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While the pregnant patient is not considered medically compromised, there are several managment issues which should be considered, in order to provide emergency and routine dental care without adversely affecting the developing fetus.

 

Fetal and Maternal Considerations:

  • First Trimester

    • Organ development most critical

    • Fetus is most susceptible to teratogenic influences and abortion

      • 15% of pregnancies terminate before the end of the first trimester and decreases thereafter

      • Most commonly caused by morphologic or chromosomal abnormalities

  • Second Trimester

    • The major aspects of organ formation are complete - the remainder of fetal development is growth and maturation

  • Third Trimester

    • Risks of syncope, hypertension are greatest

      • Fetus may put pressure on the inferior vena cava when the patient is in the supine position

      • Hypertension is the precurser to eclampsia

    • Increased risk of preterm delivery, low birth weight, perinatal mortality and congenital anomalies occurs in expectent mothers 

      • Who harbor infections (oral and extraoral)

      • Who smoke

 

Pregnancy and Breastfeeding

Introduction

Risks to the dental patient

Guidelines for Dental Treatment

  • Oral and dental disease can cause infection and pain for the mother, which may in turn effect the fetus

  • Dental radiation can be teratogenic

  • Medications used or prescribed by the dentistry can effect the fetus

  • The patient may be at increased risk for dental erosion of pregnancy sickness (morning sickness) is severe.

  • The patient may be uncomfortable or have specific medical concerns during the final trimester

  • The primary risk with the breastfeeding patient is that the drug may enter the breast milk and be transferred to the nursing infant, in whom exposure may result in adverse effect

Questions to Ask 

Clinical Findings 

  • Pregnancy gingivitis

  • Pyogenic granuloma (pregnancy tumor)

Prevention 

  • Only 9% of obstetricians preferred to be contacted in regard to "routine" dental care

  • 54% prefered to be consulted before analgesics are prescribed

  • 88% preferred to be consulted before antibiotics are prescribed

  • Alternative:

    • For all pregnant patients, send a letter describing the patient's oral problems and your treatment plan, as well as as all medications that you plan to prescribe.  Request a response if the physician would like a change to the patient's treatment.

    • This would be more of a "courtesy consultation" to keep the obstetrician informed.

  • Discuss caries as a transmissable disease that can be passed from parents to children even before children have teeth.

Timing of Treatment Summary

References

Dental Management of the Medically Compromised Patient.  Little, Falace, Miller and Rhodus. 8th Edition

Medical Consultation Recommended 

  • Are you pregnant or trying to get pregnant?

  • How far into your pregnancy are you?

  • Are you having or have you had significant pregnancy/morning sickness?

  • Do you feel as though you have a more active gag reflex?

  • Does your obstetrician consider yours to be a high risk pregnancy?

  • Are you anxious or fearful about dental treatment?

Severe or prolonged pregnancy (morning) sickness

  • May result in dental erosion which can be accelerated if the patient brushes their teeth immediately after vomiting

  • Recommend that the patient rinse with a solution of 1 teaspoon of baking soda mixed with 8 oz of water OR at least rinse with water

  • Teeth should NOT be brushed for at least one hour after vomiting

  • Prescribe fluoride gel or toothpaste such as ProNamel or PreviDent 5000 to strengthen teeth and decrease sensitivity

Hypertension

  • Take blood pressure at each visit before treatment

  • Refer patient to physician if blood pressure increases by 30 mm or more systolic and/or 15 mm or more diastolic, which could be a sign of preeclampsia.

Pregnant patients will seek treatment for all types of dental problems at any time during their pregnancy

  • Pregnant patients should be treated by carefully balancing the beneficial aspects of of dental treatment with potentially harmful procedures by minimizing or avoiding exposure of the patient (and the fetus).

  • Oral infections causing pain, infection or bleeding in pregnant patients must always be treated/managed by the general dentist.

  • It is UNETHICAL to deny a patient treatment because she is pregnant.

Dental radiographs 

  • One of the most controversial areas in the treatment of the pregnant patient

    • Ionizing radiation should be avoided if possible during the first trimester

    • However, if dental treatment is necessary, radiographs required for the accurate diagnosis and treatment planning should be used

      •  As stated by the American College of Obstetricians and Gynecologists:  "Diagnostic radiologic procedures (medical and dental) should not be performed during pregnancy UNLESS the information to be obtained from them is necessary for the care of the patient and cannot be obtained by other means"

      • Explanation for patient:

        • The gonadal/fetal dose incurred with two periapical dental films (with use of lead apron) is 700 times less than that for one day of average exposure to natural background radiation in the United States.  Don't say "a day in the sun"; it is a day of living exposed to natural background radiation, not just radiation from the sun.

        • One short explanation: 

          • "We only take the radiographs that are required for diagnosis and treatment of your condition.  We use a lead apron and digital system that greatly reduces the amount of radiation absorbed by the patient. Essentially no radiation is absorbed by the fetus."

  • Anxiolytics

  • Analgesics

    • ​If a patient is in pain that cannot be controlled with acetaminophen, consultation with the patient's obstetrician is mandatory to determine if one of the narcotic analgesics can be prescribed

  • Antibiotics

  • Local Anesthetics

Drug Administration

  • Principal concerns:

    • Drugs may cross the placenta and be toxic or teratogenic to the fetus

    • Repiratory depressants may cause maternal hypoxia, resulting in fetal hypoxia, injury or death

  • Ideally

    • No drug would be administered during pregnancy, particularly during the 1st trimester.  However, some use of drugs will often be required to treat the patient.

 

FDA Pregnancy Categories - evidence based criteria to describe the risks of any drug to the fetus

  • This information will always be found in the drug information provided by sites such as Lexi.com and Rxlist.com

​

  • Epinephrine

    • Safe for use during pregnancy

    • Limit to two cartridges of lidocaine with  1:100,000 epinephrine

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