The pandemic has affected all of us – for some, it has had positive outcomes, for others, the result has been tragic. We have been all been vulnerable – emotionally and psychologically, living with the paranoia that we might contract the COVID-19 virus at any point. For the purpose of this article, I will be focussing on how the general public’s oral health has been affected, regarding access to dental/oral health care, with a particular focus on looking at mums- to-be and the common oral challenges faced during this specific phase. It would appear that even prior to the pandemic the uptake of dental care and oral health awareness amongst expectant women has not been optimised, presenting opportunities to further increase access to oral health services for mums to be.

Last September, I won a fully funded (sponsored by Philips) place on Victoria Wilson’s (who is the creator and director of Smile Revolution) “How To Launch an Oral Health Promotion Project/Business” 5 weeks’ course. This course is aimed at helping us find our inspiration in how to help the public’s oral health and how to sustainably do so. It was here that my project “Mother of Molars” was created.

As we are all aware, a pregnant woman’s body undergoes numerous changes throughout the process – mainly due to this miraculous life growing inside of them, and the other reason would be the raging hormones having a massive impact on these individuals’ lives. Scientific studies have demonstrated possible links between gum disease and adverse pregnancy outcomes such as going into pre-term labour; but it is mentioned that ‘Periodontal treatment during pregnancy is safe and effective, but does not seem to reduce risk of adverse pregnancy outcomes’ – Phoebus Madianos, 17 March 2020

In the UK, expectant mothers are entitled to free NHS dental care; it has been documented that this free-of-charge dental service is not taken advantage of nearly enough, for various reasons – currently the primary one being a lack of access to NHS dental practices, who have been trying to cope with constant changes in guidelines, whilst implementing ways to keep themselves and their patients safe. Having spoken to a number of mums, I have realised that first time expectant mums are not aware of the NHS dental care available or have not received enough information regarding changes in their oral health during their pregnancy; yet second time mums seem more aware of oral challenges.

I messaged a few midwives who very kindly responded, explaining to me that there is not much focus on expectant women’ s oral health – they are handed general oral health advice leaflets and are informed that they are able to receive free NHS dental care; that was the extent of the data provided to them.

The following are more common complaints during pregnancy:

My gums are bleeding!

Gingivitis is the inflammation of gums, caused by the release of by-products of bacteria found in plaque – which is a biofilm consisting of food debris, saliva pellicle and oral bacteria. Fluctuations in the hormones (oestrogen and progesterone) during pregnancy tend to affect how the soft tissues react to plaque – which may lead to an increase in bleeding, swelling and sensitivity of the gums, in general and whilst toothbrushing.

If not treated on time, gingivitis may progress to a more severe oral disease called periodontitis – which is the inflammation and destruction of the supporting structures of the dentition – mainly affecting the periodontal ligament and bone. Loss of bone structure in the mouth will result in tooth mobility, and subsequently tooth loss.

It is essential that mothers-to-be (and everyone else) are taught the correct toothbrushing techniques and use of interdental aids, as well as the importance of the use of a fluoride-based toothpaste.

I have a growing lump of my gum!

Granuloma gravidarum (commonly known as pregnancy tumour) is a benign hyperplastic growth that occurs in the mouth, in 5% of pregnancies. It is usually painless and varies in size and shape. The exact cause of its occurrence is still being explored but it has been documented that it is possibly the result of a combination of the presence of plaque, calculus and trauma to localised soft tissue.

My tooth has a hole and it hurts!

Tooth decay is one of the main causes of pain, Expectant women are more prone to experience tooth decay due to altered eating habits and cravings experienced during pregnancy. For tooth decay to occur, one requires the following:

1. Teeth

2. Sugar

3. Bacteria

4. Time

If one of these factors are removed from the equation, decay is less likely to occur.

We would want to not be getting rid of our teeth just to prevent decay, but we can decrease our intake of sugar and reduce the reproduction of oral bacteria. The most important factor here is time – when it comes to caries, it is the frequency of the consumption of sugar which has a more significant impact on the creation of caries. Whilst pregnant women are often advised to eat often and in small quantities to keep their energy levels up, especially during the second and third trimesters; it is essential to inform mothers-to-be of the impact of regular intake of sugar has on teeth. Mums should be encouraged to snack on protein-based food and vegetables instead.

My teeth are so sensitive to cold!

Enamel erosion due to acid reflux and morning sickness throughout pregnancy is a common occurrence – especially during the first trimester. This is further exacerbated by the intense nausea felt when trying to brush in the morning or by the mere smell or even texture of toothpaste. Some expectant mums tend to develop a craving from citrus fruits as well, which would increase the enamel being eroded by the acidic characteristics of citrus fruits.

I have broken my tooth!

We are all prone to chipped or broken tooth and it could happen to anyone. My first and foremost concern here is safeguarding – as dental care professionals, we are responsible for raising concerns regarding signs of domestic abuse. Expectant mums are vulnerable to domestic abuse/violence – especially during the COVID-19 lockdown, where there is barely any face-to-face interaction, therefore less of an opportunity to detect abuse. “Pregnancy is a trigger for domestic abuse and has negative consequences for the woman and her child. Sixty per cent of survivors using domestic abuse services are mothers and 1 in 15 are pregnant women.”

( https://www.rcm.org.uk/media/4067/identifying-caring-for-and-supporting-women-at-risk- of_victims-of-domestic-abuse-during-covid-19-v1__13052020final.pdf )

I am not ok…

Prenatal/antenatal depression is less talked about than postnatal depression but affects expectant women the same way – raging hormones, stressful living conditions, worry about coping with a new baby and a history of depression are only a few of the factors. Women suffering from antenatal depression may be prone to self-neglect – this could result in not receiving adequate nutrition and a lack of personal hygiene – which likely involves a significant

decrease in oral hygiene routine. Poor oral hygiene may result in the challenges mentioned above – pregnancy gingivitis/periodontitis, tooth decay, pregnancy tumour.

I cannot emphasise enough on the necessity of educating pregnant women on the importance of their oral health. Mother of Molars’ mission is to create awareness in women of potential oral health manifestations which may arise during pregnancy – periodontal disease, tooth decay, enamel erosion, and how to avoid them; as well as amplifying the need to maintain good oral health during pregnancy. This article is essentially one of the first steps in creating more awareness in prenatal oral health; so please do share this article with your colleagues, your fellow mums-to-be, via email and social media, and let us all work together in starting a better way of life, from within the womb.

This article is one of the very first steps in starting to create more awareness regarding perinatal oral health. COVID-19 pandemic has impacted all of us emotionally, physically and mentally – mothers-to-be are undergoing massive changes in their body and must be given the extra support. A study carried out in The Ultrasound Department at St. Thomas Hospital in 2014 completed a questionnaire revealing that oral health knowledge amongst pregnant women is still deficient in numerous ways, especially factors playing a role in tooth decay, the importance of fluoride varnish and timing of toothbrushing ( https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5962892/ ).

A collaborative approach among healthcare professionals, in this case, midwives and health visitors, would encourage progress in prenatal oral health advice and dental care. The vision of “Mother of Molars” is to be a multi-faceted collaborative project to promote optimal oral health in the prenatal phase of motherhood and the mission is to reduce the overall oral systemic impact.