MANAGEMENT OF PREGNANT PATIENTS

IN DENTAL PRACTICE

Dr. Pramod Tatuskar Dr . Shobha Prakash

Asst. Professor, Dept. of Periodontics, Professor & Head, Dept. of Periodontics,
College Of Dental Sciences, College Of Dental Sciences,
Davangere. Davangere.
Email: pramod_mats@yahoo.co.in

ABSTRACT:
Pregnancy is a unique period in a woman's lifetime. Good oral health during pregnancy is important to the overall
health of both the expectant mother and her baby. Therefore, it is important to maintain good oral health during
pregnancy because it has the potential to reduce the transmission of pathogenic bacteria from mothers to their
children. Dental care is safe for the pregnant patient and can prevent long term health problems for both mother and
child. During pregnancy dental treatment may be modified but need not be withheld, provided that the risk
assessment is made properly for both the patient and the fetus. Oral changes in the mouth are due to the altera .. tion
in the levels of estrogen and progesterone. This variation in the female sex hormones causes an increase in oral
vasculature permeability and decrease in the host immunity, thus making the pregnant woman more prone to oral
infections. Although pregnancy is not a contraindication to dental treatments, the clinician should consult with the
patient's physician to clarify individual treatment issues. When prescribing medication during pregnancy, the main
concern is the risk of teratogenesis, because drugs cross the placenta by simple diffusion. Drugs are administered
during pregnancy only when they are essential for the pregnant woman's well-being, and the drug of choice should
always be the one that is the least toxic. Prescribing of systemic drugs of any kind ideally should be performed after
consultation with the general medical practitioner or obstetrician.

KEYWORDS: Dental treatment, Drug use, Pregnancy, Pregnancy gingivi

INTRODUCTION: Pregnancy is a unique
period in a woman's lifetime. Good oral health during
pregnancy is important to the overall health of both
the expectant mother and her baby. Oral health
assessment should be part of comprehensive prenatal
care for all women and every general medical
practitioner and obstetrician should consider referral
of a newly pregnant woman to a dentist as routine'.
Therefore, it is important to maintain good oral health
during pregnancy because it has the potential to
reduce the transmission of pathogenic bacteria from
mothers to their children.
Dental care is safe for the pregnant patient and can
prevent long term health problems for both mother and
child. Overestimation of the risk of teratogenicity in
the fetus resulting from medical and dental procedures
or drugs may cause a clinician to avoid necessary
treatment of the expectant mother.
During pregnancy dental treatment may be modified
but need not be withheld, provided that the risk
assessment is made properly for both the patient and
the fetus".

44
 CODS Journal Vol-S Issue-2, September 2013
;.._~~~~

SUMMARY OF PHYSIOLOGIC CHANGES DURING PREGNANCy3 ;

0 Uterine compression of the inferior vena cava, leading to

. venous stasis and deep venous thrombosis

0 Decreased oncotic pressure leading to lower extremity edema

CARDIOVASCULAR
0 Increased red blood cell volume, heart rate
SYSTEM
0 Flattened T waves on electrocardiogram

0 Extra heart sounds (S3, systolic murmur)

0 Increased cardiac output, increased plasma volume

0 Increased airway mucosa fragility leading to an increased

risk of edema
RESPIRATORY SYSTEM
0 Decreased Pa02 in supine position

0 Increased risk of epistasis with placement of nasal airway,

nasogastric tube

0 Progesterone-induced hyperventilation

. 0 Decreased functional residual capacity

0 Increased risk of thromboembolic disease (Leukocytosis

HEMATOLOGIC
0 Increased plasma volume creates-a physiologic anemia
SYSTEM

GASTROINTESTINAL 0 Decreased lower esophageal sphincter tone leading to and

SYSTEM increased incidence of gastroesophageal reflux disease

0 Decreased gastric motility

0 Increased intragastic pressure

0 Increased glomerular filtration rate

RENAL
0 Increased urinary stasis leading to urinary tract infections
SYSTEM
0 Progesterone-induced dilation of renal tree

