A Review on the principle of Dental Management of the Pregnant patientDr. A. K. M. Tanzir Hasan

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

Questions that a dentist may askCan I take x-rays?Can I inject local anesthesia with epinephrine?What medications can I prescribe?Are topical agents safe?When should I perform necessary procedures?Can I use mercury restorations?

Stages of Pregnancy

1st 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.

Stages of Pregnancy

2nd Trimester (13-24 weeks)Fetal growth and maturation.Safest period to provide dental care.

Stages of Pregnancy

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

Physiologic Changes in PregnancyComplex hormonal interactions cause profound physiologic changesIncrease estrogen by 10 fold and progesterone by 30 foldsIncreased hormonal secretion and fetal growth causes several systemic as well as physical changes in a pregnant women

Systemic changes in pregnancy:Cardiovascular system in blood volume by an average of 45%Anemia due to increased blood volume (20% of women) in pulse by 10-15 beats per minuteSystemic murmur occurs in 90% of pregnancies, disappears shortly after deliverycardiac outputSupine hypotension syndrome may occur .

FLAT SUPINE POSITIONING

Negatively impacts: mother and infant

SUPINE HYPOTENSIONSYNDROME (Vena Cava Compression)

SUPINE POSITION AFTER 5TH MONTH UTERUS COMPRESSES THE INFERIOR VENA CAVAVOL. BLOOD IN THE L.E.S RETURN TO THE HEART REDUCED PERFUSION OF UTERUS FETAL HYPOXIA

Supine Hypotension Syndrome

Obstruction of inferior vena cava and aorta from pressure of the large fetus. Symptoms: Sweating Nausea Weakness Sense of lack of air

Supine Hypotension Syndrome

Other symptoms:Drop in blood pressureBradycardiaPossible loss of consciousness

Prevention of Supine HypotensiveSyndrome

Elevate right hip 10-12 cm.Weight is taken off the major vessels

Treatment of Supine HypotensiveSyndrome

Roll patient onto her left side.

How should the pregnant woman be positioned?Flat position may cause hypotension and hypoxiaPlace a small pillow under right hip - left lateral displacementHead above feet

Systemic changes in pregnancy:Diaphragm rises about 4 cm. residual volume awareness of a desire to breath is common-may be interpreted as dyspnea.Increased estrogen in blood causes engorgement of the nasal capillaries and rhnitis in pregnant women.Frequent nosebleeds & predisposition to upper respiratory infection.Respiratory system

Systemic changes in pregnancy:Gastrointestinal systemGastric emptying & intestinal transit times are delayed.

Heart burn / reflux common

Nausea and vomiting common

Systemic changes in pregnancy:For pregnant patient with Hyper-emesis gravidarium ( excessive and uncontrolled vomiting) , morning appointments should be avoided.

They should be seated in a semi-supine or comfortable positionIn case of vomiting , the procedure should be stopped immediately & the patient should be repositioned uprightWhen vomiting is over rinsing mouth with cold water or mouthwash is recommended.

Systemic changes in pregnancy:Urinary System GFR & renal plasma flow by as much as 50%Nocturia to mobilize the dependent edema which accumulate during the day. Frequency from renal flow plus reduced bladder capacity from uterine growthIt is advisable to ask the patient to void the bladder just prior to starting the dental procedure.

Systemic changes in pregnancy:Endocrine Changes:Estrogen, progesterone, human gonadotropin thyroxin, steroid and insulin levelEstrogen & progesterone are insulin antagonists. level of these hormones lead to insulin resistance. Thus insulin levels are elevated in pregnant in pregnant patient to compensate this resistanceAbout 45 %of women fail to produce sufficient amount of insulin to overcome this antagonist action & thus develop gestational diabetes.

Systemic changes in pregnancy:Hematological change red RBC , ESR, HbWBC circulatory catecholamin & cortisol lead to leucositosis Coagulation factors except factor XI & XIII (anticloting factor) so pregnancy is a hypercoagulable state & risk for thromboembolism

Systemic changes in pregnancy:Pregnant women with anti-phospholipid syndrome are at risk for thrombo-embolisim.They are placed on subcutaneous low molecular weight heparin (LMWH)These patients must be hospitalized for dental care.

Pregnancy RelatedOral Health ProblemsPregnancy GingivitisPregnancy Epulis Increased Tooth MobilityDental CariesErosionDental Problems in relation to Labor and Delivery

Oral Problems in PregnancyPregnancy GingivitisMost common oral manifestation (50-100% of women)Caused by hormonal and vascular changes of pregnancy

Pregnancy Gingivitis Pathophysiology

Elevated circulating estrogen increases capillary permeability.

