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Managment of pregnant woman in the dental clinic

Managment of pregnant woman in the dental clinic

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  • Implantation occurs 1 week after conception .By the end of the 4 th week after ovulation-heart prominent, arm and leg buds .By the end of the 6 th wee after fertilization-fingers and toes present, external ear developing. Considered an embryo from biginning of 3 rd 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 toes
  • 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 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 3 rd 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.
  • It 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, 7 th Edition. Baltimore: Wiliams and Wilkins, 2005. All information above confirmed with Motherisk, Toronto, Ontario Canada at www.motherisk.org.

Manag of pregnant woman in dental clinic Manag of pregnant woman in dental clinic Presentation Transcript

  • Medical considerations of the pregnancy in dental treatment
  • Questions that a dentist may ask
    • Can 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?
    • Maternal concerns
    • Fetal concerns
    • Radiography
    • Medication
    • Maternal concerns
    • Fetal concerns
    • Radiography
    • Medication
    • Summary
  • 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
  • Maternal concerns
    • Anatomic change
    • Physiologic changes
    • Psychological changes
  • Anatomic changes
    • Uterus weight increases from 70gm  1 kg
    • Uterus volume increases from 10ml  5000 ml
    • Supine hypotensive syndrome (inferior vena cava syndrome)  Acute hypotensive episode
    • Symptoms
            • Sweating
            • Nausea
            • Weakness
            • Sense of lack of air
            • Drop in blood pressure
            • Bradycardia
            • Possible loss of consciousness
  • Supine hypotensive syndrome
    • Third trimeter  10~15%
    • Occurs as a result of compression of inferior vena cava & aorta
    • Decrease venous return to heart
    • Decrease uteroplacental perfusion and fetal distress
  • Prevention
    • Left lateral deceits position ( Place a small pillow under right hip - left lateral displacement)
    • Elevation the right hip 10~12cm
    • Sit up position
  • Maternal concerns
    • Anatomic change
    • Physiologic changes
    • Psychological changes
  • Physiologic changes
    • Cardiovascular system
    • Respiratory system
    • Gastrointestinal system
    • Renal system
    • Hematological system
  • Cardiovascular system
    • Cardiac output  increase 40%
    • Mean arterial BP decrease
    • Total blood volume  increase 40~50% (1500ml)
    • 14 th to 30 th weeks  heart rate increase 10 beats/min
  • Respiratory system
    • Diaphragm is displaced upward 3~4cm & rib flare out with chest circumference of 5~7 cm
    • Oxygen consumption increase 15~20 %
    • Respiratory rate increase
  • Gastrointestinal system
    • Increase gastric acid production
    • Decrease gastric mobility
    • Incompetence of gastroesophageal sphincter
    • Esophageal reflux
    • Excessive and uncontrolled vomiting, morning appointments should be avoided
    • Constipation
  • Renal system
    • Increase renal plasma flow
    • ↑ Frequency from ↑ renal flow plus reduced bladder capacity from uterine growth
    • Urinary tract infection
        • Nocturnal –to mobilize the dependent edema which accumulate during the day
        • It is advisable to ask the patient to void the bladder just prior to starting the dental procedure
  • Hematological system
    • Plasma volume increase 40~70c.c./kg
    • Red cell volume increase 25-30c.c./kg, ↑ESR, ↓Hb, ↑WBC & hematocrit volume decrease
    • Plasma levels of factors VII, VIII, X and fibrinogen increase
    • Fibrinolytic activity decrease
    • ↑ Coagulation factors except factor XI & XIII (anticlotting factor), so pregnancy is a hypercoagulable state & ↑ risk for thromboembolism
    • ↑ circulatory catecholamin & cortisol lead to leucocytosis
  • Psychological changes
    • Hypersensitivity regarding her size & appearance
    • Fear of pain, disability, death for her baby
    • Fear of dental procedures
    • Sedation empathy and reassurance
    • Minimize disturbance interruption & noises & to adjust room temperature & to minimize possible irritability
  • Pregnancy Related Oral Health Problems
    • Pregnancy Gingivitis
    • Pregnancy Epulis
    • Increased Tooth Mobility
    • Dental Caries
    • Erosion
    • Dental Problems in relation to Labor and Delivery
  • Oral Problems in Pregnancy
    • Pregnancy Gingivitis
    • Occurs commonly in the 2nd to 8 th months
    • Most common oral manifestation (50-100% of women)
    • Tendency to bleed easily
    • Caused by elevated circulating estrogen which increases capillary permeability and vascular changes
    • Treatment: Scaling, root-planning, curettage, OHI
  • Pregnancy Granuloma
    • Occurs in up to 5% of women
    • Most common in buccal maxillary anterior areas
    • Usually starts in an area of gingivitis
    • Rapid growth up to 2 cm
    • Single tumor-like growth usually in interdental papillae
    • Purplish to bluish in color, may be ulcerated- bleeds easily
    • May regress spontaneously after pregnancy
  • Pregnancy Granuloma
    • Maternal concerns
    • Fetal concerns
    • Radiography
    • Medication
    • Summary
  • Fetal concern
    • Fetal development
        • Ovum- from fertilization to implantation period
        • Embryonic period- from the second through eighth week
        • Fetal period- after the eighth week until term
    • Embryonic period
      • 18-55 days (2nd~8th wk)
      • Organogenesis
      • Functional & morphologic malformation
    • Fetal period
