Review on dental management of pregnant patient


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  • Review on dental management of pregnant patient

    1. 1. A Review on the principle of Dental Management of the Pregnant patient Dr. A. K. M. Tanzir Hasan
    2. 2. <ul><li>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 </li></ul>
    3. 3. Questions that a dentist may ask <ul><li>Can I take x-rays? </li></ul><ul><li>Can I inject local anesthesia with epinephrine? </li></ul><ul><li>What medications can I prescribe? </li></ul><ul><li>Are topical agents safe? </li></ul><ul><li>When should I perform necessary procedures? </li></ul><ul><li>Can I use mercury restorations? </li></ul>
    4. 4. Stages of Pregnancy <ul><li>1st Trimester (1-12 weeks) </li></ul><ul><li>Fetal organ formation and differentiation. </li></ul><ul><li>Most susceptible to adverse effects of teratogens. </li></ul><ul><li>Avoid all elective care but provide care as needed. </li></ul>
    5. 5. Stages of Pregnancy <ul><li>2nd Trimester (13-24 weeks) </li></ul><ul><li>Fetal growth and maturation. </li></ul><ul><li>Safest period to provide dental care. </li></ul>
    6. 6. Stages of Pregnancy <ul><li>3rd Trimester (25-40 weeks) </li></ul><ul><li>Fetal growth continues. </li></ul><ul><li>Focus of concern is risk to upcoming birth process and safety and comfort of the pregnant woman. </li></ul>
    7. 7. Physiologic Changes in Pregnancy <ul><li>Complex hormonal interactions cause profound physiologic changes </li></ul><ul><li>Increase estrogen by 10 fold and progesterone by 30 folds </li></ul><ul><li>Increased hormonal secretion and fetal growth causes several systemic as well as physical changes in a pregnant women </li></ul>
    8. 8. Systemic changes in pregnancy: <ul><li>Cardiovascular system </li></ul><ul><li>↑ in blood volume by an average of 45% </li></ul><ul><li>Anemia due to increased blood volume (20% of women) </li></ul><ul><li>↓ in pulse by 10-15 beats per minute </li></ul><ul><li>Systemic murmur occurs in 90% of pregnancies, disappears shortly after delivery </li></ul><ul><li>↑ cardiac output </li></ul><ul><li>Supine hypotension syndrome may occur . </li></ul>
    9. 9. FLAT SUPINE POSITIONING <ul><li>Negatively impacts: mother and infant </li></ul>
    10. 10. SUPINE HYPOTENSION SYNDROME (Vena Cava Compression) <ul><li>SUPINE POSITION AFTER 5 TH MONTH </li></ul><ul><li>UTERUS COMPRESSES THE INFERIOR VENA CAVA </li></ul><ul><li>↑ VOL. BLOOD IN THE L.E.’S </li></ul><ul><li>↓ RETURN TO THE HEART </li></ul><ul><li>REDUCED PERFUSION OF UTERUS </li></ul><ul><li>FETAL HYPOXIA </li></ul>
    11. 11. Supine Hypotension Syndrome <ul><li>Obstruction of inferior vena cava and aorta from pressure of the large fetus. </li></ul><ul><li>Symptoms: </li></ul><ul><li>Sweating </li></ul><ul><li>Nausea </li></ul><ul><li>Weakness </li></ul><ul><li>Sense of lack of air </li></ul>
    12. 13. Supine Hypotension Syndrome <ul><li>Other symptoms: </li></ul><ul><li>Drop in blood pressure </li></ul><ul><li>Bradycardia </li></ul><ul><li>Possible loss of consciousness </li></ul>
    13. 14. Prevention of Supine Hypotensive Syndrome <ul><li>Elevate right hip 10-12 cm. </li></ul><ul><li>Weight is taken off the major vessels </li></ul>
    14. 15. Treatment of Supine Hypotensive Syndrome <ul><li>Roll patient onto her left side. </li></ul>
