Pregnancy and Dentistry Management PDF

# Pregnancy and Dentistry ## The Dental Practitioner's Role: - To understand and diagnose *diseases and conditions* exclusive to pregnancy. - To take certain pathophysiologic aspects relevant to dentistry into *consideration* while treating a dental patient. - To plan a safe and effective *treatme...

# Pregnancy and Dentistry ## The Dental Practitioner's Role: - To understand and diagnose *diseases and conditions* exclusive to pregnancy. - To take certain pathophysiologic aspects relevant to dentistry into *consideration* while treating a dental patient. - To plan a safe and effective *treatment plan* that is both beneficial to the mother and safe for the fetus. ## Stages of Pregnancy: - **1st trimester** - 1-12 weeks/ first 3 months: Phase of *fetal organ* formation hence avoid elective dental treatment where possible. - **2nd trimester** - 13-24 weeks/ 3rd to 6th month: *Fetal growth* and maturation. Safest time to provide preventive and interceptive dental care. - **3rd trimester** - 25-40 weeks/ 6th to 9th month: *Concerns associated* with fetus and easy parturition. Dental treatments should be of short duration and for only dental emergencies to prevent stress induction on expectant mother. ## Physiological Changes During Pregnancy That Are of Importance to the Dental Practitioner: ### Effects of Hormonal Changes in Pregnant Mother Relevant to the Dental Practitioner: - **Pancreatic insulin changes:** - Human placental lactogen (hPL) conserves blood glucose for neonates and in some cases cause *gestational diabetes mellitus (GDM)* in the mother. - GDM is associated with significantly increased risks of maternal and infant morbidity, including preeclampsia, and *periodontitis* induced by constant inflammatory response and state of insulin resistance (caused by hPL) and in uncontrolled cases with existing periodontal conditions; *tooth mobility*. - Pregnancy does NOT cause periodontitis but aggravates existing ones. - **Adrenal gland secretions:** - There is increased secretion of estrogen, progesterone and cortisol (steroid). Steady increase of steroids may result in the formation of *pregnancy granuloma* in 1st trimester. Repeated irritation with circulating steroids lead to proliferation of the lesion. - The lesion is not associated with microorganism related infections and hence should only be excised if it becomes very large (>2cm) or becomes infected. - Laser excision is reported to be well tolerated in pregnancy without any adverse effects. - *Plaque control, scaling, curettage* are the treatment of choice otherwise. - **Facial changes as melasma "mask of pregnancy,"** appearing as bilateral brown patches in the mid-face begin during the 1st trimester and are seen in up to 73% of pregnant women. - **Parathyroid hormone increased:** - To increase calcium uptake to facilitate for foetal skeletal development. This results in *decreased serum calcium* in mothers. ### Effects of Cardiovascular Changes: - A diagram showing the changes in *hemodynamic parameters* during pregnancy. The diagram shows the changes in *heart rate, stroke volume, and cardiac output* over 40 weeks of gestation. - **Cardiac output and pulse rate continuously increases** and peaks at 3rd trimester (30-50% above normal). - **Systolic and diastolic blood pressure drops by 10-15mmHg** in the first trimester but returns to normal in the second trimester. - **Patient may develop systolic murmur limited to gestational period**. - **Hormone induced vascular permeability changes may induce gingivitis and spontaneous gum bleeding** during 2nd and 3rd trimester of pregnancy. - *Management includes scaling and curettage during 2nd trimester and oral hygiene instructions*. - **Around the 3rd trimester, uterine enlargement compresses inferior vena cava and restricts venous return** hence patient may experience postural hypotension in supine position (*Supine Hypotensive Syndrome*). - A diagram shows the compression of the *inferior vena cava* by the uterus in a supine position. ## Management of Supine Hypotensive Syndrome - **C/F-** - Caused by excess supination of the dental unit after seating the patient. - The patient exhibits sweating, nausea, fatigue and dyspnea. - Examinations may present