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Dental considerations in pregnant women

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An academic presentation on Dental considerations, interventions and precautions to ensure a safe pregnancy. The presentation deals with physiology, complications and dental considerations for treating a pregnant patient.

Published in: Health & Medicine

Dental considerations in pregnant women

  1. 1. Dr. Tanmay Singh Pathani BDS, MPH 8/27/2015 1
  2. 2. Contents  Introduction  Period of pregnancy  Physiology  Common Complaints in Pregnancy  Complications  Clinical Findings  Dental Management  Drug Administration  Oral Complications And Manifestation  Obstetrical Emergencies in Dental Office  Bibliography 8/27/2015 2
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  4. 4. Introduction  Pregnancy is a major event in any woman's life.  A pregnant patient is not considered medically compromised but consists of a unique set of management for the dentist. 8/27/2015 4
  5. 5.  Dental care should be given in such a way that it does not adversely effect the fetus .  Hormonal changes during the period of pregnancy causes changes in the body as well as the oral cavity.  All elective dental procedures can be delayed till postpartum to avoid any risk to the developing fetus. 8/27/2015 5
  6. 6.  It is still very important to maintain the pregnant woman's current state of dental health and pregnancy is the ideal opportunity to begin a preventive dental program.  Its also important to educate the pregnant patient about the common problems noticed during pregnancy. 8/27/2015 6
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  8. 8. Period of Pregnancy  GENERAL OVERVIEW Normal pregnancy last for about forty weeks and it can be divided into three stages-: Zygote It is from the time of fertilization to implantation. 8/27/2015 8
  9. 9. Embryonic Period It is from the second week to the eight week. Fetal Period-: It is from the eight week upto parturition. For practical purpose pregnancy may be divided into three trimesters-: First Trimester Second Trimester Third Trimester 8/27/2015 9
  10. 10. 1.First Trimester During the first trimester formation of organs and system occurs. The fetus is most susceptible to malformations during this period. There is an increased risk of effects by Teratogens. 8/27/2015 10
  11. 11. 2.Second Trimester The majority of formation is complete and chances of malformation are less. The organogenesis is complete. It is considered to be a more safe period. 8/27/2015 11
  12. 12. 3. Third Trimester The uterus expands with the growing fetus and placenta. The fetus come to lie directly over the inferior vena cava, femoral vessels and the Aorta. 8/27/2015 12
  13. 13. 8/27/2015 13 The First Trimester (0-12 Weeks) The Second Trimester (13-28 Weeks) The Third Trimester (29-40 Weeks)
  14. 14. 8/27/2015 14
  15. 15. Physiology 1. Endocrine • Endocrine changes are the most significant basic alterations that occur with pregnancy. • This is due to the production of maternal and placental hormones. • Modification in activity of target organs. • Most hormones rise at pregnancy. 8/27/2015 15
  16. 16. • Increase in maternal hormones estrogen & progesterone • Placental hormones are secreted. • Prolactin increases. • Follicle stimulating hormones decreases • ACTH, TSH, GH – Increases to accommodate the increase in BMR. 8/27/2015 16
  17. 17. 2.Cardiovascular System • Blood volume increase 40% • Cardiac output increase 30% to 40% • Red blood cell volume increase to 15% to 20% • Corresponding to increase in blood volume 1. High flow/low resistance circulation. 2. Tachycardia 3. Heart murmurs. 4. A benign systolic murmur develops in 90% of pregnant women & disappears shortly after delivery- (physiologic). 8/27/2015 17