    15. 16. How should the pregnant woman be positioned? <ul><li>Flat position may cause hypotension and hypoxia </li></ul><ul><li>Place a small pillow under right hip - left lateral displacement </li></ul><ul><li>Head above feet </li></ul>
    16. 17. Systemic changes in pregnancy: <ul><li>Diaphragm rises about 4 cm. </li></ul><ul><li>↓ residual volume </li></ul><ul><li>↑ awareness of a desire to breath is common-may be interpreted as dyspnea. </li></ul><ul><li>Increased estrogen in blood causes engorgement of the nasal capillaries and rhnitis in pregnant women. </li></ul><ul><li>Frequent nosebleeds & predisposition to upper respiratory infection. </li></ul>Respiratory system
    17. 18. Systemic changes in pregnancy: <ul><li>Gastrointestinal system </li></ul><ul><li>Gastric emptying & intestinal transit times are delayed. </li></ul><ul><li>Heart burn / reflux common </li></ul><ul><li>Nausea and vomiting common </li></ul>
    18. 19. Systemic changes in pregnancy: <ul><li>For pregnant patient with Hyper-emesis gravidarium ( excessive and uncontrolled vomiting) , morning appointments should be avoided. </li></ul><ul><li>They should be seated in a semi-supine or comfortable position </li></ul><ul><li>In case of vomiting , the procedure should be stopped immediately & the patient should be repositioned upright </li></ul><ul><li>When vomiting is over rinsing mouth with cold water or mouthwash is recommended. </li></ul>
    19. 20. Systemic changes in pregnancy: <ul><li>Urinary System </li></ul><ul><li>↑ GFR & renal plasma flow by as much as 50% </li></ul><ul><li>Nocturia –to mobilize the dependent edema which accumulate during the day. </li></ul><ul><li>↑ Frequency from ↑ renal flow plus reduced bladder capacity from uterine growth </li></ul><ul><li>It is advisable to ask the patient to void the bladder just prior to starting the dental procedure. </li></ul>
    20. 21. Systemic changes in pregnancy: <ul><li>Endocrine Changes: </li></ul><ul><li>↑ Estrogen, ↑ progesterone, ↑human gonadotropin </li></ul><ul><li>↑ thyroxin, steroid and insulin level </li></ul><ul><li>Estrogen & 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 resistance </li></ul><ul><li>About 45 %of women fail to produce sufficient amount of insulin to overcome this antagonist action & thus develop gestational diabetes. </li></ul>
    21. 22. Systemic changes in pregnancy: <ul><li>Hematological change </li></ul><ul><li>↑ red RBC , ↑ESR, ↓Hb </li></ul><ul><li>↑ WBC </li></ul><ul><li>↑ circulatory catecholamin & cortisol lead to leucositosis </li></ul><ul><li>↑ Coagulation factors except factor XI & XIII (anticloting factor) </li></ul><ul><li>so pregnancy is a hypercoagulable state & ↑ risk for thromboembolism </li></ul>
    22. 23. Systemic changes in pregnancy: <ul><li>Pregnant women with anti-phospholipid syndrome are at ↑ risk for thrombo-embolisim. </li></ul><ul><li>They are placed on subcutaneous low molecular weight heparin (LMWH) </li></ul><ul><li>These patients must be hospitalized for dental care. </li></ul>
    23. 24. Pregnancy Related Oral Health Problems <ul><li>Pregnancy Gingivitis </li></ul><ul><li>Pregnancy Epulis </li></ul><ul><li>Increased Tooth Mobility </li></ul><ul><li>Dental Caries </li></ul><ul><li>Erosion </li></ul><ul><li>Dental Problems in relation to Labor and Delivery </li></ul>
