Tooth decay in pregnancy is the destruction of tooth enamel, cement, dentin, detected during gestation. It is manifested by a change in the color of teeth, the appearance of dark or white spots on their surface, increased sensitivity to mechanical, temperature, chemical stimuli, the occurrence of pain syndrome during exposure. It is diagnosed by examination with a dental mirror and probe, vital staining with caries detectors, transillumination, laser examination, electro-dental diagnostics. Methods of remineralizing therapy, filling are used for treatment.
K02 Tooth decay
According to observations in the field of obstetrics, tooth decay in pregnancy is one of the most common pathologies of the gestational period. It is found in 91.4% of women with a normal pregnancy and in 94% — in the presence of gestosis. In pregnant women, the level of caries intensity increases, reflecting the average number of affected teeth. The indicator reaches 5.4-6.5 against 2.7-4.4 in the general population. 79% of patients carrying a child note an increase in sensitivity (hyperesthesia) of the enamel. Pathology is more often detected in patients from low-income families who are subjected to significant physical and emotional stress, eat carbohydrate foods with low amounts of minerals, and care for their teeth irregularly.
The main etiological factor leading to the destruction of hard tooth tissues is the effect of acids that are released by cariesogenic streptococci (Str. mutans, Str. mitis, Str. salivarius, Str. sanguis) and lactobacilli of plaque. The probability of developing caries increases with insufficient hygienic care, the presence of dental defects (pits, grooves, cracks on the enamel), the use of a large amount of fermented carbohydrates, sweet and sour foods, frequent snacks, impaired salivation, low fluoride content in water. Pregnant women have a number of additional prerequisites for the destruction of dental tissue:
- A change in the composition of saliva. Increased consumption of calcium and fluoride, necessary for the formation of fetal tissues, causes a deficiency of these trace elements in saliva. As a result, the processes of remineralization of enamel slow down or stop, it becomes more vulnerable to damage by bacteria that provoke caries.
- Reduction of humoral and cellular immunity. To prevent rejection of the fetus, which is a foreign body for a pregnant woman, an immune restructuring occurs in the woman’s body. This leads to a deterioration of the bactericidal properties of saliva, which normally ensures the elimination of a significant part of the cariesogenic microorganisms.
- Changing taste preferences. Pregnant women often experience cravings for sour, salty, sweet. The main substrate for the reproduction of cariesogenic bacteria is sugars formed during the fermentation of carbohydrates. The situation is aggravated by the creation of an acidic environment due to the use of pickles and canned foods.
The key mechanism of caries development in pregnant women is the destruction of inorganic mineral components of tooth enamel under the action of lactic, acetic, formic, propionic, and other weak organic acids. Cariesogenic bacteria of the oral cavity, the content of which increases during pregnancy, attach to the protective pellicle, forming a soft plaque. Microorganisms ferment food sugars to organic acids that diffuse into hard tissues and wash out calcium and phosphorus from the enamel. Since the remineralization of enamel is disrupted due to changes in the composition of saliva, destructive processes with the formation of a carious cavity occur faster in pregnant women than in non-pregnant women.
When systematizing the forms of tooth decay in pregnancy, specialists in the field of dentistry take into account the time of pathology detection, histological features of the process, localization, and depth of the lesion. The disease in pregnant women can be primary, secondary with the formation of a carious cavity in a sealed tooth, which recurs with the continuation of destruction in the same area. According to the international classification, there are caries of enamel, dentin, cement, and the suspended process of tooth destruction. Choosing the tactics of managing a pregnant woman, it is most convenient to use the topographic systematization of the carious process, created taking into account the stage of the disease. Based on this criterion , they distinguish:
- Initial caries (carious spot). Hard tissues undergo superficial focal demineralization. With active destruction, a white spot is formed, with a slow one — a brown one. The use of minimally invasive methods of treatment is allowed.
- Superficial caries. The destructive process does not go beyond the enamel. The dentin-enamel connection is preserved. The first clinical signs of dental damage may appear. During treatment, mechanical treatment of the cavity is mandatory.
- Medium caries. The carious cavity extends to the superficial (cloaked) dentin. Damage to the enamel-dentine joint is detected. Clinical symptoms are pronounced. It requires mandatory treatment with the removal of destroyed tissues.
- Deep caries. Periculpar dentin is involved in the destructive process, which is accompanied by an increase in pain syndrome. Without urgent treatment, it is possible to damage the pulp with subsequent complications in the form of pulpitis and periodontitis.
Pregnant women are more likely to develop subcompensated forms of caries, in which the number of damaged teeth is greater than the average intensity of the corresponding age group. Decompensation of the disease (acute caries) with the formation of multiple cavities and systemic damage to the teeth is rarely observed – with a significant violation of immunity, severe calcium deficiency, lack of dental care.
At the initial stage, the disease is asymptomatic and becomes an accidental finding during a preventive dental examination, during which a local lightening or darkening of the enamel is detected. Patients who have a carious cavity, note an increase in dental sensitivity to cold, sour, sweet, salty. With deep caries, a pregnant woman complains of short-term pain that occurs when biting a damaged tooth, the action of thermal, chemical irritants and pass after their elimination. The appearance of persistent intense pain indicates the involvement of the pulp in the process.
