Periodontal diseases stem from infections and inflammation affecting the gums and bone surrounding teeth. In its initial stage, called gingivitis, the gums appear red, swollen, and are prone to bleeding. Without intervention, gingivitis progresses to periodontitis, where gums recede, bone loss occurs, and teeth may loosen or be lost altogether. Nearly half of adults aged 30 and older have some form of periodontal disease. (30)

Not only is periodontal disease detrimental to oral health, current evidence overwhelmingly shows that it increases the risk of systemic disease – even impacting fertility and pregnancy outcomes. Therefore, incorporating routine dental care and ensuring good oral health into practice standards is a must for doctors working with patients who are or are trying to become pregnant. 

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The Connection Between Oral Health and Systemic Health

Oral health is intricately connected to systemic well-being, with emerging scientific evidence highlighting the profound impact of periodontal disease on various systemic conditions, including those influencing fertility. Periodontal disease, a chronic inflammatory condition affecting the supporting structures of the teeth, has been linked to an increased risk of systemic diseases.

Studies have established a strong association between periodontal disease and conditions such as cardiovascular disease, diabetes, respiratory diseases, and even Alzheimer's disease. The disruption of the oral microbiome, known as oral dysbiosis, contributes to low-grade systemic inflammation, fostering the development and progression of systemic pathology and chronic diseases. This chronic inflammation, accompanied by the release of inflammatory mediators from periodontal tissues, is believed to play a role in the emergence and advancement of chronic diseases.

Research suggests this oral-systemic connection is bidirectional, meaning systemic pathology can also increase the risk of periodontal diseases. For example, diabetes increases the prevalence, extent, and severity of periodontitis; the presence of diabetes elevates the risk of periodontitis by two to three times (8). Sjogren's syndrome, an autoimmune disorder characterized by damage to the moisture-producing glands leading to symptoms such as dry eyes and mouth, also increases the risk of periodontal disease by two times.

Periodontal Disease and Its Impact on Fertility

In the context of fertility, recent research has shed light on the potential impact of periodontal health. Most of the research on fertility and dental health is focused on periodontal disease and suggests that periodontal disease is correlated to adverse fertility outcomes for both men and women.

Women with polycystic ovary syndrome (PCOS) and endometriosis are more likely to be diagnosed with periodontal disease than the general population. PCOS is a hormonal disorder characterized by cystic ovaries, irregular menstruation, and elevated levels of androgenic hormones. PCOS is one of the most common causes of infertility in women. ‍

Endometriosis, also linked to female factor infertility, is a chronic and painful condition where the uterine lining grows outside the uterus. It is believed there is a two-way relationship between periodontal disease and these conditions. These female reproductive conditions can increase the risk of periodontal disease via elevated inflammation and impaired immune function. Periodontal disease, also characterized by chronic inflammation, can exacerbate insulin resistance and hormonal dysregulation, potentially worsening symptoms of PCOS and endometriosis. In women, chronic inflammation disrupts menstrual regularity, interferes with implantation, and is linked to recurrent miscarriage. (22, 36)

Studies have also found that men with poor oral health are more likely to face male factor infertility. Additionally, men who experience erectile dysfunction are more likely to have gum disease than those who do not. Poor oral health negatively influences sperm quality parameters (count, motility, and morphology) and increases the risk of bacteriospermia – the presence of infection in sperm (9). Oral pathogens can translocate from the mouth into the bloodstream, leading to bacteriospermia and potentially affecting sperm quality and male fertility. (23)

Research Findings on Dental Health and Fertility

Studies have indicated that women with compromised oral health may experience an increased time to conception. In a study including 3,737 Australian women, researchers examined the effects of periodontal disease on planned conception without fertility treatments. Non-Caucasian women with periodontal disease took two months longer to conceive than women without. There was also a statistically insignificant increase in conception time for Caucasian women. (18) 

In the context of assisted reproductive technologies (ART), such as in vitro fertilization (IVF), oral hygiene status has emerged as a topic of interest as researchers delve deeper into understanding the factors influencing high IVF failure rates. Although definitive connections have yet to be established, it is postulated that systemic inflammation triggered by periodontal disease and the presence of oral pathogens could play a role in reproductive challenges and IVF success rates. (24) 

Dental Health, Pregnancy, and Birth Outcomes

In addition to interfering with conception, poor oral health and hygiene may also contribute to adverse birth outcomes. The risks associated with maternal periodontal disease during pregnancy include an increased likelihood of preterm birth and low birth weight. 