Preexisting gingivitis may predispose to pregnancy gingivitis.

Pregnancy GingivitisOccurs commonly in the 2nd to 8th monthsTendency to bleed very easilyTreatment: 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.

Pregnancy Granuloma (continued)

Rapid growth up to 2 cm.Single tumor-like growthusually in interdental papillaePurplish to bluish in color, may be ulcerated- bleeds easily

Gum Problems - Pregnancy Granuloma

Gum Problems - Pregnancy Granuloma

Gum Changes - Pregnancy Granuloma

Pregnancy Granuloma (continued)

Treatment

Scaling and root planingExcision if it is too large or bleeds too easilyMay regress spontaneously after pregnancy

Candidiasis

Wipes offUsually asymptomatic, but may burnTreatment topical or systemic antifungals

Pregnancy MythsA mother loses a tooth for every babyNo evidence that aphthous ulcers are any more common in pregnancy

Other Oral Conditions in PregnancyDry mouthExcessive salivationTooth erosions associated with severe GERD or hyperemesis

Changes During Pregnancy that Affect Oral HealthHormonal AffectsIncreased tooth mobilitySaliva changesIncreased bacteriaGingival problems

Saliva changesDecreased buffersDecreased mineralsDecreasing flow first and last trimesterIncreased flow second trimesterMore acidic

Increased BacteriaIncreased acidityIncrease in decay-causing bacteriaIncreased SnackingMorning sickness/low blood sugarBetween-meal snacksIncrease in amount and frequency of starches/carbohydrates Crackers are commonly recommended Promotes decay-causing bacteria

Changes During Pregnancy that Affect Oral HealthMorning sicknessDifficulty with hygieneGingival diseaseTooth decayVomitingEsophogeal Reflux (heartburn)Acid exposureIrritation of the gumsWeakening of tooth enamelDental erosion

Enamel erosion caused by frequent vomiting

Treatment for Acid ExposureDo NOT brush immediately after vomitingRinse Water with baking sodaAntacidPlain waterEat some cheese

Oral Diseases Can Effect PregnancyPreterm, low birth weight (LBW) linked to periodontal diseaseThorough calculus (tartar) removal in pregnant women with periodontitis may reduce pre-term births

Periodontal Disease and Preterm LaborMaternal periodontal disease is associated with increased risk of preterm laborAnaerobic oral gram-negative bacteria cause inflammatory responseInflammatory response stimulates prostaglandin and cytokine production to stimulate labor

Periodontal Disease and Low Birth WeightPeriodontal disease is associated with low birth weightEvidence is not conclusiveBiochemical mechanism similar cascade as in preterm labor leading to placental blood flow restriction and necrosis

Periodontal Disease and PreeclampsiaEmerging dataMechanism unclearProposed mechanism:Periodontal infection leads to inflammatory vascular damage Triggers cell damage in placenta

Periodontitis and Pre-eclampsia

Periodontal disease may be associated with pre-eclampsia (Boggess, 2003)PGE2, IL-1 and TNF- from gingival crevicular fluid were higher in women with preeclampsia compared with healthy matched pregnant women (Oettinger-Barak, 2003).

Dental Considerations

timing of treatment for pregnant patients dental radiation exposure use of local anestheticsprescription of common antibiotics and analgesics nitrous oxide gas administration

Treatment TimingFirst TrimesterSpontaneous miscarriages naturally occur more often in 1st trimesterAvoid elective treatment that can be delayedOffer anticipatory guidanceSecond TrimesterThe optimal time for dental treatmentOrganogenesis complete, fetus not largeEasier to prevent than treat established diseaseThird TrimesterLate in term very uncomfortable (short visits)Position slightly on left side

Timing of Dental Treatment During Pregnancy - From Little and FallaceFirst Trimester

Plaque controlOral hygiene instructionScaling, polishing, curettageAvoid elective treatment; urgent care only

Timing of Dental Treatment During Pregnancy - From Little and Fallace

Second Trimester

Plaque controlOral hygiene instructionScaling, polishing, curettageRoutine dental care

Timing of Dental Treatment During Pregnancy - From Little and Fallace

Third Trimester

Plaque controlOral hygiene instructionScaling, polishing, curettageRoutine dental care (after middle of third trimester, elective care should be avoided)

Use of Radiation on Pregnant Patient

Dose given and time of gestation are importantdoses < 5-10 rads (cGy) not teratogenicfetus is most susceptible to radiation between the 2nd and 6th week of gestationsingle dental x-ray exposes patient to 0.01 millirads of radiation. In relative terms, this amount is 40 times less than daily dose acquired from cosmic radiation. Therefore, diagnostic radiation should not be withheld during pregnancy