hypotension, bradycardia and syncope. - Compression results in lymphatic channel obstruction and pedal oedema. - **Immediate Treatment** - Place the patient with *head above feet*. - Elevate right hip with a pillow and shift the uterine weight off the vena cava to the left side (*left lateral displacement*). - Roll the patient onto her left side. - A diagram shows the correct position of the patient with a pillow to elevate the right hip and shift the uterine weight off the vena cava. ## Respiratory System Changes: - There is increased respiratory minute volume (upto 40%) during the first trimester due to progesterone induced *respiratory alkalosis*. - There is decreased respiratory lung movement due to enlarged uterus during the third trimester. - Both situations may indicate *dyspnea* (difficulty in breathing) but are physiologic responses. - *Increased estrogen concentration may lead to rhinitis, sinusitis and other upper respiratory tract infections*. - A diagram shows the different stages of nasal obstruction: *Normal, Moderate, Severe, Obstructive*. ## Pregnancy and Asthma in Dental Practice: - Pregnant people with pre-existing and/or comorbid asthma, pneumonia, or other respiratory issues may be more prone to disease exacerbation and respiratory decompensation during pregnancy. - *Bronchodilator inhalers* have been classified as safe during pregnancy. - In severe asthma, the use of *oral corticosteroids, magnesium sulfate and beta agonists* are recommended - Medscape. - Oxygen intake should be closely monitored to prevent maternal hypoxia and maintain foetal oxygenation. - *NSAIDs should be given with precaution instead of tramadol.* Although NSAIDs stimulate bronchoconstriction, its benefits outweigh the risks of neonatal drug dependence induced by tramadol. ## Gastrointestinal Tract Changes: - **Acid reflux:** - Progesterone slows down intestinal motility and raises intragastric pressure. This results in *esophageal reflux, nausea, vomiting.* During this time a patient is more prone to have *dental erosion* if the oesophageal reflux is uncontrolled with antacids & other PPIs. - During first trimester, the patient may experience *hyperemesis gravidarum* (morning sickness), such patient should NOT be given an early morning appointment. - **Salivary changes:** - *Salivary flow decreases (Dry mouth)* during the 1st and 3rd trimester leading to reduced buffering abilities and increased cariogenic activity. *Topical fluoride* may be prescribed to control such activities while also benefitting the fetus from reduced risks of caries. - Dry mouth results in increased incidences of *oral candidiasis.* This should be managed by cleaning the infected regions and applying topical antifungal agents. - *Salivary flow increases (ptyalism)* during 2nd trimester. ## Genitourinary System Changes: - Glomerular filtration rate and and plasma flow increase. This in addition to the uterus restricting the distention of the urinary bladder results in *frequent micturition* (Bladder Compression). - A diagram shows the compression of the bladder by the pregnant uterus. - In 2nd and 3rd trimesters the patient should be asked to empty their bladders prior to treatment. During long dental procedures, office temperature should be regulated to at or above standard r.t.p. Otherwise low temperatures can trigger *cold diuresis* and trigger micturition reflex in the patient. ## Dental Radiography and Pregnancy: ### Everyday Radiation: - According to the NRC, the average American receives *0.62 rads* per year, half of which is from background and cosmic radiation. - In some Indian regions, the average annual radiation is reported to be *4.5 mGy (0.45 rads)* while in radiation prone regions it can go upto 10 mGy (1 rads). - In some Chinese regions the average annual radiation dose is *6.4 mSv (0.64 rads)*. ### Radiation Risks in Pregnancy: - Most biological responses to radiation occur during the 1st trimester, mainly the first two weeks (upto 6th week) *any dose below 25 rads (250 mGy) will NOT likely cause spontaneous abortion*. - Studies also suggest A radiation dose of *500 mGy (50 rads) in the 1st trimester, when organogenesis is initiated* causes [*congenital fetal abnormalities*]. - After 16th week of conception, the