Matern Child Health J (2006) 10:S169–S174
Oral Health in Women During Preconception and Pregnancy:
Implications for Birth Outcomes and Infant Oral Health
Kim A. Boggess · Burton L. Edelstein
Published online: 1 July 2006
C ?Springer Science+Business Media, Inc. 2006
Abstract The mouth is an obvious portal of entry to the
body, and oral health reflects and influences general health
and well being. Maternal oral health has significant implica-
birth, development of preeclampsia, and delivery of a small-
for-gestational age infant. Maternal oral flora is transmitted
to the newborn infant, and increased cariogenic flora in the
is intriguing to consider preconception, pregnancy, or intra-
partum treatment of oral health conditions as a mechanism
to improve women’s oral and general health, pregnancy out-
comes, and their children’s dental health. However, given
the relationship between oral health and general health, oral
health care should be a goal in its own right for all indi-
viduals. Regardless of the potential for improved oral health
to improve pregnancy outcomes, public policies that sup-
port comprehensive dental services for vulnerable women of
childbearing age should be expanded so that their own oral
and general health is safeguarded and their children’s risk
of caries is reduced. Oral health promotion should include
education of women and their health care providers ways to
K. A. Boggess (?)
Department of Obstetrics and Gynecology, University of North
Carolina at Chapel Hill School of Medicine,
CB 7516, Chapel Hill, NC 27599–7516
B. L. Edelstein
Department of Health Policy and Management Columbia,
University Mailman School of Public Health,
New York, NY
prevent oral disease from occurring, and referral for dental
services when disease is present.
Keywords Oral health.Pregnancy.Infant caries
A woman’s preconception and pregnancy experience with
the two most prevalent diseases of the mouth—periodontal
disease and dental caries—not only influences her own oral
health status but also may increase her risk of other diseases
such as atherosclerosis [1–4], rheumatoid arthritis , and
diabetes , impact pregnancy outcome [7–9], and her off-
13]. Although largely preventable through evidence-based
interventions, both periodontal disease and caries in women
of childbearing age are highly prevalent, particularly among
ity groups. In addition, both periodontal disease and caries
are typically asymptomatic for long periods of time with
only intermittent painful exacerbations. The combination of
high prevalence, insufficient treatment rates, missed preven-
tive opportunities, and intermittent symptoms led the US
Surgeon General to publish a report in 2001 on oral health in
America characterizing dental and oral disease as a “silent
epidemic” . Socioeconomic factors, lack of resources to
pay for care, barriers to access to care, and lack of public
understanding of the importance of oral health and effective
self-care practices all represent underlying reasons cited for
observed inadequacies in oral health.
An important oral condition affecting many pregnant
women is periodontal disease. Periodontal disease is a de-
structive inflammatory condition of the gingiva and bone
that supports teeth. It is most commonly associated with a
S170 Matern Child Health J (2006) 10:S169–S174
gram-negative anaerobic infection of these structures. Fluid
that bathes the tooth at the gingival margin, known as gingi-
val crevicular fluid, often contains inflammatory mediators
and oral pathogens associated with periodontal disease.
The mechanisms underlying this destructive process in-
volve both direct tissue damage resulting from plaque bacte-
rial products, and indirect damage through bacterial induc-
tion of the host inflammatory and immune responses .
ulation of childbearing age, with a relatively high proportion
of pregnant women demonstrating some degree of periodon-
tal disease [7, 8, 16]. Advancing age, smoking, and diabetes
are risk factors for the development of periodontal disease
. Whereas periodontal disease is a chronic, local oral
infection, systemic inflammation may also occur .
The second oral disease important to women of child-
bearing age because of its maternal-child health associations
is dental caries. Dental caries is the pathologic process by
which teeth “decay” and develop “cavities.” It occurs when
the dental plaque that metabolize dietary carbohydrates. Ac-
quisition of these cariogenic bacteria, dietary practices that
govern the caries process, use of fluorides that dampen the
and children’s experience with tooth decay through biologi-
cal, behavioral, and social pathways.
Is maternal oral health linked
to pregnancy outcome?
