Oral surgery during pregnancy Dr. Ahmed M. Adawy Professor Emeritus, Dep. Oral & Maxillofacial Surg. Former Dean, Faculty of Dental Medicine Al-Azhar University Pregnancy, also known as gestation, is the time during which a fetus develops inside a woman's uterus. Pregnancy is typically divided into three trimesters. The common belief has been that, if an oral surgery procedure is recommended, but it’s not an emergency, the second trimester is the ideal time. Pregnancy however, is not a disease and pregnant woman should not be treated differently than the general population. In short, it could be concluded that: • Dental care is safe and essential during pregnancy • Pregnancy is not a reason to defer routine dental care or treatment • Diagnostic measures, including needed dental x-rays, can be undertaken safely • Emergency care should be provided at any time during pregnancy

2. Dr. Ahmed M. Adawy
Professor Emeritus, Dep. Oral & Maxillofacial Surg.
Former Dean, Faculty of Dental Medicine
Al-Azhar University

3. Pregnancy, also known as gestation, is the time during
which a fetus develops inside a woman's uterus. It
describes the events that occur from the time of
fertilization until the infant is born. Pregnancy usually
lasts about 40 weeks, or just over 9 months , as measured
from the last menstrual period to delivery. Pregnancy is
typically divided into three trimesters (1). The first
trimester is from week one through 12 week and includes
conception. Conception is when the sperm fertilizes the
egg. The fertilized egg then travels down the fallopian
tube and attaches to the inside of the uterus, where it
begins to form the embryo and placenta. The second
trimester is from week 13 through 28 week. The third
trimester is from 29 week through 40 week

4. The clinical symptoms in the first trimester are cessation
of the menstrual flow, nausea, vomiting and breast
enlargement (2). Important structures are formed during
this period and the embryo is highly sensitive to
exogenous insults and may undergo major morphological
changes. The likelihood of an organ deformity developing
after this period is relatively low. A fetus may develop a
birth defect when exposed to chemicals that can induce
mutations in the process of cell growth and chromosome
proliferation, so teratogenic effects may appear upon fetal
exposure to drugs during this period

5. In the second trimester, abdominal enlargement becomes
increasingly noticeable due to enlargement of the uterus.
The fetus becomes less sensitive to morphological
alterations, but changes in functional capacity such as
intellect, reproduction, or aging may occur. As the uterus
increases in size, the inferior vena cava may be compressed
by the uterus when the mother is in the supine position.
This reduces venous return and, subsequently, cardiac
output. Such a phenomenon is called supine hypotensive
syndrome (3). During the third trimester, aortocaval
compression in the supine position is even more likely to
occur. Symptoms of supine hypotension can be alleviated
by positioning the patient in the left lateral decubitus
position, rather than supine position

6. The risk of supine hypotensive syndrome can be
minimized during treatment by the insertion of a cushion
or wedge under the right hip

7. Throughout the 9-month gestational period, important
physiological and transient changes take place in the
woman’s body. Relative to the mother’s overall health,
increased hormonal activity, increased blood flow,
fluctuation in blood pressure, systolic heart murmur,
anemia, respiratory changes, gastrointestinal changes, and
“gestational diabetes” are only a few of the important
transient changes that occur during pregnancy. These
directly or indirectly lead to many symptoms that manifest
during pregnancy, such as nausea and vomiting, nasal
congestion, heartburn, alteration in taste and food
cravings, hyperventilation, and shortness of breath. In
addition, fatigue and depression are also common during
pregnancy (4)

8. Pregnant women are prone to develop dental diseases.
Gingival hyperplasia, gingivitis, pyogenic granulomas,
dental decay, and various salivary alterations are some of
the changes commonly seen among pregnant women. The
role of high levels of circulating estrogen is well
established and associated with high prevalence of
gingivitis and gingival hyperplasia (5). Changes in the oral
environment and in food consumption during pregnancy
can increase the incidence of dental caries (6). Pyogenic
granulomas, also termed pregnancy tumor usually occurs
at the end of the first trimester and rapid growth usually
accompanies the steady increase of circulating estrogens
and progestrones. Partial or complete regression is
common after child birth (7)

9. Pregnancy tumor
Pregnancy gingivitis Gingival hyperplasia

10. Oral surgery involves the use of local anesthetic,
antibiotics, and sedative drugs, that may have a negative
impact on the health and wellness of an unborn child. The
common belief has been that, if an oral surgery procedure
is recommended, but it’s not an emergency, the second
trimester is the ideal time. In the first trimester the fetus’s
vital organs are rapidly developing, so exposure to x-rays,
anesthesia and other drugs should be avoided. In the third
trimester, women can be very uncomfortable on their
backs. Laying flat too long puts pressure on two major
blood vessels, the inferior and superior vena cava,
producing supine hypotensive syndrome. This also can
disrupt the flow of blood to the uterus

