Interacțiunea dintre sarcină și sănătatea orală: dovezi actuale și implicații clinice – o analiză narativă a studiilor clinice și epidemiologice

1. Introduction

Oral health is increasingly recognized as a fundamental component of general health, with implications that extend beyond the oral cavity and influence systemic conditions and overall quality of life⁽¹⁾. During pregnancy, this relationship becomes particularly significant, as the physiological, hormonal and immunological adaptations necessary to support fetal development may also alter the susceptibility to oral disease⁽²⁾. Despite this, oral health has historically remained peripheral to prenatal care models, often overshadowed by other maternal health priorities^(1,2).

Pregnancy is characterized by profound endocrine changes, including elevated estrogen and progesterone levels, which modulate vascular permeability, connective tissue turnover and inflammatory responses within the gingival and periodontal tissues⁽³⁾. Concurrent immunological adaptations aimed at maintaining maternal-fetal tolerance may further influence host-microbial interactions in the oral environment⁽⁴⁾. These biological changes occur alongside behavioral and social factors, such as altered dietary patterns, nausea and vomiting, fatigue and misconceptions regarding the safety of dental treatment, which collectively increase the vulnerability to oral inflammatory conditions⁽⁵⁾.

Beyond local oral manifestations, a growing attention has been directed toward the potential systemic implications of maternal oral diseases⁽⁶⁾. Periodontal disease – a chronic inflammatory condition driven by dysbiotic dental plaque biofilms – has been extensively investigated over the past several decades for its possible association with adverse pregnancy outcomes, including preterm birth, low birth weight, hypertensive disorders of pregnancy and impaired fetal growth. The proposed link between periodontal inflammation and obstetric outcomes aligns with the broader evidence connecting chronic inflammation and infection with adverse reproductive health outcomes^(4,5). However, despite decades of research, the strength, consistency and causality of these associations remain subjects of ongoing debates.

At the same time, pregnancy represents a critical life-course window for health promotion. Increased engagement with healthcare services during pregnancy offers unique opportunities for screening, prevention and intervention that may benefit both maternal and child health⁽⁷⁾. From this perspective, oral health during pregnancy should be viewed not only in relation to potential obstetric outcomes but also as an essential dimension of maternal well-being, health equity and intergenerational health⁽⁸⁾.

This narrative review aims to critically synthesize current evidence on oral health during pregnancy, with particular attention to physiological changes, common oral conditions, proposed biological mechanisms and im­pli­ca­tions for clinical practice. By examining the strengths and limitations of the current literature, this re­view seeks to clarify areas of consensus, highlight per­sis­tent gaps, and inform clinical practice and future research.

Unlike prior reviews that focus primarily on adverse obstetric outcomes, this narrative review situates oral health during pregnancy within a broader life-course and health equity framework, emphasizing clinical integration and preventive care.

2. Literature review approach

A narrative literature review was conducted to synthesize current evidence on oral health during pregnancy. A non-systematic search of the literature was performed using PubMed, Scopus and Web of Science.

Search terms included combinations of the following keywords: “pregnancy”, “oral health”, “gingivitis”, “pe­rio­dontitis”, “dental caries”, “adverse pregnancy out­comes”, “preterm birth” and “prenatal care”. Publications in English were considered, with priority given to stu­dies published between 2020 and 2025; earlier landmark studies were included when relevant for contextual un­der­standing.

Titles and abstracts were screened for relevance to pregnancy-related oral health changes, clinical outcomes, biological mechanisms or models of care delivery. Priority was given to systematic reviews, umbrella reviews, randomized controlled trials, large observational studies and professional guidelines published in dental, obstetric and public health journals.

Rather than aiming for exhaustive coverage, this narrative review emphasizes studies that are frequently cited, methodologically sound and clinically informative, allowing for an interpretive synthesis of heterogeneous evidence across biological, clinical and health systems domains.

A narrative review approach was selected due to the substantial heterogeneity in periodontal disease definitions, outcome measures and study designs across the available literature, which limits the feasibility and interpretability of quantitative synthesis. This approach allows for an interpretive integration of biological, clinical and health systems evidence relevant to clinical practice.

3. Physiologic changes during pregnancy and oral health

Pregnancy-related hormonal changes – particularly increases in estrogen and progesterone – exert significant effects on the oral cavity. These hormones enhance vascular permeability and alter the inflammatory response of gingival tissues, increasing susceptibility to gingival edema, erythema and bleeding. Importantly, pregnancy does not cause gingival disease in the absence of dental plaque; rather, it amplifies the inflammatory response to existing plaque biofilm.