Radiographs during Pregnancy

Take as needed with optimal methods for reducing secondary radiation and exposure time.Always use a lead apron.Exposure to fetus (with apron use) is .00001 centiGray.(rad)Daily cosmic radiation - .0004 centiGray (rad)

Risks of Dental X-RaysX-ray only if necessary (i.e. root canal therapy, trauma)When x-rays are indicated, radiation exposure is extremely lowExposure can be limited by: Lead apron shielding Modern fast film Avoiding retakes

FDA drug classification for pregnancyCombines risk statements including congenital anomalies, fetal effects, perinatal risks, and therapeutic risk-benefit ratioUntreated disease or condition may pose more serious risks to both mother and fetus than any theoretical risks from the medicationCategory A thru D and X

FDA drug classification for pregnancy

A = Controlled Studies in women fail to demonstrate a risk to the fetus in the first trimester and the possibility of fetal harm appears remote

FDA drug classification for pregnancy B = Animal studies show no risk, or if risk shown in animals, controlled trials in women showed no risk

FDA drug classification for pregnancyC = Studies in animals with adverse effects and no human studies, OR no animal or human studies, but benefits of use may outweigh potential harms

FDA drug classification for pregnancyD = There is evidence of human fetal risk, but benefits may outweigh risks

FDA drug classification for pregnancyX = Contraindicated

Common Analgesicsparacetamol (B)Ibuprofen (B/D*) Oxycodone (B/D*) Hydrocodone and codeine (C/D*)

*avoid in third trimester

Analgesics

Paracetamol is the analgesic of choice for all stages of gestationused to treat mild to moderate pain and feversshort term usage is believed to be safeavoid chronic and large doses of paracetamol

Analgesics - continued

Aspirin is nonteratogenic but may cause maternal and fetal hemorrhagelarge and chronic doses during last trimester may result in premature closure of ductus arteriosus, fetal hypertension, anemia, and low birth weightavoid ibuprofen in 3rd trimester because of possible adverse circulatory effectsshort term use of codeine seems safeavoid codeine late in gestation because of possible fetal respiratory depression and withdrawal symptoms

Analgesics to Use During1st and 2nd Trimester

Category B (for best!)Paracetamol, Ibuprofen,NaproxenCategory C (use with caution):Paracetamol with codeine or hydrocodoneParacetamol with oxycodone

Analgesics to Avoid During theThird Trimester

Causes delivery problems:Aspirin (C/ 3D)Ibuprofen (B/3D)Naproxen (B/3D)Causes neonatal respiratory depression and opioid withdrawal:Codeine (C/3D)Hydrocodone (C/3D)Oxycodone(C/3D)

Sedation in Pregnancy

Sedatives/Anxiolytics (e.g. Diazepam ) are rated D and can cause oral clefts with prolonged exposure.Nitrous oxide should not be used in 1st trimester (If used in 2nd and 3rd, do not go below 50% O2)

Common AntibioticsTo treat oral abscess or cellulitisPenicillin (B) Amoxicillin (B) Cephalexin (B)Erythromycin base* (B) (Not estolate, as it cause cholestatic hepatitis)Clindamycin (B)

Antibiotics

penicillin V and amoxicillin is preferred drug for mild to moderate infectionswidely used for many years with no ill effectsno studies show penicillin to be teratogenicamoxicillin extensively used without harming the fetusDrug classes: B: penicillin, cephalosporins, erythromycin, clindamycin, Azithromycin D: Tetracycline

Antibiotics To Use During Pregnancy

Penicillin VAmoxicillinErythromycin (base form)Cephalexin, cephalosporinClindamycinMetronidazole

Antibiotics to Avoid duringPregnancy

DoxycyclineTetracyclineErythromycin (estolate form)Vancomycin

The Problem With Tetracycline

Accumulates in bones and chelates calciumInhibits bone growthDiscolors teeth

Other Antimicrobial Agents

OK to use:Nystatin (B)Chlorhexidine rinse (B)Use with caution:Clotrimazole (C)Ketoconazole (C)Fluconazole (C)Do not use:Doxycycline (D)

Local Anesthetic Use inPregnancy

Class B:Lidocaine (Xylocaine)EtidocainePrilocaine Class C:ProcaineBupivicaineMepivicaine

Use of Local Anesthetics

Lidocaine + vasoconstrictor: most common local anesthetic used in dentistryextensively used in pregnancy with no proven ill effectsaccidental intravascular injections of lidocaine pass through the placenta but the concentrations are too low to harm fetusprilocaine might cause methemoglobinemia

Ulcer healing drugsCimetidine FDA category B FamotidineFDA category BRanitidineFDA category B not known to be harmful

