Dent Clin N Am 50 (2006) 677–697

Pregnancy: Physiologic Changes

and Considerations for Dental Patients
Tracy M. Dellinger, DDS, MSa,b,*,
H. Mark Livingston, DDS, MSb,c
a
Advanced Education in General Dentistry Residency Program, University of Mississippi
School of Dentistry, 2500 North State Street, Jackson, MS 39216, USA
b
Department of Advanced General Dentistry, University of Mississippi School of Dentistry,
2500 North State Street, Jackson, MS 39216, USA
c
General Practice Residency Program, University of Mississippi School of Dentistry,
2500 North State Street, Jackson, MS 39216, USA

Pregnancy is a dynamic physiological state evidenced by several transient

changes. These can develop into various physical signs and symptoms that
can affect the patient’s health, perceptions, and interactions with others in
her environment. Patients may not always understand the relevance of their
bodies’ ongoing adaptations or how they relate to either her or her fetus’s
health. A gestational woman requires various levels of support throughout
this time, such as medical monitoring or intervention, preventative care, and
physical and emotional assistance.
Practitioners with minimal training in gestational medicine may be hesi-
tant to treat their pregnant patients. Because of a fear of injuring either the
mother or unborn child, some practitioners may withhold care or medica-
tions from their patients, inadvertently causing harm. An understanding
of the patient’s physiologic changes, the effects of chronic infection or illicit
drug and alcohol usage, and the risks or benefits of medications is necessary
to adequately advise a patient on her options regarding medical care.
Occasionally, the patient’s underlying medical conditions or status of her
pregnancy may limit the comprehensive care options available. Dentists, for
example, may delay certain elective procedures to coincide with periods of
pregnancy devoted to maturation versus organogenesis. Other times, dental
care professionals need to alter their normal pharmacologic armamentarium

* Corresponding author. Department of Advanced General Dentistry, University of

Mississippi School of Dentistry, 2500 North State Street, Jackson, MS 39216, USA.
E-mail address: tdellinger@sod.umsmed.edu (T.M. Dellinger).

0011-8532/06/$ - see front matter Ó 2006 Elsevier Inc. All rights reserved.
doi:10.1016/j.cden.2006.06.001 dental.theclinics.com
678 DELLINGER & LIVINGSTON

to address patient needs versus fetal demands. By being better informed

about the physiological changes of pregnancy, medical and dental providers
will be more comfortable and, hence, willing to treat their pregnant patients.

Physiologic changes during pregnancy

This 9-month period of a woman’s life is not only defined by the devel-
opment of her unborn child, but also the adaptive changes that she un-
dergoes to support the pregnancy. Many women complain of various
symptoms that develop during this time. The most common complaints in-
clude nausea and vomiting, nasal congestion, heartburn, alteration in taste
and food cravings, hyperventilation and shortness of breath, and fatigue.
These symptoms are often caused by the physiologic changes of various sys-
tems, including the cardiovascular, respiratory, gastrointestinal, musculo-
skeletal, and hematological systems.

Respiratory system
The oxygen demand during pregnancy consistently increases. The grow-
ing fetus presses the gravid uterus upwards on the diaphragm by as much as
4 cm, which decreases the functional residual capacity of the lungs by ap-
proximately 18% [1,2]. To overcome this change, various physiological
compensations develop to increase the availability of oxygen. Anatomically,
the lower ribs flare and the chest’s transverse diameter increases approxi-
mately 2 cm [3–8]. A progesterone hormone drive causes an increase in
the central ventilation drive and a resulting hyperventilation [4,9,10]. Pro-
gesterone also lowers the carbon dioxide content of alveolar air by promot-
ing transfer of carbon dioxide and oxygen [4,10,11]. These adaptations assist
with up to a 20% increase in oxygen consumption as the pregnancy prog-
resses [1]. Even with these temporary physiologic changes, approximately
60% of women still report a shortness of breath at some time during their
pregnancies [12–14].
Due to the ongoing changes during pregnancy, dyspnea and hyperventi-
lation are common sequalae [9]. The hyperventilation may be from either
the oxygen demands of the mother or lessened residual capacity of the lungs.
Dyspnea may be related to this or by the hormonal changes to the mucosal
vasculature of the respiratory tract. Elevated progesterone levels lead to cap-
illary engorgement and swelling of the lining in the nose, oropharynx, lar-
ynx, and trachea [12].