Immunologic adaptations during pregnancy, designed to support fetal tolerance, may also influence host response to oral bacteria. Alterations in cell-mediated immunity and cytokine profiles have been proposed as contributing factors to increased gingival inflammation. In addition, pregnancy-related changes in saliva composition and flow, as well as potential shifts in the oral microbiome, may affect caries risk and periodontal health.

Behavioral factors further interact with physiologic changes. Increased frequency of eating, cravings for carbohydrate-rich foods, reduced oral hygiene due to fatigue or gag reflex, and nausea-related vomiting may all contribute to plaque accumulation, enamel erosion and caries development.

4. Common oral conditions during pregnancy

4.1. Pregnancy gingivitis

Pregnancy gingivitis is the most frequently reported oral condition during pregnancy. It is characterized by gingival inflammation, swelling and bleeding, typically emerging or worsening during the second trimester. The condition is reversible and often improves postpartum; however, without adequate plaque control, gingivitis may progress to periodontitis in susceptible women. Preventive strategies include effective oral hygiene, professional dental cleanings and patient education.

4.2. Periodontitis

Periodontitis is a chronic inflammatory disease involving destruction of the supporting structures of the teeth, including periodontal ligament and alveolar bone. While pregnancy may exacerbate gingival inflammation, periodontitis generally predates pregnancy. Risk factors include smoking, diabetes, low socioeconomic status, stress and limited access to dental care. The systemic inflammatory burden associated with periodontitis has prompted extensive research into its potential role in adverse pregnancy outcomes.

4.3. Dental caries and enamel erosion

Pregnant women may experience an increased risk of dental caries due to dietary changes, decreased salivary buffering capacity and reduced attention to oral hygiene. Recurrent vomiting associated with nausea or hyper­emesis gravidarum can expose teeth to gastric acid, leading to enamel erosion and dentin hypersensitivity. Preventive measures include fluoride use, dietary counseling and appropriate management of nausea-related oral acid exposure.

4.4. Pregnancy epulis (pyogenic granuloma)

Pregnancy epulis is a benign, localized gingival overgrowth that may occur in response to local irritation and hormonal influences. These lesions may bleed easily and cause discomfort, but often regress after delivery. The management typically focuses on improved oral hygiene and elimination of local irritants, with surgical intervention reserved for persistent or symptomatic cases.

5. Oral health and adverse pregnancy outcomes

5.1. Biological mechanisms

Several mechanisms have been proposed to explain a potential link between periodontal disease and adverse pregnancy outcomes. One hypothesis involves the systemic dissemination of inflammatory mediators such as prostaglandins and cytokines, which have been hypothesized to play a role in pathways associated with preterm labor. Another proposes translocation of periodontal pathogens or their endotoxins into the maternal bloodstream, potentially affecting placental tissues and fetal development.

The key pathways and clinical implications linking oral health and pregnancy outcomes are summarized in Table 1.

5.2. Epidemiologic evidence

Numerous observational studies have reported associations between maternal periodontitis and outcomes such as preterm birth, low birth weight and preeclampsia^(8,9). However, findings have been inconsistent, with considerable heterogeneity in periodontal disease definitions, outcome measures and adjustment for confounding factors. Social determinants of health, including access to care, nutrition and smoking, complicate the interpretation of these associations. Importantly, most available evidence is observational, limiting causal inference and underscoring the need for cautious interpretation. These findings should be interpreted as associative rather than causal, given the predominance of observational designs and residual confounding by shared social and behavioral risk factors.

5.3. Impact of periodontal treatment

Randomized controlled trials and meta-analyses examining the effect of periodontal therapy during pregnancy have consistently demonstrated improvements in periodontal health and safety of treatment^(5,7,8). However, evidence regarding reductions in adverse pregnancy outcomes remains inconclusive. Differences in study design, disease severity, timing of intervention and population risk profiles likely contribute to variable findings.

6. Safety of dental care during pregnancy

Dental care during pregnancy is widely considered safe and beneficial. Preventive services, diagnostic procedures and necessary restorative treatments should not be delayed. The second trimester is often preferred for elective procedures due to patient comfort, although urgent care is appropriate at any gestational stage.

Local anesthetics are commonly used and considered safe when appropriately administered. Dental radiographs may be performed when clinically indicated, using modern low-dose techniques and appropriate shielding. Deferral of necessary dental treatment may increase the risk of infection and systemic inflammation, potentially posing greater risk than the treatment itself.

7. Prevention and integration into prenatal care

Prenatal care presents a critical opportunity to promote oral health. Simple screening questions regarding oral symptoms, bleeding gums, dental pain and last dental visit can identify women in need of referral. Patient education should emphasize the safety of dental care, the importance of oral hygiene and strategies to manage pregnancy-related oral challenges.