Preterm birth, delivery at less than 37 weeks’ gestation, oc-
curs in approximately 12% of all births [18, 19]. Prematurity
is the leading cause of neonatal morbidity and mortality in
geneous factors associated with preterm birth, such as low
maternal body mass index, maternal smoking, and mater-
nal infections . In 1996, Offenbacher and colleagues 
first reported a potential association between maternal pe-
riodontal disease and delivery of a preterm/low birthweight
infant. In a case-control study of 124 pregnant women, they
observed that women who delivered at less than 37 weeks’
gestation or an infant <2500 g had significantly worse peri-
odontal disease than control women. The adjusted odds ratio
for delivery of a preterm, low birth weight infant was ∼7;
may represent a previously unrecognized and clinically sig-
nificant risk factor for delivery of a preterm low birth weight
infant . Extrapolation from these data suggested that 18%
of the preterm, low birth weight infants born annually might
be attributable to periodontal disease, and thus account for
a significant proportion of the $5.5 billion annual hospital
costs associated with the care of preterm/low birthweight in-
fants. In a subsequent case-control study, Dasanayake et al.
studied 55 pairs of women. Logistic regression indicated
that mothers with ‘healthy gingiva’ were at lower risk for
low birth weight infants . Women in both of these case-
control studies were examined at the end of pregnancy or
after delivery, which does not convincingly prove an an-
tecedent exposure and thus causality. Despite this limitation,
bacteria, primarily Gram-negative anaerobes, may serve as
a source for endotoxin and lipopolysaccharides, which then
increases localinflammatory mediators including PGE2,and
diators that can then lead to preterm birth . Additionally,
Jeffcoat et al.  examined the relationship between mater-
1313 pregnant women, and found that moderate/severe ma-
ternal periodontal disease identified early in pregnancy was
associated with an increased risk for spontaneous preterm
birth, independent of other traditional risk factors .
that other studies have failed to demonstrate any association
between maternal periodontal disease and preterm birth. In
a case control study conducted in London, Davenport et al.
 examined 236 infants born at <37 weeks’ gestation or
<2500 g and compared them to a random sample of 507
control infants born at ≥38 weeks’ gestation and weighing
≥2500 g. The authors found no evidence for an association
between delivery of a preterm, low birth weight infant and
periodontal disease and somewhat surprisingly, found that
deeper mean tooth pocket depths at delivery was associated
with a reduction in the risk of delivery of a preterm, low
birth weight infant . The authors surmised that these
discrepant findings might be due at least in part to racial
differences in study populations. In a follow-up longitudinal
study of 3738 women, Moore et al.  found no associa-
However, there was an increase in second trimester fetal loss
rates among women with periodontal disease .
In an effort to better understand the possible mecha-
preterm delivery, Offenbacher and colleagues  measured
gingival crevicular levels of PGE2and IL-1ß in 48 mothers
who delivered preterm, low birth weight infants compared to
control women and discovered that gingival crevicular fluid
levels of PGE2were significantly higher in case compared to
delivering preterm, low birth weight infants, a significant in-
gestational age and gingival crevicular PGE2levels .
It is not yet clear whether the relationship between peri-
odontal disease and adverse pregnancy outcomes is causal
Matern Child Health J (2006) 10:S169–S174 S171
or is a surrogate for another maternal factor. As further ev-
idence to support the concept that maternal oral health is
important for normal pregnancy outcome, other investiga-
tors have examined the effect of antepartum treatment of
periodontal disease on preterm birth risk. Three published
studies of antepartum versus delayed (postpartum) treatment
of maternal periodontal disease demonstrate promise for this
intervention for preterm birth prevention. The effect of pe-
riodontal interventions on pregnancy outcome was assessed
in a prospective study designed to examine the relationship
between periodontal disease and preterm low birthweight
infants in a cohort of young, minority, pregnant and postpar-
tum women. Of 164 women for whom birth outcome data
were available, 74 were subjected to oral prophylaxis during
pregnancy, and 90 received no periodontal treatment. The
preterm/low birthweight rate was lower among women who
received periodontal treatment compared to those who did
ized clinical trial to assess the impact of periodontal treat-
tum on preterm low birthweight infant rates. The incidence
of preterm/low birthweight infants in the antepartum treat-
ment group was 1.8% (3/163) and in the delayed/postpartum
group was 10.1% (19/188), (odds ratio [OR] 5.5, 95% con-
fidence interval [CI] 1.7–18.2, P=0.001). Multivariable lo-
gistic regression analysis showed that periodontal disease
was the strongest factor related to delivery of a preterm/low
birthweight infant (OR 4.7, 95% CI 1.3–17.1) . The data
from these two studies suggest that treatment of periodontal
disease during pregnancy could reduce preterm/low birth-
weight infant rates [26, 27].
In a pilot intervention trial designed to assess the feasibil-
ity of conducting a trial to determine whether treatment of
periodontal disease reduces the risk of spontaneous preterm
birth, Jeffcoat et al. found that among women at high risk
for preterm birth and presence of periodontal disease, scal-
ing and root planning therapy initiated during pregnancy is
tolerated by pregnant women and may reduce spontaneous
preterm birth .
Other adverse pregnancy outcomes
sible for significant maternal and fetal morbidity and mortal-
ity. Preeclampsia affects up to 5% of pregnant women .
