Lesions of the oral mucosa and periodontal disease behavior in pregnant patients

DÍAZ-GUZMÁN LM, CASTELLANOS-SUÁREZ JL. LESIONS OF THE ORAL MUCOSA AND PERIODONTAL DISEASE BEHAVIOR IN PREGNANT PATIENTS. MED ORAL PATOL ORAL CIR BUCAL 2004;9:430-7.

ABSTRACT

-Aims. A study is made to contrast the prevalence and severity of periodontal disease, the needs for periodontal treatment, and the prevalence of lesions of the oral mucosa in pregnant (study group) and non-pregnant women.
-Study design. During the period 1991-1999, a prospective observational study was made of 7952 women seen in the Dental School of De La Salle Bajío University (León, Gto. Mexico). The following variables were documented: age, disease antecedents, simplified periodontal index, and lesions of the oral mucosa. Two patient groups were defined: pregnant and non-pregnant women exhibiting a similar age distribution. The data were presented as percentages, and comparisons were made based on the chi-square test.
-Results. Pregnancy was not found to be a decisive factor for the development of periodontal disease, no differences in the prevalence of gingivitis (54.54 and 50.50%) and periodontitis (31.82 and 31.75%) being observed between the two groups. However, the severity of periodontitis was significantly greater among the pregnant women (18.18% versus 9.88%; p< 0.01). The prevalence of oral mucosal lesions was similar in both groups (30%), 13 lesions being identified in the study group, with a predominance of leukoedema, traumatic ulceration, red traumatic lesions, benign migratory glossitis (geographic tongue), irritative keratosis and pyogenic granuloma. The non-pregnant women in turn exhibited 57 lesions. Pyogenic granuloma and benign migratory glossitis exhibited significant differences between the two groups (p< 0.005).
-Conclusions. Gingivitis and periodontitis showed similar prevalences in pregnant and non-pregnant women, though severe periodontitis was more frequent among the former. Pyogenic granuloma and benign migratory glossitis were the lesions with the greatest prevalences during pregnancy.

Key words: Pregnancy, gingivitis, periodontitis, pyogenic granuloma.

INTRODUCTION

Pregnancy constitutes a special physiological state characterized by a series of temporary adaptive changes in body structure, as the result of an increased production of estrogens, progesterone, gonadotropins, and relaxin, among other hormones. The oral cavity is also affected by such endocrine actions, and may present both transient and irreversible changes as well as modifications that are considered pathological (1). In this context, different oral lesions are reported to be common during pregnancy. In effect, an increased prevalence of dental alterations has been documented, including particularly caries (99.38%) and erosions (2-7). The mechanisms by which women are susceptible to dental loss during pregnancy have not been fully clarified; however, rather than a direct consequence of pregnancy as such, they seem to be more attributable to altered oral hygiene habits (1).

Gingivitis and gingival growth are considered by some authors to be so common during this period that some investigators consider gingival bleeding and growth to be “normal” in such patients. Gingival inflammation can reach prevalences of 50-98.25% in such situations (1,4). On the other hand, periodontitis is also considered to be common during pregnancy, and some authors have reported an increase in tooth mobility during gestation. In turn, periodontal disease in pregnant women has been suggested to be a risk factor for premature birth or low birth weight (8-15).

Regarding the oral lesions, pyogenic granuloma (or pregnancy tumor) seems to be common in pregnant women, with a prevalence of about 5% in the gestating female population. This phenomenon is usually explained in terms of the increase in estrogen activity and its influence upon the vascular component of tissues (16-18).

The international literature abounds with epidemiological studies of oral lesions (19-24), though few studies offer information on the oral lesions characterizing pregnancy (18). Knowledge of such lesions, derived from actual pregnancy or attributable to the circumstances associated with this special physiological state, may allow early identification and management of such alterations - thus helping dental professionals and health authorities to anticipate the associated service demands and costs.

The present study explores the prevalence and severity of periodontal disease, the needs for periodontal treatment, and the prevalence of lesions of the oral mucosa in pregnant (study group) and non-pregnant women, with a view to define strategies for the diagnosis and management of such problems among the former population subgroup.

MATERIAL AND METHODS

The study comprised all consecutive patients over 15 years of age requesting dental care in the Admission and Diagnostic Clinic of the Dental School of De La Salle Bajío University (León, Gto. Mexico), during the period between January 1991 and December 1999. Patient age and personal disease antecedents were documented in all cases.