11. Although many elective procedures may be delayed until
the baby has been delivered, several circumstances exist in
which care cannot be postponed, including those involving
trauma, acute infections of the head and neck (8), erupting
or impacted teeth that are causing problems, benign (9) and
malignant tumors (10). Because of a fear of injuring either
the mother or unborn child, some practitioners may
withhold care or medications from their patients,
inadvertently causing harm. An understanding of the
patient’s physiologic changes, the effects of chronic
infection, and the risks or benefits of medications is
necessary to adequately treat a patient (11)

12. The guidelines laid down by food and drug authority should
always be borne in mind while selecting the medications used
for pregnant and lactating mothers. The FDA established five
letter risk categories - A, B, C, D or X - to indicate the
potential of a drug to cause birth defects if used during
pregnancy. The categories were determined by assessing the
reliability of documentation and the risk to benefit ratio (12).
Category A: Adequate and well-controlled studies have failed
to demonstrate a risk to the fetus in the first trimester of
pregnancy (and there is no evidence of risk in later trimesters).
Category B: Animal reproduction studies have failed to
demonstrate a risk to the fetus and there are no adequate and
well-controlled studies in pregnant women.

13. Category C: Animal reproduction studies have shown an
adverse effect on the fetus and there are no adequate and well-
controlled studies in humans, but potential benefits may
warrant use of the drug in pregnant women despite potential
risks.
Category D: There is positive evidence of human fetal risk
based on adverse reaction data from investigational or
marketing experience or studies in humans, but potential
benefits may warrant use of the drug in pregnant women
despite potential risks.
Category X: Studies in animals or human have
demonstrated fetal abnormalities and /or there is positive
evidence of human fetal risk based on adverse reaction
data from investigational or marketing experience, and the
risks involved in use of the drug in pregnant women
clearly outweigh potential benefits.

14. The final rule replaces the current product-letter categories
A, B, C, D and X. The new Pregnancy and Lactation
Labeling Final Rule (PLLR) rule went into effect June 30,
2015 (13). Lidocaine, prilocaine, and etidocaine were given
the FDA pregnancy Category B. This meant that “animal
reproduction studies have failed to demonstrate a risk to
the fetus and there are no adequate and well-controlled
studies in pregnant women.” Mepivacaine, bupivacaine,
and articaine were placed in FDA Category C. “Animal
reproduction studies have shown an adverse effect on the
fetus and there are no adequate and well-controlled studies
in humans, but potential benefits may warrant use of the
drug in pregnant women despite potential risks.”

15. Local anesthetics do cross the placenta and theoretically
have the potential to affect the fetus. Hagai et al. (14)
recently reported no significant difference in the rate of
birth defects of the fetus between pregnant women who
were exposed to local anesthetics for dental treatment and
those who were not exposed, although 53% of all pregnant
women included in this study were exposed to the local
anesthetics during the first trimester. These results provide
no clear evidence that use of local anesthetics in pregnant
women for routine dental treatment increases complication
rates for the mother and the fetus. According to the
authors of the study, the results showed “that use of dental
local anesthetics, as well as dental treatment during
pregnancy, do not represent a major teratogenic risk.”

16. Several categories of drugs are known to be teratogenic,
including alcohol, tobacco, cocaine, anticonvulsant medications,
warfarin compounds, and certain antimicrobial agents. Due to the
potential for maternal and fetal side effects, antimicrobials should
only be used when the indication is clear and the risk: benefit
ratio justifies their use. Some of the antibiotics that may be
prescribed safely during pregnancy include: Penicillins, including
amoxicillin, ampicillin, Cephalosporins, including cefaclor,
cephalexin, Erythromycin, and Clindamycin. Certain other
antibiotics are believed to pose risks during pregnancy. For
example, fetal ototoxicity with Gentamycin. Discoloration of
teeth with Tetracycline. Maternal toxicity/fetal death with
Chloramphenicol. Aminoglycosides and Vancomycin are
oto-nephrotoxic for the fetus

17. Use of other medications calls for consultation with the
patient’s obstetrician to weigh risks and benefits. An
example of a situation that may benefit from consultation is
pain relief. Several analgesics have been placed in
pregnancy Category B, which indicates that they are
typically safe to use. However, in 2015, the U.S. Food &
Drug Administration blocked off that classification, stating
that the published research is “too limited to make any
recommendations” on pain reliever use in this
population. This suggests that decisions made about
medications for pain relief should be arrived at after
consultation with the obstetrician. That said, emergencies
call for immediate implementation of standard emergency
protocols

