Clinical

PRACTICE

Oral Health Care for the Pregnant Patient

ABSTRACT
Pregnancy is a unique time in a w omans life, accompanied by a variety of physiologic, anatomic and hormonal changes that can af fect ho w oral health care is provided. Ho w ever, these patients are not medically compromised and should not be denied dental treatment simply because they are pregnant. This article discusses the normal changes associated with pregnancy, general considerations in the care of pregnant patients, and possible dental complications of pregnancy and their management.

For citation purposes, the electronic version is the definitive version of this article: www.cda-adc.ca/jcda/vol-75/issue-1/43.html

ost pregnant patients are generally healthy and need not be denied dental treatment solely because they are pregnant. However, even a healthy pregnancy causes major changes in maternal anatomy, physiology and metabolism. ese can include changes in the cardiovascular, respiratory and gastrointestinal systems, as well as changes in the oral cavity and increased susceptibility to oral infection. Although these adaptations of maternal organ systems are normal, they do necessitate consideration and adjustments in treatment by any dentist who is providing oral health care and prescribing medications for the patient. is article discusses the various changes that occur during normal pregnancy and suggests modi cations in dental management that should be considered. Systemic Changes Cardiovascular System Cardiovascular changes in pregnancy include increases in cardiac output, plasma volume and heart rate. A benign systolic ejection murmur, caused by increased blood ow across the pulmonic and aortic valves, occurs

in 96% of pregnant women,1 but no treatment is required. In addition, as a result of vasomotor instability, pregnant patients are susceptible to postural hypotension. Consequently, changes in dental chair position from reclining to upright should be performed very slowly. As the uterus increases in size, it causes pressure on the vena cava and aorta, which can result in decreases in cardiac output, venous return and uteroplacental blood ow. Aortocaval compression, which occurs speci cally in the supine position, leads to supine hypotensive syndrome, which is characterized by symptoms and signs such as lightheadedness, weakness, sweating, restlessness, tinnitus, pallor, decrease in blood pressure, syncope and, in severe cases, unconsciousness and convulsions. Patients who experience this syndrome are usually aware of its occurrence and can alert their caregivers if they begin to notice symptoms developing. e condition can be corrected by having the patient roll on her le side and placing a pillow or rolled towels to elevate her right hip and buttock by about 15. is manoeuvre li s the uterus o the vena cava and re-establishes aortocaval patency.2
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Oral changes Gingivitis Pyogenic granuloma Ptyalism Enamel erosion Xerostomia Tooth mobility

Pregnant dental patient

Emergency care Perform at any time in pregnancy for pain relief and infection control (pulp extirpation, incision and drainage, uncomplicated extractions) Notify obstetrician of patients condition

Radiography (if necessary for diagnosis) Panoramic radiographs Periapical radiographs as needed Bitewing radiographs Digital radiographs

Systemic changes Increased cardiac output, plasma volume and heart rate Systolic ejection murmur Supine hypotensive syndrome Nasal congestion, epistaxis Increased intragastric pressure, gastric acid reflux

Elective care Scaling and curettage Routine restorations Elective extractions Endodontic therapy All best performed in second or third trimester, except scaling and curettage, which can be done anytime

Drugs (FDA pregnancy safety category)

Analgesics Acetaminophen (B) Codeine with acetaminophen (C) Hydrocodone with acetaminophen (C) Ibuprofen (B, D)a Oxycodone with acetaminophen (C) Propoxyphene (C)

Antimicrobials Amoxicillin (B) Cephalexin (B) Chlorhexidine rinse (B) Ciprofloxacin (C)a Clindamycin (B) Doxycycline (D) Erythromycin (B) Metronidazole (B)a Penicillin (B) Tetracycline (D)

Local anesthetics Articaine (C) Bupivacaine (C) Epinephrine (C) Lidocaine (B) Mepivacaine (C) Prilocaine (B)

Anxiolytics Barbiturates (D) Benzodiazepines (D) Nitrous oxide (not rated; avoid in first trimester)

Figure 1: Summary of somatic changes associated with pregnancy and diagnostic and treatment options in dental management of pregnant women. See Table 1 for denitions of U.S. Food and Drug Administration (FDA) drug risk categories. aSee text for further explanation.