Interprofessional collaboration between obstetric providers, midwives, family physicians and dental professionals is essential to improving access and continuity of care. Addressing structural barriers, such as cost, insurance coverage, transportation and misconceptions about dental safety, is particularly important for reducing disparities.

8. Discussion

The literature on oral health during pregnancy reflects a convergence of biological, clinical and social determinants that shape maternal oral health outcomes. Across diverse populations, pregnancy is consistently associated with increased prevalence and severity of gingival inflammation, a finding that has been robustly attributed to hormonally mediated modulation of the host inflammatory response rather than pregnancy-specific pathogenic processes⁽⁹⁾.

This concept is well supported by longitudinal and mechanistic studies demonstrating that dental plaque remains the primary etiological factor, with pregnancy acting as an amplifying condition rather than a causal one⁽¹⁰⁾.

Importantly, recent evidence suggests that periodontal disease may function as a marker of underlying systemic and social vulnerability rather than a direct causal agent⁽¹⁰⁾.

Within a life-course framework, pregnancy represents a window for identifying oral health-related vulnerability rather than a period in which periodontal treatment alone can reverse the obstetric risk.

Periodontal disease has received particular attention because of its potential systemic implications. Early studies proposed periodontal disease as a potential marker associated with adverse pregnancy outcomes, a hypothesis subsequently examined and synthesized in recent systematic reviews and umbrella analyses⁽¹¹⁾. Subsequent observational studies and systematic reviews have reported associations between periodontitis and preterm birth, low birth weight, preeclampsia and, less consistently, gestational diabetes mellitus^(12,13). Proposed biological mechanisms include increased systemic levels of inflammatory mediators, such as prostaglandin E2 and tumor necrosis factor alpha, as well as translocation of periodontal pathogens and endotoxins to the fetoplacental unit.

Taken together, the existing literature suggests that periodontal disease during pregnancy may be better understood as a clinical marker of cumulative inflammatory burden and social vulnerability rather than as an independent causal factor for adverse pregnancy outcomes. This framework helps reconcile the apparent discrepancy between consistent observational associations and the largely null findings of randomized controlled trials evaluating periodontal treatment during pregnancy. Periodontal disease shares multiple upstream risk factors with adverse pregnancy outcomes, including smoking, socioeconomic disadvantage, psychosocial stress, obesity and limited access to healthcare, which may confound observed associations and limit the effectiveness of late gestational interventions.

Despite the biological plausibility and supportive observational data, the causal nature of these associations remains controversial. A major limitation of the existing literature is the heterogeneity in periodontal disease definitions, diagnostic thresholds and outcome measures, which complicates comparisons across studies⁽¹⁴⁾. Furthermore, periodontal disease shares common risk factors with adverse pregnancy outcomes, including smoking, low socioeconomic status, psychosocial stress, obesity and limited access to healthcare. Inadequate adjustment for these confounders likely inflates the observed associations in some studies, raising the possibility that periodontal disease functions as a marker of broader health and social vulnerability rather than an independent causal factor.

Interventional studies provide critical insights into this debate. Large randomized controlled trials and meta-analyses have consistently demonstrated that nonsurgical periodontal therapy during pregnancy is safe and effective for improving periodontal parameters, such as probing depth and bleeding on probing^(15,16). However, these interventions have not consistently resulted in reductions in preterm birth or low birth weight, a finding reinforced by Cochrane reviews and umbrella analyses^(17,18). Several explanations have been proposed, including insufficient timing of intervention, irreversible early pregnancy inflammatory programming and the possibility that periodontal treatment must be performed preconceptionally to influence the pregnancy outcomes.

Beyond biological mechanisms, the literature increasingly emphasizes the structural and health system factors influencing oral health during pregnancy. Multiple studies have documented low rates of dental care utilization among pregnant women, even in high-income countries, largely due to misconceptions regarding the safety of dental treatment, lack of provider referral, cost barriers and fragmented care systems^(19,20). Importantly, prenatal care providers often report limited training in oral health assessment, further contributing to missed opportunities for prevention and early intervention in this population.

The emerging evidence suggests that integrated, interprofessional models of care may help address these gaps. Educational interventions targeting prenatal care providers have been shown to improve knowledge, confidence and referral behaviors, while patient-centered counseling has been shown to increase dental service utilization during pregnancy^(21,22). From a public health perspective, pregnancy represents a critical life-course window during which oral health interventions may yield benefits extending beyond the mother to the child, including a reduced risk of early childhood caries through decreased vertical transmission of cariogenic bacteria.