The etiology of preeclampsia remains elusive. The underly-
ing pathology may be related to a generalized intravascular
hyperinflammatory state . Some investigators have hy-
pothesized a potential role for maternal periodontal disease
as a risk factor for preeclampsia. In a retrospective analysis
of data collected as part of the Oral Conditions and Preg-
nancy Study, Boggess et al. reported that women were at
higher risk for preeclampsia if they had severe periodontal
disease at delivery (adjusted odds ratio 2.4, 95% confidence
interval 1.1, 5.3), or if they had periodontal disease pro-
gression during pregnancy (adjusted odds ratio 2.1, 95%
confidence interval 1.0, 4.4) . In a case-control study,
Canakci et al. found that pre-eclamptic patients were 3.5
(95% CI=1.1–11.9) times more likely to have periodon-
tal disease than normotensive patients [P < 0.01) . In
a study of 30 pregnant women, significantly higher peri-
odontal probing depth and clinical attachment level scores
were found among preeclamptic women compared with
non-preeclamptic women. Gingival crevicular fluid levels of
PGE2, TNF-α, and IL-1β levels were all significantly higher
in the preeclamptic group . Further study on the mater-
and on placental pathology in women with periodontal dis-
periodontal disease and preeclampsia is causal or simply as-
sociative. If the relationship between maternal periodontal
disease and preeclampsia risk proves causal in nature, then
prevention of periodontal disease before pregnancy or treat-
ment of periodontal disease during pregnancy may represent
a novel approachs to the prevention of preeclampsia.
Is maternal oral health linked to children’s
experience with tooth decay?
Cariogenic bacteria are typically acquired by young children
through direct salivary transmission from their mothers .
Factors influencing transmission are the levels of these bac-
of transmission, and the child’s receptivity to implantation,
which is largely diet dependent. Additional factors include
timing of transmission, which is affected by the window of
infectivity and the age of the child, and the composition and
tial the transfer will be. For this reason, mothers who have
themselves experienced extensive tooth decay and therefore
most likely harbor high titers of mutans streptococci in their
saliva will more effectively transmit this infection vertically,
thereby puttingtheiryoung childrenatelevated riskforearly
childhood caries. Although maternal cariogenic bacteria can
be isolated in the pre-dentate infant’s mouth , these or-
surface only after teeth first appear at around six months of
age. Because oral flora tends to remain stable over time, a
woman’s cariogenic flora before and during pregnancy an-
ticipates her flora during the child’s first years of life as well
as the likelihood of transmitting infection early to her off-
spring. The lag time between infection and expression of a
including the frequency of simple carbohydrate exposure in
S172 Matern Child Health J (2006) 10:S169–S174
a child’s diet, oral hygiene, and exposure to fluorides. The
evidence that caries is frequently established as a pathologic
process in the mouths of very young children is strong, as
28% of US children, over 4 million toddlers and preschool-
ers, experience one or more frank cavities by ages 2–5 years
Given the biological and behavioral pathways that gov-
ern intergenerational transmission of caries activity, disease
management, and use of dental care, it is not surprising
that disparities in dental caries among adults are mimicked
among their children. As with adults, children of color and
children of low-income families experience substantially
more extensive and severe disease and less treatment than
their peers without these risk factors . Fortunately, de-
spite the high prevalence of caries in women and children,
this disease is readily preventable or manageable though
early and regular dental care, exposure to fluoridated water,
use of appropriate topical fluorides including those in tooth-
pastes, application of sealants to primary teeth, and adoption
of a health-promoting diet like that suggested in the Dietary
Guidelines for Americans .
Is preconception preventive oral health
care the answer?
It is intriguing to consider preconception, pregnancy, or in-
to improve women’s oral and general health, pregnancy out-
comes, and their children’s dental health. Evidence is cur-
rently weakest for interventions that seek to reduce the in-
cidence of preterm low birth weight through oral care. The
mechanism of periodontal disease-associated adverse preg-
nancy outcomes is as yet unclear, and although it is hypoth-
esized that if the ‘insult’ occurs early (either at conception
or implantation) the risk is greater, no direct evidence to
confirms that this is the case. However, given the strong re-
lationship between oral health conditions and periodontal
disease and general health and well-being, oral health care
should be a goal in its own right for all individuals. If treat-
ment of periodontal disease is going to impact pregnancy
outcomes, then it is likely that the therapy will be of greatest
benefit before or in very early pregnancy.
The science supporting interventions before, during, and
after pregnancy to reduce caries transmission is much
stronger. Educational and behavioral interventions that re-
duce caries activity through appropriate use of fluorides, di-
etary guidelines, chlorhexidine gels and varnishes, and xyl-
itol , can reduce a woman’s caries activity and salivary
cariogenic flora, thereby improving her own oral health and,
at the same time, also reducing the risk of transmission to
her offspring. In two landmark Swedish studies [12, 13],
children of mothers who had their cariogenic oral flora sup-
pressed were less likely to experience cavities, more likely
to develop cavities later if they were affected, and had fewer
cavities than children of control mothers. Pregnancy is it-
self often regarded as an opportune time for anticipatory
guidance and oral health education, and is a suitable time,
particularly during the second trimester, for dental repair.