Respiratory System Increased estrogen production during pregnancy causes the capillaries in the mucosa of the nasopharynx to become engorged, which results in edema, nasal congestion and predisposition to epistaxis.1 Nasal breathing becomes more di cult, and there is a tendency to breathe with the mouth open, especially at night. If xerostomia subsequently develops, patients lose the protection against dental decay a orded by saliva. 3 Patients who are experiencing these problems, especially those with a high caries index, should undergo early caries control to minimize deleterious e ects on the dentition. Gastrointestinal System e increase in progesterone levels during pregnancy causes a decrease in lower esophageal tone and gastric and intestinal motility. e combined e ects of hormonal and mechanical changes in the gastrointestinal system and greater sensitivity of the gag re ex also increases the risk of gastric acid re ux. In addition, the stomach is displaced superiorly as the uterus increases in size, which
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increases intragastric pressure. Consequently, the chair should be kept as upright as possible during dental treatment to relieve abdominal pressure and keep the patient comfortable. Ptyalism (excessive secretion of saliva) is a complication of pregnancy that occurs most o en in women su ering from nausea. e presence of excessive saliva in the mouth may also re ect the inability of nauseated women to swallow normal amounts of saliva rather than a true increase in production. In some cases as much as 2 L of saliva per day is lost through drooling. Reducing the consumption of complex carbohydrates may improve this condition.1 High-Risk Patients Obstetric consultation is usually not required before initiating dental treatment for normal, healthy pregnant patients. However, consultation should be sought before caring for patients who have been identi ed by the obstetrician as being at risk for pregnancy complications, such as those with pregnancy-induced hypertension,

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Table 1 Pregnancy drug risk categories, as defined by the U.S. Food and Drug Administration 4 Category A B Evidence Adequate, well-controlled studies in pregnant women have not shown an increased risk of fetal abnormalities. Animal studies have revealed no evidence of harm to the fetus, however, there are no adequate and wellcontrolled studies in pregnant women. or Animal studies have shown an adverse e ect, but adequate and well-controlled studies in pregnant women have failed to demonstrate a risk to the fetus Animal studies have shown an adverse e ect and there are no adequate and well-controlled studies in pregnant women. or No animal studies have been conducted and there are no adequate and well-controlled studies in pregnant women. Studies, adequate well-controlled or observational, in pregnant women have demonstrated a risk to the fetus. However, the bene ts of therapy may outweigh the potential risk. Studies, adequate well-controlled or observational, in animals or pregnant women have demonstrated positive evidence of fetal abnormalities. e use of the product is contraindicated in women who are or may become pregnant.

D X

gestational diabetes, threat of spontaneous abortion or history of premature labour. High-risk pregnant patients can usually be identi ed by taking a good medical history and asking questions about the course and nature of the pregnancy. Careful measurement and recording of baseline blood pressure, pulse and respiratory rate are required before any invasive procedure, including administration of a local anesthetic. Blood pressure is o en at or below the range expected for healthy women of childbearing age. If blood pressure is repeatedly elevated, especially above 140/90 mmHg, and fear and pain can be ruled out as causes, the obstetrician should be noti ed. Dental Treatment Figure 1 summarizes physiologic and other changes associated with pregnancy, and outlines the various diagnostic and treatment options for dental concerns. ese patients have a heightened awareness of and sensitivity to taste, smell and environmental temperature. Unpleasant tastes and odours can cause severe nausea or even gagging and vomiting, and overheating can lead to fainting. Acknowledged awareness and concern on the part of the dental sta and control of the o ce environment to the extent possible will contribute to patients comfort and sense of well-being. Hypoglycemia may cause fainting; it can be prevented by recommending that the patient eat a snack containing protein and complex carbohydrates before the appointment. Patients should be well hydrated, and the duration of chair treatment time should be as short as possible.

