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.

1. Dr. Tanmay Singh Pathani
BDS, MPH
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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
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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.
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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.
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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.
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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.
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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
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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.
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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.
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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.
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The First Trimester (0-12 Weeks)
The Second Trimester (13-28 Weeks)
The Third Trimester (29-40 Weeks)

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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.
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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.
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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).
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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
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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. Supine Hypotensive Syndrome
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21. Comparison of Supine and Left Lateral Position
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22. Left Lateral Position
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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.
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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.
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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)
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27. Common Complaints in Pregnancy
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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
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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
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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.
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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
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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.
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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
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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
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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.
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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.
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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
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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.
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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.
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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.
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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.
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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.
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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.
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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
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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
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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
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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
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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.
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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
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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.
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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.
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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.
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Fetal Warfarin Syndrome
Depressed nasal
bridge
Nasal Hypoplasia

58. Penicillin
 FDAB
 All trimester are safe
 No teratogenic
 Pass the placenta
 Inhibit cell wall synthesis
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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
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TETRACYCLINE STAINS

61. Chloramphenicol
 Bone marrow depression irreversible aplastic anemia,
agranulocytosis
 FDAC
 Gray-baby syndrome
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62. Analgesics
 Identify the cause of the pain
 Eliminate it rather than relying on symptomatic relief with
analgesic medication
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63. Acetaminophen
 No teratogenesis
 Most frequency used
 Analgesic and antipyretic but no anti-inflammation
activity
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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.
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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.
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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.
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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.
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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.
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69. Corticosteroid
 Cleft palate
 Inhibit brain growth
 Indicated only for treatment of severe systemic maternal
illness
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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.
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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)
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72. Human Teratogenic Drugs
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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
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74. Fetal Alcohol Syndrome
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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)
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76. SMOKING:
Raise the risk of –
1)Still births
2)Diminishes infants birth weight
3)Impairs child’s subsequent mental and physical
development
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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.
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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.
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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.
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81. Pregnancy Gingivitis
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82. PREGNANCY
GINGIVITIS
Gingival Inflammation
Second month of
Pregnancy
Fiery red Edematous inter
proximal papillae
Tender
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83. Changes During
Pregnancy
Gingivitis
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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
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85. Pregnancy Tumor
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86. PREGNANCY
TUMOUR
•Seen in 1% gravid women.
•Hyperplastic Response.
•Labial aspect of interdental
papilla.
•Asymptomatic.
•Trauma by brushing.
•Bleeding.
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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
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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.
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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.
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90. Obstetrical emergencies in dental office
 Syncope
 Morning sickness
 Seizure
 Bleeding & cramping
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91. Syncope
 All trimester
 Hypotensive, dehydration, anemia, hypoglycemia and
neurogenic disorder
 Not revived with ammonia
 Oxygen, vital sign, drinking fluid.
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92. Seizure
 Eclampsia
 Mortality rate17%
 Under age 20, older than 35 and first-time pregnancy,
chronic hypertensive pregnancy, obese pregnancy,
multiple gestation.
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93. Preeclampsia
 Generalized edema
 Elevated blood pressure
 Proteinuria over 300mg
 Hyper uremia
 Headache, blurred vision, abnormal pain
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94. High risk pregnancy
 Recent cramping
 Light or intermittent bleeding or frank bleeding
 Diabetes
 Multiple spontaneous abortion
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95. Always Remember
 If question arise regarding a particular patient status,
consult the obstetrician before beginning treatment.
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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
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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!!!!!!!!
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