The Saudi Mouth — Part 6: The Appointment She Didn't Make

Nearly 40% of pregnant women in Riyadh have never visited a dentist during pregnancy. Periodontitis more than triples the risk of preterm birth. Dental treatment is safe throughout pregnancy. Here is what needs to change.

Research

By Dr. Mahmoud H. Al-Johani

Oral Health During Pregnancy — What the Evidence Says, and What Saudi Patients Are Not Being Told

She is sitting in an OBGYN waiting room, three months pregnant, with a list of appointments to schedule: ultrasounds, blood panels, glucose tolerance tests, dietary counseling.

A dental visit is not on the list.

It should be.

The evidence connecting maternal oral health to pregnancy outcomes is no longer preliminary. It is robust, replicated, and increasingly specific. Untreated periodontal disease during pregnancy is independently associated with preterm birth, low birth weight, and preeclampsia. The mechanism is biological, not incidental. And the gap between what the evidence says and what Saudi pregnant women are actually doing about their oral health is, by any measure, significant.

This is Part 6 — and the final installment — of The Saudi Mouth.

What Pregnancy Does to the Mouth

Before the outcomes data, the physiology.

Pregnancy is not neutral on oral health. Rising levels of estrogen and progesterone during the first and second trimesters exaggerate the gingival inflammatory response to bacterial plaque — a phenomenon so consistent it has a clinical name: pregnancy gingivitis. Gingival blood flow increases, vascular permeability rises, and the immune modulation of pregnancy — which exists to prevent rejection of the fetus — simultaneously reduces the host's capacity to contain periodontal bacterial challenge.¹

Hormonal changes also alter the oral microbiome, increasing the proportion of gram-negative anaerobic bacteria associated with periodontal destruction. Progesterone directly promotes the growth of specific periodontal pathogens — Porphyromonas gingivalis, Prevotella intermedia — that are key drivers of the inflammatory cascade in periodontitis.¹

The result: a patient with mild or subclinical gingivitis before pregnancy may develop frank gingivitis by the second trimester. A patient with pre-existing periodontitis may experience accelerated progression. The oral environment changes in pregnancy — and for women who already have periodontal disease, it changes for the worse.

The Pregnancy Outcomes Data

The link between maternal periodontal disease and adverse pregnancy outcomes has been studied for three decades. The current evidence base is substantial.

A 2025 systematic review and meta-analysis found that periodontitis affords a more than three-fold increase in the risk of preterm birth and low birth weight combined.² A comprehensive meta-analysis found a 2.43-fold higher risk of delivering a low birth weight infant in women with periodontal disease (OR 2.43, 95% CI 1.72–3.59).³

The mechanism is not speculative. Periodontal infection generates systemic inflammatory burden — elevated prostaglandin E₂, interleukin-1β, TNF-alpha, and C-reactive protein. These inflammatory mediators, when present in sufficient concentrations systemically, can stimulate uterine contractions, cervical dilation, and premature rupture of membranes. The prostaglandin pathway that drives labor can, under conditions of sustained systemic inflammation from periodontal infection, be activated prematurely.

The evidence on preterm birth is graded as moderate certainty in recent systematic reviews.⁴ It is not absolute causation — obstetric outcomes are multifactorial. But the association is consistent, biologically plausible, and of a magnitude that justifies clinical action.

Gestational Diabetes: Closing the Loop

Part 4 of this series established the bidirectional link between diabetes and periodontitis. Pregnancy adds a third dimension.

Gestational diabetes mellitus (GDM) amplifies the periodontal risk of pregnancy. A 2025 study confirmed that women with GDM are approximately twice as likely to present with periodontitis compared to non-diabetic pregnant women.⁵ A 2025 PMC review documented that pregnant women with GDM show significantly poorer periodontal health than healthy controls.⁶

The bidirectionality runs through pregnancy: GDM worsens periodontal inflammation, periodontal inflammation worsens insulin resistance, and uncontrolled glycemia carries its own fetal risks. The pregnant patient with both GDM and periodontitis is sitting at the intersection of two compounding pathologies — both clinically addressable.

What Saudi Pregnant Women Know — and Do Not Know

A 2025 cross-sectional study from Princess Nourah bint Abdulrahman University surveyed 1,120 pregnant women across government and private maternal hospitals in Riyadh. The findings are striking.

59.7% had very poor oral health knowledge. 23.8% had poor knowledge. More than 83% of this large Saudi cohort demonstrated inadequate understanding of oral health during pregnancy.

66.4% had poor oral health practices.

39.6% had never sought dental care during pregnancy at all.⁷

Nearly four in ten pregnant women in the Saudi capital had never visited a dentist during their entire pregnancy. This is not primarily an access problem. It reflects a systemic failure to communicate — at the OBGYN clinic, at the maternal hospital, and in the dental practice — that oral health is a component of prenatal care.

A parallel study found that one-third of pregnant women globally avoid dental visits during pregnancy, most citing the belief that dental treatment is unsafe for the fetus.⁸ This belief is medically incorrect — and it is causing harm through omission.

The Safety Question

The single most common reason Saudi pregnant women give for avoiding dental visits is fear that treatment will harm the baby.

The evidence is unambiguous: dental treatment is safe throughout pregnancy.

The American Dental Association, the American College of Obstetricians and Gynecologists, and the Royal College of Obstetricians and Gynaecologists all confirm that preventive, diagnostic, and restorative dental treatment is safe in all three trimesters.

Local anesthesia with lidocaine and 1:200,000 epinephrine is safe and recommended.⁹ Dental radiographs with appropriate abdominal and thyroid shielding are safe at any stage of pregnancy.⁹ Untreated dental infection during pregnancy is far more dangerous to the fetus than any procedure used to treat it.