Ulcer healing drugsOmeprazoleFDA category B.Not known to be harmful EsomeprazoleFDA category BLansoprazoleFDA category BPantoprazoleAvoid unless potential benefit outweighs riskfetotoxic in animals

Ulcer healing drugsMisoprostolFirst, second, third trimesters: Avoidpotent uterine stimulant (has been used to induce abortion) and may be teratogenic

Ulcer healing drugsAntacidsAlmunium hydroxide/Magnesium hydroxideFDA category BCalcium carbonateFDA category C

SimetheconeFDA category C

Use of Nitrous Oxide Gas

used over 150 years safety is being debatedSHORT TERM exposure do not cause birth defects or spontaneous abortionCHRONIC exposure may result in fetal loss and infertilityliterature suggests that nitrous oxide should be avoided until more conclusive research is available FDA Drug class: not yet assigned

Common PreventivesFluorideNo increased risk during pregnancyXylitolNo studies; no harm reportedChlorhexidineNo increased risk during pregnancy

Are topical agents safe?FluorideToothpaste & mouthrinseXylitol chewing gum Chlorhexidine (11% alcohol)No over the counter mouthrinses with alcohol (Listerine 20% alcohol)

Pre-natal Fluoride

Daily 2.2 mg tablet of sodium fluoride during 3rd through 9th monthsdecreases caries rate in offspring.Safe and effective.

Glenn, FB, 1982

Is it safe to use mercury restorations?No evidence of harmful effect Benefits outweigh risksCanada, Germany, and New Zealand have some restrictionsDetermine the best option

References

Wasylko L, Matsui D, Dykxhoorn SM, Rieder MJ, Weinberg S. A Review of Common Dental Treatments During Pregnancy. J Canadian Dental Association. 64:434-439 1998Little JW, Donald AF, Craig SM, Rhodus NL. Dental Management of the Medically Compromised Patient - 5th edition. Mosby, Toronto. Pp.434-442. 1997.Livingston HM, Dellinger TM, Holder R. Considerations in the management of the pregnant patient. Special Care in Dentistry. 18:5 pp183-188. 1998.Larimore WL, Petrie KA. Drug use during pregnacy and lactation. Primary Care; Clinics in Office Practice. 27:1 35-53. 2000 Health Canada. The Safety of DentalAmalgam. Minister Of Supply and Services Canada. 1996.

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96. Rosen MA. Nitrous oxide for relief of labor pain: a systematic review. Am J Obstet Gynecol 2002;186(Suppl Nature):S110-6.97. Sands TD, Pynn BR. Management considerations for the pregnant or nursing emergency patient. Ont Dent 1998;75: 17-9.98. Daya S. Recurrent spontaneous early pregnancy loss and low dose aspirin. Minerva Ginecol 2003;55:441-9.99. Sinclair C. Handbook of obstetrical emergencies. 1st ed. Philadelphia: WB Saunders; 1996. p. 29-39, 69.100. Tarsitano BF, Rollings RE. The pregnant dental patient: evaluation and management. Gen Dent 1993;41:226-34.101. Livingston MH, Dlllinger TM, Holder R. Consideration in the management of the pregnant patient. SCD Special Care in Dentistry 1998;18:183-8.

Thank you

Implantation occurs 1 week after conception .By the end of the 4th week after ovulation-heart prominent, arm and leg buds .By the end of the 6th wee after fertilization-fingers and toes present, external ear developing. Considered an embryo from biginning of 3rd weeks from fertilization( 10 weeks from last menses)By the end of 12 weeks centre of ossification have appeared in most fetal bones, fingers and toesAntiphospholipid syndrom in pregnancy is characterized by the presence of autoantibodies in association with recurrent fetal loss and sever complication such as pre-eclamsia, fetal growth retardation, or placental insufficiency.In about 5 to 10% of women, the increased response of the gums in the presence of pregnancy hormones can cause irritated gum tissue to grow into a lumpy mass known as a pregnancy granuloma (often misnamed a Pregnancy Tumor). These usually start growing during the second trimester and are usually found between the teeth. They bleed easily and have a red, raw-looking rumpled surface. If they are small and do not cause any problems, your dentist will probably advise you to wait and see if they go away after the baby is born. If they do not go away after delivery, they can be removed surgically. When a pregnancy granuloma becomes too large, it can get in the way of chewing. They can even cause too much bleeding and become painful. If this happens, your dentist will probably want to remove it right away and clean the teeth around the area thoroughly.This pregnant woman has a very large granuloma, and severe irritation of the gums surrounding the other teeth as well. This lesion will probably have to be removed so the mother can eat and clean her teeth properly.

