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A Review on the principle of Dental Management of the Pregnant patient

Dr. A. K. M. Tanzir Hasan

Pregnancy has been considered an impediment to dental treatment However, preventive, emergency, and routine dental procedures are all suitable during various phases of a pregnancy, with some treatment modifications and initial planning

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?

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.

Stages of Pregnancy

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

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.

Physiologic Changes in Pregnancy


Complex hormonal interactions cause profound physiologic changes Increase estrogen by 10 fold and progesterone by 30 folds Increased hormonal secretion and fetal growth causes several systemic as well as physical changes in a pregnant women

Systemic changes in pregnancy:

Cardiovascular system
in blood volume by an average of 45% Anemia due to increased blood volume (20% of women) in pulse by 10-15 beats per minute Systemic murmur occurs in 90% of pregnancies, disappears shortly after delivery cardiac output Supine hypotension syndrome may occur .

FLAT SUPINE POSITIONING


Negatively impacts: mother and infant

SUPINE HYPOTENSION SYNDROME (Vena Cava Compression) SUPINE POSITION AFTER 5TH MONTH UTERUS COMPRESSES THE INFERIOR VENA CAVA VOL. BLOOD IN THE L.E.S RETURN TO THE HEART REDUCED PERFUSION OF UTERUS FETAL HYPOXIA

Supine Hypotension Syndrome


Obstruction of inferior vena cava and aorta from pressure of the large fetus. Symptoms: Sweating Nausea Weakness Sense of lack of air

Supine Hypotension Syndrome

Other symptoms: Drop in blood pressure Bradycardia Possible loss of consciousness

Prevention of Supine Hypotensive Syndrome

Elevate right hip 10-12 cm. Weight is taken off the major vessels

Treatment of Supine Hypotensive Syndrome

Roll patient onto her left side.

How should the pregnant woman be positioned?


Flat position may cause hypotension and hypoxia Place a small pillow under right hip - left lateral displacement

Head above feet

Systemic changes in pregnancy: Respiratory system


Diaphragm rises about 4 cm. residual volume awareness of a desire to breath is common-may be interpreted as dyspnea. Increased estrogen in blood causes engorgement of the nasal capillaries and rhnitis in pregnant women. Frequent nosebleeds & predisposition to upper respiratory infection.

Systemic changes in pregnancy:

Gastrointestinal system
Gastric emptying & intestinal transit times are delayed. Heart burn / reflux common
Nausea and vomiting common

Systemic changes in pregnancy:


For pregnant patient with Hyper-emesis gravidarium ( excessive and uncontrolled vomiting) , morning appointments should be avoided. They should be seated in a semi-supine or comfortable position In case of vomiting , the procedure should be stopped immediately & the patient should be repositioned upright When vomiting is over rinsing mouth with cold water or mouthwash is recommended.

Systemic changes in pregnancy: Urinary System


GFR & renal plasma flow by as much as 50% Nocturia to mobilize the dependent edema which accumulate during the day. Frequency from renal flow plus reduced bladder capacity from uterine growth It is advisable to ask the patient to void the bladder just prior to starting the dental procedure.

Systemic changes in pregnancy: Endocrine Changes:


Estrogen, progesterone, human gonadotropin thyroxin, steroid and insulin level Estrogen & progesterone are insulin antagonists. level of these hormones lead to insulin resistance. Thus insulin levels are elevated in pregnant in pregnant patient to compensate this resistance About 45 %of women fail to produce sufficient amount of insulin to overcome this antagonist action & thus develop gestational diabetes.

Systemic changes in pregnancy:


Hematological change
red RBC , ESR, Hb WBC circulatory catecholamin & cortisol lead to leucositosis Coagulation factors except factor XI & XIII (anticloting factor) so pregnancy is a hypercoagulable state & risk for thromboembolism

Systemic changes in pregnancy:


Pregnant women with anti-phospholipid syndrome are at risk for thromboembolisim. They are placed on subcutaneous low molecular weight heparin (LMWH) These patients must be hospitalized for dental care.

Pregnancy Related Oral Health Problems


Pregnancy Gingivitis Pregnancy Epulis Increased Tooth Mobility Dental Caries Erosion Dental Problems in relation to Labor and Delivery

Oral Problems in Pregnancy


Pregnancy Gingivitis Most common oral manifestation (50100% of women) Caused by hormonal and vascular changes of pregnancy

Pregnancy Gingivitis Pathophysiology

Elevated circulating estrogen increases capillary permeability.


Preexisting gingivitis may predispose to pregnancy gingivitis.

Pregnancy Gingivitis

Occurs commonly in the 2nd to 8th months Tendency to bleed very easily Treatment: Scaling, rootplaning, currettage, OHI

Pregnancy Granuloma Occurs in up to 5% of women. Most common in buccal maxillary anterior areas. Usually starts in an area of gingivitis.