The second trimester — weeks 14 to 27 — is the optimal window for elective treatment. But the clinical message is not "treat only in the second trimester." It is: treat whenever treatment is needed, throughout pregnancy.

Deferring necessary dental care because of unfounded concerns about safety does not protect the pregnancy. It removes a protective intervention from a patient who needs it.

What the Dental Team Can Do

On the treatment side: Pregnant patients should receive a full periodontal assessment at the first prenatal dental visit, ideally in the first trimester. Active periodontal disease should be treated — non-surgical periodontal therapy is safe and evidence-supported in pregnancy. A 2025 meta-analysis of 14 randomized controlled trials found that periodontal disease treatment during pregnancy may reduce the risk of preterm birth.⁴ Preventive care, caries risk assessment, and oral hygiene instruction should be delivered without modification for pregnancy status.

On the communication side: The message that needs to reach every pregnant patient in Saudi Arabia is simple: dental care is safe during pregnancy. Untreated gum disease is not. A dental check-up is part of prenatal care, not separate from it.

This message needs to come from two directions: dentists who ask "are you pregnant?" and obstetricians who ask "have you seen your dentist?" The interprofessional gap is where the problem lives. Pregnant women are not failing to attend dental appointments because they do not care about their health. They are failing because no one has told them that they should.

The Series Closes Where It Began

The Saudi Mouth started with children — with the caries crisis affecting Saudi schools, the preventive infrastructure not meeting the need.

It ends with pregnancy — with the oral health of the woman before, during, and after that child is born.

The connection is not metaphorical. The mother's periodontal status during pregnancy is associated with her child's birth weight, gestational age, and early oral colonization patterns. The bacteria that seed an infant's mouth in the first months of life come largely from the primary caregiver. The oral health habits of a household are shaped by the parents' own relationship with dental care.

The Saudi mouth does not begin at the child's first dental appointment. It begins earlier — in the prenatal consultation, in the dental practice the pregnant woman never visited.

The evidence is available. The interventions are safe, straightforward, and evidence-based. What remains is communication — consistent, clinician-to-clinician, patient-to-patient.

That is what this series has been about.

Key Takeaways

  1. Pregnancy exaggerates gingival inflammation through hormonal changes and altered oral microbiome composition. Pre-existing periodontitis worsens. This is predictable physiology, not incidental finding.
  2. Periodontitis during pregnancy is associated with more than a three-fold increased risk of preterm birth and low birth weight. The mechanism — systemic inflammatory mediators triggering premature uterine activity — is biologically plausible and well-documented.
  3. Saudi women with gestational diabetes are approximately twice as likely to have periodontitis. GDM and periodontitis are bidirectionally linked through inflammatory and glycemic pathways.
  4. A 2025 Riyadh survey of 1,120 pregnant women found that 83% had poor or very poor oral health knowledge, and 39.6% had never visited a dentist during their pregnancy.
  5. Dental treatment — including local anesthesia, radiographs with shielding, scaling and root planing, and restorations — is safe throughout all three trimesters. Untreated dental infection is the real risk.
  6. Treating periodontal disease during pregnancy may reduce preterm birth risk. The interprofessional gap between OBGYNs and dentists is where the most urgent change is needed.

References

  1. Effects of Pregnancy on Oral Health — Narrative Review. PMC. 2025. https://pmc.ncbi.nlm.nih.gov/articles/PMC12626342/
  2. Periodontitis and more than three-fold increased risk of PTB/LBW. PMC Systematic Review. 2025. https://pmc.ncbi.nlm.nih.gov/articles/PMC12748043/
  3. Periodontal disease and 2.43-fold increased risk of low birth weight. Comprehensive meta-analysis. ResearchGate. 2024. https://www.researchgate.net/publication/378997089
  4. Effect of dental treatments on reduction of preterm birth — meta-analysis of 14 RCTs. Science Direct. 2025. https://www.sciencedirect.com/article/pii/S2589933325002824
  5. Women with GDM twice as likely to present with periodontitis. MDPI Dentistry Journal. 2025. https://www.mdpi.com/2304-6767/14/3/139
  6. GDM and significantly poorer periodontal health. PMC. 2025. https://pmc.ncbi.nlm.nih.gov/articles/PMC12505645/
  7. Oral health knowledge, practices, and dental service utilization among pregnant women in Riyadh. PLOS ONE. 2025. https://doi.org/10.1371/journal.pone.0319508
  8. One-third of pregnant women globally do not visit dental clinics. MDPI Healthcare. 2024. https://www.mdpi.com/2227-9032/12/23/2413
  9. Dental treatment safety in pregnancy: local anesthesia and radiographs. PMC. 2023. https://pmc.ncbi.nlm.nih.gov/articles/PMC10315135/
  10. ACOG Oral Health Care During Pregnancy guidelines. https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2013/08/oral-health-care-during-pregnancy-and-through-the-lifespan

The Saudi Mouth is a SaudiDent original series by Dr. Mahmoud H. Al-Johani. Part 1 — Our Children's Teeth: https://saudident.com/blog/our-childrens-teeth-dental-caries-saudi-arabia Part 2 — The Shisha Session: https://saudident.com/blog/the-saudi-mouth-shisha-waterpipe-oral-health Part 3 — The Lesion You Should Not Miss: https://saudident.com/blog/the-saudi-mouth-oral-cancer-screening Part 4 — The Sixth Complication: https://saudident.com/blog/the-saudi-mouth-diabetes-periodontitis Part 5 — The Implant You Might Lose: https://saudident.com/blog/the-saudi-mouth-peri-implantitis-implant-failure

Read on SaudiDent