Access to oral health care during pregnancy
The CDC’s Pregnancy Risk Assessment Monitoring System
ceived dental care during their pregnancies [36, 37]—a rate
only half to two-thirds of US women’s overall use of dental
services (67%) (14). The PRAMS data revealed that overall,
pregnant women covered by Medicaid were 24%–53% less
likely to obtain a dental visit during pregnancy than women
who are privately insured. Similarly, women who initiated
prenatal care later than the first trimester, who did not in-
tend the pregnancy, and who were poor were also less likely
to obtain dental care . In contrast, the Behavioral Risk
Factor Surveillance System (BRFSS) revealed that 70% of
pregnant women in the years 1999 and 2002 had received
a dental visit in the prior 12 months . One possible ex-
planation for the higher level reported by BRFSS is that it
includes three or more months of pre-pregnancy time, dur-
the national norm for women. However, in contrast to rec-
ognized disparities in dental care utilization , race and
ethnicity were not significantly associated with dental care
during pregnancy in the BRFSS study. The authors suggest
tors such as prevailing attitudes toward dental care, provider
availability and practice norms, and salient features of medi-
covered by Medicaid were 24%–53% less likely to obtain a
dental visit during pregnancy than women who are privately
insured. Similarly, women who initiated prenatal care later
than the first trimester, who did not intend the pregnancy,
and who were poor were also less likely to obtain care.
An important additional consideration is that dentists are
reportedly reluctant to provide care to pregnant women be-
cause of concern about possible risks . Current prac-
tice typically limits non-urgent dental treatment of pregnant
sible teratogenic consequences during the first trimester and
trimester. A single study relating antepartum dental radiog-
raphy with full term low birth weight raised concern about
the safety of dental care during pregnancy , but was crit-
icized for its methodology. Neither professional associations
nor government agencies have promulgated any authorita-
tive guidance regarding dental care of pregnant women, al-
Matern Child Health J (2006) 10:S169–S174S173
determine the impact of dental care for periodontal disease
during pregnancy on preterm low birth weight outcomes.
Currently, the New York State Department of Health is de-
veloping “Guidelines for Prenatal Care, Oral Health, and
Child Health Professionals” that promotes routine use of
dental care during pregnancy.
Independent of pregnancy, the presence and source of
dental insurance coverage is an important predictor of dental
care utilization, with publicly insured adults experiencing
higher levels of oral diseases but less access to dental care.
women as this program covers approximately 1/3rd of births
in the US. However, states vary widely in adult Medicaid
dental coverage, and at present only 7 jurisdictions provid-
ing comprehensive care to eligible adults. In contrast, low
income pregnant women seeking dental services find them-
selves with no coverage in 8 states, coverage for only relief
of pain or infection in 18 states or eligible for a limited range
of services in 18 states. Three states (UT, LA, CA) have
recently expanded dental benefits specifically to pregnant
women in anticipation of reduced rates of unfavorable preg-
nancy outcomes. Pregnancy may be the only time that some
low-income woman can readily obtain dental care as some
state Medicaid programs provide adult dental coverage only
to pregnant women or enhanced coverage during pregnancy.
Conclusions and future directions
Data are emerging to support a role for maternal periodontal
tal disease and the possibility of preterm birth prevention by
treatment of oral infection make this a novel approach to im-
to-be born children. Further studies to better understand the
mechanism of periodontal disease-associated preterm birth
will enable us to tailor treatment to those women who might
benefit the most.
Data on the relationship between maternal and child ex-
gardless of the potential for improved oral health to improve
pregnancy outcomes, public policies that support compre-
hensive dental services for vulnerable women of childbear-
ing age should be expanded, so not only their own oral and
general health is safeguarded but also so that their children’s
risk of caries is reduced. Particularly if NIH trials confirm
the incidence of unfavorable birth outcomes, the Centers for
ber 2004 coverage expansions for pregnant women by
for pregnant women.
The power of prevention needs to be brought to bear, as
both periodontal disease and caries are overwhelmingly pre-
and effective home care for periodontal disease and use of
provides a “teachable moment” in self-care and future child-
care, prenatal education should universally adopt an oral
health component. This educational intervention should pri-
oritize those mothers who have suffered significantly from
dental caries so that they can learn to effectively prevent
transfer of this disease to their children.
To be effective, oral health promotion must first seek to
educate women and their health care providers about the
importance of oral health and must promote an understand-
ing of their ability to prevent and manage both periodontal
disease and caries and to thereby limit the personal and in-
tergenerational consequences of both conditions.
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