Candidiasis is often seen as a thick whitish layer on the tongue and buccal surfaces. It can be wiped off, which helps differentiate it from other oral white lesions. It is often asymptomatic, but can burn. It is more common in pregnancy because of the relatively immunocompromised state. There are other forms of oral candidiasis including angular chelitis. Treatment consists of topical and/or systemic antifungals.

Fotos PG, Vincent SD, Hellstein JW. Oral candidosis: Clinical, historical and therapeutic features of 100 cases. Oral Surg Oral Med Oral Pathol 1992;74:41-9.Progesterone and estrogen can increase circulation bringing more blood to the gums, causing swelling (gingivitis) and sensitivity to bacteria. Teeth can loosen during pregnancy, but healthy teeth will not simply fall out. However, if a patient has pre-exising caries, gingivitis, or periodontal disease, it can worsen during pregnancy if good hygiene is not maintained and contribute to tooth loss. Women should be encouraged to brush, floss, and see a dentist for cleanings and preventive care during pregnancy.

The precise etiology of aphthous ulcers is unknown, but there is no evidence specifically linking them to pregnancy.

Photo shows an aphthous ulcer.

McCarten BE, Sullivan A. Obstet Gynecol 1992;80 [3 Pt 1]:455-458.Scheutz F, Baelum V, Matie MI, Mwangosi I. Motherhood and dental disease. Community Dent Health 2002; 19:67-72.Lee A, McWilliams M, Janchar T. Care of the Pregnant Patient in the Dental Office. Dent Clin North Am 1999;43:485-495. Pregnant women can have either dry mouth (xerostomia) or excess saliva. The former can contribute to more active caries and gingivitis.Enamel erosions induced by gastric acid can occur in the patients with severe GERD or hyperemesis gravidarum.

American Dental Association Council on Access, Prevention, and Interprofessional Relations (ADA). ADA oral health care series: Women's oral health issues. Chicago, IL: American Dental Association, 1995. Hey-Hadavi JH. Womens Oral Health Issues: Sex differences and clinical implications. Women Health Primary Care. 2002;5(3):189-199.Hormone changes, mainly estrogen and progesterone, can cause many changes in the mouthThe same hormones that increase ligament laxity in other joints during pregnancy can also cause increased mobility of the teeth. Severe mobility, however, may be a sign of severe periodontal disease and should be evaluated by a dentist as soon as possible.Hormonal changes can also cause changes in saliva flow, either increasing or decreasing it. Changes in the quantity and quality can also occur, making it less protective.Some types of bacteria that normally live in the mouth increase in numbers during pregnancy. These bacteria can cause tooth decay or gum disease.One of the bodys primary defenses against tooth decay is saliva. Saliva contains proteins and electrolytes that buffer and neutralize bacterial acids. It also contains the minerals calcium and phosphorus, which help to remineralize (harden) teeth. During pregnancy, saliva composition may show a decrease in buffering ability and calcium levels. During pregnancy, saliva may develop a lower pH or become more acidic. This change has been shown to be associated with increased levels of decay-causing bacteria.Decreased saliva flow can cause dry mouth or Xerostomia. Some women experience the opposite problem of excessive salivation, or Pryalism.Any of these changes in saliva may increase a womans susceptibility to tooth decay, so maintaining good oral hygiene habits becomes particularly important.Many women experience nausea or hypoglycemia during pregnancy, which necessitates the consumption of between-meal snacks. Commonly promoted foods such as crackers may be high in starches (fermentable carbohydrates) that promote tooth decay. This increased frequency of food consumption and increase in carbohydrate intake can promote tooth decay by increasing the acid production of decay-causing bacteria.

Morning sickness can cause problems with oral health if the nausea makes it difficult for the pregnant woman to use a toothbrush or floss. Some women are so sensitive that they have a difficult time tolerating anything placed in the mouth.If this causes a disruption of normal hygiene such as brushing or flossing, the bacteria that are normally present in the mouth are likely to cause pregnancy gingivitis or tooth decay.The nausea that is often experienced during the first trimester is sometimes accompanied by vomiting. During the third trimester some women also develop severe heartburn or esophogeal reflux which propels stomach acid up into the mouth. Stomach acids irritate the gingival tissue. Stomach acids also soften the outer layers of tooth enamel allowing it to be removed easily. If this happens repeatedly the enamel will become thinned. This process is called dental erosion.