Gastrointestinal system
Multiple changes occur throughout the gastrointestinal tract during preg-
nancy. Beginning in the first trimester, women present with decreased gastric
peristalsis and intestinal motility [15]. This is in part a result of reduced
muscular tone and decreased frequency and strength of peristalsis. Primarily
 PREGNANT PATIENTS 679

due to the effect of progesterone, reduced peristaltic activity and diminished

tone are evident in bowel function, resulting in constipation, which is aggra-
vated by vitamins containing iron [12]. The constipation, in turn, may lead
to an increase in hemorrhoids as the pregnancy progresses [12].
The organs of the abdominal cavity are also altered during female gesta-
tion. Gallbladder emptying time is increased during pregnancy, affecting the
patient’s digestion and increasing the risk of gallstone formation [16]. The
liver has increased hepatic production of hormone-binding globulins and de-
creased albumin, resulting in significant impact on the pharmacokinetics of
certain medications [17]. There are also elevations of the liver-dependent
clotting factors, such as fibrinogen, as well as the liver’s production of alka-
line phosphatase, which can be elevated to a level two to four times that for
nongestational women [17].
Nausea and vomiting may also be related to physiologic changes of the gas-
trointestinal tract. First, an unknown pathway leads to hypersalivation in
pregnant women. Next, the decreased muscle tone of the gastrointestinal tract
leads to delays in gastric emptying [12]. Additionally, the soft tissues of the
nose, oral cavity, and larynx become edematous during pregnancy [15]. This
may lead to widely varied symptoms, such as nasal congestion, altered taste,
altered sense of smell, or a bothersome cough [12,18]. Any of these alterations
may lead to an increase in nausea or vomiting. However, studies have also
found an increase in free thyroxine and human chorionic gonadotropin,
with a resulting increase in thyroid function, in patients suffering from the nau-
sea and vomiting associated with ‘‘morning sickness’’ [12,19–22].
Women often mention increased hunger and strange food cravings, also
known as ‘‘pregnancy pica,’’ during pregnancy [23]. Common myths and
colloquialisms, such as ‘‘eating for two’’ and ‘‘pickles and ice cream,’’
have aggravated tendencies to gain weight [12]. However, women are now
encouraged to increase their low-impact aerobic activities and to limit their
total gain to a total of 12 to 14 kg (approximately 26–30 lb) [24].

Circulatory system
Multiple changes of the circulatory system are characteristic during preg-
nancy. Vasodilatation and an increase in vascular proliferation along with
increased venous pressure in lower extremities can lead to varicosities [12].
The bone marrow becomes hyperplastic, which can result in a slight increase
in leukocytes or erythrocytes. Many coagulation factors are increased, in-
cluding factors V, VII, VIII, X, and X [25]. Serum protein concentrations,
serum lipids, and fibrinogen concentrations also rise during pregnancy.
These changes result in a hypercoagulable state [1].
There is a 40% to 50% increase in total blood volume, resulting from
a threefold increase in plasma volume, usually between 4 and 7 L, versus
a more mild increase in red blood cell counts or hemoglobin [1,9,24]. The
red cell mass may increase by upwards of 500 mg, leading to a corresponding
680 DELLINGER & LIVINGSTON

rise in maternal demand for iron. This is why dietary iron supplements are
often recommended for pregnant women [9]. Increased blood volume during
pregnancy serves two purposes. First, higher blood volumes help facilitate
the maternal and fetal exchanges of respiratory gases, nutrients, and metab-
olites. Second, higher blood volumes help offset maternal blood loss during
birth when anywhere from 500 mL, in the case of vaginal birth, to 1000 mL,
in the case of cesarean section, may be lost [26,27].
The disparity between the fluid and the cellular elements of the blood
is responsible for the dilution anemia, which usually stabilizes at around
32 weeks of gestation [9]. The anemia is evidenced by a decrease in overall
percentage concentrations of red blood cells, plasma proteins, and plasma
colloid osmotic pressures [28].
This increase in the plasma volume parallels the curve of increase in car-
diac output [28]. Cardiac output is a product of heart rate and stroke vol-
ume, which can gradually increase by as much as 30% to 50% during
gestation with a concurrent total blood volume increase of 40% to 50%
[1,24]. This leads to an increase in total stroke volume, a transient tachycar-
dia in most gestational women, and the development of a systolic ejection
murmur noted over the pericordium in over 50% of pregnant patients
[1,9]. This type of heart murmur typically is not a result of subacute bacte-
rial endocarditis, and disappears shortly after the end of the pregnancy
[1,29]. However, there are usually no physical changes to the heart except
for a shifting toward a more anterior and left placement due to its displace-
ment from the enlarging uterus and, also, a slight ventricular mass increase
during the first trimester [9,28].
Blood pressures are also affected during pregnancy. While systemic arte-
rial pressure never increases during normal gestation, a slight decrease in di-
astolic pressure can be recognized during midpregnancy [24]. Meanwhile,
pulmonary arterial pressure remains constant [28]. Most patients’ hypoten-
sive complaints occur late in normal pregnancy. These complaints are often
attributed to the impeded venous return to the heart as the heavy, gravid
uterus falls on the inferior vena cava when the patient is either in a supine
position or reclined [9]. For this reason, many women in their third trimester
may elevate their right hip when reclining for long periods of time, thus
shifting their gravid uterus toward the left and alleviating pressure on the
inferior vena cava (Fig. 1).
Hypertension may be present either pregestation or develop during the
pregnancy itself. While chronic hypertension may be of general concern, de-
velopment of hypertension in the second or third trimester could be an initial
sign of preeclampsia, which is present in approximately 5% of all pregnancies
worldwide [2]. Severe hypertension may lead to both maternal and fetal
mortality through placental abruption, stroke risks, or eclampsia [2]. Of
most concern is any symptomology that can be a precursor for eclampsia.
Hypertension control during pregnancy commonly requires frequent
monitoring. When medications are warranted, physicians often favor
 PREGNANT PATIENTS 681