    24. 25. Oral Problems in Pregnancy <ul><li>Pregnancy Gingivitis </li></ul><ul><li>Most common oral manifestation (50-100% of women) </li></ul><ul><li>Caused by hormonal and vascular changes of pregnancy </li></ul>
    25. 26. Pregnancy Gingivitis Pathophysiology <ul><li>Elevated circulating estrogen increases capillary permeability. </li></ul><ul><li>Preexisting gingivitis may predispose to pregnancy gingivitis. </li></ul>
    26. 27. Pregnancy Gingivitis <ul><li>Occurs commonly in the 2nd to 8 th months </li></ul><ul><li>Tendency to bleed very easily </li></ul><ul><li>Treatment: Scaling, root-planing, currettage , OHI </li></ul>
    27. 28. Pregnancy Granuloma <ul><li>Occurs in up to 5% of women. </li></ul><ul><li>Most common in buccal maxillary anterior areas. </li></ul><ul><li>Usually starts in an area of gingivitis. </li></ul>
    28. 29. Pregnancy Granuloma (continued) <ul><li>Rapid growth up to 2 cm. </li></ul><ul><li>Single tumor-like growth </li></ul><ul><li>usually in interdental papillae </li></ul><ul><li>Purplish to bluish in color, may be ulcerated- bleeds easily </li></ul>
    29. 30. Gum Problems - Pregnancy Granuloma
    30. 31. Gum Problems - Pregnancy Granuloma
    31. 32. Gum Changes - Pregnancy Granuloma
    32. 33. Pregnancy Granuloma (continued) <ul><li>Treatment </li></ul><ul><li>Scaling and root planing </li></ul><ul><li>Excision if it is too large or bleeds too easily </li></ul><ul><li>May regress spontaneously after pregnancy </li></ul>
    33. 34. Candidiasis <ul><li>Wipes off </li></ul><ul><li>Usually asymptomatic, but may burn </li></ul><ul><li>Treatment topical or systemic antifungals </li></ul>
    34. 35. Pregnancy Myths <ul><li>“ A mother loses a tooth for every baby” </li></ul><ul><li>No evidence that aphthous ulcers are any more common in pregnancy </li></ul>
    35. 36. Other Oral Conditions in Pregnancy <ul><li>Dry mouth </li></ul><ul><li>Excessive salivation </li></ul><ul><li>Tooth erosions associated with severe GERD or hyperemesis </li></ul>
    36. 37. Changes During Pregnancy that Affect Oral Health <ul><li>Hormonal Affects </li></ul><ul><ul><li>Increased tooth mobility </li></ul></ul><ul><ul><li>Saliva changes </li></ul></ul><ul><ul><li>Increased bacteria </li></ul></ul><ul><ul><li>Gingival problems </li></ul></ul>
    37. 38. Saliva changes <ul><li>Decreased buffers </li></ul><ul><li>Decreased minerals </li></ul><ul><li>Decreasing flow first and last trimester </li></ul><ul><li>Increased flow second trimester </li></ul><ul><li>More acidic </li></ul>
    38. 39. Increased Bacteria <ul><li>Increased acidity </li></ul><ul><ul><li>Increase in decay-causing bacteria </li></ul></ul><ul><li>Increased Snacking </li></ul><ul><ul><li>Morning sickness/low blood sugar </li></ul></ul><ul><ul><li>Between-meal snacks </li></ul></ul><ul><li>Increase in amount and frequency of starches/carbohydrates </li></ul><ul><ul><li>Crackers are commonly recommended </li></ul></ul><ul><ul><li>Promotes decay-causing bacteria </li></ul></ul>
    39. 40. Changes During Pregnancy that Affect Oral Health <ul><li>Morning sickness </li></ul><ul><ul><li>Difficulty with hygiene </li></ul></ul><ul><ul><ul><li>Gingival disease </li></ul></ul></ul><ul><ul><ul><li>Tooth decay </li></ul></ul></ul><ul><ul><li>Vomiting </li></ul></ul><ul><li>Esophogeal Reflux (heartburn) </li></ul><ul><li>Acid exposure </li></ul><ul><ul><li>Irritation of the gums </li></ul></ul><ul><ul><li>Weakening of tooth enamel </li></ul></ul><ul><ul><li>Dental erosion </li></ul></ul>