Tooth brushing should never be performed immediately after the mouth is exposed to stomach acid. The brushing action can remove the softened outer layer of enamel, causing it to thin.Rinsing with a solution of water that contains baking soda will neutralize the acid and allow the saliva to remineralize the tooth. If baking soda is not available, liquid antacids or plain water may be used. Studies have shown that eating a small piece of cheese will quickly neutralize acids in the mouth and boost calcium levels, helping to protect the teeth from damage.If acid exposure happens repeatedly on a daily basis, tell your dentist. You may need a fluoride mouth rinse or prescription fluoride gel to prevent dental erosion.

Many studies have shown that women who have a preterm delivery are more likely to have had gum disease during pregnancy. This makes sense because gum disease is a bacterial infection. It has long been known that infections in other areas of the body can cause preterm labor and delivery. Disease-causing bacteria produce toxins that pass into the bloodstream and cause the body to produce chemicals to try to fight off the disease process. These chemicals are the same ones that can induce contractions.

There is a growing body of evidence (prospective and case control studies; no randomized controlled trials) that periodontal disease is associated with an increased risk of preterm labor. The onset of new periodontal disease or activated chronic disease is caused by gram negative bacteria which may cause recurrent bacteremias and a release of lipopolysaccharide endotoxins which leads to hepatic acute inflammatory response. This in turn leads to production of cytokines and biological mediators such as prostaglandins (PGE2) and interleukins (IL-1, IL-6) as well as the systemic production of serum antibodies. These mediators can initiate labor.

Photo illustrates moderate periodontal disease.

Offenbacher S, Boggess KA, Murtha AP, Jared HL, Lieff S, McKaig RG, et al. Progressive periodontal disease and the risk of very preterm labor. Obstetrics and Gynecology 2006;107(1):29-36. Jeffcoat MK, Geurs NC, Reddy MS, Cliver SP, Goldenberg RL, Hauth JC. Periodontal infection and preterm birth: Results of a prospective study. J Am Dent Assoc 2001;132;875-880.Offenbacher S, Lieff S, Boggess KA, Murtha AP, Madianos PN, Champagne CM, et al. Maternal periodontitis and prematurity. Part I: Obstetric outcome of prematurity and growth restriction. Annals of Periodontology. 2001;6(1):164-174.Madianos PN, Lieff S, Murtha AP, Boggess KA, Auten RL Jr, Beck JD, and Offenbacher S. Maternal periodontitis and prematurity. Part II: Maternal infection and fetal exposure. Ann Periodontol. 2001 Dec;6(1):175-182.Offenbacher S, Katz V, Fertik G, Collins J, Boyd D, Maynor G, et al. Periodontal infection as a possible risk factor for preterm low birth weight. Journal of Periodontology. 1996;67(10 Suppl):1103-1113.Dasanayake AP. Poor periodontal health of the pregnant woman as a risk factor for low birth weight. Ann Periodontol 1998;3:206-212.Lopez NJ, Smith PC, Gutierrez J. Higher risk of preterm birth and low birth weight in women with periodontal disease. J Dent Res 2002;81:58-63.Romero BC, Chiquito CS, Elejalde LE, Bernardoni CB. Relationship between periodontal disease in pregnant women and the nutritional condition of their newborns. J Periodontol 2002;73:1177-1183.Lpez, NJ, DaSilva I, Ipinza J, Gutierrez J. Periodontal therapy reduces the rate of preterm low birth weight in women with pregnancy-associated gingivitis. J Periodontol. 2005;76(11-s):2144-2153.Jeffcoat M, Hauth JC, Geurs NC, Reddy MS, Cliver SP, Hodgkins PM, et al. Periodontal disease and preterm birth: Results of a pilot intervention study. J Periodontol 2003;74(8):1214-18.Newnham, J. Poster Presentation Society for Gynecological Investigation. Fam Pract News, Sept 1, 2005.

The following case-control and prospective British studies showed no association with PTL or LBWB:

Davenport ES, Williams CECS, Stern JAC, Murad S, Sivapathasundram V, Curtis MA. Maternal periodontal disease and preterm low birthweight: case-control study. Journal of Dental Research 2002;81:313-18.Moore S, Ide M, Coward PY, Randhawa M, Borkowsaka E, Baylis R, Wilson RF. A prospective study to investigate the relationship between periodontal disease and adverse pregnancy outcome. British Dental Journal 2004;197:251-8.Moore S, Randhawa M, Ide M. A case-control study to investigate an association between adverse pregnancy outcome and periodontal disease. J Clin Periodontal 2005;32:1-5.As with preterm labor, animal models and human studies have demonstrated gram negative bacteria from the mouth initiating an inflammatory cascade that leads to an increase release of prostaglandins (PGE2) and interleukins (IL-1, IL-6), which in turn induce uterine contractions, placental blood flow restriction and placental necrosis with resulting intrauterine growth restriction. In some cases it may also lead to preterm labor and/or premature rupture of membranes. It is unclear which mechanism actually results in the low birth weight. Each study has controlled for confounding risks for low birth weight. However, many studies have looked at preterm labor and low birth weight concurrently which may affect outcomes.