From this perspective, periodontal disease may reflect broader systemic and structural determinants of maternal health rather than functioning as a modifiable causal exposure during pregnancy.

Given the predominantly observational nature of the available evidence, causal inferences should be made with caution.

Taken together, the literature supports a paradigm in which oral health during pregnancy is understood not only through the lens of obstetric outcomes, but also as an essential component of maternal health and health equity. While uncertainty remains regarding the impact of periodontal therapy on pregnancy outcomes, the evidence strongly supports preventive care, early assessment and the integration of oral health into routine prenatal services.

9. Gaps and future directions

Despite a substantial and growing body of literature on oral health during pregnancy, several critical gaps persist that limit definitive conclusions and hinder translation into practice. One of the most significant limitations of this study is the heterogeneity in the definition and measurement of periodontal disease across studies. Variability in diagnostic criteria, probing protocols, examiner calibration and disease severity thresholds complicates comparisons across studies and contributes to inconsistent findings regarding associations with pregnancy outcomes. Standardized case definitions and reporting frameworks are required to improve the comparability and reproducibility.

Methodological limitations also extend to the study design. Most evidence linking periodontal disease to adverse pregnancy outcomes is derived from observational studies, which are inherently vulnerable to residual confounding. Shared risk factors, such as smoking, low socioeconomic status, limited access to healthcare, psychosocial stress, obesity and nutritional deficiencies, were not uniformly or adequately controlled across studies. Future research should prioritize well-designed prospective cohort studies with rigorous confounder adjustment and causal inference approaches that can better distinguish correlation from causation.

Interventional research presents additional challen­ges to researchers. While randomized controlled trials have demonstrated the safety of periodontal therapy during pregnancy, its ability to influence obstetric outcomes may be limited by the timing of the intervention. Treatment initiated during the second trimester may occur too late to modify the inflammatory pathways or placental processes established earlier in gestation. Future trials should explore preconception and early pregnancy interventions, assess the dose-response relationships between periodontal treatment intensity and outcomes, and consider stratification by baseline periodontal disease severity and obstetric risk.

Another important gap lies in the limited understanding of the biological mechanisms linking oral disease and pregnancy outcomes. While systemic inflammation and microbial translocation have been widely proposed, direct mechanistic evidence in human pregnancy remains sparse. Advances in microbiome research, immunology and placental biology offer opportunities to elucidate host-microbe interactions, inflammatory signaling pathways and genetic or epigenetic modifiers that may mediate susceptibility to these diseases. The integration of clinical studies with translational and omics-based approaches could substantially advance this field.

Health systems and implementation research remain underdeveloped in the literature. Although professional guidelines increasingly recommend the integration of oral health into prenatal care, evidence of effective, scalable implementation models is limited. Further research is needed to evaluate interprofessional care pathways, provider education interventions, reimbursement policies and digital or community-based strategies that improve access to dental care during pregnancy, particularly among underserved populations.

Finally, disparities in maternal oral health outcomes and access to care warrant greater attention in future studies. The existing studies disproportionately represent high-income settings, whereas data from low- and middle-income countries remain scarce. Future research should adopt equity-focused frameworks to examine how social, structural and policy-level determinants shape pregnant women’s oral health and contribute to intergenerational health inequities.

Addressing these gaps will require interdisciplinary collaboration across the fields of dentistry, obstetrics, epidemiology, immunology and public health. Strengthening the evidence base through methodologically rigorous and equity-oriented research is essential for informing clinical guidelines and fully integrating oral health into comprehensive maternal care.

10. Conclusions

Oral health conditions are common during pregnancy, and may significantly affect maternal comfort and quality of life. Dental care during pregnancy is safe, and should be encouraged as part of comprehensive prenatal care. While associations between periodontal disease and adverse pregnancy outcomes have been reported, causality remains uncertain, and periodontal treatment during pregnancy has not consistently reduced the adverse obstetric outcomes. Nonetheless, integrating oral health promotion, screening and referral into prenatal care represents a practical and evidence-based strategy for improving maternal health and reducing inequities.

Future efforts should prioritize preconception and early pregnancy oral health interventions and the development of integrated prenatal-dental care models.

Institutional Review Board Statement: The study was conducted in accordance with the Declaration of Helsinki. Ethical review and approval were not required for this study, as it is based exclusively on previously published literature.

Autor corespondent:  Lucian Șerbănescu E-mail: lucian.serbanescu@365.univ-ovidius.ro

CONFLICT OF INTEREST: none declared.

FINANCIAL SUPPORT: none declared.

This work is permanently accessible online free of charge and published under the CC-BY.