  18. 18.  Blood changes -: Anemia  WBC increase due to neturophelia.  Fibrinogen, factor VII, VIII, IX, X & FSP increase – hyper coagulation – thrombosis.  Pregnancy can worsen anemia particularly sickle cell anemia 8/27/2015 18
  19. 19. 8/27/2015 19 3.Supine Hypotensive syndrome  Third trimester 10~15%  Compression of inferior vena cava & aorta  Decrease venous return to heart  Decrease uteroplacental perfusion and fetal distress
  20. 20. Supine Hypotensive Syndrome 8/27/2015 20
  21. 21. Comparison of Supine and Left Lateral Position 8/27/2015 21
  22. 22. Left Lateral Position 8/27/2015 22
  23. 23. Manifests by an abrupt fall in BP, -Bradycardia -Sweating - Nausea - Weakness -Air hunger 4.Respiratory System • Reduced expiratory reserve volume • Increased rate of respiration. • Dysponea at supine position. • Hyperemia and edema of respiratory tract. 8/27/2015 23
  24. 24. 5.Kidney and Liver • Renal blood flow & glomerular filtration rate increases about 50% from 4th to 7th months of gestation. • Creatinine levels drop & increase frequency of urination. • Blood flow to maternal liver is essentially unchanged during pregnancy • During pregnancy - kidney & liver of mother & fetus are primary organs responsible for drug detoxification. 8/27/2015 24
  25. 25. 6.DIET • Increase appetite & craving for unusual food. • Taste alterations & increased gag response. • 90% of pregnant women vulnerable to nausea & vomiting. • Glycosuria & impaired glucose tolerance – gestational diabetes. 7. Facial pigmentation ( chloasma or melasma gravidarum) 8/27/2015 25
  26. 26. 8/27/2015 26
  27. 27. Common Complaints in Pregnancy 8/27/2015 27
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  29. 29. Complications  Infection  Glucose abnormalities  Hypertension  Rare complication (5%)-Preclampsia Albuminuria Edema Pre-eclampsia progresses Eclampsia If seizures & coma develop. Malignant hypertension Blurred vision Seizures Coma  Spontaneous abortion 8/27/2015 29
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  31. 31. Clinical Findings  WEIGHT GAIN  AMENORRHOEA  ABDOMINAL PROTUBERANCE  ANAEMIA  FATIGUE  PERIPHERAL OEDEMA  VENOUS STASIS  TACHYCARDIA  TACHYAPNOEA  NAUSEA & VOMITING  ANXIOUSNESS, NERVOUSNESS  In 3rd trimester – FATIGUE& MILD DEPRESSION 8/27/2015 31
  32. 32. 8/27/2015 32
  33. 33. Dental Management 1.Diagnosis • Absence of an expected menstrual period. • Test – Latex inhibition test. • Pelvic examination – uterine enlargement. • Confirmation – By evidence of fetal heart tones & ultrasound detection. 8/27/2015 33
  34. 34. 2. Medical Considerations • Determination of general health with through a thorough history. • Current physician. • History of Gestational Diabetes. • Miscarriage • Hypertension • Morning sickness • Contacting patients obstetrician for discussion • about -; 1.Medical status 2.Dental need 3.Proposed dental treatment 8/27/2015 34
  35. 35. 3. General Guidelines • Detailed history about the number of times patient has been pregnant, number of children conceived, history of abortion ( spontaneous and elective). • Appointments to be kept short and the best chair position is sitting up or left lateral position with the head of the chair elevated. • Elective dental treatment should be deferred to post term. • Dental radiographs are best avoided. If unavoidable then second trimester is preferred. • Prescription of drugs to be done with care. 8/27/2015 35
  36. 36. 4. Preventive Program Healthy Oral environment Optimum Oral hygiene Plaque Control Program Minimize inflammatory response Limiting carbohydrate intake Coronal scaling Curettage 2.2 mg Fluoride tablet Reduction in S.mutans 8/27/2015 36