Timing of Treatment Coronal scaling, polishing and root planing may be performed at any time as required to maintain oral health. However, routine general dentistry should usually only be done in the second and third trimester of pregnancy. Organogenesis is completed by the end of the rst trimester, and uterine size has not increased to the extent that sitting in the dental chair is uncomfortable. Moreover, nausea has generally ceased by the end of the rst trimester. Extensive elective procedures should be postponed until a er delivery. Any treatment should be directed toward controlling disease, maintaining a healthy oral environment and preventing potential problems that could occur later in the pregnancy or during the postpartum period. 3 Radiography Oral radiography is safe for pregnant patients, provided protective measures such high-speed lm, a lead apron and a thyroid collar are used. No increase in congenital anomalies or intrauterine growth retardation has been reported for x-ray radiation exposure during pregnancy totalling less than 510 cGy, 5,6 and a full-mouth series of dental radiographs results in only 8 10 4 cGy.5 A bitewing and panoramic radiographic study generates about one-third the radiation exposure associated with a full-mouth series with E-speed lm and a rectangular collimated beam.7 Patients who are concerned about radiography during pregnancy should be reassured that in all cases requiring
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Infection Odontogenic infection should be treated promptly at any time during pregnancy. Although pregnant patients are usually not immunocompromised, the maternal immune system does become suppressed in response to the fetus.1 As such, there is a decrease in cell-mediated immunity and natural killer cell activity. Consequently, odontogenic infections Figure 3: Pyogenic granuloma. Figure 2: Pregnancy gingivitis. have the potential to develop rapidly into deep-space infections and to compromise the oralpharyngeal airway. Abscesses should be drained such imaging, the dental sta will practise the ALARA (As and the o ending pulp extirpated or the tooth removed Low As Reasonably Achievable) principle and that only to control the infection. e obstetrician should be informed of the patients status and the planned course of radiographs necessary for diagnosis will be obtained.8 and rationale for treatment discussed. Patients who are in Periodontal Disease acute dental pain should be cared for in a similar manner. Pregnancy gingivitis (Fig. 2) usually appears in the Long-term use of analgesics instead of de nitive treatrst trimester of pregnancy. is form of gingivitis re- ment is inappropriate. e patient should not have to wait sults from increased levels of progesterone and estrogen until a er delivery before treatment is provided. causing an exaggerated gingival in ammatory reaction to local irritants. e interproximal papillae become Medications red, edematous and tender to palpation, and they bleed Another concern is the prescribing and administration easily if subjected to trauma. In some patients, the of drugs. e most obvious concern is that the drug will condition will progress locally to become a pyogenic cross the placental barrier and cause teratogenic e ects to granuloma or pregnancy tumour, which is most com- the fetus. e U.S. Food and Drug Administration (FDA) monly seen on the labial surface of the papilla (Fig. 3). has de ned categories of pregnancy risk associated with Small lesions respond well to local debridement, chlor- various drugs (Table 1), and guidelines for safely prehexidine rinses and improved oral hygiene measures, but scribing drugs during pregnancy have been published.4 large lesions require deep excision. Because intraoperaAnalgesics tive bleeding can be di cult to control, such surgery Analgesic drug categories are based on short-term should be performed by clinicians with requisite training use (over 2 or 3 days) to treat a speci c disease process. and experience. Acetaminophen, which is in pregnancy risk category B, is Tooth mobility is a sign of periodontal disease the safest analgesic for use during pregnancy. However, caused by mineral changes in the lamina dura and disbecause various strengths and preparations are available turbances in the periodontal ligament attachments. and because there is a potential for liver toxicity, paVitamin C de ciency contributes to this problem, so tients should be instructed on how to take the drug and the patient should be advised accordingly. 3 Removal the maximum recommended daily dose (no more than of local gingival irritants, therapeutic doses of vita- 4 g/day for adults). min C and delivery typically result in reversal of the e majority of the other commonly prescribed antooth mobility. 3 algesics are in pregnancy risk category C. It should be Some observational and interventional studies have remembered that although category C drugs are generally shown an association between periodontal disease and safe, information from well-controlled human studies adverse pregnancy outcomes such as preterm labour is not available. erefore, prescriptions for these drugs and low birth weight,9,10 but other studies have shown should specify the most e ective therapeutic dose for no relation between periodontal disease and pregnancy the shortest time. Ibuprofen is a category B analgesic outcomes.11 While research continues into the patho- in the rst and second trimesters, but it is a category D physiology of a cause-and-e ect relation between oral drug during the third trimester because it has been ashealth and pregnancy outcomes, it is prudent to keep the sociated with lower levels of amniotic uid, premature pregnant patients periodontal system as free of disease closure of the fetal ductus arteriosus and inhibition of labour when taken during this time.12 It should be as possible.
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prescribed only a er consultation with and advice from the obstetrician. Obstetricians o en prescribe a combination of acetaminophen and codeine or oxycodone in place of nonsteroidal anti-in ammatory drugs. Prolonged use of narcotic analgesics in the third trimester can lead to neonatal respiratory depression. 3 In general, this does not appear to be a concern for the dose regimens typically prescribed in association with dental treatment. Recently, however, concern has been raised about the use of codeine by nursing mothers. In some women, codeine is more rapidly metabolized into morphine, and the morphine can be passed along by a mother who is breast-feeding an infant. Genetic testing is the only way to determine whether someone is a rapid metabolizer, so nursing mothers who are taking codeine should be made aware of the signs of morphine overdose in their infants. A mother should contact her doctor if her baby shows signs of increased sleepiness (more than 4 hours at a time), limpness or di culty nursing or breathing.13 Antibiotics and Antimicrobials Most antibiotics that are commonly prescribed by dentists are category B drugs, with the exception of tetracycline and its derivatives (e.g., doxycycline), which are in category D because of their e ects on developing teeth and bone. Cipro oxacin, a broad-spectrum oroquinolone antibiotic used to treat periodontal disease associated with Actinobacillus actinomycetemcomitans, is in category C. Its use in pregnancy has been restricted because of arthropathy and adverse e ects on cartilage development observed in immature animals. ere are not enough data to de nitively determine its safety in humans.14 Metronidazole is in category B. Some authors caution against its use in the rst trimester because of potential harm to the fetus; however, recent studies showed no de nitive teratogenic e ects.1517 e riskbene t ratio for the patient should be determined and the obstetrician consulted before prescribing this drug. e estolate form of erythromycin should be avoided because of deleterious e ects on the mothers liver. Chlorhexidine gluconate is a category B antimicrobial mouth rinse. Local Anesthetics Local anesthetics are relatively safe when administered properly and in the correct amounts. Lidocaine and prilocaine are category B drugs, whereas mepivacaine, articaine and bupivacaine are in category C. Epinephrine is also a category C drug. is drug has been studied in amounts of up to 0.1 mg added to local anesthetics used for epidural anesthesia (administered for pain relief during labour); no unusual side e ects or complications have been reported in this context.18 During administration of a local anesthetic with epinephrine, an intravascular injection may, at least theoretically, cause insu ciency of uteroplacental blood ow. However, for