Fig. 1. Gravid women may be more comfortable and less inclined to develop postural
hypotension when reclined in a dental chair if the fetus is displaced from the inferior vena
cava. Placing a pillow or folded blanket under the patient’s right hip will aid in this placement.

medications with a proven record of hypertensive success as well as safety

during pregnancy. This means physicians rule out angiotension converting
enzyme inhibitors, which the US Food and Drug Administration (FDA)
has given a category X pregnancy risk rating due to multiple reports of fetal
death or renal problems in live births [2].
Preeclampsia affects 5% to10% of pregnancies after they have progressed
20 weeks [29]. Unfortunately, the etiology of preeclampsia is unknown, but
it is imperative that the condition is closely monitored once it develops. This
syndrome causes diffuse vasospasm in the liver, kidneys, lungs, heart, or
brain, which may lead to eclampsia. Signs of eclampsia include renal dys-
functions, edema, proteinuria, hypertension, thrombocytopenia, seizures,
and even sudden death [2,30].
Patients should be queried frequently during their pregnancy about any
rapid weight gain, visual problems, migraine-type headaches, or epigastric
pain associated with the liver [2]. Physical exams should include blood
panels to see if platelet levels are falling, as well as observations and tests
watching for developing hypertension, increased tendon reflexes, or retinal
changes [30]. If preeclampsia is suspected, common treatments include hos-
pitalization to enable close monitoring and to reduce the patient’s activity
level, hypertension therapy with magnesium sulfate, and delivery of the fetus
at 37 weeks or as soon as the fetus may be delivered safely [2,31].
Preeclampsia conditions can rapidly deteriorate, causing serious medical
consequences for the mother, including maternal death. Signs of elevated
maternal and fetal risk are hemolysis, elevated liver enzymes, and low
682 DELLINGER & LIVINGSTON

platelet counts, which together are known as the HELLP syndrome [2].
HELLP may predict cerebral hemorrhage, disseminated coagulopathy,
acute renal failure, pulmonary edema, and seizures [2,32]. If seizures occur,
the patient has progressed to eclampsia and a higher risk of death.
Once delivery of the baby is complete, most signs and symptoms of pre-
eclampsia resolve. However, some cases of preeclampsia and eclampsia may
persist or present postpartum up to 3 months following delivery of the child
[2]. Preeclampsia is difficult to prevent and has an 18% chance of recurrence
with additional pregnancies [2,33].

Musculoskeletal system
Musculoskeletal changes are common in the later stages of pregnancy.
Painful leg cramps, or ‘‘charley horses,’’ are common complaints of late preg-
nancy. Changes in calcium and phosphate metabolism lead to leg cramps
[12,34]. Increases in both vascular dilation and venous stasis have both been
attributed as causes of leg-muscle cramps and lower extremity edema [9].
The venous drainage from the pelvic region may also relate to pelvis and
sacroiliac pain. Hormonal changes can increase the mobility of the sacroiliac,
sacrococcygeal, and pubic joints, and cause lower back pain and pelvic dis-
comfort [12,35]. Increases in weight may also result in a larger strain on the in-
tervertebral disks, leading to generalized back pain. The increase in the size of
the gravid uterus leads to lordosis, which causes muscle strain and pain of the
lower back. Studies reveal that close to 49% of pregnant women experience
some back pain during gestation [12,35]. A woman’s changing body contours
and center of gravity may lead to a transient decrease of coordination and pos-
sibly a chance of minor traumas, such as contusions and bruising, from falls.

Endocrine system
As fetal requirements increase, so does the need for nutrients. Thus, ges-
tational changes are made to alter maternal metabolism to ensure nutrition
to the developing fetus [36]. Changes in the release of systemic hormones,
which alter cellular responses to insulin, and thyroid hormone are mecha-
nisms that allow for elevated glucose, lipid, and triglyceride levels in the
blood, which are needed to better nourish the developing fetus [36].
The thyroid undergoes several physiologic changes during pregnancy. Ele-
vated estrogens increase the response of pituitary thyrotropin to thyrotropin-
releasing hormone and thyroxine-binding globulin [20,37–39]. Hyperplasia of
glandular elements, new follicular formation, and increased thyroid vascular-
ity are also temporary effects of maternal gestation [20].
Elevated levels of progesterone, estrogen, cortisol, and chorionic somato-
mammotropin are all related to increased insulin resistance among
a mother’s cells [36,40]. Thus, there is a significant risk for pregnant women
to develop diabetes. Gestational diabetes mellitus (GDM) is found in
 PREGNANT PATIENTS 683

approximately 4% of cases, though more frequently in Hispanic and Cauca-

sian women [41,42]. Women with GDM often have children with 4 kg or
higher birth weights [41]. The fetal macrosomia makes the children more
susceptible to trauma during vaginal births as well as more likely to have
congenital deformities [40]. The newborns also have an increased risk of hy-
pocalemia, hypoglycemia, and polycythemia [41,43].
Gestational control of diabetes requires a combination of monitoring, di-
etary control, and human insulin supplements [40]. Only 15% to 20% of
GDM mothers require human insulin supplements, and most cases resolve
following the end of the pregnancy. However, patients have an increased
risk of developing type-2 diabetes over their lifetime, as well as a 30%-to-
60% likelihood of developing GDM during subsequent pregnancies [44].