0 Suppression of the maternal immune system, secondary to decreased

IMMUNE
neutrophil chemotaxis, cellmediated immunity, and natural killer cell
SYSTEM
activity
 COOS Journal Vol-S Issue-2, September 2013
~ -
ORAL CHANGES IN PREGNANCy4;
Changes in the mouth are due to the altera=tion in the levels of estrogen and progesterone. This variation in the
female sex hormones causes an increase in oral vasculature permeability and decrease in the host immunity, thus
making the pregnant woman more prone to oral infections4. Common oral problems seen in preg=nancy are

D Gingivitis is inflammation of gingiva

which is commonly seen in pregnant
PREGNANCY GINGIVITIS
women as a response to plaque which is
present due to increase in circulating
progesterone levels.
D This condition is ephemeral and recedes
after delivery .
0 Good oral hygiene can help in the preven-
tion of gingivitis during pregnancy.

D Seen in about 1-5% of pregnant women.

D Increase angiogenesis coupled with
gingival irritation by local factors such as
plaque is believed to be the cause.
D The lesion presents as an erythematous
with smooth surface and lobulated painless
PYOGENIC GRANULOMA / swelling seen commonly on the labial
PREGNANCY TUMOUR aspect of inter dental papilla. Other parts of
. the oral cavity like tongue, palate, buccal
mucosa can also be involved.
D This lesion is benign and seen to occur at
the end of first trimester.
D No treatment is required unless some
complications like bleeding from tumour or
difficulty in mastication occurs. In such
cases, tumour can be surgically removed.
D Oral prophylaxis coupled with good patient
education and oral hygiene minimizes the
frequency and severity of the lesion.
D Vomiting is a very common symptom seen
in pregnant women.
D Excessive vomiting causes erosion of the
EROSION enamel of teeth due to continuous contact
of teeth with gastric acid
D To prevent erosion, pregnant women
should be advised to use fluoride mouth
wash and advised not to brush immediately
after vomiting.
D Drugs like antiemetic and antacids can be
prescribed to reduce vomiting.
D This increased risk is mainly due to the
CARIES . . .. .
increase III caryogemc nncroorgamsms
produced by the nutritional changes and to

