregnancy and menopause (1–3, 7, 8). This aspects of pregnant patients. There appears to be a tendency belief is also supported by research that report an increase gin- towards self-negligence and maintenance of poor oral hygiene gival inflammation in women taking steroid hormones, oral con- habits during pregnancy (36). For many years, education cam- traceptives and other drugs that contain oestrogen and paigns have followed the Knowledge-Attitude-Behaviour (K-A-B) progesterone (9–12). Animal studies have also demonstrated Model. The K-A-B model asserts that education leads to that there is an increase in gingival inflammation in experimen- greater awareness and attitude change and this leads to respon- tal animals that are treated with systemically administered male sible behaviour. Behaviour is also affected by social contexts and female sex hormones (13–15). Studies have shown that and social norms that may contribute towards changing behav- pregnant women have an increased incidence of gingival inflam- iour, as well as personal motivations, religious and cultural mation compared with non-pregnant women (16, 17). Progester- beliefs, and knowledge about the consequences of actions one has been shown to increase gingival exudates, affect the (6, 37). Thus, being cognizant of these important issues is criti- gingival vascularity and integrity of the capillary endothelial cal for the dental profession who could play a major role in cells (13, 14). Sex hormone-induced alterations in the subgingi- patient education and oral health awareness.
val microflora lead to an increase in periodontal inflammation (17, 18). During pregnancy, there could be immunosuppression Periodontal health during orthodontic where CD4:CD8 ratios may be decreased (19) and there could also be low lymphocyte responsiveness (20, 21). The presence of increased sex hormones during pregnancy may cause epithe- Some professionals believe that long-term periodontal health lial separation and an increase in vascular permeability (15).
benefits from orthodontic care, while others believe that it Int J Dent Hygiene 8, 2010; 3–9 Mukherjee and Almas. Gingival health during pregnancy does not (38–40). Orthodontic therapy can provide benefits to tions such as diabetes mellitus or previous pregnancy compli- adult periodontal health in several cases such that crowding cations are important to know in advance before starting where improvement in the alignment allows better access to orthodontic treatment (14, 33). The patient's perception of oral hygiene maintenance. In addition, opening embrasures in their own health is considered to be an important aspect of some cases could help regain lost papilla and obvious aesthetic their psychosocial make up and potential compliance. If the improvement caused by adjusting gingival margin especially in patient has suffered previously from certain complications dur- the anterior region (41). However, especially during pregnancy, ing her pregnancy and is at a risk as per her medical care pro- in cases that have pre-existing gingival inflammation, presence vider, it may be best to wait until postpartum to start of orthodontic appliances could increase the demand of rigor- ous oral hygiene maintenance and in patients who lack that A complete dental history provides the orthodontist knowl- self-motivation, the periodontal condition may get aggravated edge about the patient's attitude towards dental care and when orthodontic appliances are present in the oral cavity. It patient's priorities. A patient who does not receive routine den- is known that fixed appliances can act as plaque-retaining tal care and is negligent about oral care is unlikely to be compli- devices. However, when coupled with pre-existing gingival ant during orthodontic treatment. A record for the cause of tooth inflammation that may be present in a pregnant patient, there loss if any is also important. History of trauma and sensitivity could be fast progression towards periodontal disease. Ideally, with previously traumatized teeth is extremely important to tooth movement should not be done during active gingival know prior to commencement of orthodontic treatment. As the inflammation because of increased risk of periodontal abscess number of adult patients seeking orthodontic treatment is on an formation. According to some reports, the prevalence of peri- increase, it is important that the orthodontists must be more odontal disease in pregnancy is around 35–100% (22). There is active and capable of diagnosing gingival and periodontal prob- also an additional factor of self-neglect among pregnant women lems. If the patient already has signs such as gingival inflamma- as we have discussed earlier (36). Also postpartum, women's tion, bleeding on probing, presence of pockets and poor oral oral health condition has been shown to deteriorate further.
hygiene, it may be wise to start orthodontic therapy after the While there is literature to support that oral health of women pregnancy. However, there are no obvious contraindications to is not optimal during pregnancy and after childbirth, there orthodontic therapy in a healthy pregnant patient. However, it have been three case–control cohort and cross-sectional studies may be advisable to limit the visits to shorter appointments to that have demonstrated that periodontal disease may be a avoid the patient being in extreme supine position especially potential independent risk factor for preterm low-birth-weight during the later stages of the pregnancy. Radiographic imaging babies (29, 30, 42). Thus, it is of paramount importance to cre- such as a panoramic film and periapical films are routinely used ate awareness in the dental profession and also to educate to assess periodontal health and root inclinations. According to women about the importance of oral health care during ortho- American Dental Association (ADA), every precaution should dontic therapy especially if they are pregnant.
be taken to minimize radiation during pregnancy. However, if there is an acute dental infection, it must be addressed and radiographs can be taken. In addition, the radiation caused by Orthodontic considerations and management oral radiography is minimal. It is advisable to coordinate the orthodontic treatment plan with the obstetric care provider to Medical, dental and psycho-social history establish guidelines that will benefit maternal oral health and Like any other form of dental care, before starting orthodontic perinatal outcomes.
therapy, a thorough and detailed medical history is critical.
