What to expect (when your patients are expecting)

Kawasaki disease in childrenCharlotte Wake takes a closer look at the associations between pregnancy, perio and the little-known Kawasaki disease.

As we find our way out of lockdown and start getting to grips with living alongside COVID-19, people are likely to be more anxious. Perhaps they will become even more aware of their own health.

People may not be as wealthy as they once were. It’s important to make sure we keep informing them of the benefits of dentistry while they are pregnant or have a newborn.

There have been other scares during this coronavirus pandemic. There’s been an increase in the number of children showing signs of a Kawasaki-like disease. With the condition having oral manifestations, perhaps this encourages more questions about this illness?

Wonder and worry

Finding out that the patter of tiny feet will be arriving is terrifying as much as it is exciting.

Some pregnancies will go perfectly. From a dental view, this will ideally involve minimal sugary cravings and plenty of oral health care. No one wishes any pregnancy to have associated morning sickness and, of course, we all wish for a healthy mum and baby.

But other pregnancies are challenging, with plenty of oral symptoms that we have all seen in our time. Including bleeding gums (associated with a hormonal response) and plenty of erosion or
caries in response to changes in diet or sickness. Perhaps even an unexpected pregnancy epulis will present, and require treatment and reassurance.

I worry that pregnant patients may feel more anxiety and worry in this post-coronavirus way of life as they proceed through their pregnancy.

Some may fear seeking dental treatment during pregnancy. But perhaps some will have read up during lockdown and know the benefits of maintaining their oral health.

Will the look of our PPE heighten their anxiety or even be enough for them to delay treatment? We have not known times like these before and they bring with them some big hurdles to overcome.

Some parents will want to access information about their pregnancy, especially if this is their firstborn. Leaflets may help, or it may be useful to direct them to websites such as the Oral Health Foundation (www.dentalhealth.org).

There are great articles here, including simple explanations about hormonal responses during pregnancy. Also, information on the reassurance of safe periodontal treatment while pregnant and the importance of prevention and their diet.

Establishing associations

Research around periodontal disease continues. We continue to try to understand the connections between premature birth, birth weight, and the effects of pregnancy on periodontal disease to name but a few areas.

The Oral Health Foundation has a great article referring to research by Jacobsson and colleagues published in January 2019. It concludes that: ‘Pregnant women with gum disease are significantly more likely to go into early labour, according to the findings of a new study’.

In 2017, an overview of systematic reviews of periodontal disease and pregnancy outcomes was undertaken (Daalderop et al, 2017).

The authors concluded: ‘We propose that the association between periodontal disease and various common and severe adverse pregnancy outcomes is now sufficiently established for the field to start moving beyond conducting additional primary epidemiologic studies and systematic reviews in this area.’

What future research will tell us about the coronavirus’ relationship to periodontitis, to pregnancy and ultimately the oral cavity is uncertain. If it does materialise it will help us add to the jigsaw of understanding risk factors and help us take a holistic approach.

Kawasaki disease

During the COVID-19 outbreak it was worrying to see reports of young children presenting with symptoms similar to Kawasaki disease. I realised that I needed to revise my knowledge on this illness.

It was clear there were oral manifestations from the pictures. I felt sure some of my patients might ask me about it if they were pregnant or had young children.

The NHS website has clear information about the disease. It appears to mainly affect children under the age of five. Symptoms include a high temperature for more than five days, a rash, swollen glands in their neck, red fingers and/or toes, cracked lips and red eyes.

As with a lot of childhood illnesses, Kawasaki disease can present similarly to other illnesses. Although children can recover in six to eight weeks, the NHS website tells us that it is important to seek treatment quickly as complications can develop.

Kawasaki treatment

Kawasaki disease is treated in a hospital environment. The NHS website advises that the main treatments are ‘intravenous immunoglobulin (IVIG), a solution of antibodies, and aspirin’.

The research around Kawasaki disease has led the NHS website to inform us that the disease is more prevalent in boys and affects around eight in 100,000 children each year in the UK. Great Ormond Street Hospital (www.gosh.nhs.uk) has a highly informative page on Kawasaki disease. This is worth reviewing during a practice meeting to make sure the whole team is aware of this illness. Even though it is rare.

Great Ormond Street advises that the cause of Kawasaki disease isn’t fully understood. Howwever, they say that: ‘Some children may be genetically predisposed to the condition, and environmental factors such as infections, and the way a child’s body responds to that infection, could play a part too.’

Kawasaki disease is an illness that causes swelling of the blood vessels of the heart. Because of this, those children whose hearts are affected may have long-term reviews to check their heart function.

Oral presentation

The oral manifestations of Kawasaki disease are, of course, of most interest to us.

There is an interesting paper (Faden, 2013) that analyses the case of a 24-year-old female with a history of Kawasaki disease. She presented with a recurrent painless swelling of her upper lip. This is particularly interesting as an upper lip swelling is not an usual oral manifestation of Kawasaki disease.

The oral manifestations we can expect to see are cracked lips, inflamed oral mucosa (‘strawberry tongue’). The Patient Info website (https://patient.info) describes this in particular as the tongue presenting with prominent papillae and ‘extremely erythramatous’.

Let us hope we do not see Kawasaki disease present in our practices. It has, of late, been quieter within the media. We can only hope that the Kawasaki-like illness may be less common now than it was in April.

I do wonder if sometimes just wearing the tunic encourages questions from our patients that are not always limited to the oral cavity.

If we see expectant parents, or those with small children, I wonder whether we will be talking more about the effects of COVID-19 in light of the press coverage. Even if we seem to repeat that common sentence: ‘We need more research before we can give conclusive answers’. Let’s hope that isn’t too far into the future.

References

Daalderop L, Wieland B, Tomsin K, Reyes L, Kramer B, Vanterpool S, Been J (2017) Periodontal disease and pregnancy outcomes: overview of systematic reviews. JDR Clinical & Translational Research 3(1): 10-27

Faden A (2013) Recurrent lip swelling as a late presentation of Kawasaki disease: Case report and review of literature. The Saudi Dental Journal 25(1): 43-7

Radochova V, Stepan M, Kacerovska Musilova I, et al (2019) Association between periodontal disease and preterm prelabour rupture of membranes. J Clin Periodontol 46(2): 189-96


This article first appeared in Oral Health magazine. You can read the latest issue here.

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