MANAGEMENT OF PREGNANT
~~~~--~~--~--~--~----~=--~~
PATIENTS IN DENTAL PRA(';TICE 46
 CODS Journal Vol-S lssue-Z, September 2013

GUIDELINES FOR TREATMENT IN PREGNANCY 5:

Ideal timing for dental treatment: Although pregnancy is not a contraindication to dental treatments, the
clinician should consult with the patient's physician to clarify individual treatment issues, especially
when dental emergencies arise during the first trimester.Unless emergency treatment is required, it is
advisable to defer elective treatment the first trimester because of the potential vulnerability of the fetus.
The second trimester is the safest time to perform routine dental care. In this period treatment planning
should include elimination of potential problems that could arise later in pregnancy or during the imme-
diate postpartum period. The early part of the third trimester is still a relatively good time to provide
routine dental care. However, no elective dental treatment is advisable late in the third trimester. Exten-
sive reconstructive procedures such as crowns and partial dentures should preferably not be performed
at any time during pregnancy-? .

FIRST SECONiD THIIRD

TR'IMESlER TRIMESTER TRIMESTER

t
Root sC3Iir:t:g~pllani!lg
AvoidX-mv>
Avoid X·ray~
Elective dental treatment
Only EMERG€NCf
treatment
Avo.id treatment in second
halt of ~nird tri mester

Controll of dental plaque ~ _1

Penodontal prophvlaxi'S:
 COOS Journal Vo!-5 lssue-Z, September 2013

AnytimeDuring Dagnoo::a"W'lS Aceta I oplle {B) Lidocail1ie with I No (ll'idence 3(% nitrous oxrcle Penici IJin (6)
Pr~nancy alesafeduli 9 Me~rtdmeIB) epil'l,ephrinQ' (2%) i thatthelype can be used when Amoxicij!ln {B)
pregnancy M'Orph' e (B) (B),consideredsafe , 01mercury tcckalo focal Cepnalosporins (81
Codeirne (0 duringpre{illan.cy I released frOrnil anesthetics are Clindam)'cin (8)
I exi Slin9 6l1ing s ina de'quare Er)"hromycin not in
A.cet;; i opnen-
IthY(1Jd co]!a I . Mepi1/,lCdline(3M harms the fews ..s!olate form 1(6)
Codeine (0
<llidiaOOOOlefl (C), use ifbenl?fit Pregna nt women
shierd ACifliJ i ophen", OI!il"Ic~;ghsp~sib!e ' Use nlbber dam require lower leviOl.s Qllinolones (C)
H:yotlrocodo e ((J Fi,s'k toietus and high·spe~d 01nitrous o~ide to (iarith romycill !C)
~.g.Vi 00] acllteveseda~on
A.cetJmi ophen ... As p,ophylaxi~ for
Oxycoc!one (C) e.g. dental surgery: use
Pe.lcoc,e· same cri!e.rJa·for all
people at risK fo.r
bacteremia

1st Tlimester Spontaneouspr~na ('floss oecursjn 1 Ci" l5~~ 01 ~II dinicillJy·rrecognized p~egnilnd!?s in the • rst triffi€s!el. Mo.>! bssss are AVOID:
(1. ll'i'ITKSl due to duo ow e a bn ormafiti es, ¥"t, women may prefer to wait until the ssecnd trime5'tel n 4':""W~€ [ f r dental care. Metronidazole (S)
-

2nd Tfimestel
(11'2'1 WEEKS)
I
I
i
3rd Ttimester NEVE!! USE NSAlDs AV01D:
(lS·~OI'IH~'SII e.g.lbup!'ciEln IOJ SulfoJ1lamid~s'l()
Indome°hadrn

NMR& NEVER USE Aspirin Ca . n; CONSULT NEVERUS'E

CAUllONS ~!?SS, pr"'scribt-rllby '.yith Iprenaril ca r,e Tetracydirtes ,(0)
the prenatal care provrder jf'tlsi 9 El)I!hlOmy(irt in
provider 3MS!" esiaotner ,es!o!ate form
than a local bl tICk
CJution: Consult
e.g. IV seda·ion Of
l,'ldtru prena'al cai'~
general ~nesthes.ia
provido?! ~iore
r!leO I ~ n.ding
Ibu profen (E)
or apros}'n (8)
dUlling the ist and
2nd trimeSiers

•Cat B:No evidence of risk in hurma s;,either ,anlmalstudies snowilisk (humalil findings. do not)' Of, if noadE<luate human 5tudi~. dome, anJma'l nrndings negative.
• Cat (; Human stooies are lac' ·ng and animal studies are either positive for fetal risk or tJ(king as "",ell;potential benefits may jus'tify I'he potential risk,
• Cat D:iPasiti\'ele'~ic!ence of risk I vestigational or post ma~xetin9 data show risk to fetus. Nevertheless. potential benefits may QIJt'I,·eigh the rilst

48
 C:OD5Journal Vol-5 lssue-Z, September 2013

POSITION OF PREGNANT PATIENT IN DENTAL CHAIR:

In!erlof'
Vena, Qa\'a

~ Impaired venous return to the heart that results from compression of inferior vena cava by

gravid uterus.

~ So when working on a gravid patient, the position of the patient is utmost important.

~ The ideal position of the gravid patient in the dental chair is the left lateral decubitus position

with the right buttock and hip elevated 15°.