    40. 41. Enamel erosion caused by frequent vomiting
    41. 42. Treatment for Acid Exposure <ul><li>Do NOT brush immediately after vomiting </li></ul><ul><li>Rinse </li></ul><ul><ul><li>Water with baking soda </li></ul></ul><ul><ul><li>Antacid </li></ul></ul><ul><ul><li>Plain water </li></ul></ul><ul><li>Eat some cheese </li></ul>
    42. 43. Oral Diseases Can Effect Pregnancy <ul><li>Preterm, low birth weight (LBW) linked to periodontal disease </li></ul><ul><li>Thorough calculus (tartar) removal in pregnant women with periodontitis may reduce pre-term births </li></ul>
    43. 44. Periodontal Disease and Preterm Labor <ul><li>Maternal periodontal disease is associated with increased risk of preterm labor </li></ul><ul><li>Anaerobic oral gram-negative bacteria cause inflammatory response </li></ul><ul><li>Inflammatory response stimulates prostaglandin and cytokine production to stimulate labor </li></ul>
    44. 45. Periodontal Disease and Low Birth Weight <ul><li>Periodontal disease is associated with low birth weight </li></ul><ul><li>Evidence is not conclusive </li></ul><ul><li>Biochemical mechanism similar cascade as in preterm labor leading to placental blood flow restriction and necrosis </li></ul>
    45. 46. Periodontal Disease and Preeclampsia <ul><li>Emerging data </li></ul><ul><li>Mechanism unclear </li></ul><ul><li>Proposed mechanism: </li></ul><ul><ul><li>Periodontal infection leads to inflammatory vascular damage </li></ul></ul><ul><ul><li>Triggers cell damage in placenta </li></ul></ul>
    46. 47. Periodontitis and Pre-eclampsia <ul><li>Periodontal disease may be associated with pre-eclampsia (Boggess, 2003) </li></ul><ul><li>PGE2, IL-1 and TNF-α from gingival crevicular fluid were higher in women with preeclampsia compared with healthy matched pregnant women (Oettinger-Barak, 2003). </li></ul>
    47. 48. Dental Considerations <ul><li>timing of treatment for pregnant patients </li></ul><ul><li>dental radiation exposure </li></ul><ul><li>use of local anesthetics </li></ul><ul><li>prescription of common antibiotics and analgesics </li></ul><ul><li>nitrous oxide gas administration </li></ul>
    48. 49. Treatment Timing <ul><li>First Trimester </li></ul><ul><ul><li>Spontaneous miscarriages naturally occur more often in 1st trimester </li></ul></ul><ul><ul><li>Avoid elective treatment that can be delayed </li></ul></ul><ul><ul><li>Offer anticipatory guidance </li></ul></ul><ul><li>Second Trimester </li></ul><ul><ul><li>The optimal time for dental treatment </li></ul></ul><ul><ul><li>Organogenesis complete, fetus not large </li></ul></ul><ul><ul><li>Easier to prevent than treat established disease </li></ul></ul><ul><li>Third Trimester </li></ul><ul><ul><li>Late in term very uncomfortable (short visits) </li></ul></ul><ul><ul><li>Position slightly on left side </li></ul></ul>
    49. 50. Timing of Dental Treatment During Pregnancy - From Little and Fallace <ul><li>First Trimester </li></ul><ul><li>Plaque control </li></ul><ul><li>Oral hygiene instruction </li></ul><ul><li>Scaling, polishing, curettage </li></ul><ul><li>Avoid elective treatment; urgent care only </li></ul>