Effects of alcohol, drug, or tobacco use

Social habits of tobacco or substance abuse are of great concern, not only
for the patient’s health but also for the health of her unborn child. Medical
professionals must screen all of their patients for use of tobacco, alcohol, or
illegal drugs. Studies estimate that from 1.8% to 32% of pregnant women
have used an illicit drug sometime during their gestation [45–47]. In some
states, medical professionals are required by law to report suspicion of ille-
gal drug use. Thus, medical professionals should be familiar with local laws
as well as with their professional and ethical guidelines.
When suggesting to patients that they stop using tobacco, alcohol, or
other drugs, the health professional should be aware of the available treat-
ment options as well as other factors that may relate to success. First, pa-
tient motivation and desire for change are essential to success. Such issues
as underlying medical or psychological conditions need to be addressed
for the patient’s overall health and effective management. Additionally, con-
sideration for treatment or counseling options, finances, and family or
household obligations should be addressed [45].

Tobacco
Premature and lower birth weights associated with tobacco use were first
reported in the 1950s [48,49]. Since the 1970s, cigarette packages have in-
cluded warnings related to the harmful effects of tobacco on both the
population in general and pregnant women specifically. Tobacco cessation
is of extreme importance as the known consequences of smoking include
low birth weight, risks of spontaneous abortions or preterm deliveries,
and increased risk of sudden infant death syndrome [50]. Animal studies
have proven that both nicotine and carbon monoxide cross the placenta
and cause direct effects on developing fetuses [49,51,52]. Long-term effects
of tobacco have also been reported as increased risks for mental retardation
684 DELLINGER & LIVINGSTON

and attention-deficit/hyperactivity disorder in children who were exposed to

smoking in utero [50].
While tobacco cessation is difficult for most patients, 25% to 40% of
smokers report strong motivation to quit while pregnant. Of those who quit
smoking, only 21% to 35% of women reported relapse during their pregnancy
[50]. Successful methods for tobacco cessation include patient motivation as
well as behavioral and coping counseling or the availability of educational ma-
terials [49,53–55]. If this is insufficient, bupropion has been used with success
for nonpregnant patients. The FDA has given bupropion a B classification for
pregnancy risk [50]. Nicotine concentrates in the fetal circulation after passing
the placental barrier and causes vasoconstriction of both placental and uterine
blood vessels [50,56]. As such, it is an FDA category C medication and nico-
tine patches should only be used when their benefits clearly outweigh the risk
of smoking or other cessation methods [50].

Alcohol
Alcohol abuse among pregnant women is of such concern that the Center
for Substance Abuse Treatment has required that alcohol treatment centers
that receive federal substance abuse block grants must give priority to preg-
nant women [50,57]. Health professionals should ask all their pregnant pa-
tients about alcohol use. However, many do not because only about 65% of
gestational women report being queried regarding their alcohol consump-
tion [50,58]. To aid this discussion, various standardized questionnaires
have been developed to identify alcoholic tendencies.
Women who abuse alcohol while pregnant are at high risk for miscar-
riage or spontaneous abortion [49]. Alcohol abuse can also lead to fetal al-
cohol syndrome (FAS), which is characterized by several physical and
cognitive birth defects. Cleft palate, visual defects, thin upper lips with ab-
sent philtrums, epicanthal folds, and flat midfaces are just some of the facial
deformities associated with FAS [49,59]. Heart defects, such as ventricular
septal defects, vertebral defects, and hip defects are also reported as physical
anomalies [50,60]. Lower intelligence, attention-deficit/hyperactivity disor-
der and other behavioral problems, along with decreased growth potential
and failure to thrive, have been correlated with FAS [50].

