to share knowledge regarding management of pregnant patients in dental clinic

1. COSIDERATIONS FOR
DENTAL MANAGEMENT OF
THE PREGNANT PATIENT
DENTAL MANAGEMENT GUIDELINES
SUPINE HYPOTENSIVE SYNDROME
DRUG USE DURING PREGNANCY
Osama Al-Khalifa

2. Supine hypotensive syndrome
Affects 8% to 10% of pregnant women
occurs mainly after the late part of second
trimester

3. Supine hypotensive syndrome
When the pregnant woman is in
the supine position, there is
impaired venous return to the
heart due to compression of the
inferior vena cava by the fetus
This leads to hypotension,
nausea, dizziness, and fainting.

4. Management
1- Rolling the patient to the
left side to lift the uterus
off the inferior vena cava
2- The pregnant woman
should have the right hip
and buttocks elevated by
about 15 degrees (10 to
12 cm)
3- Administer oxygen

5. Prevention
• Semi-supine positon
• Left lateral decubitus position with the right
buttocks and hip elevated 15 degrees

6. DENTAL MANAGEMENT GUIDELINES
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 postconception. Therefore, the greater risk of
susceptibility to stress and teratogens occurs during this
time and 50% to 75% of all spontaneous abortions occur
during this period
The recommendations are:
1. Educate the patient about maternal oral changes during
pregnancy.
2. Emphasize strict oral hygiene instructions and thereby
plaque control.
3. Limit dental treatment to periodontal prophylaxis and
emergency treatments only.
4. Avoid routine radiographs. Use selectively and when
needed.

7. DENTAL MANAGEMENT GUIDELINES
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:
1. Oral hygiene, instruction, and plaque control.
2. Scaling, polishing, and curettage may be
performed if necessary.
3. Control of active oral diseases, if any.
4. Elective dental care is safe.
5. Avoid routine radiographs. Use selectively and
when needed.

8. DENTAL MANAGEMENT GUIDELINES
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. Short dental appointments should be
scheduled with appropriate positioning while in the chair
to prevent supine hypotension. 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
The recommendations are:
1. Oral hygiene, instruction, and plaque control.
2. Scaling, polishing, and curettage may be performed if
necessary.
3. Avoid elective dental care during the second half of the
third trimester.
4. Avoid routine radiographs. Use selectively and when
needed

9. Dentist’s Opinion Toward Treatment of Pregnant
Patients
;
Extract a non-restorable painful tooth
55% would extract
43% would not perform any extraction
during pregnancy and would manage the
pain by prescriptions or extirpating the
pulp of the painful tooth
2% did not know the answer
Ra’ed Al-Sadhan and Abdullatif Al-Manee 2008

10. Dentist’s opinion toward treatment of pregnant
patients
Local Anesthetic Agent Choices
75% would use lidocaine without
vasoconstrictor and would not use
prilocaine with felypressin vasoconstrictor.
Ra’ed Al-Sadhan and Abdullatif Al-Manee 2008

11. Dentist’s opinion toward treatment of pregnant
patients
Antibiotic Choices
96% would prescribe Amoxicillin.
65% would not prescribe Clindamycin while 23.5% would
prescribe it and 11.5% were uncertain.
93.5% avoided Tetracycline during while only 1.5% would
prescribe it and 5% were uncertain.
Metronidazole and Cephalosporines approximately had
similar results as 73.5 – 70% of participants avoided
prescribing them for pregnant patients while 15 – 18.5%
would prescribe them and 11.5% of the participants were
uncertain
Ra’ed Al-Sadhan and Abdullatif Al-Manee 2008

12. Dentist’s opinion toward treatment of pregnant
patients
Analgesic Choices
96.7% would prescribe Paracetamol
27.5% would prescribe Acetaminophen
5 - 13% would prescribe Ibuprofen, Aspirin
and Codeine 76.5 – 85% avoided them
8 – 10.5 % were uncertain
Ra’ed Al-Sadhan and Abdullatif Al-Manee 2008

13. FDA Classifications for drugs used in pregnant and
lactating patients
Category A
Adequate, well-controlled studies in pregnant women
have not shown an increased risk of fetal Abnormalities.