    50. 51. Timing of Dental Treatment During Pregnancy - From Little and Fallace <ul><li>Second Trimester </li></ul><ul><li>Plaque control </li></ul><ul><li>Oral hygiene instruction </li></ul><ul><li>Scaling, polishing, curettage </li></ul><ul><li>Routine dental care </li></ul>
    51. 52. Timing of Dental Treatment During Pregnancy - From Little and Fallace <ul><li>Third Trimester </li></ul><ul><li>Plaque control </li></ul><ul><li>Oral hygiene instruction </li></ul><ul><li>Scaling, polishing, curettage </li></ul><ul><li>Routine dental care (after middle of third trimester, elective care should be avoided) </li></ul>
    52. 53. Use of Radiation on Pregnant Patient <ul><li>Dose given and time of gestation are important </li></ul><ul><li>doses < 5-10 rads (cGy) not teratogenic </li></ul><ul><li>fetus is most susceptible to radiation between the 2nd and 6th week of gestation </li></ul><ul><li>single 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 </li></ul>
    53. 54. Radiographs during Pregnancy <ul><li>Take as needed with optimal methods for reducing secondary radiation and exposure time. </li></ul><ul><li>Always use a lead apron. </li></ul><ul><li>Exposure to fetus (with apron use) is .00001 centiGray.(rad) </li></ul><ul><li>Daily cosmic radiation - .0004 centiGray (rad) </li></ul>
    54. 55. Risks of Dental X-Rays <ul><li>X-ray only if necessary (i.e. root canal therapy, trauma) </li></ul><ul><li>When x-rays are indicated, radiation exposure is extremely low </li></ul><ul><li>Exposure can be limited by: </li></ul><ul><ul><li>Lead apron shielding </li></ul></ul><ul><ul><li>Modern fast film </li></ul></ul><ul><ul><li>Avoiding retakes </li></ul></ul>
    55. 56. FDA drug classification for pregnancy <ul><li>Combines risk statements including congenital anomalies, fetal effects, perinatal risks, and therapeutic risk-benefit ratio </li></ul><ul><li>Untreated disease or condition may pose more serious risks to both mother and fetus than any theoretical risks from the medication </li></ul><ul><li>Category A thru D and X </li></ul>
    56. 57. FDA drug classification for pregnancy <ul><li>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 </li></ul>
    57. 58. FDA drug classification for pregnancy <ul><li>B = Animal studies show no risk, </li></ul><ul><li>or if risk shown in animals, controlled trials in women showed no risk </li></ul>
    58. 59. FDA drug classification for pregnancy <ul><li>C = Studies in animals with adverse effects and no human studies, </li></ul><ul><li>OR no animal or human studies, but benefits of use may outweigh potential harms </li></ul>
    59. 60. FDA drug classification for pregnancy <ul><li>D = There is evidence of human fetal risk, but benefits may outweigh risks </li></ul>
    60. 61. FDA drug classification for pregnancy <ul><li>X = Contraindicated </li></ul>
    61. 62. Common Analgesics <ul><li>paracetamol (B) </li></ul><ul><li>Ibuprofen (B/D*) </li></ul><ul><li>Oxycodone (B/D*) </li></ul><ul><li>Hydrocodone and codeine (C/D*) </li></ul><ul><ul><ul><li> *avoid in third trimester </li></ul></ul></ul>
    62. 63. Analgesics <ul><li>Paracetamol is the analgesic of choice for all stages of gestation </li></ul><ul><li>used to treat mild to moderate pain and fevers </li></ul><ul><li>short term usage is believed to be safe </li></ul><ul><li>avoid chronic and large doses of paracetamol </li></ul><ul><li>􀂋 </li></ul>