Offenbacher S, Lieff S, Boggess KA, Murtha AP, Madianos PN, Champagne CM, McKaig RG, Jared HL, Mauriello SM, Auten RL Jr, Herbert WN and Beck JD. Maternal periodontitis and prematurity. Part I: Obstetric outcome of prematurity and growth restriction. Ann Periodontol. 2001;6(1):164-174.Newnham J. Poster Presentation Society for Gynecological Investigation. Fam Pract News, Sept 1, 2005.Offenbacher S, Boggess KA, Murtha AP, Jared HL, Lieff S, McKaig RG, Mauriello SM, Moss KL, Beck JD. Progressive Periodontal Disease and the Risk of Very Preterm Labor. Obstetrics and Gynecology. 2006;107(1):29-36. Offenbacher S, Katz V, Fertik G, Collins J, Boyd D, Maynor G, et al. Periodontal infection as a possible risk factor for preterm low birth weight. Journal of Periodontology. 1996;67(10 Suppl):1103-13.Lopez NJ, Smith PC, Gutierrez J. Higher risk of preterm birth and low birth weight in women with periodontal disease. J Dent Res 2002;81:58-63.Lpez, NJ, DaSilva I, Ipinza J, Gutierrez J. Periodontal therapy reduces the rate of preterm low birth weight in women with pregnancy-associated gingivitis. J Periodontol. 2005;76(11-s):2144-2153.

The following case-control and prospective British studies showed no association with PTL or LBWB:

Davenport ES, Williams CECS, Stern JAC, Murad S, Sivapathasundram V, Curtis MA. Maternal periodontal disease and preterm low birthweight: case-control study. Journal of Dental Research 2002;81:313-18.Moore S, Ide M, Coward PY, Randhawa M, Borkowsaka E, Baylis R, Wilson RF. A prospective study to investigate the relationship between periodontal disease and adverse pregnancy outcome. British Dental Journal 2004;197:251-8.Moore S, Randhawa M, Ide M. A case-control study to investigate an association between adverse pregnancy outcome and periodontal disease. J Clin Periodontal 2005;32:1-5. Less definitive data exists for the relationship between periodontal disease and preeclampsia. Small studies point to the inflammation cascade as the culprit which causes vascular damage and placenta cell death thus initiating the same pathophysiologic responses that are proposed for any woman who develops preeclampsia. One cohort study of 1115 women found an adjusted odds ratio of 2.4 (CI 1.1-5.3) for preeclampsia for those with severe periodontal disease and an adjusted odds ratio of 2.1 (CI 1.0-4.4) for preeclampsia if pre-existing periodontal disease progressed during pregnancy (Boggess). Interventions to prevent preeclampsia in women with periodontal disease have not been studied. Oettinger-Barak O, Barak S, Ohel G, Oettinger M, Kreutzer H, Peled M, et al. Severe pregnancy complication (preeclampsia) is associated with greater periodontal destruction. J Periodontol 2005; 76(1):134-137.Boggess KA, Lieff S, Murtha AP, Moss K, Beck J, Offenbacher S. Maternal periodontal disease is associated with an increased risk for pre-eclampsia. Obstet Gynecol 2003;101:227-231.

Dental procedures are not associated with miscarriage. However, delaying elective treatment until the 2nd trimester avoids having the treatment occur at a time when the patient is at high risk of spontaneous miscarriage (20% of all pregnancies and 80% of those miscarriages occur in the first trimester). By the second trimester, organogenesis is complete, thereby reducing the risk of any necessary medication exposures. The fetus is not large, making it easier for mom to recline in the dental chair for prolong periods. In the third trimester it is more difficult to lie for long periods, so extensive dental work should be broken up into multiple smaller visits. If a visit will take some time, pregnant mothers should be encouraged to get up and walk intermittently, and positioned slightly on the left side with a towel prop to avoid vena cava syndrome. ACOG cautions that some interventions can precipitate labor.