a healthy pregnant patient, the 1:100,000 epinephrine concentration used in dentistry, administered by proper aspiration technique and limited to the minimal dose required, is safe.3 Fluoride Fluoride is a category C drug. Fluoride treatment may be needed for patients with severe gastric re ux caused by nausea and vomiting during early pregnancy, which can cause erosion of tooth enamel. In these cases, uoride treatment and restorations to cover the exposed dentin can diminish the sensitivity of and injury to the dentition. Topical uoride gel may cause nausea, so application of a uoride varnish may be better tolerated. e application of topical uoride should follow evidence-based guidelines.19 Sedatives and Anxiolytics Barbiturates and benzodiazepines are category D drugs and should be avoided during pregnancy. Benzodiazepines have been implicated in the development of cle lip and palate. Nitrous oxide is not rated in the FDA classi cation system, and its use during dental treatment is still controversial. e results of a survey of more than 50,000 dentists and dental hygienists, which suggested that long-term exposure to nitrous oxide may be associated with reproductive problems such as spontaneous abortion and birth defects, have been called into question because of perceived inherent biases of the study design. However, nitrous oxide is known to a ect vitamin B12 metabolism, rendering the enzyme methionine synthase inactive in the folate metabolic pathway. Because methionine synthase is vital for the production of DNA, it is best to avoid the use of nitrous oxide in the rst trimester of pregnancy, when organogenesis is occurring.20 e greatest concern for patient safety during the administration of nitrous oxide analgesia is the potential for hypoxia. e use of modern anesthetic machines, which are equipped with fail-safe and ow-safe systems, greatly diminishes the potential for hypoxia. If nitrous oxide is necessary for patient comfort, the analgesia technique should be discussed with the patient and obstetrician to be sure the pregnancy is progressing normally. A er the rst trimester of pregnancy, short-term administration of nitrous oxide (to ease apprehension during administration of a local anesthetic), with a minimal concentration of 50% oxygen, should be safe. 3,20 Conclusions Optimal oral health is very important for the pregnant patient and can be provided safely and e ectively. Paying attention to the physiologic changes associated with pregnancy, practising careful radiation hygiene measures, prescribing medications on the basis of drug safety
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categories and timing appointments and aggressive management of oral infection appropriately are important considerations. Given the possibility that periodontal disease may a ect pregnancy outcomes, dentists need to play a proactive role in the maintenance of the oral health of pregnant women. THE AUTHORS
Dr. Giglio is a professor and director, pre-doctoral education, department of oral and maxillofacial surgery, School of Dentistry, and a professor of surgery, department of surgery, division of oral and maxillofacial surgery, School of Medicine, Virginia Commonwealth University, Richmond, Virginia. Dr. Lanni is an associate professor and director, labor and delivery, department of obstetrics and gynecology, School of Medicine, Virginia Commonwealth University, Richmond, Virginia. Dr. Laskin is a professor and chairman emeritus, department of oral and maxillofacial surgery, School of Dentistry, and professor of surgery, department of surgery, division of oral and maxillofacial surgery, School of Medicine, Virginia Commonwealth University, Richmond, Virginia. Ms. Giglio is a certi ed nurse-midwife in private home birth practice, Richmond Birth Services, Inc., Richmond, Virginia. Correspondence to: James A. Giglio, Virginia Commonwealth University School of Dentistry, Department of oral and maxillofacial surgery, P.O. Box 980566, Richmond, VA 23298-0566. e authors have no declared nancial interests. is article has been peer reviewed.