The patients were systematically examined based on the head and neck clinical examination protocol used in our institution (25), with recording of the following variables:

a)Simplified periodontal index (15)

This index allows the classification of healthy subjects and patients with gingival alterations, early and advanced periodontitis, or edentulism, and helps identify the needs for periodontal treatment. Six representative teeth of the permanent dentition and located in both arches are evaluated: two molars, two premolars and two central incisors (teeth 16, 21, 24, 36, 41 and 44). The following is recorded for each of these teeth: (a) depth (in mm) of the gingival sulcus at two locations (mesiobuccal and distolingual), using a Michigan-O periodontal probe; (b) tooth mobility (0 = no mobility, 1 = mobility); and (c) bleeding (0 = none, 1 = positive). The minimum index score for each tooth is two (1 mm mesiobuccal and distolingual depth, without mobility or bleeding), while the maximum score is 22 (10 mm depth for each gingival sulcus location, with one point for mobility and another point for positive bleeding). The recorded scores are then summed to yield a figure corresponding to the simplified periodontal index. Based on this scoring system, prevalence and morbidity are rated as follows: healthy (12-24 points), gingival alterations (25-35 points), early periodontitis (36-45 points), and advanced periodontitis (46-132 points). Edentulous patients are assigned a score of zero.

b)Oral mucosal lesions

All identified oral lesions were recorded - with the exception of localized mucosal lesions of pulp origin, due to the great frequency of such alterations. The lesions were clinically diagnosed by one of the investigators, with experience in oral pathology. All lesions requiring histological evaluation for diagnosis were biopsied accordingly.

Two groups were defined: pregnant women (study group) and non-pregnant women (control). The latter group only included subjects with the same age distribution as the study group, in order to allow comparisons between the two patient populations. The results obtained were expressed as percentages. The frequency of periodontal disease and oral mucosal lesions among the controls was taken to be the expected frequency of such alterations, to the effects of statistical comparison (based on the chi-square test) with the group of pregnant women.

RESULTS

A total of 7952 women (all over 15 years of age) were interviewed and examined, and distributed as follows: (a) study group (93 pregnant women) and (b) control group (5537 non-pregnant women aged 16-47 years, in coincidence with the age range of the pregnant women). The rest of the series was not included in the evaluation of results, i.e., a final total of 5630 patients were subjected to statistical analysis (see demographic data in Table 1). The mean patient age (± standard deviation, SD) was 30.03 (± 6.60) and 33.16 years (± 15.31) in the group of pregnant women and in the control series, respectively.

Pregnancy was not found to be a decisive factor for the development of gingival disease, no differences in the prevalence of gingivitis (54.54 and 50.50%) and periodontitis (31.82 and 31.76%) being observed between the two groups (Table 1). However, the severity of periodontitis was significantly greater among the pregnant women (18.18% versus 9.88%; p< 0.01). Edentulism was only observed in the non-pregnant group (0.34%).

Over 30% of the women (both pregnant and non-pregnant) presented periodontal problems amenable to specialized periodontal treatment.

The prevalence of oral mucosal lesions was similar in both groups (30%), though slightly greater among the controls (27.10% versus 24.73% in the pregnant women). Table 2 summarizes the 13 lesions identified in the study group. The non-pregnant women in turn exhibited 57 lesions. The prenant patients showed a predominance of leukoedema (5.38%), traumatic ulceration (4.30%), red traumatic lesions (4.30%), benign migratory glossitis (geographic tongue)(3.23%), irritative keratosis (3.23%) and pyogenic granuloma (pregnancy tumor)(2.15%). On contrasting the prevalence of oral mucosal lesions between the two patient groups (Table 2), significant differences between them were observed for pyogenic granuloma and benign migratory glossitis (p< 0.005).

DISCUSSION

Much has been written in the literature on the increased prevalence of gingival and periodontal problems during pregnancy. However, the results of the present study suggest similar percentages relating to periodontal health, gingivitis and periodontitis in pregnant and in non-pregnant women. A number of recent studies have likewise failed to detect significant differences in the prevalence and severity of gingival or periodontal disease between pregnant women and non-pregnant women, or alternatively report an increased prevalence of gingivitis among the former, but no comparatively greater periodontal destruction. In Chile, López et al. (14) obtained results similar to our own. These authors found that pregnant women with previously established periodontitis do not suffer an increase in dental supportive tissue destruction - despite the absence of periodontal treatment.

Other authors (26-27) have described a close relation between the severity and intensity of the clinical manifestations of gingivitis and periodontitis, and patient socioeconomic and cultural status. Accordingly, an increased cultural level, education in dental care, and compliance with post-periodontal treatment control visits seem to improve periodontal health during pregnancy. Although these variables were not addressed in the present study, they may be the key to interpreting the results obtained.

During pregnancy, the placenta produces abundant estrogens (up to 100-fold the normal levels) and progesterone (up to 10-fold the normal concentrations). Progesterone is partially metabolized in inflamed gingival tissue, thus generating a greater amount of the active form of this hormone - which in turn favors the proliferation of different cell types, including endothelial cells. Ojanotko-Harri et al. (28) suggest that high progesterone levels induce a degree of immune suppression, which in turn contributes to inhibit inflammatory cell function and produce alterations in the response to bacterial plaque - the outcome being gingivitis with more intense clinical manifestations. Progesterone and estrogens in this context increase vascularization and contribute to magnify the corresponding inflammatory responses.