  37. 37. 5. Treatment Timing • Plaque Control oral hygiene instructions, scaling, polishing curettage • Avoid elective treatment urgent care only. FIRST TRIMESTER • Plaque Control oral hygiene instructions, scaling, polishing curettage • Routine dental care. SECOND TRIMESTER • Plaque Control oral hygiene instructions, scaling, polishing curettage. • Routine dental care. THIRD TRIMESTER 8/27/2015 37
  38. 38. • Good Plaque control. • Elective dental care is best avoided during the first trimester because of potential vulnerability. • Second trimester is the safest period in which routine dental care can be provided. • Control of any active disease. • Eliminate potential problems that could occur later in pregnancy or in immediate post partum period. • Early part of third trimester is still good time to provide routine dental care. • Postpone elective dental care in third trimester. 8/27/2015 38
  39. 39. 6. Dental Radiographs • Avoided especially during 1st trimester • Safety – 1. Fast exposure technique (E speed film) 2. Filtration 3. Collimation (Rectangular Collimation) 4. Lead Aprons 5. High kilo voltage 6. Constant beams • Radiographs to be used selectively and only when necessary • Mandibular Radiographs are considered more safe as vertical angulations is negative and tube head pointed upwards. 8/27/2015 39
  40. 40. Comparative Radiation Exposure To Fetal or Embryonic Tissue Source of Radiation Absorbed Exposure (cGy)  Upper GIT Series  Chest Radiograph  Skull Radiograph  Daily Background radiation  Full Mouth Dental Series  0.330  0.008  0.004  0.0004  0.00001 8/27/2015 40
  41. 41. 7. Prematurity • Premature infants may have orofacial defects. • Enamel hypoplasia due to trauma, infections, metabolic and nutritional disorders. • Laryngoscopy can damage the unerupted maxillary anterior teeth and oropharyngeal tube can cause grooving of anterior maxillary ridge. 8/27/2015 41
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  43. 43. Drug Administration  Ideally, no drug should be administered during pregnancy especially 1st trimester.  ALL DRUGS SHOULD BE AVOIDED UNLESS POTENIAL BENEFIT OUT WEIGHS POTENTIAL RISKS. 8/27/2015 43
  44. 44. Principles of prescribing during pregnancy –  Whenever possible use non drug therapy.  Prescribe drugs only when definitely needed choose the drug having best safety record over time.  Avoid newer drugs.  As far as possible, avoid medication in initial 1o weeks of gestation  Use the lowest effective dose.  Use drug for the shortest period necessary.  If possible give drug intermittently. 8/27/2015 44
  45. 45.  PHARMACOKINETICS IN PREGNANCY – >Drug Absorption – 1. Slower drug absorption 2. Parenteral drug administration 3. Drug compliance poor >Drug Metabolism – 1. Hepatic drug metabolizing enzymes are induced 2. Rapid metabolic degradation >Drug Excretion – 1. Renal plasma flow increases by 100% & glomerular filtration rate by 70% 2. Rapid elimination Most commonly used drugs in dental practice can be given during pregnancy with relative safety. 8/27/2015 45
  46. 46. Food and Drug Admistration Classification System Controlled studies showed no risk to the fetus. This group limited to multivitamins and prenatal vitamins , not mega vitamins. Either animal studies have shown no fetal effects , but there is no controlled human studies during pregnancy, or animal studies have shown adverse effect that was not confirmed in controlled studies during first trimester. Penicillins are in this family. There are no adequate studies, or animal studies have shown adverse effect , but controlled studies in women are not available. Potential benefit must be greater than the risk to the fetus if these medications are used. 8/27/2015 46
  47. 47. Evidence of fetal risk is proven, but potential benefit must be thought to be outweigh the risks. Proven fetal risk clearly outweighs any potential benefits. 8/27/2015 47