Cocaine and opiate abuse

Cocaine has been a common recreational drug since the 1980s and is still
of concern today. Cocaine is a stimulant associated with hypertension and
peripheral vasoconstriction [49,61]. Cocaine also has multiple effects on
both the mother and the fetus, as the drug easily crosses the placental
barrier. It is known to cause uterine arteries to constrict and to inhibit the
metabolism of epinephrine and norepinephrine at neural junctions
[45,49,62–64]. Cocaine also increases the contractility of the pregnant
 PREGNANT PATIENTS 685

woman’s uterus, which may lead to uterine rupture [45,65]. Additionally,

cocaine-related hypertension can be associated with a preeclampsia-like
syndrome. Congenital anomalies include heart and vision defects, hydroen-
cephaly, cerebral infarcts, and other neurological defects [63]. Children
with in utero cocaine exposure have been found to have attention deficit dis-
orders during childhood and unknown effects toward their maturation
[45,66].
Long-term narcotic exposure to the fetus is of concern, too. Maternal nar-
cotic dependency has been associated with low birth weights and increased
neonatal mortality rates [49]. Additionally, fetal dependency on narcotics
has been associated with long-term maternal usage. Neonatal symptoms
may also include irritability, gastrointestinal problems, tremors, and even sei-
zures [45]. Marijuana is another frequently abused drug, though few long-term
effects have been noted for the fetus, newborn, or children [49].

Infection
Pregnant women may be more susceptible than other women to infection
[67]. This vulnerability can be traced in part to the physiological effects that
can precipitate infections, as well as the alterations in pharmacokinetics. The
increased total blood volume and vasodilation increases the dissemination
of bacteria throughout the body. Also, pregnancy may alter the cell-medi-
ated immune function, resulting in a delayed immune response to infection
[15]. Diminished gastrointestinal motility can delay peak concentration of
oral medications and the increased blood volume, when combined with an
increased cardiac output and glomerular filtration rate, can cause rapid dif-
fusion, but also rapid metabolism and excretion of water soluble medica-
tions [9]. For example, ampicillin suffers this fate, so that patients
receiving lower dosages may not obtain therapeutic levels of the drug [9].

Pharmacology
Medications may be either a boon or liability during a woman’s preg-
nancy. This determination can only be made if the weight of her medical
condition, the fetus’s exposure risk, and the need for medical treatment is
evaluated and balanced [63]. Physicians, dental professionals, or patients
may have an irrational belief that all medications may be harmful to the un-
born child. However, some medical conditions, left untreated, may be more
detrimental to the fetus. This may lead to progressive maternal disease
status, teratogenesis, impaired fetal growth or development, premature
birth, spontaneous miscarriage, or abortion [68]. While some medications
may be harmful to a fetus, safe alternatives are often available to treat
many of these medical conditions. Both the patient and medical professional
need to make an informed choice.
686 DELLINGER & LIVINGSTON

Once the decision for medical management has been made, selection of
a medication must be balanced by the therapeutic options available, the de-
gree of control required for a medical condition, the potential and degree of
fetus exposure, the maternal and fetus risks of various medications, dosages
necessary for control and safety, and long-term effects of the medication on
the fetus [68]. Due to ethical concerns, there are few controlled studies
related to adverse effects of medications on either human fetuses or future
development and maturation of the child and adult. While there may be
various anecdotal reports on adverse effects of medication, these may
not adequately reflect a drug’s safety status. A reliable rule of thumb may
include reviewing nonpharmacologic treatments, becoming familiar with
current pharmacologic standards of care, and considering older pharmaceu-
tical treatments that have a longer record of safety [68].
The medical professional must use scientific literature and study reviews;
confer with the patient’s obstetrician, physicians, or pharmacists familiar
with pregnancy interactions; or make use of reliable published reference
sources. In the United States, the FDA has developed a five-category system
to determine fetal risks of medications [69]. Categories range from A, the
safest listing, to the final category, X, which is completely contraindicated
during pregnancy [70] (Table 1).
Many factors play roles in determining fetal risk of medications. First, it
should be determined if a drug is tetragenic in nature. Most fetal organogen-
esis occurs during the first trimester, which is the period of most concern for
many medication effects on the fetus. Next of concern would be the degree

Table 1
FDA Drug Categories During Pregnancy: Level and outcome of testing required to determine
a pregnancy risk factory category
Percentage
Category Outcome of testing of drugs in category
A Controlled studies in humans have failed to !0.7
demonstrate a risk to the fetus, and the possibility
of fetal harm appears remote.
B Animal studies have not indicated fetal risk, and 19
human studies have not been conducted; or
animal studies have shown a risk, but
controlled human studies have not.
C Animal studies have shown a risk, but controlled 66
human studies have not been conducted;
or studies are not available in humans or animals.
D Positive evidence of human fetal risk exists, 7
but in certain situations the drug may be
used despite its risk.
X Evidence of fetal abnormalities and fetal risk exists 7
based on human experience, and the risk
outweighs any possible benefit of use during pregnancy.
Data from Refs. [63,70,73].
 PREGNANT PATIENTS 687

