MANAGEMENT OF THE PREGNANT PATIENT

Introduction:
Issues faced by dentists in respect to safety & pregnancy represent
common problems in toxicology e.g. risk of low level exposure of substance
(mercury)/procedure (x-ray) that are known to be harmful at high levels of
exposure. hese issues can be related to the benefits of the procedure and
a conclusion can be reached on the risk-benefit balance. he risks/benefits
should be discussed with the patient (!t) and she can make an informed
decision about the proposed treatment.
Is your !t pregnant" #tudies show that $%&' of pregnancies are
unplanned
(
. )&' of women (*) didn+t know they were pregnant at ,wk -.
//' at )wks. (%' at 0wk & %' at (1wk
1
. here is $(' chance that any
women of childbearing age who presents to a dentist is in the first 0wk+s of
pregnancy
(
.
Oral manifestations of pregnancy:
he physiologic alterations that occur in pregnancy such as fluctuations of
estrogen & progesterone are related to the oral changes that occur in
pregnancy. hese changes include2 3oral vascular permeability. 4host
immunocompetence. 3risk of oral infections. In general the effects of
pregnancy on the oral cavity are largely limited to the soft tissues
)
.
Dental caries2 Incidence has been shown to increase in pregnancy

and
this is related to nutritional changes
/
. 5ther studies have found no
relationship between caries and pregnancy
,
. 6x2 7iet alteration. caries
risk assessment.
Erosion: !erimylolysis can result from severe morning sickness
(hyperemesis). 6x2 ooth mouse. fluoride rinse. sodawater.
Perio health:
a) !regnant * have more gingivitis than non-pregnant * (/&-(&&')
but pregnancy doesn+t cause gingivitis. elevated hormones 8ust
exacerbate existing disease. In /&-9%' an acute form of the
disease occurs
%
. 6x2 :einforce 5;I. pla<ue removal and scaling
when necessary.
b) !yogenic granuloma (pregnancy epulis) occurs in &.1-=.)' of
pregnant * usually in the (
st
trimester and in response to trauma
)
.
c) -estational diabetes occurs in ,' of pregnant*. hese women
are => more likely to have perio disease. ?ut further research is
needed
9
. @o difference in incidence between pregnant* and
controls
=.(&
.
General Management Guidelines:
x of all active dental disease should be carried out before pregnancy
or before delivery if possible.
Alective procedures should be postponed till after delivery
/.).0
.
!rophylaxis can be done at any stage of pregnancy
/.)
.
!ain & infection should be treated regardless of trimester
/.0
.
Bctive dental disease (cavities) is best treated in 1
nd
trimester
/
.
Cse lead apron. collimation. high-speed film when taking >-rays and
only take them for diagnosis
/.).0
.
Cse DB with vasoconstrictor (category B)
/.((
Cse @151 for only short (/&min) durations & avoid in (
st
trimester
/.((
.
#ystemic fluoride is not advised as not beneficial
/.0.((
.
Bvoid prescribing drugs in categories ? (metronidaEole. acyclovir).
F (Bspirin. benEodiaEepines. corticosteriods. @#BI7#. opiates) 7 &
> (tetracycline)
RI!"#ENEFIT ANA$%I OF RO&TINE 'ENTA$ PRO(E'&RE
Removal of plaque & calculus:
he risk associated with this procedure is related to causing a
temporary bacteraemia. Gorst scenario is placental/fetus infection
resulting in premature birth
((
.
-ravid * with perio disease in one study (meta analysis) were 9> more
likely to have an adverse pregnancy outcome (eg premaure birth)
(1
. B
number of other more recent studies & studies not included in the meta
analysis failed to find an association
(/-(0
.
#tudies that looked at perio tx to improve pregnancy outcome showed
no improved pregnancy outcomes in / & 1 showed a benefit
(=
.
Topical Fluoride: @ot teratogenic
1&
. 5nly beneficial in !t+s with high caries
risk. :isk of fluorosis only in /rd trimester & one study showed (mg/d for
the last )mths caused a low rate (/') of fluorosis but no caries protection
1(
.
Xrays: B single dental radiograph with 7-speed film results in (.9m-y
((9&mrad) exposure. ?ut appropriate shielding results in &.&&(m-y
exposure to the fetus. he C# nataional council on radioation protection
recommends max. cumulative fetal dose of %m-y
11
.
ocal !naesthetics & sedation:
-enerally thought to be safe in pregnancy
1,.1,
. Axcess exposure near
term (eg epidural) can cause bradycardia. muscle weakness & F@#
depression
1%
.
Bccidental I.H in8ection of DB with adrenalin could theoretically cause
uterine artery constriction and fetal hypoxia.
Ielypressin is structurally related to oxytocin hence IH in8ection could
theoretically cause uterine contractions thus cautionary use in
pregnancy
1)
.
@151 is toxic at prolonged exposure (1,h) due to Hit?(1 inactivation
19
.