  48. 48. Drug Administration During Pregnancy DRUG FDA Category Use During Pregnancy Risk Use During Breast- feeding 1. Local Anesthetics Lidocaine B Yes - Yes Prilocaine B Yes - Yes Mepivacainet C Use with caution consult physician Fetal bradycardia Yes 8/27/2015 48
  49. 49. DRUG FDA Category Use During Pregnancy Risk Use During Breast- feeding 1.Analgesics Asprin C/D3 Avoid in 3rd trimester Post partum hemorrhage constriction ductus arteriosuss Avoid Acetaminophe n B Yes - Yes Ibuprofen B Caution avoid in second half of pregnancy Delayed labour Yes 8/27/2015 49
  50. 50. DRUG FDA Category Use During Pregnancy Risk Use During Breast- feeding 1.Antibiotics Penicillin B Yes Yes Erythromycin B Yes avoid estolate form - Yes Cephalosporin B Yes - Yes Tetracycline D Avoid Tooth discoloratio n bone deformities Avoid Metronidazole B Yes Mutagenic Yes 8/27/2015 50
  51. 51. DRUGs FDA Category Use During Pregnancy Risk Use During Breast- feeding 1.Sedatives/Hy pnotics Barbiturates D Avoid Neonatal Respiratory Depression Avoid Benzodiazepin es D/X Avoid Oral clefts Avoid 2.Corticosteroi ds Prednisone B Yes Delaylabour Yes 8/27/2015 51
  52. 52. Anesthetics: LA + EPINEPHRINE= SAFE Conscious sedation 1. Diazepam or Midazolam are hazardous. 1st trimester and last month of third trimester 2. Anxiolytic: nitrous oxide  Interferes with vitamin B12 and folate metabolism  Chronic nitrous oxide-oxygen inhalation – cellular abnormalities in animals. 8/27/2015 52
  53. 53. GUIDELINES: • Restrict use to second and third trimester. • Limit duration of exposure<30min. • Use 50% oxygen to avoid hypoxia. • Avoid repeated exposure. • Scavenging in dental surgery to minimize staff • exposure 8/27/2015 53
  54. 54. Warfarin  Warfarin is contraindicated in pregnancy.  It passes through the placental barrier and may cause bleeding in the fetus.  Warfarin use during pregnancy is commonly associated with spontaneous abortion, stillbirth, neonatal death, and preterm birth. 8/27/2015 54
  55. 55. Fetal Warfarin Syndrome  When warfarin (or another coumarin derivative) is given during the first trimester—particularly between the sixth and ninth weeks of pregnancy it leads to Fetal Warfarin Sndrome.  It is a constellation of birth defects  Also known as warfarin embryopathy, or coumarin embryopathy. 8/27/2015 55
  56. 56.  Symptoms of Fetal warfarin syndrome  Nasal hypoplasia .  Depressed nasal bridge.  Deep groove between nostril and nasal tip.  Stippling of uncalcified epiphyses during first year.  Mild hypoplasia of nail. 8/27/2015 56
  57. 57. 8/27/2015 57 Fetal Warfarin Syndrome Depressed nasal bridge Nasal Hypoplasia
  58. 58. Penicillin  FDAB  All trimester are safe  No teratogenic  Pass the placenta  Inhibit cell wall synthesis 8/27/2015 58
  59. 59. Tetracycline  It chelates with calcium.  Gets deposited in the skeleton of the fetus resulting in depression of bone growth  Discoloration of teeth.  Maternal fatty liver degeneration.  FDAD 8/27/2015 59
  60. 60. 8/27/2015 60 TETRACYCLINE STAINS
  61. 61. Chloramphenicol  Bone marrow depression irreversible aplastic anemia, agranulocytosis  FDAC  Gray-baby syndrome 8/27/2015 61
  62. 62. Analgesics  Identify the cause of the pain  Eliminate it rather than relying on symptomatic relief with analgesic medication 8/27/2015 62
  63. 63. Acetaminophen  No teratogenesis  Most frequency used  Analgesic and antipyretic but no anti-inflammation activity 8/27/2015 63
  64. 64. Aspirin  Oral clefts and other defects  Intrauterine death, growth retardation, pulmonary hypertension  Longer pregnancies & longer the average period of labor  Tetralogy of Fallot  Increase the risk of antepartum and postpartum hemorrhage. 8/27/2015 64