Pregnancy Granuloma (continued)

Rapid growth up to 2 cm. Single tumor-like growth usually in interdental papillae Purplish to bluish in color, may be ulcerated- bleeds easily

Gum Problems - Pregnancy Granuloma

Gum Problems - Pregnancy Granuloma

Gum Changes - Pregnancy Granuloma

Pregnancy Granuloma (continued)

Treatment Scaling and root planing Excision if it is too large or bleeds too easily May regress spontaneously after pregnancy

Candidiasis

Wipes off Usually asymptomatic, but may burn Treatment topical or systemic antifungals

Pregnancy Myths
A mother loses a tooth for every baby No evidence that aphthous ulcers are any more common in pregnancy

Other Oral Conditions in Pregnancy

Dry mouth Excessive salivation Tooth erosions associated with severe GERD or hyperemesis

Changes During Pregnancy that Affect Oral Health


Hormonal Affects
Increased tooth mobility Saliva changes Increased bacteria Gingival problems

Saliva changes
Decreased buffers Decreased minerals Decreasing flow first and last trimester Increased flow second trimester More acidic

Increased Bacteria
Increased acidity
Increase in decay-causing bacteria

Increased Snacking
Morning sickness/low blood sugar Between-meal snacks

Increase in amount and frequency of starches/carbohydrates


Crackers are commonly recommended Promotes decay-causing bacteria

Changes During Pregnancy that Affect Oral Health


Morning sickness
Difficulty with hygiene
Gingival disease Tooth decay

Vomiting

Esophogeal Reflux (heartburn) Acid exposure


Irritation of the gums Weakening of tooth enamel Dental erosion

Enamel erosion caused by frequent vomiting

Treatment for Acid Exposure


Do NOT brush immediately after vomiting Rinse
Water with baking soda
Antacid Plain water

Eat some cheese

Oral Diseases Can Effect Pregnancy


Preterm, low birth weight (LBW) linked to periodontal disease Thorough calculus (tartar) removal in pregnant women with periodontitis may reduce pre-term births

Periodontal Disease and Preterm Labor


Maternal periodontal disease is associated with increased risk of preterm labor Anaerobic oral gramnegative bacteria cause inflammatory response Inflammatory response stimulates prostaglandin and cytokine production to stimulate labor

Periodontal Disease and Low Birth Weight Periodontal disease is associated with low birth weight Evidence is not conclusive Biochemical mechanism similar cascade as in preterm labor leading to placental blood flow restriction and necrosis

Periodontal Disease and Preeclampsia Emerging data Mechanism unclear Proposed mechanism:
Periodontal infection leads to inflammatory vascular damage Triggers cell damage in placenta

Periodontitis and Pre-eclampsia


Periodontal disease may be associated with pre-eclampsia (Boggess, 2003) PGE2, IL-1 and TNF- from gingival crevicular fluid were higher in women with preeclampsia compared with healthy matched pregnant women (Oettinger-Barak, 2003).

Dental Considerations
timing of treatment for pregnant patients dental radiation exposure use of local anesthetics prescription of common antibiotics and analgesics nitrous oxide gas administration

Treatment Timing
First Trimester
Spontaneous miscarriages naturally occur more often in 1st trimester Avoid elective treatment that can be delayed Offer anticipatory guidance

Second Trimester
The optimal time for dental treatment Organogenesis complete, fetus not large Easier to prevent than treat established disease

Third Trimester
Late in term very uncomfortable (short visits) Position slightly on left side

Timing of Dental Treatment During Pregnancy - From Little and Fallace

First Trimester
Plaque control Oral hygiene instruction Scaling, polishing, curettage Avoid elective treatment; urgent care only

Timing of Dental Treatment During Pregnancy - From Little and Fallace Second Trimester
Plaque control Oral hygiene instruction Scaling, polishing, curettage Routine dental care

Timing of Dental Treatment During Pregnancy - From Little and Fallace Third Trimester
Plaque control Oral hygiene instruction Scaling, polishing, curettage Routine dental care (after middle of third trimester, elective care should be avoided)

Use of Radiation on Pregnant Patient


Dose given and time of gestation are important doses < 5-10 rads (cGy) not teratogenic fetus is most susceptible to radiation between the 2nd and 6th week of gestation 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. Therefore, diagnostic radiation should not be withheld during pregnancy

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)

Risks of Dental X-Rays


X-ray only if necessary (i.e. root canal therapy, trauma) When x-rays are indicated, radiation exposure is extremely low Exposure can be limited by:
Lead apron shielding Modern fast film Avoiding retakes

FDA drug classification for pregnancy


Combines risk statements including congenital anomalies, fetal effects, perinatal risks, and therapeutic riskbenefit ratio Untreated disease or condition may pose more serious risks to both mother and fetus than any theoretical risks from the medication Category A thru D and X

FDA drug classification for pregnancy

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

FDA drug classification for pregnancy


B = Animal studies show no risk, or if risk shown in animals, controlled trials in women showed no risk

FDA drug classification for pregnancy


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

FDA drug classification for pregnancy


D = There is evidence of human fetal risk, but benefits may outweigh risks

FDA drug classification for pregnancy

X = Contraindicated

Common Analgesics paracetamol (B) Ibuprofen (B/D*) Oxycodone (B/D*) Hydrocodone and codeine (C/D*)
*avoid in third trimester