of fetus exposure to a medication. Not all drugs readily pass through the pla-
cental barrier. Those that do not thus spare the unborn child from exposure.
For example, drugs with little or no fetal contact are those that bind to protein
or are made up of large molecules that cannot transfer through the barrier [68].
Drugs that would readily go across the placental barrier include lipid-binding
drugs, acidic medications, or those that depend on renal clearance [71].
One example of fetal harm secondary to medication is thalidomide,
a drug that falls into fetal risk category X. This drug resulted in multiple re-
ports of malformations of the musculoskeletal system and extremity forma-
tion, and led to a revision in the United States food-and-drug laws [63].
Tetracycline and minocycline, though effective antibiotics, are known to
be associated with abnormalities in both bone and dental development.
These drugs are thus not advised for pregnant patients [70]. Alcohol is
also contraindicated during gestation as it has been proven to cause neuro-
developmental defects after repeated or high-dose exposure [49].
The pharmacokinetics of a drug may be altered by pregnancy. For exam-
ple, vasodilation leads to increased hepatic metabolisms and renal clearance
rates. The increase in blood volume causes a larger volume of distribution of
a given medication [1]. Pregnancy is also associated with slower peristalsis
and gastric emptying, as well as increased cardiac output, blood volume,
body fat, and glomerular filtration [24,68]. Thus, unbound free drugs may
transfer across the placenta and drugs that are usually cleared by the kidney
do so at a faster rate. This leads to lower serum drug concentrations, thus
lower effectiveness unless the dosage is adjusted [68].
Fortunately, many drugs in a dental office’s armamentarium are considered
generally safe for both pregnant patients and their unborn children. Most den-
tal professionals should have access to a medication reference if questions arise
regarding a proposed drug’s efficacy or safety. However, if a dental profes-
sional has any doubts about either dental medication choices or risk factors
for pregnant patients, he or she should refer to the patient’s obstetrician.
Local anesthetics are among of the most commonly used medications by
dentists. Lidocaine and prilocaine have been given an FDA category B rat-
ing when given in a therapeutic range, and should be first-line choices for
local anesthesia for pregnant women who do not have any contraindication,
such as allergy [70,72]. Bupivicaine, mepivicaine, and articaine have each
been given FDA category C ratings. Bupivicaine’s rating stems from animal
studies demonstrating embryo death with higher-than-therapeutic dosages.
Mepivicaine and articaine are category C drugs because of insufficient ani-
mal studies [73]. None of the above listed local anesthetic agents have been
associated with poor fetal outcomes when given in dental therapeutic dose
ranges [72,73]. Additionally, the use of vasoconstrictors, such as epinephrine
or levonorderfrin, is not contraindicated when part of the commercially
available local anesthetics. Though given a C rating, these vasoconstrictors,
when used in low concentrations in pre-packaged local anesthetic cartridges,
cause no fetal harm as long as normal precautions are taken. These
688 DELLINGER & LIVINGSTON

precautions include avoiding injection within blood vessels and maintaining

total dosages at or below therapeutic ranges, such as 0.04 mg for epineph-
rine and 0.2 mg for levonorderfrin [72,73].
Frequently, the best treatment option for a patient is to immediately ad-
dress pain or infections at the source [73–75]. However, there are occasions
when infections cannot be treated immediately with invasive dental care and
antibiotics may be a necessary course of action. Many of a dentist’s first line
antibiotics are rated by the FDA as category B for pregnancy risk. These
include the penicillin family, the erythromycins (except for the estolate
form), azithromycin, clindamycin, metronidazole, and the cephalosporins
[70]. However, tetracycline, minocycline, and doxycycline are given D rat-
ings due to their likelihood of chelating in bones and teeth. Thus, tetracy-
cline, minocycline, and doxycycline should normally avoided [70]. Fungal
infections may be treated with nystatin, which is the best topical choice be-
cause it has received a category B rating based on animal studies. Insufficient
animal testing for the oral use of fluconazole and ketoconazole have resulted
in category C ratings, although these drugs are still considered generally safe
for gestational women [70].
When discussing pain, the dental professional should be aware of many
potential pitfalls. Not all nonsteroidal anti-inflammatory drugs are safe
for the fetus. Neither aspirin nor diflusinal are recommended for a pregnant
woman. Aspirin and diflusinal have both been associated with prolonged
gestation and labor, anemia, increased bleeding potential, and premature
closure of the ductus arteriosus of the heart [73]. Even ibuprofen, ketopro-
fen, and naproxen are contraindicated in the third trimester of pregnancy,
where they are considered FDA category D choices, due to their risks of
prolonged labor, hemorrhage risk during delivery, and premature closure
of the ductus arteriosus. However, these three analgesics are given a category
B rating for the first two trimesters of pregnancy [73]. Instead, the first-line
nonsteroidal anti-inflammatory of choice should be acetaminophen. Acet-
aminophen has earned an FDA B rating for all three trimesters of preg-
nancy [70]. If stronger pain medication is necessary, most narcotic
combinations are relatively safe for short durations, despite their risks for
fetal growth retardation or fetal dependency if prescribed for long periods.
Oxycodone has received B ratings for short-term usage, while meperidine,
hydrocodone, propoxyphene, and codeine are FDA category C narcotic
medications, though still considered reasonably safe for short-duration
pain control [70]. However, long-term narcotic usage is ill-advised as the
fetus may develop either neonatal depression or withdrawal symptoms [69].
When treating anxiety in the dental setting, nonpharmaceutical methods
are preferred because they reduce the fetus’s exposure to medication. Most
benzodiazepines for anxiolytic relief must be administered with extreme cau-
tion and consultations with the patient’s physician because most drugs in
this class are classified in categories C or D for pregnancy risk [1,73]. Tria-
zolam, listed by the FDA in category X, is absolutely contraindicated in
 PREGNANT PATIENTS 689