It is important for the orthodontist to know if the patient is However, in case of pregnancy, it is important to get the opin- self motivated and enthusiastic about receiving orthodontic ion of the gynaecologist if any known complications are to be treatment. It is especially important to take into account the expected. A history of current medications is also valuable hormonal and physiological changes that will be anticipated because various drugs have oral side effects and may influence during the course of pregnancy and the patient must be men- the course of the orthodontic therapy. Drugs such as bis- tally prepared to visit the orthodontist for regular adjustments.
phosphonates and vitamin D metabolites could probably cause It is critical to discuss in depth about the entire course of the a reduction in tooth movement during orthodontic therapy, treatment, the expected number of visits and the level of while non-steroidal anti-inflammatory drugs have also been cooperation that will be required for successful completion of shown to reduce bone resorption. Any previous medical condi- orthodontic treatment to achieve ideal function and aesthetics.
Int J Dent Hygiene 8, 2010; 3–9 Mukherjee and Almas. Gingival health during pregnancy shown to be successful to motivate patients in improving their Orthodontic treatment plan oral hygiene. Knowledge about this technique will enable the It is of utmost importance to plan a simple and realistic treat- clinicians to provide the necessary information to their patients ment plan in patients who are pregnant. A good communica- to improve their level of understanding of their oral health tion between the orthodontist and the patient is a key for issues. Thus, constant motivation of the patient could help successful results. If the patient wants to undergo orthodontic improve patient compliance during orthodontic treatment. It is therapy primarily for frontal aesthetics and is not willing to be critical for the dental care provider to focus on changing the compliant for a 2-year treatment plan and comprehensive ther- individual's perceived need towards oral health and ⁄ or values apy, this needs to be established at the beginning. In such associated. Especially during orthodontic treatment, which is patients, limited treatment should only be performed. As an over a period of a couple of years, constant reinforcement and alternative in some patients, it may be advisable to wait until periodic monitoring and occasional discussions with the patient after the pregnancy to start orthodontic treatment.
are extremely crucial. Most importantly, there needs to be a psy- chological change and motivation in the patient that will make them conscious about their oral hygiene status. It is important to Oral hygiene maintenance during orthodontic treatment emphasize that professional tooth cleaning alone is not sufficient Before starting orthodontic treatment, any pre-existing peri- for preventing gingival and periodontal issues and conscientious odontal condition must be addressed. Because of pre-existing oral home care is also of paramount importance. Thus, a combi- hormonal changes during pregnancy, the gingival tissues may nation of professional tooth cleaning and educational reinforce- be already inflamed in pregnancy women. Thus, a more rigor- ment of oral hygiene will prove to be successful. The model in ous oral hygiene routine will be required to maintain optimal Fig. 1 depicts steps for successful orthodontic treatment during oral health. Frequent dental prophylaxis will be helpful and pregnancy and also highlights causes of failure.
meticulous home-care regimens will need to be employed to ensure success. In addition to tooth brushing, a detailed Patient summary (A) instruction in the manipulation of dental floss will enable the patient to floss when the braces are in the mouth. Many inter- Figure 2(a) are the initial intra-oral pictures of an 18-year-old dental cleaning aids such as tooth picks or miniature bottle patient presented to the Orthodontic Resident Clinics at the brushes can be attached to handles for the convenience of University of Connecticut Health centre with a chief com- manipulation around teeth (8), Thus oral hygiene regimen plaint ‘I do not like my teeth'. Patient was diagnosed with a maintained at home and coupled with professional dental class I malocclusion with 0% overbite and 4 mm overjet.
cleaning will ensure successful oral health and keep orthodon- Patient had retained primary maxillary canines, buccally erupt- tic patients during pregnancy free of gingival and periodontal ing maxillary left canine and a transposed maxillary right disease during active treatment.