Hit?(1 is needed for 7@B synthesis and this has significance in
pregnancy. :ats exposed to high dose @151 (1,h. %&-9%') during the
organogenic period had significant increase in IC-: and malformations.
?ut lower dose for 1,h didn+t have this effect
10
.
!mal"am: he idea that mercury exposure to the fetus is harmful came
from the 6inamata and Ira< grain disasters. 6ercury (;g) exposure from
amalgam is in the form of ;g vapour (elemental ;g). here is no evidence
that maternal exposure to this is harmful to the human fetus but animal
studies have shown maternal ;g vapour exposure results in a dose-
dependant accumulation in the fetus and localiEation in the fetal brain & the
offspring showed 4 learning ability & behavioural changes
1=-//
. Bs the brain
mostly develops in the 1
nd
& /
rd
trimesters this period could be considered
the most important in reducing maternal ;g exposure. hus unless there is
a strong benefit its hard to 8ustify ;g exposure in this period
((
.
#omposite resin: hese contain base monomers ?is--6B & C76B.
diluent monomers A-76B & ;A6B. & organic fillers. (, and 11 organic
leachables from / different F:+s highlights the potential toxicity of F:
/,./%
.
#ome of the leached chemicals show cytotoxicity. mutagenicity.
carcinogenicity teratogenicity and estrogenic properties. #tudies show
detectable levels of ?is--6B ((&)ppb) in saliva of pts immediately after F:
placement but is wasn+t detected in saliva (detection limit %ppb)
/)
. Aven
though F: leach toxic chemicals the level of systemic exposure is likely to
be too low to cause toxicity thus the very low risk to the fetus is outweighed
by the benefit of dental tx
((
.
Endodontics: Involves multiple exposure to drugs. radiation & other
agents. he medicament pastes are unlikely to result in significant systemic
levels. he only new exposure not previously detailed previously is that of
corticosteriods. Forticosteriods in the (
st
trimester have been shown to 3 the
risk of oral clefts in some studies but not in others
/9
. he risk of not treating
is self- or prescribed medication. systemic infection and tooth loss. hus the
benefit of tx is substantial and outweighs the risks.
Timing of treatment:
6ost x can be carried out in pregnancy but drugs prescribed will be
restricted (eg metronidaEole. @#BI7. corticosteriods).
(st trimester2 his is when most congenital malformations occur. @o dental
procedure is unsuitable in this trimester.
Ge are told that safest period for tx is the 1
nd
trimester. his is because of
organogenesis. uterine sensitivity to external stimuli & compression of vena
cava/aorta causing postural hypotension
/.0
.
1. Gebster G#. Ireeman JB. !rescription drugs and pregnancy. Axpert 5pin
!harmacother 1&&/K,2=,=-=)(
2. Iloyd :D. 7ecoufle !. ;ungerford 7G. Blcohol use prior to pregnancy
recognition. Bm J !rev 6ed (===K(92(&(-(&9.
3. Divingstone (==0
4. :atetitschak (=)9
5. ?arak #. 5ettinger-?arak 5. 5ettinger 6. 6achtei AA. !eled 6. 5hel -.
Fommon 5ral 6anifestations 7uring !regnancy2 B :eview. 5bstet -ynecol #urv
1&&/K%02)1,-)10.
6. :ussell #. 6ayberry D. !regnancy and 5ral ;ealth2 B :eview and
:ecommendations to :educe -aps in !ractice and :esearch. he Bmerican
Journal of 6aternal/Fhild @ursing. 1&&0K //(() /1-/9.
7. >iong >. ?uekens !. Hastardis #. !rid8ian -. !eriodontal disease and gestational
diabetes mellitus. Bmerican Journal 5f 5bstetrics and -ynecology. 1&&)K
(=%2(&0)-(&0=.
8. Hir L. 7ental reatment and 6anagement of the !regnant !atient. Fenter for
7iagnostic #ciences. Cniversity of #ouhtern Falifornia #chool of 7entistry.
?ulletin. 6ay 1&&%. Issue ((.
9. Amar 1994
10. Dow & #tillness (=)/
11. Gebster G#. Bbela 7. ;owe B6. B critical review of the risks and benefits of
dental care in pregnancy and recommendations for the dental practitioner.
(Bwaiting publication in B7B 8ournal) 1&&0.
12. Lhader M#. aNani O. !eriodontal diseases and preterm and low birth weight2 B
meta-analysis. J !eriodontol 1&&%K9)2()(-()%.
13. 7avenport A#. Gilliams FA. #terne JB. 6urad #. #ivapathasundram H. Iearne
J6. Furtis 6B. he Aast Dondon study of maternal chronic periodontal disease
and preterm low birth weight infants2 study design and prevalence data. Bnn
!eriodont (==0K/21(/-11(.
14. 7avenport A#. Gilliams FA. #terne JB. 6urad #. #ivapathasundram H. Furtis 6B.
6aternal periodontal disease and preterm low birthweight2 case-control study. J
7ent :es 1&&1K0(2/(/-/(0.