gestational patients [73]. Intranasal nitrous oxide use is very controversial

because there is risk of reduced uterine blood flow or tetratogenic effects
when used in high concentrations [1]. Short-term (ie, %30 minutes) use of
nitrous oxide when used in combination with O50% oxygen for nonelective
dental procedures may be warranted if patient management is not possible
without anxiolytic management. However, anecdotal reports have indicated
risks of cleft palate development associated with short-tern use of nitrous
oxide in combination with oxygen [1,76].
Herbal medications have been used throughout human history and are
once again gaining popularity in Western cultures. While physicians com-
monly prescribe vitamin supplements for their pregnant patients, they
may be unaware or uncomfortable discussing other natural products with
patients. Americans are more frequently adding dietary supplements to their
daily routine and may be using these agents during their pregnancies. Be-
cause herbs are considered natural products, patients may not perceive
them as risky [68]. The FDA, in conjunction with the Dietary Supplement
Health and Education Act of 1994, has recently begun reviewing the efficacy
and safety of herbs. Controlled scientific studies related to herbs are needed.
The effects and risks associated with most natural substances are dose re-
lated. For example, garlic and ginger have been used as spices for genera-
tions without reported effects on pregnancy. Yet, high doses of garlic may
increase the risk of heavy bleeding by its antiplatelet aggregation properties
[63]. Other herbs, such as blue cohosh and passionflower, may alter uterine
contraction patterns, which then affect labor [63]. Table 2 lists some com-
mon herbal medications.
Dental providers need to become comfortable with routinely querying
their patients about herbal and supplement usage above and beyond the
use of vitamins (Fig. 2). Dentists should also reference available scientific lit-
erature regarding the risks and benefits of natural products. Unfortunately,
locating controlled scientific studies can be difficult due to the sparse litera-
ture on their safety during pregnancy.

Dental treatment during pregnancy

Many dental professionals may be apprehensive about providing dental
care to their gestational patients due to fears of inadvertently harming the
fetus. However, few dental procedures are contraindicated during noncom-
plicated pregnancies. The need to minimize systemic infection and disease is
of utmost importance during this period [29,75]. Multiple studies have re-
ported that the bacteria associated with periodontal disease have been asso-
ciated with low birth weights and premature birth [77–83]. Porphyromonas
gingivalis, Actinobacillus actinomycetemcomitans, Bacteroides forsythus,
and Treponema denticola are periodontal-associated pathogens that have
been studied and found in higher levels in mothers of low–birth-weight
children associated with preterm birth [77,79–81,84]. It is assumed that
690 DELLINGER & LIVINGSTON

Table 2
Common herbals and their uses, effects, and risks to pregnant women
Herb Uses and effects Pregnancy risk category
Blue cohosh Stimulate labor C
Relieve menstrual cramps
Antirheumatic
Laxative
Echinacea Enhance wound healing C
Immune system stimulant
Anti-inflammatory agent
Garlic Inhibit platelet aggregation C
Antimicrobial
Lowers lipid levels
Antihypertensive
Ginger Antitussive C
Antiemetic
Antimicrobial
Immune system stimulant
Ginkgo biloba Improve mentation C
Antitussive
Expectorant
Digestive aid
Ginseng Immunoregulation B
Nutmeg Anticholinergic C
Passion flower Potential uterine stimulant C
Sedative
Burn compress
Hemorrhoid treatment
St. John’s wort Management of anxiety C
Management of depression
Enhance wound healing
Improve gastritis
Valerian Sedative B
Hypnotic
Antihypertensive
Anticonvulsive
Data from Briggs GG, Freeman RK, Yaffe SJ. Drugs in pregnancy and lactation, 7th
edition. Philadelphia: Lippincott, Williams, & Wilkins; 2005. p. xiiii–xix, 168–71,362–77,714–7,
1249–51; and Wynn RL, Meiller TF, Crossley HL. Drug information handbook for dentistry.
10th edition. Hudson (OH): Lexi-Comp; 2005. p. 47–50, 145–8, 174–7, 294–6, 348–50, 369–71,
471–4, 562–3, 594–6, 603–5, 702–4, 783–5, 823–6, 870–2, 917–20, 931–4, 1003–4, 1027–8, 1118–20,
1136–8, 1280–2, 1555–6.

the bacteria associated with periodontal disease increases prostaglandin E2,

tumor necrosis factor a, and interleukin 1-B. These in turn set up an inflam-
matory response that may stimulate cervical dilation and labor, leading to
premature birth [84–88]. Thus, dental procedures that minimize the mother’s
oral bacterial load are beneficial for her unborn child.
Dental hygiene procedures, such as prophylaxis, deep scaling, or root
planning are allowable in any trimester of a normal pregnancy [89]. Dental
prophylaxis is encouraged to not only minimize the bacterial load of peri-
odontal pathogens, but also to reinforce good oral hygiene habits for the
 PREGNANT PATIENTS 691