Uncomplicated caries does not affect the course and outcome of gestation, however, in the presence of pain syndrome, it can worsen the quality of life of a pregnant woman, disrupt her emotional state, increase irritability. Due to accelerated tissue destruction, tooth decay in pregnancy is more often complicated by pulpitis, periodontitis, and in the absence of adequate treatment – periostitis of the upper or lower jaw, abscesses, osteomyelitis, phlegmon of the soft tissues of the face, sepsis. In the event of infectious-septic complications, the probability of intrauterine infection of the fetus, chorioamnionitis, endometritis, premature birth increases. A long-term consequence of untreated caries is the destruction of the tooth with the need for its extraction and replacement with a prosthesis.
If a pregnant woman has characteristic symptoms, confirmation of the diagnosis is not particularly difficult. The list of the main tasks of the diagnostic search includes the exclusion of non-carious diseases and the timely identification of forms of the carious process in which urgent treatment is necessary. A feature of the diagnosis of tooth decay in pregnancy is the X-ray of the tooth only in urgent cases and the complete rejection of X-ray studies in the 1st trimester of pregnancy. The most informative methods of examination are considered to be:
- Examination of the oral cavity. Pregnant women with caries have white and dark spots on the enamel, cavities with softened contents. If necessary, methylene blue and other caries detectors adsorbed by the carious spot are applied to doubtful areas. A dental mirror and a probe are used to examine cavities and determine sensitivity. To detect caries of the touching surfaces of the teeth, thermal reflectors are used.
- Electro-dental diagnostics of the tooth. The method is recommended as an alternative to X-ray examination. Based on the data on the strength of the electric current, the depth of tissue damage is estimated. In pathological processes, the electrical excitability of the pulp worsens. The presence of caries is indicated by an increase in the level of current causing the tooth reaction to 9-20 µA. In complicated forms of the disease, this indicator reaches 21-80 mcA or more.
- Dental transillumination. When illuminated with a cold light beam, the initial caries has the appearance of specks of different sizes with an uneven contour, the cavity is defined as a brown hemisphere, delimited from the surrounding healthy tissues. The effectiveness of the technique is higher when examining the frontal teeth. The advantages of transillumination are non-invasiveness and safety, due to which the study is recommended for pregnant women.
- Laser diagnostics. The method is based on changing the reflection of the laser beam from damaged tissues. The diagnostic device signals the detection of caries by sound. The study is characterized by safety and high sensitivity, allows you to identify the carious process in the early stages, in areas that are difficult to inspect (interdental spaces, dental root areas). It can be used to diagnose a secondary process.
Initial caries is differentiated with non—carious diseases in pregnant women — spotted forms of systemic and local enamel hypoplasia, endemic fluorosis, superficial, medium and deep – with a furrowed form of systemic hypoplasia, erosive fluorosis, erosion, wedge-shaped defect, acid necrosis of teeth, chronic fibrous periodontitis, acute focal, chronic fibrous or gangrenous pulpitis. According to the indications, an obstetrician-gynecologist or dentist prescribes consultations of a periodontist, a maxillofacial surgeon to the patient.
A key feature of the choice of therapeutic tactics during pregnancy is the limited use of a number of methods and drugs traditionally used to repair damaged tissues. When drawing up a dental treatment plan, the gestational age, the dynamics of development, the severity of caries symptoms, and the presence of complications are taken into account. The recommended methods of therapy are:
- Remineralization of damaged tissues. Applications or electrophoresis of calcium- and fluorine-containing preparations are indicated at the stage of a carious spot. Before the start of the treatment procedure, the tooth is cleaned of plaque and pellicles, the chalky spot is treated with weak acid solutions and washed with water. The effectiveness of remineralization increases with careful oral care, the use of fluoride-containing therapeutic toothpastes by a pregnant woman.
- Filling of the carious cavity. The optimal solution for restoring the integrity of the tooth with superficial, medium, deep caries. Before installing the seal during preparation, the damaged tissues are removed by a drill or manually by a dental excavator, after which the defect is replaced with composite materials, amalgam, ceramics. In the presence of deep caries, a therapeutic and insulating gasket is installed under the seal.
The most favorable period for filling is the second trimester of pregnancy, when the risk of undesirable effects on the fetus is minimal. When choosing anesthetics, analgesics, antibiotics, their toxicity is taken into account. In the first trimester, due to the possible effect on embryogenesis, caries treatment is carried out only in the presence of acute pain and purulent inflammation. Limitations for performing therapeutic manipulations in the third trimester are the increased sensitivity of the uterus to external stressful influences, which can provoke premature birth, and the risk of developing inferior vena cava syndrome in a pregnant woman with a prolonged stay in a reclining position. Removal of destroyed teeth, prosthetics, installation of implants is recommended to be carried out in the postpartum period. Pregnant women suffering from caries are shown natural childbirth. Caesarean section is performed when obstetric complications are detected.
Prognosis and prevention
Tooth decay in pregnancy usually does not pose a danger to the pregnant woman and the fetus. Patients with signs of tooth destruction need to sanitize the oral cavity before the planned gestation, and during pregnancy regularly visit a dental hygienist. For preventive purposes, it is recommended to clean teeth after each meal with pastes with a remineralizing effect, mouthwash with antiseptic elixirs, and the use of dental floss. It is necessary to limit the use of sweet, flour, especially confectionery, supplement the diet with products containing calcium and complex vitamin and mineral supplements. Early filling in the second trimester allows you to save the tooth by dissecting its smaller part.