By Kevin J. Hale, DDS, and Martin J. Makowski, DDS
Although few outside of the immediate stakeholders within oral health are aware of it, significant activities have taken place over the last few years regarding perinatal and infant oral health. The state of Michigan, in its ongoing efforts to lower infant morbidity and mortality, has stepped up activities surrounding this issue including the oral health of pregnant women, new mothers and their babies. In order to achieve improved outcomes, the dental community is reaching out to our medical colleagues by providing better understanding and rationale for early intervention.
Understanding cariology
To understand cariology, one must first grasp the dynamic of normal flora or indigenous biota. Normal flora is, for the most part, species and site specific. Once established, normal flora is relatively stable throughout the life of the host (us) and, interestingly, resistant to the introduction of new organisms. In fact, it has been theorized that the evolutionary function of normal flora is to form a complex eco-system that results in a symbiotic mutualism between the host and their flora. The human mouth is no exception.
The mouth is home to nearly as many micro-organisms as there are humans on this globe. These 6 to 7 billion organisms are made up of an estimated 1000 different species of microbes. Of these, nearly 80% are benign, causing no pathology; however, within the remaining 20% of microbes are those responsible for periodontal disease and dental decay. The problem arises when environmental changes occur within the mouth that select for an overgrowth of pathologic organisms resulting in pathology. Thus, periodontal disease and dental decay are classified as non-classical infectious diseases, since they arise from shifts in sub-population ratios between benign and pathogenic normal flora.
Dental decay results from an overgrowth of specific microbes that are both acidogenic (acid producing) and aciduric (acid enduring). Thus, the study of shifts within microbial sub-populations resulting in dental decay is called "cariology." Caries is the process and dental decay is the pathologic endpoint. One who is prone to cavities is said to have caries, and the intervention strategy is to manage the patient's caries process so it does not result in decay. Since normal flora, once established are tenaciously resistant to qualitative change, individuals with caries are chronically managed rather than cured, and successful management requires time and behavioral changes on the part of the patient.
Many of the environmental influences upon the mouth that can enhance a patient's predisposition to decay are obvious, while others are subtle. Simple sugars that are concentrated by plaque (which microbes use to hang on to the teeth) have been shown to increase dental decay, as have poor oral hygiene practices and reduced fluoride exposure. Additionally, patients who smoke or suffer from gastroesophageal reflux disease (GERD) are more prone to decay, and mothers often report enhanced decay associated with their pregnancies.
Intergenerational aspects of caries
It has been known since the 1940s that caries patterns tend to run in families along the maternal line. This is of little surprise, since the mother is the most likely colonization source for the normal flora of her children, including oral flora. What remains a curiosity in this process is that decay patterns can vary widely within sibling order. Although there are numerous statistical outliers, by in large, later order siblings are most prone to decay.
An explanation for these observations can be derived by examining the environmental changes that occur within the mouth of the mother prior to and after delivery of her infant. Dietary, endocrine, oral hygiene and a multitude of additional changes that accompany pregnancy result in shifts in sub-population ratios of benign to cariogenic flora. Additionally, these environmental changes result in epi-genetic transitions in the flora, resulting in increased virulence of the cariogenic flora of the mother's mouth. This coupled with colonization timing, diet and oral care of her newborn will result in a child who is more or less prone to early decay.
Interventional strategies
The greatest care we can provide to patients is to seek out opportunities for enhanced outcomes. The goal of therapeutic interventions regarding perinatal and infant oral health is to prevent disease, mitigate suffering and contain cost; however, given the appropriate timing of intervention, dentists cannot do this alone.
Pregnant women should receive dental care throughout their pregnancies1 and immediately afterward and infants should visit the dentist by one-year of age.2 A Dental Home is the most effective means by which a mother and her infant's caries processes can be managed, with the ultimate goal of sparing a very young child the ordeal of dental, surgical intervention.
On behalf of dentists of Michigan, we ask that you work with us to provide better outcomes for all our patients. Dentists who accept pregnant women and infants can be located through the Points of Light website at www.points-of-light.org or by contacting the Michigan Dental Association.
Dr. Hale is director of the Points of Light Project and a Fellow of the American Academy of Pediatric Dentistry. Dr. Makowski served as president of the Michigan Dental Association during 2014-15 and is a Fellow of the American Academy of Pediatric Dentistry.
References
- American Academy of Pediatric Dentistry, Council on Clinical Affairs. Guideline on Perinatal Oral Health Care. Chicago (IL) 2011; 36: 135-140.
- American Academy of Pediatrics, Section on Oral Health. Maintaining and Improving the Oral Health of Young Children. Pediatrics 2014; 134: 1224-1229.