Fig. 2. Dental professionals should become accustomed to querying each pregnant patient
about her medications, about her use of herbal and natural supplements, about her health,
and about the health of the fetus. The best time to ask is during a brief medical update at
the beginning of each appointment.

patient [74,90,91]. Dental hygiene should be encouraged during pregnancy

due to the high incidence (from 30%–100% of study patients) of gingivitis
in pregnant patients [92–94]. Estrogen analogs, such as estradiol, tend to
supplement a favorable environment of intra-oral Porphyromonas interme-
dia [95]. This is found to increase gingival inflammation throughout the
oral cavity or even contribute to the formation of pyogenic granulomas,
also known as ‘‘pregnancy tumors’’ [1,29,96]. While benign, pregnancy tu-
mors can be a painful, nonesthetic soft tissue growth that is frequently re-
moved either during the patient’s pregnancy or recent postpartum period
[29,89,95]. Also, most gestational women must increase their caloric intake
during pregnancy. Frequently, this intake is in the form of multiple, small
meals, or increased carbohydrate-based food, which exposes the patient’s
teeth to higher acid levels and caries risk [74,89,97]. Lowered pH creates
an oral environment more favorable for dental decay development, which
reinforces the need for adequate dental hygiene habits and frequent recalls
for pregnant patients [98].
If dental caries is a source of pain or acute infection in an otherwise
healthy gestational woman, a dentist should provide invasive care no matter
what the patient’s phase of pregnancy [74,75]. Dental decay also presents an
additional source of bacterial load on the patient. Oral-maxillofacial ab-
scesses may release various exotoxins, cytolytic enzymes, as well as gram-
positive and gram-negative bacteria [99].
As previously mentioned, most local anesthetics are acceptable for use for
pregnant women. Additionally, there is no contraindication to using diag-
nostic procedures deemed necessary, such as appropriate radiographs, dur-
ing a patient’s pregnancy, as long as normal safety precautions are followed.
These precautions includes beam collimation, high-speed film, limited
692 DELLINGER & LIVINGSTON

exposures, and lead-apron protection for the patient [29]. It is estimated that
the average full-mouth dental film series may expose the fetus to 1  10 5
rads of radiation, far below the tetragenic risk to the unborn child [1,74,100].
The delivery of elective dental care during pregnancy is controversial, but
not necessarily contraindicated. It is best not to expose a pregnant woman
to medical risks unnecessarily, which is why elective care is often postponed
until gestation has concluded. However, as the second trimester of preg-
nancy is usually devoted to maturation and not commonly associated
with preterm birth in healthy pregnancies, many dentists feel comfortable
delivering elective dental care during this period [29,74,101]. Even though
the third trimester is also devoted to fetal maturation, gestational women
may be more prone to muscle cramps, back pain, or positional hypotension
when reclined in the dental chair, which may lead to an uncomfortable en-
vironment to deliver elective care [101].
Bouts of great joy, anxiety, or fear can be common during pregnancy
[102]. When combined with dental fears or phobia, pregnant patients may
delay or avoid dental care. Anxiety may lead to transient increases in blood
pressure, gastrointestinal upset, hyperventilation, or uterine cramping.
Often, counseling and addressing the causes of the patient’s fears help re-
lieve the symptomology.
Benzodiazepines, as previously discussed, are contraindicated due to the
risk of oral cleft developments during the first trimester and the risk of neo-
natal toxicity and withdrawal symptoms during the third trimester [73,102].
However, short-term nitrous oxide use for anxiolysis is usually deemed
acceptable if nonpharmaceutical methods for anxiety reduction are
unsuccessful [76].

Summary
Pregnancy is a unique period of various physiologic changes that support
the formation and maturation of new life. Every gestational woman should
be encouraged to seek medical and dental care during her pregnancy, as fail-
ure to treat developing problems affects the health of both the mother and
the unborn child. However, a network of health care professionals who are
trained and comfortable in treating patients during pregnancy is also re-
quired for the overall well-being of these patients. Dental care professionals
should educate themselves by gaining a basic understanding of the underly-
ing physiologic changes of pregnancy, influences related to the use of med-
ications or illicit drugs or substances during gestation, and how these may
interact with the delivery of dental care. This understanding aids the devel-
opment of a treatment plan and delivery of necessary medical, nutritional,
and dental care, as well as prepare the professional for counseling their
pregnant patients on relevant issues, such as nutritional supplement usage
or the need to avoid chemicals or substances that may be harmful to either
the mother or child.
 PREGNANT PATIENTS 693

Acknowledgments
The authors wish to acknowledge the assistance of Dr. Ray Holder and
Dr. Neeta Mehta for the preparation of this article.

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