PRINCIPLE OF DENTAL

MANAGEMENT OF THE PREGNANT

PATIENTS

BY: MALIHA TAHIR

Pregnancy has been considered an impediment to dental treatment However, preventive, emergency, and routine dental procedures are all suitable during various phases of a pregnancy, with some treatment modifications and initial planning.

Before embarking a dental treatment the possibility of pregnancy should be considered.

Considerations for dental treatment should be made throughout the phase of pregnancy and subsequent breast-feeding.

Pregnancy represents a relative contraindication to elective dental care, especially during the first trimester.

Consultation with the patient’s physician before commencing any treatment is indicated, especially if there are any problems with this or prior pregnancies.

Stages of Pregnancy1ST TRIMESTER (1-12

WEEKS):Fetal organ formation and differentiation.Most susceptible to adverse effects of teratogens.Avoid all elective care but provide care as needed.

2ND TRIMESTER (13-24 weeks):Fetal growth and maturation.Safest period to provide dental care.

3RD TRIMESTER (25-40 weeks): Fetal growth continues. Focus of concern is risk to upcoming birth process and safety and comfort of pregnant woman.

How should the pregnant woman be positioned?

Flat position may cause hypotension and hypoxia

Place a small pillow under right hip - left lateral displacement

Head above feet

Pregnancy RelatedOral Health Problems Pregnancy Gingivitis Pregnancy Epulis Increased Tooth Mobility Dental Caries Dry mouth Excessive salivation Tooth erosions associated with

severe GERD or hyperemesis Dental Problems in relation to

Labor and Delivery

Pregnancy Gingivitis Occurs commonly in the 2nd to 8th months Tendency to bleed very easily Treatment: Scaling, root-planing, currettage, OHI.

Pregnancy Granuloma Occurs in up to 5% of women. Most common in buccal maxillary anterior areas. Usually starts in an area of gingivitis.

Gum Problems - Pregnancy Granuloma

Treatment

Scaling and root planing Excision if it is too large or bleeds too

easily May regress spontaneously after

pregnancy

Changes During Pregnancy that Affect Oral Health Hormonal Affects

Increased tooth mobility Saliva changes Increased bacteria Gingival problems

Salivary changes Decreased buffers Decreased minerals Decreasing flow first and last trimester Increased flow second trimester More acidic

Enamel erosion caused by frequent vomiting

Treatment for Acid Exposure Do NOT brush immediately after

vomiting Rinse with

Water with baking soda Antacid Plain water

Eat some cheese

Dental Considerations Timing of treatment for pregnant

patients Dental radiation exposure Use of local anesthetics Prescription of common antibiotics

and analgesics Nitrous oxide gas administration

Treatment Timing First Trimester

Spontaneous miscarriages naturally occur more often in 1st trimester

Avoid elective treatment that can be delayedOffer anticipatory guidance

Second TrimesterThe optimal time for dental treatmentOrganogenesis complete, fetus not largeEasier to prevent than treat established

disease Third Trimester

Late in term very uncomfortable (short visits)

Position slightly on left side

Timing of Dental Treatment During Pregnancy - From Little and Fallace

First Trimester

Plaque control Oral hygiene instruction Avoid elective treatment; urgent care

only

Second Trimester

Plaque control Oral hygiene instruction Scaling, polishing, curettage Routine dental care

Third Trimester

Plaque control Oral hygiene instruction Scaling, polishing, curettage Routine dental care (after middle of

third trimester, elective care should be avoided)

Use of radiation on pregnant patient Although radiographs in the region of the jaws

don’t cause direct irradiation of the abdominal area, these should be restricted to clinical necessity, as should all radiographs. (Avoid X-Rays)

(General dental treatment): Avoid dental radiographs unless information about tooth roots or bone is necessary for proper dental care.

If radiographs must be taken, use proper shielding. use both abdominal aprons and thyroid collars, whenever practical, to minimize radiation exposure

(Surgery) In case of imaging, use of protective aprons and taking digital periapical films of only the areas requiring surgery can accomplish this.

Patients should be reassured that the risk is minimal. (When radiographs are necessary)

fetus is most susceptible to radiation between the 2nd and 6th week of gestation

FDA Classifications for drugs used in pregnant and lactating patients

A: Controlled human studies - no risk found

B: Animal studies do not show risk, human

studies not adequate or complete yet.C: Animal studies show risk but benefits outweigh risks.D: Evidence of fetal risk, benefits may outweigh risksX: Risk outweighs benefits

Use of Local Anesthetics Lidocaine + vasoconstrictor: most common �

local anesthetic used in dentistry extensively used in pregnancy with no proven

ill effects accidental intravascular injections of lidocaine �

pass through the placenta but the concentrations are too low to harm fetus

prilocaine might cause methemoglobinemia Drug classes:� B: lidocaine, prilocaine, etidocaine C: mepivacaine, bupivacaine� Not yet assigned: Procaine�

Anesthesia Dental procedures requiring general

anesthesia or sedation should also be avoided due to the risk of fetal hypoxia.

Avoid sedatives and Hypnotics as there may have deleterious effects on the fetus.

All sedative drugs are best avoided in pregnant patients.

Nitrous oxide should not be used during the first trimester but if necessary can be used in the second and third trimester as long as it is delivered with at least 50% oxygen, and not more that 9hr in a week

Antibiotics penicillin V and amoxicillin is preferred drug

for mild to moderate infections widely used for many years with no ill effects

no studies show penicillin to be teratogenic� amoxicillin extensively used without �

harming the fetus Drug classes:� B: penicillin, cephalosporins, erythromycin, � clindamycin D: Tetracycline�

Analgesics acetaminophen is the analgesic of

choice for all stages of gestation used to treat mild to moderate pain and �

fevers short term usage is believed to be safe� avoid chronic and large doses of �

acetaminophen Drug Class: Not yet assigned�

ASA is nonteratogenic but may cause maternal and fetal hemorrhage

large and chronic doses during last trimester may �result in premature closure of ductus arteriosus, fetal hypertension, anemia, and low birth weight

avoid ibuprofen in 3rd trimester because of �possible adverse circulatory effects

short term use of codeine seems safe�

avoid codeine late in gestation because of �possible fetal respiratory depression and withdrawal symptoms

Common Preventives Fluoride

No increased risk during pregnancy Xylitol

No studies; no harm reported Chlorhexidine

No increased risk during pregnancy

Pre-natal Fluoride Daily 2.2 mg tablet of sodium fluoride

during 3rd through 9th months decreases caries rate in offspring. Safe and effective.