14. FDA Classifications for drugs used in pregnant and
lactating patients
Category B
Animal studies have revealed no evidence of harm to the
fetus, however, there are no adequate and well-
controlled studies in pregnant women.
or
Animal studies have shown an adverse effect, but
adequate and well-controlled studies in pregnant women
have failed to demonstrate a risk to the fetus

15. FDA Classifications for drugs used in pregnant and
lactating patients
Category C
Animal studies have shown an adverse effect
and there are no adequate and well-controlled
studies in pregnant women.
or
No animal studies have been conducted and
there are no adequate and well-controlled
studies in pregnant women.

16. FDA Classifications for drugs used in pregnant and
lactating patients
Category D
Adequate well-controlled or observational
studies, in pregnant women have
demonstrated a risk to the fetus. However,
the benefits of therapy may outweigh the
potential risk.

17. FDA Classifications for drugs used in pregnant and
lactating patients
Category X
Adequate well-controlled or observational
studies, in animals or pregnant women
have demonstrated positive evidence of
fetal abnormalities. The use of the product
is contraindicated in women who are or
may become pregnant.

18. FDA Classifications for drugs used in pregnant and
lactating patients
• Drugs in category A and category B are
considered safe for use, whereas drugs in
category C may be used only if the
benefits overweigh the risks
• Drugs in category D are avoided with
some exceptional circumstances while
drugs in category X are strictly avoided

19. Local anesthetics
Anesthetic agents
• Lidocaine, prilocaine and etidocaine are
category B drugs,
• Mepivacaine, articaine and bupivacaine
are in category C

20. Local anesthetics
Epinephrine
The use of epinephrine, a naturally
occurring hormone, in local anesthesia in
the doses used for dental treatment is not
associated with fetal abnormality, and is
considered to be safe during pregnancy,
but caution should be taken to avoid
accidental intravenous administration.

21. Local anesthetics
Use during lactation
There is no contraindication to using local
anesthetics in a nursing mother, except
cocaine, which is absolutely
contraindicated

22. Local anesthetics
Prilocaine + felypressin use during pregnancy
Felypressin has oxytocic action contraindicating its
use in pregnant patients
STANLEY MALAMED
HANDBOOK OF LOCAL ANESTHESIA
FOURTH EDITION 1997

23. Local anesthetics
Prilocaine + felypressin use during pregnancy
Felypressin has mild oxytocic effect which, in
theory, could impede placental circulation and
therefore is probably better avoided in
pregnancy.
IVOR CHESTNUTT
Clinical Dentistry 3rd edition 2007

24. Local anesthetics
Prilocaine + felypressin use during pregnancy
Felypressin should not be used for a pregnant patient as
it has oxytocic effect which may impede the placental
circulation by interfering with the tone of the uterus. This
contraindication is made particularly valid by the fact that
felypressin is normally available with prilocaine which
also passes the placental barrier and a high dose may
cause fetal methaemoglobinaemia
ROBERTS & SOWRAY
LOCAL ANALGESIA IN DENTISTRY
2nd edition 1979

25. Analgesics
Acetaminophen
Acetaminophen, FDA category B, is the
most useful analgesic to be used during
pregnancy. It can be used in any stage of
pregnancy and in nursing mothers.
Maternal anemia and fetal renal disease
was reported, however, used in high
doses

26. Analgesics
Opioid analgesics
Certain opioid analgesics (oxycodone,
morphine which are category B or
propoxyphene which is category C ) can
be used during pregnancy and lactation.
However, chronic use of narcotics may
result in growth retardation and physical
dependency

27. Analgesics
Aspirin
Aspirin is FDA category C. It is a
prostaglandin inhibitor and it is known to
cause constriction of the ductus arteriosus
and prolongs labour. It is also secreted in
the breast milk. Therefore, it should be
avoided particularly during the third
trimester of pregnancy and while nursing

28. Analgesics
Ibuprofen
Ibuprofen is a category B analgesic in the
first and second trimesters, but it is a
category D drug during the third trimester
because it has been associated with lower
levels of amniotic fluid, premature closure
of the fetal ductus arteriosus and inhibition
of labour when taken during this time. It
should be prescribed only after
consultation with and advice from the
obstetrician.