15. 6c-aw !eriodontal disease and preterm delivery of low birth weight newborns.
J Fan 7ent Bssoc 1&&1K)02()%-()=.
16. ;olbrook G!. 5skarsdottir B. Irid8onsson . Ainarsson ;. ;auksson B. -eirsson
:. @o link between low-grade periodontal disease and preterm birth2 a pilot study
in a healthy Faucasian population. Bcta 5dontol #cand 1&&,K)12(99-(9=.
17. 6oore #. Ide 6. Foward !M. :andhawa 6. ?orkowska A. ?aylis :. Gilson :I. B
prospective study to investigate the relationship between periodontal disease and
adverse pregnancy outcome. ?r 7ent J 1&&,K(=921%(P1%0.
18. @oack ?. Llingenberg J. Geigelt J. ;offmann . !eriodontal status and preterm
low birth weight2 a case control study. J !eriodont :es 1&&%K,&2//=-,%.
19. Ierguson JA 1nd. ;ansen GI. @ovak LI. @ovak 6J. #hould we treat periodontal
disease during gestation to improve pregnancy outcomes".Flin 5bstet -ynecol
1&&9K%&2,%,-,)9.
20. ;orvath F. 7oes fluoride interfere with normal gestation in the rat" eratology
(=0=K,&210%.
21. Deverett 7;. Bdair #6. Haughan ?G. !roskin ;6. 6oss 6A. :andomiEed
clinical trial of the effect of prenatal fluoride supplements in preventing dental
caries. Faries :es (==9K/(2(9,-(9=.
22. @ational Founcil on :adiation !rotection and 6easurements. :eport number (102
:adionuclide Axposure of the Ambryo/Ietus. ?ethesda. 6d.2 (==0.
23. ;aas 7B. !ynn ?:. #ands 7. 7rug use for the pregnant or lactating patient. -en
7ent 1&&&K,02%,-)&.
24. ?ahl :. Docal anesthesia in dentistry. Bnesth !rog 1&&,K%(2(/0-(,1.
25. ?riggs --. Ireeman :L. Maffe #J. 7rugs in !regnancy and Dactation )th
edition. ?altimore. 672 Gilliams & Gilkins. 1&&1 p )-=
26. herapeutic -uidelines. 5ral and 7ental Hersion (. Adited by an 5ral and 7ental
Axpert group. herapeutic -uidelines Dtd 1&&9
27. Geimann J. oxicity of nitrous oxide. ?est !rac :es Flin Bnaesth 1&&/K(92,9-)(.
28. 6aEEe :I. Gilson BI. :ice #B. ?aden J6. :eproduction and fetal development
in rats exposed to nitrous oxide. eratology (=0,K/&21%=-1)%.
29. Lhayat B. 7encker D. Ietal uptake and distribution of metallic mercury vapour in
the mouse2 Influence of ethanol and aminotriaEole. Int J ?iol :es !regnancy
(=01K/2/0-,).
30. 7anielsson ?:. Iredriksson B. 7ahlgren D. -ardlund B. 5lsson D. 7encker D.
Brcher . ?ehavioural effects of prenatal metallic mercury inhalation exposure in
rats. @eurotoxicol eratol (==/K(%2/=(-/=).
31. Garfvinge L. ;ua J. Dogdberg ?. 6ercury distribution in cortical areas and fibres
systems of the neonatal and maternal adult cerebrum after exposure of pregnant
s<uirrel monkeys to mercury vapour. Anviron :es (==,K)92(=)-1&0.
32. 7anielsson ?:-. Lhayat B. 7encker D. Ioetal and maternal distribution of
inhaled mercury vapour in pregnant mice2 Influence of selenite and
dithiocarbomates. !harmacol. oxicol. (==&K)92111-11).
33. Garfvinge L. 6ercury distribution in the neonatal and adult cerebellum after
mercury vapor exposure of pregnant s<uirrel monkeys. Anviron :es
1&&&K0/2=/-(&(
34. Dygre ;. ;Ql !J. #olheim A. 6oe -. 5rganic leachables from polymer-based
dental filling materials. Aur J 5ral #ci (===K(&92/90-/0/.
35. Inoue L. ;ayashi I. :esidual 6onomer (?is--6B) of Fomposite :esins. J 5ral
:ehab (=01K=2,=/-,=9.
36. Iung AM. Awoldsen @5. #t -ermain ;B Jr. 6arx 7?. 6iaw FD. #iew F. Fhou ;@.
-runinger #A. 6eyer 76. !harmacokinetics of bisphenol B released from a
dental sealant. J Bm 7ent Bssoc 1&&&K(/(2%(-%0.
37. 5ren 7. @ulman I. 6akhi8a 6. Ito #. Loren -. Csing corticosteroids during
pregnancy. Bre topical. inhaled. or systemic agents associated with risk" Fan
Iam !hys 1&&,K%&2(&0/-(&0%.
38.
39.