safety threshold dose rises to *50-70 rads (<700 mGy)*. ### Radiation Risk to Pregnancy in Dentistry: - Exposure to the brain from 4 bitewings is approximately *0.07 mGy (0.007 rads)*, and from a panoramic examination about *0.02 mGy (0.002 rads)* - Medscape. - A single periapical radiograph can cause *0.01 millirads* of radiation. - Thus, It is safe to Do a diagnostic radiograph on a pregnant person if deemed necessary. However *avoidance of radiography during the 1st trimester* is advised. - Risks can be reduced even further by using a shield: Lead apron to protect the fetus and using *modern RVG*. ## Pregnancy and Dental Drugs ### 1. Analgesics: | Drug | Safe during Pregnancy | Notes | |---|---|---| | Acetaminophen | Yes | | | Morphine | | | | Aspirin | Avoid in 3rd Trimester | | | Ibuprofen | Avoid in 3rd Trimester | | | Naproxen | Avoid in 3rd Trimester | | | Oxycodone | With Caution | | | Hydrocodone | With Caution | | | Pentazocine | With Caution | | | | | **Drugs to Avoid in 3rd Trimester:** *Aspirin causes post partum hemorrhage, Naproxen and Ibuprofen complicates parturition (delivery). Opoid group of drugs (codone & codeine) cause neonatal respiratory depression after withdrawal from prolonged therapy.* | ### 2. Antibiotics and Antiprotozoal Drugs: | Drug | Safe during Pregnancy | Notes | |---|---|---| | Amoxicillin and Penicillin | Yes | | | Cephalosporin | Yes | | | Metronidazole | Yes | | | Clindamycin | Yes | | | Tetracycline | No | *Inhibits bone growth.* | | Erythromycin (estolate form) | No | *May cause cholestatic hepatitis.* | | Chloramphenicol | No | | | | | **Avoid Antibiotics:** Erythromycin (Estolate form) may cause *cholestatic hepatitis*. Doxycycline, Vancomycin, Tetracycline: *inhibits bone growth.* | ### 3. Local Anesthesia and Sedatives: | Drug | Safe during Pregnancy | Notes | |---|---|---| | Lidocaine with/without epi. | Yes | | | Prilocaine | Yes | | | Etidocaine | Yes | | | Mepivacaine | No | *May cause fetal bradycardia.* | | Bupivacaine |No | *May cause fetal bradycardia.* | | Nitrous Oxide | Not in 1st Trimester | *Administration of nitrous oxide leads to spontaneous abortion in the 1st trimester. Nitrous oxide can be used upto 50% oxygen in 2nd and 3rd Trimesters.* | | Barbiturates | No | | | Benzodiazepines | No | *Prolonged exposure to benzodiazepines result in oral clefts in neonates.* | ### 4. Antifungal Drugs: | Drug | Safe during Pregnancy | Notes | |---|---|---| | Clotrimazole | Yes | | | Nystatin | Yes | | | Fluconazole | With caution. Best Avoided | | | Ketoconazole | With caution. Best Avoided | | ### 5. Corticosteroids: | Drug | Safe during Pregnancy | Notes | |---|---|---| | Prednisolone | Yes | | ### 6. Fluoride Supplements: - The use of *topical fluorides* and fluoride tablets are *considered safe* from the 2nd trimester. ### 7. Anti Ulcer Drugs (Peptic & Duodenal Ulcer Prophylaxis): | Drug | Safe during Pregnancy | Notes | |---|---|---| | **Proton Pump Inhibitors** | | | | Omeprazole | Yes | | | Esomeprazole, Pantoprazole | Safety not tested | | | | | | | **H2 Receptor Blockers** | | | | Ranitidine, famotidine | Yes | | | | | | | **Antacids and mucosa protectives** | Yes | | | Misoprostol | No | *Causes spontaneous abortion.* | ### 8. Antihistamines and Anti-allergen: | Drug | Safe during Pregnancy | Notes | |---|---|---| | **1st Generation anti histamines** | | | | Chlorpheniramine | Yes | | | Hydrozine, promethazine | No | | | | | | | **2nd Generation anti histamines** | | | | Cetrizine, Loratidine | Yes | | | Fexofenadine | Not Recommended | | ## A Proposed Treatment Plan: - **1st Trimester** - Educate the patient about maternal oral changes during pregnancy. - Emphasize strict oral hygiene instructions and thereby plaque control. - Limit dental treatment to periodontal prophylaxis and emergency treatments only. - **2nd Trimester** - Oral hygiene instruction, and plaque control. - Scaling, polishing, and curettage may be performed if necessary. - Control of active oral diseases, if any. - *Elective dental care is safe.* - **3rd Trimester** - Oral hygiene instruction, and plaque control. - Scaling, polishing, and curettage may be performed if necessary. - Avoid elective dental care during the second half of the third trimester. # Thank You.