29. Antibiotics
Penicillins and cephalosporins
Beta-lactam ring-derived antibiotics
(penicillins and cephalosporins) are the
first-choice antibiotics for orofacial
infections. They are categorized as FDA
class B drugs. These antibiotics cross the
placenta but are known to be safe when
used in pregnancy.

30. Antibiotics
Macrolides
Macrolides (erythromycin, with the exception of
estolate form, clindamycin, azithromycin) are
categorized as FDA class B drugs. They pass
the placental barrier but only in small amounts.
Therefore, they are recommended for use in
pregnant women who are allergic to penicillin.
Clarithromycin, also a macrolide, is categorized
as FDA class C. It is mostly recommended for
use in pregnant HIV patients for the treatment of
Mycobacterium avium complex (MAC)

31. Antibiotics
Tetracyclines
Tetracyclines are classified FDA category
D, and thus should only be used when
there is no other alternative treatment
available, such as in the treatment of a
patient with syphilis who has an allergy to
penicillin

32. Antibiotics
Aminoglycosides
Aminoglycosides (streptomycin,
gentamycin) are categorized FDA class C
drugs. They pass the placental barrier
readily but there have been no
documented reports of neonatal toxicity
from exposure to aminoglycosides in
humans.

33. Antibiotics
Ciprofloxacin
Ciprofloxacin, a broad-spectrum
floroquinolone antibiotic used to treat
periodontal disease associated with
actinobacillus actinomycetemcomitans, is
in category C. Its use in pregnancy has
been restricted because of arthropathy
and adverse effects on cartilage
development observed in immature
animals. There are not enough data to
definitively determine its safety in humans

34. Chlorhexidine mouth rinse
Chlorhexidine is categorized as a class B
drug by the FDA and is safe to use during
pregnancy and lactation

35. Antifungal drugs
Nystatin and clotrimazol are FDA class B drugs
and they are considered to be safe during
pregnancy and lactation. Ketoconazole and
fluconazole are FDA class C. Ketoconazole is
secreted in breast milk and is reported to cause
adrenal insufficiency and hepatotoxicity in
newborns, therefore it should be avoided during
nursing. There are no reported adverse effects
of using fluconazole during nursing

36. Corticosteroids
Corticosteroids are FDA category C drugs.
Corticosteroids are commonly used to
treat various inflammatory oral conditions.
Corticosteroids are generally used as local
topical preparations (ointments, mouth
washes, lozenges) in treating inflammatory
oral conditions.

37. Corticosteroids
systemic corticosteroids complications that
arise are premature rupture of embryonic
membranes, hypertension, and gestational
diabetes mellitus. When administered
systemically, the lowest effective dosage
should be given and the fetus should be
monitored for infections and adrenal
insufficiency

38. Corticosteroids
Despite the secretion of corticosteroids in
the breast milk, the American Academy of
Pediatrics Committee on Drugs
recommends using prednisone and
prednisolone in nursing mothers when it is
indicated.

39. Sedatives and hypnotics
Nitrous oxide (N2O) has not been classified into any
category by the FDA and its use in pregnancy is
controversial due to unproven deleterious effects on the
pregnant woman and fetus. Nitrous oxide inhibits
methionine synthetase activity in rats, but it is not known
to affect humans. Nitrous oxide also causes
vasoconstriction and may reduce uterine blood supply.
Because methionine synthetase is vital for the
production of DNA, it is best to avoid the use of nitrous
oxide in the first trimester of pregnancy, when
organogenesis is occurring

40. Sedatives and hypnotics
• If N2O is required, it is better given in the
second and third trimesters, to be
administered for less than 30 minutes with
at least 50% oxygen.
• Barbiturates and benzodiazepines are
categorized as FDA class D drugs and
should be avoided during pregnancy and
nursing

41. Conclusion
During pregnancy, dental treatment may
be modified but need not be withheld,
provided the risk assessment is made
properly for both the patient and the fetus