    63. 64. Analgesics - continued <ul><li>Aspirin is nonteratogenic but may cause maternal and fetal hemorrhage </li></ul><ul><li>large and chronic doses during last trimester may result in premature closure of ductus arteriosus, fetal hypertension, anemia, and low birth weight </li></ul><ul><li>avoid ibuprofen in 3rd trimester because of possible adverse circulatory effects </li></ul><ul><li>short term use of codeine seems safe </li></ul><ul><li>avoid codeine late in gestation because of possible fetal respiratory depression and withdrawal symptoms </li></ul>
    64. 65. Analgesics to Use During 1st and 2nd Trimester <ul><li>Category B (for best!) </li></ul><ul><li>Paracetamol, Ibuprofen, </li></ul><ul><li>Naproxen </li></ul><ul><li>Category C (use with caution): </li></ul><ul><li>Paracetamol with codeine or hydrocodone </li></ul><ul><li>Paracetamol with oxycodone </li></ul>
    65. 66. Analgesics to Avoid During the Third Trimester <ul><li>Causes delivery problems: </li></ul><ul><li>Aspirin (C/ 3D) </li></ul><ul><li>Ibuprofen (B/3D) </li></ul><ul><li>Naproxen (B/3D) </li></ul><ul><li>Causes neonatal respiratory depression and opioid withdrawal: </li></ul><ul><li>Codeine (C/3D) </li></ul><ul><li>Hydrocodone (C/3D) </li></ul><ul><li>Oxycodone(C/3D) </li></ul>
    66. 67. Sedation in Pregnancy <ul><li>Sedatives/Anxiolytics (e.g. Diazepam ) are rated D and can cause oral clefts with prolonged exposure. </li></ul><ul><li>Nitrous oxide should not be used in 1st trimester (If used in 2nd and 3rd, do not go below 50% O2) </li></ul>
    67. 68. Common Antibiotics <ul><li>To treat oral abscess or cellulitis </li></ul><ul><ul><li>Penicillin (B) </li></ul></ul><ul><ul><li>Amoxicillin (B) </li></ul></ul><ul><ul><li>Cephalexin (B) </li></ul></ul><ul><ul><li>Erythromycin base* (B) (Not estolate, as it cause cholestatic hepatitis) </li></ul></ul><ul><ul><li>Clindamycin (B) </li></ul></ul>
    68. 69. Antibiotics <ul><li>penicillin V and amoxicillin is preferred drug for mild to moderate infections </li></ul><ul><li>widely used for many years with no ill effects </li></ul><ul><li>no studies show penicillin to be teratogenic </li></ul><ul><li>amoxicillin extensively used without harming the fetus </li></ul><ul><li>Drug classes: </li></ul><ul><li>􀂋 B: penicillin, cephalosporins, erythromycin, </li></ul><ul><li>clindamycin, Azithromycin </li></ul><ul><li>D: Tetracycline </li></ul>
    69. 70. Antibiotics To Use During Pregnancy <ul><li>Penicillin V </li></ul><ul><li>Amoxicillin </li></ul><ul><li>Erythromycin (base form) </li></ul><ul><li>Cephalexin, cephalosporin </li></ul><ul><li>Clindamycin </li></ul><ul><li>Metronidazole </li></ul>
    70. 71. Antibiotics to Avoid during Pregnancy <ul><li>Doxycycline </li></ul><ul><li>Tetracycline </li></ul><ul><li>Erythromycin (estolate form) </li></ul><ul><li>Vancomycin </li></ul>
    71. 72. The Problem With Tetracycline <ul><li>Accumulates in bones and chelates calcium </li></ul><ul><li>Inhibits bone growth </li></ul><ul><li>Discolors teeth </li></ul>
    72. 73. Other Antimicrobial Agents <ul><li>OK to use: </li></ul><ul><li>Nystatin (B) </li></ul><ul><li>Chlorhexidine rinse (B) </li></ul><ul><li>Use with caution: </li></ul><ul><li>Clotrimazole (C) </li></ul><ul><li>Ketoconazole (C) </li></ul><ul><li>Fluconazole (C) </li></ul><ul><li>Do not use: </li></ul><ul><li>Doxycycline (D) </li></ul>