Studies have demonstrated a correlation between periodontal disease and an elevated risk of preterm birth. Chronic inflammation and the release of inflammatory mediators associated with periodontal disease may trigger systemic responses that influence uterine contractions and cervical function, potentially leading to preterm labor. Multiple studies support the association between maternal periodontal disease, preterm birth (before 37 weeks gestational age), and low birth weight relative to gestational age (21, 26,27).

Guidelines for Dental Care in Fertility Patients

During the first trimester (1-12 weeks) of pregnancy, it's advisable to schedule patients for dental assessments to inform them about potential oral health changes during pregnancy and discuss strategies for preventing maternal dental problems. However, dental procedures are generally not recommended during this time due to concerns about fetal development and the risk of spontaneous abortions. The focus is on educating patients about maternal oral changes, emphasizing strict oral hygiene, and limiting dental treatment to only periodontal prevention and emergency procedures. Routine radiographs should be avoided unless necessary. (19) 

In the second trimester (13-24 weeks), when organogenesis (the growth and differentiation of tissues into organs) is complete and fetal risk is low, dental procedures such as scaling, polishing, and curettage may be performed as needed. The patient should continue to practice good oral hygiene practices. (19) 

In the third trimester (25-40 weeks), the focus shifts to ensuring the safety and comfort of the pregnant woman, with elective dental treatments avoided in the latter part of this trimester. The recommendations remain centered on oral hygiene and the performance of necessary dental procedures. (19)

Integrating Dental Check-Ups into Fertility Care Plans

Oral health assessments should be integrated into routine medical examinations for patients seeking prenatal and conception care to optimize overall health and pregnancy outcomes. Research has increasingly highlighted the intricate interplay between oral and systemic health, particularly during pregnancy. Approximately 40% of pregnant women have some form of periodontal disease. 

During the initial prenatal visit, healthcare providers should evaluate their patient's oral health. This can be done by asking the three questions listed below and examining the patient's oral cavity:

• Do you have swollen or bleeding gums, a toothache, problems eating or chewing food, or other problems in your mouth?
• When was your last dental visit?
• Do you need help finding a dentist?

As part of standard counseling, healthcare providers should advise all men and women to schedule a dental check-up if it has been over six months since their last examination or if any oral health issues are present. Treatment for dental problems, such as extractions, root canals, and restoration (amalgam or composite) of untreated caries, can be safely administered to prevent complications. (2) 

Counseling should also emphasize the importance of routine oral health practices, such as limiting sugary foods and beverages, brushing teeth twice daily, flossing, and biannual dental visits. (2) 

Educating Patients About the Importance of Dental Health

According to postpartum survey data, 56% of mothers had no dental care, and 60% did not have teeth cleanings during their last pregnancies. According to this same survey, over half of women did not receive any counseling or education about oral health during pregnancy. Fortunately, many women are motivated to adopt healthy behaviors during pregnancy, and patients who receive prenatal oral health counseling are more likely to engage in routine teeth-cleaning practices, 

Integrating dental care into fertility health plans should include educating patients about the importance of dental health for overall well-being and fertility outcomes. To effectively convey this message, providers can utilize various strategies. Firstly, they can offer educational resources such as pamphlets or online materials that outline the connection between oral health and fertility outcomes. These resources should emphasize the potential impact of poor dental health on reproductive health and the importance of preventive measures. Additionally, providers can engage in one-on-one discussions with patients, using clear and easy-to-understand language while also addressing any concerns or questions the patient may have. Referring patients to trusted dental professionals for comprehensive oral health assessments and treatment can further reinforce the importance of dental care. By employing these strategies, healthcare providers can empower fertility patients to prioritize their dental health as part of their overall reproductive care plan.

Challenges and Barriers to Care

Health disparities in dental care refer to the differences in access to and quality of dental services experienced by various population groups. These disparities can be influenced by socioeconomic status, race, ethnicity, geographic location, and insurance coverage. Individuals from low-income backgrounds or marginalized communities often face barriers to accessing dental care due to financial constraints, lack of insurance, or limited availability of dental providers in their area. Additionally, racial and ethnic minorities may encounter cultural or language barriers that impede their access to appropriate dental services. These disparities can result in untreated dental conditions and poorer oral health outcomes. (16) 

Furthermore, dental fear and anxiety are common problems that deter individuals (even those with the means and access) from going to the dentist. Dental anxiety can be managed with psychotherapeutic and pharmacologic interventions. 

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Key Takeaways

Dental health supports male and female fertility and ensures successful pregnancy outcomes. Providers must recognize the significance of dental health assessments as a standard component of preconception and fertility care.

By integrating dental evaluations into routine practice, healthcare providers can promptly identify and address oral health issues, potentially reducing the risk of adverse pregnancy outcomes associated with poor oral health.

This proactive approach supports a holistic fertility journey and promotes patients' and their future children's overall health and well-being.