18. Regarding radiographic exposure, the estimated fetal dose
from dental radiograph is about 0.0001 rad for about
50,000 examinations. Fetal risk is considered to be
negligible at 5 rad or less, and the risk of malformations is
significantly increased above control levels only at doses
above 15 rad (15). Dental radiographs are, thus safe for
pregnant women. The most sensitive period for inducing
developmental abnormalities is during the period of
organogenesis in the first trimester, between 18 and 45
days of gestation Therefore, the radiation risk depends
upon the gestational age at the time of exposure, fetal
cellular repair mechanisms, and the absorbed radiation
dose level

19. Many organizations, including the American Dental
Association (ADA), the American Academy of Pediatrics
(AAP), and the American Academy of Pediatric Dentistry
(AAPD), have developed protocols and norms in order to
improve the oral health of pregnant women and babies.
They stress that pregnancy is not a disease, thus pregnant
women should not be treated differently than the general
population. Further, the American College of Obstetricians
and Gynecologists published a committee opinion
affirming that treatment of oral conditions is safe during
pregnancy and may be accomplished at any time during
pregnancy, particularly conditions that require immediate
treatment (16)

20. In short, it could be concluded that:
• Dental care is safe and essential during pregnancy
• Pregnancy is not a reason to defer routine dental care or
treatment
• Diagnostic measures, including needed dental x-rays, can
be undertaken safely
• Emergency care should be provided at any time during
pregnancy
• Delay in necessary treatment could cause unforeseen
harm to the mother and possibly to the fetus

22. 1. Office on Women's Health. (2010). Stages of pregnancy. Retrieved May
20, 2016.
2. Pradel EC. The pregnant oral and maxillofacial surgery patient. Oral
Maxillofac Surg Clin N Am; 10: 471, 1998.
3. Lanni SM, Tillinghast J, Silver HM. Hemodynamic changes and
baroreflex gain in the supine hypotensive syndrome. Am J Obstet Gynecol;
187: 1636, 2002.
4. Dellinger TM, Livingston HM. Pregnancy: Physiologic changes and
considerations for dental patients. Dent Clin N Am; 50: 677, 2006.
5. Amini H, Casimassimo PS. Prenatal dental care: A review. Gen Dent; 58:
176, 2009.
6. Kidd E, Fejerskov O. Essentials of dental caries. 3rd ed. Oxford, Oxford
University Press. pp 88-108, 2005.
7. Jafarzadeh H, Sanatkhani M, Mohtasham N. Oral pyogenic granuloma: a
review. J Oral Sci; 48: 167, 2006.
8. Osunde O, Bassey G, Ver-or N. Management of Ludwig’s Angina in
pregnancy: A review of 10 cases. Ann Med and Health Sci Res; 4: 361,
2014.
9. Ababneh K, Al-Khateeb T. Aggressive pregnancy tumor mimicking a
malignant neoplasm: A case report. J Contemp Dent Pract; 10: 72, 2009.

23. 10. Murphy J, Berman DR, Edwards SP, et al. Squamous cell carcinoma of
the tongue during pregnancy: A case report and review of the literature.
J Oral Maxillofac Surg; 74: 2557, 2016.
11. Dellinger TM, Livingston HM. Pregnancy: Physiologic changes and
considerations for dental patients. Dent Clin N Am; 50: 677, 2006.
12. Content and format of labeling for human prescription drugs and
biological products; Requirements for pregnancy and lactation labeling.
Federal Register/Vol. 73, No. 104/Thursday, May 29, 2008.
13. U.S. Food and Drug Administration. Pregnancy & Lactation: Improved
Benefit-Risk Information. 2015. Accessed June 1 2017.
14. Hagai A, Diav-Citrin O, Shechtman S, et al. Pregnancy outcome after in
utero exposure to local anesthetics as part of dental treatment: A prospective
comparative cohort study. J Am Dent Assoc; 146: 572, 2015.
15. McCollough CH, Schueler BA, Atwell TD, et al. Radiation exposure
and pregnancy: when should we be concerned? Radiographics; 27: 909,
2007.
16. American College of Obstetricians and Gynecologists Women’s Health
Care Physicians, Committee on Health Care for Underserved Women.
Committee Opinion No. 569: oral health care during pregnancy and through
the lifespan. Obstet Gynecol; 122: 417, 2013.