    73. 74. Local Anesthetic Use in Pregnancy <ul><li>Class B: </li></ul><ul><li>Lidocaine (Xylocaine) </li></ul><ul><li>Etidocaine </li></ul><ul><li>Prilocaine </li></ul><ul><li>Class C: </li></ul><ul><li>Procaine </li></ul><ul><li>Bupivicaine </li></ul><ul><li>Mepivicaine </li></ul>
    74. 75. Use of Local Anesthetics <ul><li>Lidocaine + vasoconstrictor: most common local anesthetic used in dentistry </li></ul><ul><li>extensively used in pregnancy with no proven ill effects </li></ul><ul><li>accidental intravascular injections of lidocaine pass through the placenta but the concentrations are too low to harm fetus </li></ul><ul><li>prilocaine might cause methemoglobinemia </li></ul>
    75. 76. Ulcer healing drugs <ul><li>Cimetidine </li></ul><ul><li>FDA category B </li></ul><ul><li>Famotidine </li></ul><ul><li>FDA category B </li></ul><ul><li>Ranitidine </li></ul><ul><li>FDA category B </li></ul><ul><li>not known to be harmful </li></ul>
    76. 77. Ulcer healing drugs <ul><li>Omeprazole </li></ul><ul><li>FDA category B.Not known to be harmful </li></ul><ul><li>Esomeprazole </li></ul><ul><li>FDA category B </li></ul><ul><li>Lansoprazole </li></ul><ul><li>FDA category B </li></ul><ul><li>Pantoprazole </li></ul><ul><li>Avoid unless potential benefit outweighs risk—fetotoxic in animals </li></ul>
    77. 78. Ulcer healing drugs <ul><li>Misoprostol </li></ul><ul><li>First, second, third trimesters: Avoid—potent uterine stimulant (has been used to induce abortion) and may be teratogenic </li></ul>
    78. 79. Ulcer healing drugs <ul><li>Antacids </li></ul><ul><li>Almunium hydroxide/Magnesium hydroxide—FDA category B </li></ul><ul><li>Calcium carbonate—FDA category C </li></ul><ul><li>Simethecone—FDA category C </li></ul>
    79. 80. Use of Nitrous Oxide Gas <ul><li>used over 150 years </li></ul><ul><li>safety is being debated </li></ul><ul><li>SHORT TERM exposure do not cause birth defects or spontaneous abortion </li></ul><ul><li>CHRONIC exposure may result in fetal loss and infertility </li></ul><ul><li>literature suggests that nitrous oxide should be avoided until more conclusive research is available </li></ul><ul><li>FDA Drug class: not yet assigned </li></ul>
    80. 81. Common Preventives <ul><li>Fluoride </li></ul><ul><ul><li>No increased risk during pregnancy </li></ul></ul><ul><li>Xylitol </li></ul><ul><ul><li>No studies; no harm reported </li></ul></ul><ul><li>Chlorhexidine </li></ul><ul><ul><li>No increased risk during pregnancy </li></ul></ul>
    81. 82. Are topical agents safe? <ul><li>Fluoride </li></ul><ul><ul><li>Toothpaste & mouthrinse </li></ul></ul><ul><li>Xylitol chewing gum </li></ul><ul><li>Chlorhexidine (11% alcohol) </li></ul><ul><li>No over the counter mouthrinses with alcohol (Listerine 20% alcohol) </li></ul>
    82. 83. Pre-natal Fluoride <ul><li>Daily 2.2 mg tablet of sodium fluoride during 3rd through 9th months </li></ul><ul><li>decreases caries rate in offspring. </li></ul><ul><li>Safe and effective. </li></ul><ul><li>Glenn, FB, 1982 </li></ul>
    83. 84. Is it safe to use mercury restorations? <ul><li>No evidence of harmful effect </li></ul><ul><li>Benefits outweigh risks </li></ul><ul><li>Canada, Germany, and New Zealand have some restrictions </li></ul><ul><li>Determine the best option </li></ul>
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    98. 99. Thank you