This document summarizes key medical considerations for providing dental treatment during pregnancy. It discusses maternal concerns, fetal concerns, guidelines for radiography, and classifications and safety of medications. The three stages of pregnancy are outlined, with the first trimester posing the highest risk. Procedures should generally be avoided then unless necessary, and provided with caution in the second trimester when risk is lowest. In the third trimester, focus is on the upcoming birth and mother's comfort.

1. Medical considerations of the pregnancy in dental treatment

2. 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?

3. Maternal concerns Fetal concerns Radiography Medication

4. Maternal concerns Fetal concerns Radiography Medication Summary

5. 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

6. Stages of Pregnancy 2nd Trimester (13-24 weeks) Fetal growth and maturation Safest period to provide dental care

7. 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

8. Maternal concerns Anatomic change Physiologic changes Psychological changes

9. 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

10. 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

11. Prevention Left lateral deceits position ( Place a small pillow under right hip - left lateral displacement) Elevation the right hip 10~12cm Sit up position

12. Maternal concerns Anatomic change Physiologic changes Psychological changes

13. Physiologic changes Cardiovascular system Respiratory system Gastrointestinal system Renal system Hematological system

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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

20. Pregnancy Related Oral Health Problems Pregnancy Gingivitis Pregnancy Epulis Increased Tooth Mobility Dental Caries Erosion Dental Problems in relation to Labor and Delivery

21. 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

22. 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

23. Pregnancy Granuloma

24. Maternal concerns Fetal concerns Radiography Medication Summary

25. 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

26. 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

27. The First Trimester (0-12 Weeks) The Second Trimester (13-28 Weeks) The Third Trimester (29-40 Weeks) The Second Trimester

28. 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

29. 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)

30. Maternal concerns Fetal concerns Radiography Medication Summary

31. Hazard from irradiation of embryo Death of embryo Birth of a deformed child Increase frequency of malignancy decrease in childhood e.g. leukemia

32. 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

33. 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

34. 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)

35. 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

36. Maternal concerns Fetal concerns Radiography Medication Summary

37. Medication Local anesthesia with or without vasoconstrictor Antibiotics Analgesics Corticosteroids Sedatives

38. 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

39. 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

40. Food and drug administration (F.D.A) classification system

41. Analgesics Identify the cause of the pain Eliminate it rather than relying on symptomatic relief with analgesic medication

42. 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

43. 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

44. 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 )

45. 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 )

46. 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)

47. Chloramphenicol FDA  C Irreversible bone marrow depression aplastic anemia agranulocytosis Contraindicated

48. 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)

49. Common Preventives Fluoride No increased risk during pregnancy Xylitol (chewing gum) No studies; no harm reported Chlorhexidine (11% alcohol) No increased risk during pregnancy

50. Is it safe to use mercury restorations? No evidence of harmful effect Benefits outweigh risks Canada, Germany, and New Zealand have some restrictions

51. 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

52. Local Anesthetic Used in Pregnancy Class B: Lidocaine (Xylocaine) Etidocaine Prilocaine Class C: Procaine Bupivicaine Mepivicaine

53. 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

54. 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

55. Corticosteroid Cleft palate Inhibit brain growth Indicated only for treatment of severe systemic maternal illness

56. Barbiturates Cross the placental membrane Chronic barbiturate use-withdrawal syndrome Cleft palate-lip

57. 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

58. 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

59. 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

60. 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

61. 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

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