canine. During the initial consultation, it was noted that the patient was 6 weeks pregnant. Apart from the pregnancy, there was no other significant medical history. Her oral hygiene sta- Patient education and awareness tus was fair. The patient was advised to obtain physician's To increase the use of dental care services among pregnant women, it will be beneficial for dental care professionals to work in conjunction with prenatal healthcare professionals and other Orthodontic treatment during pregnancy dental specialties. It is important that medical professionals dealing with prenatal care be educated the importance of dental Causes of failure during care to their patients. In addition, the dental healthcare provid- Successful treatment ers must be aware of the importance of dental care during preg- nancy and effects of poor periodontal health on pregnancy and • Patient education • Lack of patient awareness the baby. It is also important for social care services to identify • Patient motivation • Lack of self motivation and eliminate barriers such as low educational and socio-eco- • Good oral hygiene • Poor oral hygiene • Inadequate professional help nomic status that may interfere and prevent pregnant women • Professional prophylaxis from obtaining dental care. Various behavioural modification Fig. 1. Proposed model for success and ⁄ or failure for orthodontic techniques could be employed. The K-A-B model has been treatment during pregnancy.
Int J Dent Hygiene 8, 2010; 3–9 Mukherjee and Almas. Gingival health during pregnancy Fig. 2 (a) Pretreatment intra-oral photographs of patient A (0 months). Patient has class I maloc- clusion, zero overbite and 4 mm overjet. Patient has retained primary maxillary canines and a transposed maxillary right permanent canine. (b) Progress at 3 months. Primary maxillary canines have been extracted and upper arch is bonded.
Patient presents with gingival inflammation aro- und the orthodontic brackets. (c) Progress at 6 months. Compromised oral hygiene, increase in gingivitis and presence of pseudo pockets (on approval prior to the start of her orthodontic therapy. Some of first molar was endodontically treated and had a periapical the major concerns during her orthodontic treatment were gin- lesion. It was scheduled for extraction by her general dentist.
gival inflammation and bleeding exacerbated with poor oral Patient's thumb sucking habit was addressed with positive hygiene. Figure 2(b and c) demonstrate the gingival inflamma- reinforcement and orthodontically, she was to be treated with tion around brackets in 3 and 6 months after initiating ortho- upper bicuspid extraction and using an extrusion arch, we dontic treatment. Although the orthodontic treatment in this planned to close the open bite. Patient wanted to get implants case was not difficult, the management of this case became in the future to replace her mandibular first molars. Figure 3(b more complex because of inflammatory reaction seen during and c) illustrate progress pictures 3 and 6 months later. There pregnancy and lack of patient compliance to maintain good was improvement with the open bite and there were no clini- oral hygiene.
cally visible signs of gingivitis around the orthodontic brackets.
The patient's oral hygiene was maintained by educating the patient, motivation and good home-care regimen.
Patient summary (B) Figure 3(a) are the initial intra-oral pictures of a 19-year-old patient with the chief complaint ‘I do not like the gap in the front'. Patient was diagnosed with class II malocclusion with Professional knowledge anterior open bite caused by thumb sucking habit. She was 3 months pregnant at the start of treatment. Lower right first From literature review and case report, it has been found molar was extracted 2 years ago because of caries. Lower left that orthodontic treatment during pregnancy may aggravate Fig. 3. (a) Pretreatment intra-oral photographs of patient B (0 months). Patient is end-on class II with 5 mm anterior open bite and 3 mm over- jet. Lower left first molar had been extracted 2 years ago because of decay. (b) Progress intra- oral pictures after 3 months of orthodontic treatment. Patient's oral hygiene is good and no clinical signs of gingival inflammation around orthodontic brackets. (c) Progress at 6 months.
Improvement with the open bite and patient's oral hygiene is well maintained.
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(Brazilian Interdisciplinary Association of AIDS) (Working Group on Intellectual Property) Enough of attacks to Health protection measures! The case of the drug lopinavir/ritonavir expose the poor functioning of the patent system, distorted attack from pharmaceutical companies and lag of the judiciary. Given the disappointing outcome of a trial held this week at the Court of the 2nd district of Rio de Janeiro, the Working Group on Intellectual Property of the Brazilian Network for Peoples Integration (GTPI/Rebrip), collective of civil society organizations acting in defense of the access to drugs, repudiate the claims filed by transnational corporations in order to weaken the mechanisms established in Brazil to protect health policies from the negative impact of pharmaceutical patents. It is still worth to remember that improperly granted patents unnecessarily raise the price of drugs and high prices drain public resources. Many international bodies have already concluded in their studies that the combination unlawful patents-high prices frequently lead to systematic branches of the Human Rights.

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