      • 56 days until term
      • Growth & development
    • Ovum period
      • Conception to 17 days
      • Cellular mitotic activity
      • Sensitivity to toxic substances which may precipitate spontaneous abortion
    • The First Trimester (0-12 Weeks)
    • The Second Trimester (13-28 Weeks)
    • The Third Trimester (29-40 Weeks)
    The Second Trimester
  • First trimester
    • Most of the baby structure begin to develop
    • Most susceptible to the risks of physical and mental abnormalities
    • 50% of abortion
    • 5~7 wks in uterus  cleft in lips & palate
  • Fetal concerns
    • Avoidance of fetal hypoxia avoid (hypoventilation or hypotention)
    • Avoidance of premature abortion
        • Position of the mother
        • No relationship between premature labor& local anesthesia
        • G.A.  increase of fetal loss
    • Avoidance of teratogens (some drugs; Aspirin , may be harmful during this period)
    • Maternal concerns
    • Fetal concerns
    • Radiography
    • Medication
    • Summary
  • Hazard from irradiation of embryo
    • Death of embryo
    • Birth of a deformed child
    • Increase frequency of malignancy decrease in childhood e.g. leukemia
  • Radiography
    • High dose (over 250 rads) prior to 16 wks
          • Microcephaly
          • Mental retardation
          • Cataracts
          • Growth retardation
          • Spontaneous abortion
    • High dose after 20 wks
          • Hair loss
          • Skin lesions
          • Bone marrow suppression
  • Use of Radiation on Pregnant Patient
    • Dose given and time of gestation are important
    • 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
    • fetus is most susceptible to radiation between the 2nd and 6th week of gestation
    • 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)
  • Procedure in making radiographs safer for pregnancy patients
    • Make only the film absolutely essential for diagnosing the conditions (i.e. root canal therapy, trauma)
    • Use lead apron shielding
    • Use long cone
    • Use proper collimation & shielding
    • Limited to affected tooth
    • Use m odern fast film
    • Extra care should be used while taking essential films to eliminate the need for repeated exposure
    • Maternal concerns
    • Fetal concerns
    • Radiography
    • Medication
    • Summary
  • Medication
    • Local anesthesia with or without vasoconstrictor
    • Antibiotics
    • Analgesics
    • Corticosteroids
    • Sedatives
  • FDA drug classification for pregnancy
    • Category A thru D and X
    • Combines risk statements including congenital anomalies, fetal effects, perinatal risks, and therapeutic risk-benefit ratio
    • Untreated disease or condition may pose more serious risks to both mother and fetus than any theoretical risks from the medication
  • FDA drug classification for pregnancy
    • Category 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
    • Category B = Animal studies show no risk, or if risk shown in animals, controlled trials in women showed no risk
    • Category C = Studies in animals with adverse effects and no human studies, OR no animal or human studies, but benefits of use may outweigh potential harms
    • Category D = There is evidence of human fetal risk, but benefits may outweigh risks
    • Category X = Contraindicated
  • Food and drug administration (F.D.A) classification system
  • Analgesics
    • Identify the cause of the pain
    • Eliminate it rather than relying on symptomatic relief with analgesic medication
  • Common Analgesics
    • paracetamol (B) : This is the analgesic of choice for all stages of gestation and used to treat mild to moderate pain and fevers
    • Ibuprofen (B/D * )
    • Oxycodone (B/D * )
    • codeine (C/D * )
    *avoid in third trimester
  • Common Analgesics
    • Aspirin is non-teratogenic but may cause maternal and fetal hemorrhage and may cause o ral clefts and other defects, intrauterine death, growth retardation, pulmonary hypertension, fetal hypertension, anemia, and low birth weight
    • avoid ibuprofen in 3 rd trimester because of possible adverse circulatory effects
    • short term use of codeine seems safe
    • avoid codeine late in gestation because of possible fetal respiratory depression and withdrawal symptoms
  • Sedation in Pregnancy
    • Sedatives/Anxiolytics (e.g. Diazepam ) are rated ( FDA:D ) and can cause oral clefts with prolonged exposure
    • Nitrous oxide should not be used in 1 st trimester (If used in 2 nd and 3 rd , do not go below 50% O 2 )
  • Common Antibiotics
    • To treat oral abscess or cellulitis
          • Penicillin ( FDA: B ) Inhibit cell wall synthesis and it Passes the placenta
          • Amoxicillin ( FDA: B )
          • Cephalexin ( FDA: B )
          • Erythromycin base ( FDA: B ) Clindamycin ( FDA: B )
          • Metronidazole ( FDA: B )
  • Antibiotics to Avoid during Pregnancy
    • Doxycycline
    • Erythromycin (estolate form)
    • Vancomycin
    • Tetracycline ( FDA: D ) (Accumulates in bones and chelates calcium, inhibits bone growth, it causes fatty liver degeneration and causes teeth discoloration)
  • Chloramphenicol
    • FDA  C
    • Irreversible bone marrow depression
    • aplastic anemia
    • agranulocytosis
    • Contraindicated
  • Other Antimicrobial Agents that can be used in pregnancy
    • Nystatin (B)
    • Chlorhexidine rinse (B)
    • The following drugs can be used with caution:
    • Clotrimazole (C)
    • Ketoconazole (C)
    • Fluconazole (C)
    • Do not use:
    • Doxycycline (D)
  • Common Preventives
    • Fluoride
          • No increased risk during pregnancy
    • Xylitol (chewing gum)
          • No studies; no harm reported
    • Chlorhexidine (11% alcohol)
          • No increased risk during pregnancy
  • Is it safe to use mercury restorations?