'18l A preventive 6-inch soft wedge( rolled towel) should be placed on the patients right side

when she is reclined for the treatment.

DRUG USE IN PREGNANCy2:

When prescribing medication during pregnancy, the main concern is the risk of teratogenesis, because
drugs cross the placenta by simple diffusion. Drugs are administered during pregnancy only when they are
essential for the pregnant woman's well-being, and the drug of choice should always be the one that is the
least toxic. In practice, dentists mainly prescribe antibiotics to control infections and painkillers to relieve
the pain. Any drug that is prescribed during pregnancy should have the fewest possible side effects and it
should aim to improve the health of the mother or the fetus .In human pregnancy, the time from 2 to 4
weeks from the last menstrual period represents the pre differentiation period of the fetus2. During this
period, the human fetus is relatively resistant to teratogens. The period of maximum teratogenic risk is
organogenesis, which occurs from the end of the predifferentiation period until the end of the lOth week
after the last menstrual period. To determine the risks associated with the use of drugs in pregnancy, the
United States Food and Drug Administration (FDA) has classified drugs based on the level of risk they
pose to the fetus . Accordingly, drugs in category A and category B are considered safe for use, whereas
drugs in category C may be used only if the benefits outweigh the risks. Drugs in category D are avoided
with some exceptional circumstances, while drugs in category X are strictly avoided in pregnant women",
 (ODS Journal Vol-5 Issue-2, September 2013
------------~~~
-- - .,
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

B Either animal reproduction studies have not demonstrated a fetal

risk but there are no controlled studies in pregnant women or

animal reproduction studies have shown an adverse effect that

was not confirmed in controlled studies in women in the first

trimester

C Either studies in animals have revealed adverse effects on the

fetus and there are no controlled studies in women or studies in

women and animals are not available. Drug should only be given

if the potential benefit justifies the potential risk of the fetus.

D There is a positive evidence of human fetal risk, but the benefits

of use in pregnant women may be acceptable despite the risk.

X Studies in animals or human beings have demonstrated fetal

abnormalities or there is evidence of fetal risk based on human

experience or both and. risk of the use of the drug in pregnant

> women clearly outweighs any possible benefit. The drug is

contraindicated in women who are pregnant or may become

pregnant.

L~ aresmencs: Iqe-c'.nh)e
Artic::3ine C 'res. Ye'!O
Bup ....cccrre B y""
lJdoc:ll."1e B y~
~',e~ne C Ye-=o
Prilocaine B y.,. Ye!O
Loe:tl ane~~.rC1,: TC;:Mcl
Scnzocoine
D.tc\co.ne
l,;doca;ne
Ietracccoe Ye~
A.t-~gesics
AcebmiOOOOen 9 y~ Yes
kpmn C/o- Do not use In!l.-d tnraester U!:ec..:u..1tClU!..'y
!).flunoooJ qO· 00 not eee 3rd b';r.'1e::ter
In U:;.e c:ruhovs.'y
Etcco'ac BID- Dc not use in 3..-ri trimester 'res
Muttl:opmfen 9/0· 00 not we in :3tdttim~t Yes
[bo;:.ro5en 8/0" Do not use a"I 3;-ctnme:;!eJ'" Ye!O
Kemrol3C 8/0- Do not cee 1f'13rd tnm~f
Kd:opro~n SfD- Do not U!>-C" In ard trimeser
Na;:lIoce-n 810- Do not use in 3m trime&el Ye!l'
Co<!<>",. C Low dose. $l-.ert d~o:'! ~o:;e~le Yes
O><ycodono B Low eese. short duration accep:ta:»e Y••
:.I.e;:eridlne B Low dose. 5hcrt duration accectcoe Us.ec."lUbou!.ly
P~pho:no C low ecee, sncet d1Jr.1tfon ;;1:CCCpbfl~ u-..., =.I1iov,,¥
Antitrucroblab
I=bnicllln B y"" Ye::
Amo<~lmn B Yes Yes
Arnc::OOcilin ... cbvuJoruc-acld B Yeo Ye'!:
Ocx:lCllbn B Ye:o Ve!:
Cephabs;:oOre B Yes
Ery".hrom,oore B Yes lee no! we e-!:'tO!~)

Cfond=t,oc· B Yes Yes

CbnL~ro!TIicin C use cautious!t,· 'res
Azit..h:-omycin B Yes Yes
Tetr.lcYc5ne D No Ve!:-
DRUGS USED IN THE PREGNANT ~;,.,
lV.c~ronlC!::zaic
D
B
No
ce cuU!io.u:.!y
No

N;=tin B Yeo Yes

OR LACTATING DENTAL PATIENT2: ~oeon.:u.olc c se outiovs¥ No
FiucoI1;JZCe C Use couti:J.us1y No
Chlorhe:xidrne once 3 Yeo ve.e

M~NAGEMENT OF PREGNANT PATIENTS IN DENTAL PR~€TI€E 50

 COOS Journal Vol-5 Issue-2, September 2013