13. M edscape A lerts. FDA w arns against codeine for mothers of nursing infants. Available: w w w.medscape.com/vie w article/561590?src= mp (accessed 20 08 Nov 10). 14. U.S. Food and Drug A dministration/Center for Drug Evaluation and Research. Cipro (Ciprofloxacin) use by pregnant and lac tating w omen. Available: w w w.fda.gov/cder/drug/infopage/cipro/cipropreg.htm (accessed 20 08 Nov 10). 15. M edicineN et, Inc. M etronidazole. Available: w w w.medicinenet.com/ metronidazole/article.htm (accessed 20 08 Nov 10). 16. Diav- Citrin O, Shechtman S, G otteineer T, Arnon J, Ornoy A . Pregnancy outcome after gestational exposure to metronidazole: a prospective controlled cohort study. Teratology 20 01; 63(5):186 92. 17. Kazy Z, Puh E, Czeizel AE. Teratogenic potential of vaginal metronidazole treatment during pregnancy. Eur J O bstet Gynecol Reprod Biol 20 05; 123(2):1748. 18. G urbet A , Turker G , Kose D O, Uckunkaya N. Intrathecal epinephrine in combined spinal-epidural analgesia for labor: doseregimen relationship for epinephrine added to a local anesthetic-opioid combination. Int J O bstet A nesth 20 05; 14(2):1215. 19. Levy SM . A n update on fluorides and fluorosis. J Can Dent A ssoc 20 0 4; 69(5):286 91. 20. Clark MS, Branick AL. Handbook of nitrous oxide and oxygen sedation. 2nd ed. St. Louis: C V M osby; 20 03. p. 17390.

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