  65. 65. Diclofenac Sodium  Teratogenic in some animals and found to cause cleft palate.  At maternal toxic doses it causes intrauterine growth retardation (IUGR).  It can decreased fetal survival chances and may prolonged the pregnancy. 8/27/2015 65
  66. 66.  No well controlled human data is available when used during first trimester.  No association with congenital anomalies has been reported.  If used in third trimester can cause constriction of ductus arteriosus with subsequent neonatal pulmonary hypertension and impaired fetal renal function. 8/27/2015 66
  67. 67. Ibuprofen  No adequate human data is available when the exposure occurs in 1st trimester.  It has been reported that ibuprofen has a doubtful association with some congenital anomalies (anencephaly, cerebral palsy, microphthalmia, nasal cleft, and tooth staining) and fetal death. 8/27/2015 67
  68. 68.  Use of the drug in 3rd trimester causes constriction of ductus arteriosus with subsequent pulmonary hypertension and oligohydramnios by affecting fetal renal function.  Inhibits labour, prolongs pregnancy. 8/27/2015 68
  69. 69. Corticosteroid  Cleft palate  Inhibit brain growth  Indicated only for treatment of severe systemic maternal illness 8/27/2015 69
  70. 70. TERATOGENICITY:  Capacity of drug to cause fetal abnormalities when administered to pregnant mother  Thalidomide disaster (1558-1961) resulting in thousand of babies born with PHOCOMELIA. Type of malformation depends on –  Drug  Stage of exposure of teratogen  Blood level  Duration for which drug remains in maternal circulation. 8/27/2015 70
  71. 71. Avoidance of teratogens  Before implantation (14days) death of the ovum  14-60 days major morphologic defects (organogenesis)  60 days later function impairment (reduce intellect) 8/27/2015 71
  72. 72. Human Teratogenic Drugs 8/27/2015 72
  73. 73. FETAL ALCOHOL SYNDROME(FAS)  Term given to spectrum of disorders that can result when pregnant women consumes alcohol  Serious fetal damage caused by alcohol – single exposure can cause fetal brain damage DIAGNOSIS  Triad of abnormalities in new born Cluster of cranio-facial abnormalities ( 1st trimester) CNS dysfunction 8/27/2015 73
  74. 74. Fetal Alcohol Syndrome 8/27/2015 74
  75. 75. Pre-&/or post natal stunting of growth Hearing, language & speech disorders may become evident as child ages INCIDENCE .5-1 per 1000 births in general population African, American Lower social economic status of mother. FAE(Fetal alcohol defects) 8/27/2015 75
  76. 76. SMOKING: Raise the risk of – 1)Still births 2)Diminishes infants birth weight 3)Impairs child’s subsequent mental and physical development 8/27/2015 76
  77. 77. DENTAL AMALGAM: Research has failed to establish any link between amalgam use and systemic disease. European countries and Canada-recommends avoiding the placement of amalgam Amalgam restorations release mercury vapor when chewed on or brushed. Some of mercury vapor is inhaled and some may dissolve in saliva and be swallowed but most amalgam entering in body is excreted. 8/27/2015 77
  78. 78. Small amount accumulate in kidneys, to very much lesser extent in brain, lungs, liver & GIT. Mercury can cross the placenta to fetus & detected in breast milk. No evidence of link between amalgam use & birth defects or still births. It may be prudent to avoid it during pregnancy. 8/27/2015 78
  79. 79. 8/27/2015 79
  80. 80. Oral Complications And Manifestations 1. Pregnancy gingivitis  Due to exaggerated inflammatory response to local irritants  Less than meticulous oral hygiene during periods of increased secretion of estrogen & progesterone & altered fibrinolysis.  Accentuated gingival inflammation & hyperplasia.  Gingivitis begins at marginal & interdental gingiva( 2nd trimester) most prominent interproximally.  Marginal gingiva appears fiery red, swollen & tender whereas papillae becomes compressible, edematous & lumpy. 8/27/2015 80