MEDICAL CONDITIONS AND DENTAL Chemical mediators, principally CRP, might be a

TREATMENT CONSIDERATIONS 6: plausible mediator of the association between
l8! Hypertensive disorders, including both preexisting or chronic periodontitis and adverse pregnancy outcomes.
hypertension and gestational hypertension, occur in 12-22% of When periodontal disease is present, the number of
HYPERTENSrvE
pregnant women. bacteria significantly increases by as much as
DISORDERS AND
l8! Oral health professionals should be aware of hypertensive disorders 10,000 times the original population. The immune
PREGNANCY
in pregnancy. Uncontrolled severe hypertension may increase the risk system relaxes slightly during pregnancy so as not
of bleeding during dental procedures. Prenatal care providers should to harm the fetus. More bacteria grow when the
be consulted before initiating dental procedures in women with immune system is not working full throttle.
hypertension to classify the type and severity of hypertension and to Bleeding gums let bacteria enter the blood stream,
rule out preeclampsia if indicated. travel through the mother's body, and enter the
~ Gestational diabetes occurs in 2-5% of pregnant women in the U.S. placenta. While there appears to be an association
o It is usually diagnosed after 24 weeks of gestation. between periodontal disease and preterm low birth
o Any inflammatory process, including acute and chronic periodontal weight, the causal role of periodontal disease in
DIABETES AND
infection, can make diabetes control more difficult.
adverse pregnancy outcomes is yet to be studied
PREGNANCY
o Poorly controlled diabetes is associated with adverse pregnancy
further",
outcomes such as preeclampsia, congenital anomalies, and large-for
REFERENCES:
gestational age newborns. Meticulous control to avoid or minimize
1. Dental Care Throughout Pregnancy: What a
dental infection is important for pregnant women with diabetes.
Dentist Must Know: OHDM - VoL 11 - No. 4 -
o Controlling all sources of acute or chronic inflammation helps
December, 2012.
control diabetes.
2. The pregnant patient: consideration for dental
o Pregnant women with the diagnosis of thrombophilia may be

HEPARIN AND
management and drug use. Quintessence
receiving daily injections of heparin to improve pregnancy outcome.

PREGNANCY
international 2007;38:133-142.
Additionally, some women may be on low molecular weight heparin

products (e.g. enoxaparin).

PREGNANCY OUTCOMES
BY PERIODONTITIS 8:
For a long time we have known that risk factors such
as smoking, alcohol use and drug use may contribute
to produce an alteration, disruption or teratogenic
consequence. New research suggests a new risk factor
- periodontal disease",
Systemic inflammation and its chemical mediators
play a major role in the pathogenesis of preterm
delivery, including pre-eclampsia intrauterine
growth restriction , and preterm delivery Chronic
infections like intrauterine infection and
chorioarnnionitis are linked to both preterm birth and
elevated CRP levels. Previous research reported that
periodontal infections cause a faster-than-normal
increase in the levels of prostaglandin and tumor
necrosis factor molecules that induce labor.
Furthermore, periodontal disease has been associated
with increased risk of preterm low birth weight, low
birth weight, and preterm birth.
3. Management of the Pregnant Oral
andMaxillofacial Surgery Patient: J Oral
Maxillofac Surg 60: 1479-1488, 2002.
INFLUENCED 4. Dental considerations in pregnancy: review, Rev
Clin Pesq OdontoL 2010 maio/ago;6(2):161-5.
5. Oral Healthcare Considerations for the Pregnant
Woman: Dental Update: 51: January/February
2012.
6. Oral Health Care During Pregnancy and Early
Childhood: Practice Guidelines. New York, NY:
New York State Department of Health, 2006.
7. Oral Health Care During Pregnancy
Recommendations for Oral Health Professionals:
New York State Dental Journal: 2009:75(6).
8. Relationship between pregnancy and
periodontal disease: Medicine and Biology VoL14,
No 1,2007, pp.10 - 14.
9. Dental considerations in pregnancy and
menopause: J Clin Exp Dent. 2011 ;3(2):e 135-44.
10. Adolescent Pregnancy: A Review of Dental
Treatment Guidelines: Kelly K. Hilgers, Joanna
Douglass, Gregory P. Mathieu, Pediatric Dentistry
- 25:5,2003.

j 51