    • No evidence of harmful effect
    • Benefits outweigh risks
    • Canada, Germany, and New Zealand have some restrictions
  • Local anesthesia
    • Local anesthesia are not teratogenic , and may be administered to pregnant patient in the usual clinical doses
    • Large dose of prilocaine are known to cause methemoglobinemia which could cause maternal & fetal hypoxia
  • Local Anesthetic Used in Pregnancy
    • Class B:
    • Lidocaine (Xylocaine)
    • Etidocaine
    • Prilocaine
    • Class C:
    • Procaine
    • Bupivicaine
    • Mepivicaine
  • Use of Local Anesthetics
    • Lidocaine + vasoconstrictor: most common local anesthetic used in dentistry
    • extensively used in pregnancy with no proven ill effects
    • accidental intravascular injections of lidocaine pass through the placenta but the concentrations are too low to harm fetus
    • prilocaine might cause methemoglobinemia
  • Vasoconstrictors
    • Advantages of V.C.
    • Local vasoconstriction
    • Delay uptake from the site of injection
    • Increase the effectiveness & duration
    • There is no specific contraindication to these vasoconstrictors in a pregnant patient although it is prudent to use minimal effective dose
  • Corticosteroid
    • Cleft palate
    • Inhibit brain growth
    • Indicated only for treatment of severe systemic maternal illness
  • Barbiturates
    • Cross the placental membrane
    • Chronic barbiturate use-withdrawal syndrome
    • Cleft palate-lip
    • Anxiolytic agents (Diazepam)
    • Cleft lip and palate
    • Chronic diazepam use- tremors in infants
    • Accumulate in the tissue of fetus
    • Inhalation sedatives
    • Increase the rate of spontaneous abortion in chronic exposed persons
    • Routine dental procedures are all suitable during various phases of a pregnancy, with some treatment modifications and initial planning
    • The most care & consideration should be given to use of non-pharmacological technique such as good patient management verbal sedation
    • If question arise regarding a particular patient status, consult the obstetrician before beginning treatment
  • Summary First trimester (conception to 14th week)
    • The most critical and rapid cell division and active organogenesis occur between the second and the eighth week of post-conception. Therefore, the greater risk of susceptibility to stress and teratogens occurs during this time
    • The recommendations are:
    • 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
    • Avoid routine radiographs. Use selectively and when needed
    Pregnancy and lactation:OOO; Vol. 97 No. 6 June 2004 Lakshmanan Suresh and Lida Radfar
  • Summary Second trimester (14th to 28th week)
    • Organogenesis is completed and therefore the risk to the fetus is low. This is the safest period for providing dental care during pregnancy
    • The recommendations are
    • 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
    • Avoid routine radiographs. Use selectively and when needed
    Pregnancy and lactation:OOO; Vol. 97 No. 6 June 2004 Lakshmanan Suresh and Lida Radfar
  • Summary Third trimester (29th week until childbirth)
    • Although there is no risk to the fetus during this trimester, the pregnant mother may experience an increasing level of discomfort
    • The recommendations are:
    • It is safe to perform routine dental treatment in the early part of the third trimester, but from the middle of the third trimester routine dental treatment should be avoided
    • 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
    • Use routine radiographs selectively and when needed
    • Short dental appointments with appropriate positioning to prevent supine hypotension
    Pregnancy and lactation:OOO; Vol. 97 No. 6 June 2004 Lakshmanan Suresh and Lida Radfar
  • Thank you