  81. 81. Pregnancy Gingivitis 8/27/2015 81
  82. 82. PREGNANCY GINGIVITIS Gingival Inflammation Second month of Pregnancy Fiery red Edematous inter proximal papillae Tender 8/27/2015 82
  83. 83. Changes During Pregnancy Gingivitis 8/27/2015 83
  84. 84. Pyogenic Granuloma or Pregnancy Tumor Location – labial aspect of interdental papilla  Asymptomatic  Polyploid or pedunculated mass is bright red, fleshy, soft & bleeds easily.  Surgical or laser excision 8/27/2015 84
  85. 85. Pregnancy Tumor 8/27/2015 85
  86. 86. PREGNANCY TUMOUR •Seen in 1% gravid women. •Hyperplastic Response. •Labial aspect of interdental papilla. •Asymptomatic. •Trauma by brushing. •Bleeding. 8/27/2015 86
  87. 87. Periodontal Disease 4. Facial pigmentation (Chloasma or Melasma Gravidarum). 5. Hypersensitive gag reflex – In combination with morning sickness may constitute to episodes of regurgitation leading to halitosis & enamel erosion. 6. Dental caries 7. Tooth mobility – ( Localized or generalized) uncommon finding during pregnancy. 8. Tooth loss • Misconception • Prescription of calcium 8/27/2015 87
  88. 88. Pregnancy and Periodontitis • Peridontitis has a peculiar association with pregnancy. • It may alter the normal Cytokine and hormone regulated gestation which could lead to preterm labour ,premature rupture of membranes, and preterm birth. • Studies have connected gum disease to low birth weight and prematurity. • Dental infections have also been linked to miscarriage. 8/27/2015 88
  89. 89. • Chronic periodontal disease and the presence of the microorganisms, such as Porphyromonas gingivalis ; Tannerella forsythia ; and Eikenella corrodens were significantly associated with preeclampsia in pregnant women. • Pregnancy gingivitis can easily turn into a periodontal disease. • If the infection enters the bloodstream, the body produces chemicals to fight it off, which may induce early labour. 8/27/2015 89
  90. 90. Obstetrical emergencies in dental office  Syncope  Morning sickness  Seizure  Bleeding & cramping 8/27/2015 90
  91. 91. Syncope  All trimester  Hypotensive, dehydration, anemia, hypoglycemia and neurogenic disorder  Not revived with ammonia  Oxygen, vital sign, drinking fluid. 8/27/2015 91
  92. 92. Seizure  Eclampsia  Mortality rate17%  Under age 20, older than 35 and first-time pregnancy, chronic hypertensive pregnancy, obese pregnancy, multiple gestation. 8/27/2015 92
  93. 93. Preeclampsia  Generalized edema  Elevated blood pressure  Proteinuria over 300mg  Hyper uremia  Headache, blurred vision, abnormal pain 8/27/2015 93
  94. 94. High risk pregnancy  Recent cramping  Light or intermittent bleeding or frank bleeding  Diabetes  Multiple spontaneous abortion 8/27/2015 94
  95. 95. Always Remember  If question arise regarding a particular patient status, consult the obstetrician before beginning treatment. 8/27/2015 95
  96. 96. 8/27/2015 96
  97. 97. Bibliography  BIBLIOGRAPHY: • Oral diagnosis, Oral Medicine & treatment planning- BRICKER LANGLAIS MILLER • Dental management of medically compromised patient- LITTLE FALACE MILLER RHODUS • Oral Medicine- BURKITT • Medical Pharmacology- K.D.TRIPATHI • Medical Pharmacology- GOODMAN & GILLMAN • Human Physiology- A.K.JAIN • Local Anesthetics in Oral Surgery- MALAMED 8/27/2015 97
  98. 98. Pregnancy is a special event in a women’s life & hence it is an emotionally charged one……so establishing a good PATIENT-DENTIST RELATIONSHIP that encourage OPENESS,HONESTY & TRUST is an integral part of successful management. THIS KIND OF RELATIONSHIP DECREASES STRESS & ANXIETY FOR BOTH PATIENT & DENTIST!!!!!!!! 8/27/2015 98

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