Shrout MK, Potter BJ, Comer RW, Powell BJ. Treatment of pregnant dental patients: a survey of general dental practitioners. Gen Dent. 1994;42:164-167.Tarsitano BF, Rollings RE. The pregnant dental patient: Evaluation and management. Gen Dent 1993;41:226-231.Wong, D. L., & Perry, S. E. Maternal Child Nursing Care. St. Louis: Mosby-Year Book, Inc, 1998.Bobak IM, Lowdermilk DL, Jensen MD. Maternity Nursing. (4th ed.). St. Louis: Mosby, 1995. Radiation exposures are extremely low during dental x-rays. Patients and their unborn child are generally at higher risk from the oral disease affecting the pregnancy (such as preterm labor) than they are from radiation exposure. Fetal risk is theoretically for inducing cancer and mental retardation based on animal testing and studies of pregnant patients exposed to radiation after an atomic bomb. A significantly at risk exposure is 10 uSvs of radiation; a full mouth series using modern fast film results in an exposure of 0.005 uSvs. Exposure can be minimized by using appropriate shielding of the fetus, thyroid, and ovaries. Dentists should also be encouraged to avoid retakes during pregnancy.

Maillie HD, Gilda JE. Radiation induced cancer risk in radiographic cepahalometry. Oral Surg Oral Med Oral Pathol 1993;75:631-637.Abbott P. Are dental radiographs safe? Aust Dent J. 2000;45:208-213.Langlais RP, Langland OE. Risks from dental radiation in 1995. CDA J. 1995;May:33-39.American Dental Association Council on Access, Prevention, and Interprofessional Relations (ADA). ADA oral health care series: Women's oral health issues. Chicago, IL: American Dental Association, 1995. This slide outlines the current rating system for medications in pregnancy.Dental pain originating from infections or extensive carious lesions can be severe. Physicians should not refrain from using the above analgesics with several caveats. Ibuprofen should be avoided in the 3rd trimester because of the risk of premature closure of the ductus arteriosus and oligohydramnios. Prolonged or high dose opioids should be avoided in the third trimester due to the risk of newborn opioid withdrawal.

Briggs GG, Freeman RK, Yaffe SJ. Drugs and Pregnancy in Lactation. Lippincott, Williams and Wilkins, 7th edition, 2005.Hilgers KK, Douglass JM, Mathieu GP. Adolescent Pregnancy: A Review of Dental Treatment Guidelines. Pediatr Dent 2003;25:459-467. Maternal anemia and fetal renal disease was reported when used in high doseIt is common to have to treat an abscess or other infection originating in the mouth such as cellulitis. The above medications are all safe in pregnancy. Erythromycin and clindamycin are appropriate choices in a penicillin allergic patient.

*Note that while erythromycin base is safe, erythromycin estolate is relatively contraindicated as it is associated with cholestatic hepatitis in pregnancy.

Briggs GG, Freeman RK, Yaffe SJ. Drugs and Pregnancy in Lactation. Lippincott, Williams and Wilkins, 7th edition, 2005.Motherisk. Toronto, Ontario, Canada at www.motherisk.org (which included referencing National Collaborative Perinatal Project, 1959-1974, Record Group 443, National Institutes of Health.)Hilgers KK, Douglass JM, Mathieu GP. Adolescent Pregnancy: A Review of Dental Treatment Guidelines. Pediatr Dent 2003;25:459-467.Chow AW, Jewesson PJ. Use and safety of antimicrobial agents during pregnancy. West J Med 1987;146(6):761-64.Fluoride retards bacteria growth and strengthens enamel. The Collaborative Perinatal Project (50 000 woman 12 US health centers, 1959-1974, evaluating teratogenicity of medications and drugs in first four months of pregnancy) showed no increased risk when taken during pregnancy.

Xylitol gum stimulates salivation which retards bacterial growth, induces a more neutral oral pH, and assists with enamel re-mineralization.No direct studies in pregnancy have been performed, but studies where it has been used as an intervention have not demonstrated harm.

Chlorhexidine has antimicrobial activity and can reduce gingivitis and plaque deposition. Vaginal application studies have shown no harm to fetus. No studies of oral use are available, but exposure would be similar when used as a rinse and spit preparation, and absorption from the gastrointestinal tract is poor.

Brambilla E, Felloni A, Gagliani M, Malerba A, Garcia-Godoy F, Strohmenger L. Caries prevention during pregnancy: Results of a 30 month study. J Am Dent Assoc 1998;129(7):871-877.Gunay H, Dmoch-Bockhorn K, Gunay Y, Geurtsen W. Effect on caries experience of a long-term preventive program for mothers and children starting during pregnancy, Clinical Oral Investigations. 1998;2(3): 137-142 Wang Y, van Eys J. Nutritional significance of fructose and sugar alcohols. Ann Rev Nutr 1981;1:437-75.Briggs GG, Freeman RK, Yaffe SJ. Drugs in Pregnancy and Lactation, 7th Edition. Baltimore: Wiliams and Wilkins, 2005.

All information above confirmed with Motherisk, Toronto, Ontario Canada at www.motherisk.org.