Hormone levels during pregnancy do not appear to have influenced the development of gingival disease in the women belonging to the study group, since gingivitis and periodontitis were observed in both pregnant and non-pregnant women - thus suggesting that the disorder may have been present since before pregnancy. While pregnancy does not intrinsically cause periodontal disease, it seems to intensify already established periodontal damage.

Prevalence studies of oral lesions inform us of the buccal health of the population. Meeting the important demand for specialized oral care, reflected by the fact that over 30% of the pregnant women required periodontal treatment, would imply important economic costs and the need for considerable personnel capacitation. However, such treatment could contribute to eliminate the notion that “all pregnant women must lose one tooth per child”.

Regarding oral mucosal lesions, pyogenic granuloma traditionally has been described as part of the alterations accompanying pregnancy, and our own results appear to confirm this. The prevalence found in pregnant women (2.15%) falls within the range reported by other investigators such as Díaz-Romero et al. (29), and differs considerably from the figure reported for the general population (19,20,23-24). Pyogenic granuloma is a benign reactive inflammatory lesion composed of proliferating capillaries. It tends to present as a smooth or lobulated, sessile or pediculate red mass. In the oral cavity it usually develops in the papillary gingiva, and less frequently in the labial or cheek mucosa, or tongue. When present during pregnancy it is also referred to as pregnancy tumor or gravid granuloma (16). According to Daley, pyogenic granulomas and pregnancy tumors are different lesions exhibiting the same histological structure - the latter depending for their development and growth on the presence of high levels of estrogens and progesterone, since these hormones induce important vascularization. In searching for an explanation for the high prevalence of these lesions during pregnancy, Whitaker et al. (30) quantified estrogen and progesterone receptors, without observing significant differences in their numbers in the pyogenic granulomas of pregnant versus and non-pregnant women, or males. They concluded that the presence of these receptors does not intervene in the pathogenesis of such lesions.

Estrogens and progesterone do not intrinsically seem to induce the development of these lesions; rather, they increase the vascularity of gums affected by gingivitis and periodontitis. The inflammation delays progesterone metabolism, increasing the levels of the hormone in its active form within these tissues, and therefore facilitating the action of local irritants such as trauma or bacterial plaque, and the development of pyogenic granuloma. (28) As early as 1967, Lindhe et al. (31) showed the local application of estrogens and progesterone to favor vascular development in areas of minor traumatism. Some authors have reported an increased presence of vascular endothelial growth factor (VEGF) and fibroblastic growth factor (bFGF) in these lesions - a situation which would contribute to the development of important vascularization in pyogenic granuloma (32-33) .

Of note is the fact that benign migratory glossitis showed a significantly greater prevalence in pregnant women (3.23%) versus non-pregnant women - though this figure is similar to that reported by Bouquot (3%) in Anglo-Saxon women pertaining to the general population (19). Musyka et al. in turn reported a 6% prevalence in pregnant human immunodeficiency virus (HIV)-negative women, versus 4.3% in pregnant HIV-positive women (18). Benign migratory glossitis traditionally has not been included among the oral alterations associated with pregnancy, and may constitute a casual observation in our series. Considering the lack of information regarding the possible association between benign migratory glossitis and pregnancy, further studies are advisable to further explore the increased presence of this disorder in pregnancy.

Special centers for the care of pregnant women could contribute prevalence and severity statistics relating to both periodontal disease and oral mucosal lesions different to those reported in our study. The dental services offered by such centers would possibly also deal with a greater number of acute cases; however, since neither oral lesions nor periodontal problems constituted the reason for consultation in our series (with the exception of three patients), the findings corresponding to this group of subjects requesting oral care could be extrapolated to pregnant women in general.

The specific oral requirements of pregnant women point to the need for schemes or protocols for the management of pregnant women in the dental clinic (34,35), including not only exhaustive preventive programs in terms of bacterial plaque control and the elimination of sources of local irritation, but also the early identification of periodontal disease or lesions such as pyogenic granuloma. The dental professional in contact with such patients must be able to offer adequate management for early periodontal disease, with specialist interconsultation as required, in the presence of moderate or advanced periodontitis.

CONCLUSIONS

Pregnancy does not appear to constitute a risk factor for increased gingivitis and early periodontitis. Apparently, the periodontal problems recorded in our series of patients were already established prior to pregnancy. However, in relation to advanced periodontitis, the increase in hormone levels characterizing pregnancy seems to intensify dental supportive tissue destruction.

Although the needs for specialized periodontal treatment were similar in both patient series (pregnant and non-pregnant women), the requirements were comparatively greater among pregnant women - with an increased presence of advanced periodontitis.

The prevalence of oral mucosal lesions was similar in pregnant and non-pregnant women (30%). Pyogenic granuloma and benign migratory glossitis were the only lesions seen to be more common during pregnancy. The increase in hormone concentrations characterizing pregnancy favors the development of pyogenic granuloma, particularly in patients exposed to the action of local irritants.

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