Analgesics
Paracetamol is the analgesic of choice for all stages of gestation used to treat mild to moderate pain and fevers short term usage is believed to be safe avoid chronic and large doses of paracetamol

Analgesics - continued Aspirin is nonteratogenic but may cause maternal and fetal hemorrhage large and chronic doses during last trimester may result in premature closure of ductus arteriosus, fetal hypertension, anemia, and low birth weight avoid ibuprofen in 3rd 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

Analgesics to Use During 1st and 2nd Trimester Category B (for best!) Paracetamol, Ibuprofen, Naproxen Category C (use with caution): Paracetamol with codeine or hydrocodone Paracetamol with oxycodone

Analgesics to Avoid During the Third Trimester Causes delivery problems: Aspirin (C/ 3D) Ibuprofen (B/3D) Naproxen (B/3D) Causes neonatal respiratory depression and opioid withdrawal: Codeine (C/3D) Hydrocodone (C/3D) Oxycodone(C/3D)

Sedation in Pregnancy

Sedatives/Anxiolytics (e.g. Diazepam ) are rated D and can cause oral clefts with prolonged exposure. Nitrous oxide should not be used in 1st trimester (If used in 2nd and 3rd, do not go below 50% O2)

Common Antibiotics
To treat oral abscess or cellulitis Penicillin (B) Amoxicillin (B) Cephalexin (B) Erythromycin base* (B) (Not estolate, as it cause cholestatic hepatitis) Clindamycin (B)

Antibiotics
penicillin V and amoxicillin is preferred drug for mild to moderate infections widely used for many years with no ill effects no studies show penicillin to be teratogenic amoxicillin extensively used without harming the fetus Drug classes: B: penicillin, cephalosporins, erythromycin, clindamycin, Azithromycin D: Tetracycline

Antibiotics To Use During Pregnancy Penicillin V Amoxicillin Erythromycin (base form) Cephalexin, cephalosporin Clindamycin Metronidazole

Antibiotics to Avoid during Pregnancy

Doxycycline Tetracycline Erythromycin (estolate form) Vancomycin

The Problem With Tetracycline

Accumulates in bones and chelates calcium Inhibits bone growth Discolors teeth

Other Antimicrobial Agents


OK to use: Nystatin (B) Chlorhexidine rinse (B) Use with caution: Clotrimazole (C) Ketoconazole (C) Fluconazole (C) Do not use: Doxycycline (D)

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

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

Ulcer healing drugs


Cimetidine FDA category B Famotidine FDA category B Ranitidine FDA category B not known to be harmful

Ulcer healing drugs


Omeprazole FDA category B.Not known to be harmful Esomeprazole FDA category B Lansoprazole FDA category B Pantoprazole Avoid unless potential benefit outweighs riskfetotoxic in animals

Ulcer healing drugs

Misoprostol First, second, third trimesters: Avoid potent uterine stimulant (has been used to induce abortion) and may be teratogenic

Ulcer healing drugs

Antacids Almunium hydroxide/Magnesium hydroxideFDA category B Calcium carbonateFDA category C SimetheconeFDA category C

Use of Nitrous Oxide Gas


used over 150 years safety is being debated SHORT TERM exposure do not cause birth defects or spontaneous abortion CHRONIC exposure may result in fetal loss and infertility literature suggests that nitrous oxide should be avoided until more conclusive research is available FDA Drug class: not yet assigned

Common Preventives

Fluoride
No increased risk during pregnancy

Xylitol
No studies; no harm reported

Chlorhexidine
No increased risk during pregnancy

Are topical agents safe?


Fluoride
Toothpaste & mouthrinse

Xylitol chewing gum

Chlorhexidine (11% alcohol)


No over the counter mouthrinses with

alcohol (Listerine 20% alcohol)

Pre-natal Fluoride
Daily 2.2 mg tablet of sodium fluoride during 3rd through 9th months decreases caries rate in offspring. Safe and effective.

Glenn, FB, 1982

Is it safe to use mercury restorations? No evidence of harmful effect


Benefits outweigh risks Canada, Germany, and New Zealand have some restrictions Determine the best option

References
Wasylko L, Matsui D, Dykxhoorn SM, Rieder MJ, Weinberg S. A Review of Common Dental Treatments During Pregnancy. J Canadian Dental Association. 64:434-439 1998 Little JW, Donald AF, Craig SM, Rhodus NL. Dental Management of the Medically Compromised Patient - 5th edition. Mosby, Toronto. Pp.434-442. 1997. Livingston HM, Dellinger TM, Holder R. Considerations in the management of the pregnant patient. Special Care in Dentistry. 18:5 pp183-188. 1998. Larimore WL, Petrie KA. Drug use during pregnacy and lactation. Primary Care; Clinics in Office Practice. 27:1 3553. 2000 Health Canada. The Safety of DentalAmalgam. Minister Of Supply and Services Canada. 1996.

REFERENCES
1. Weiss G. Endocrinology of parturition. J Clin Endocrinol Metab 2000;85:4421-5. 2. Theunissen IM, Parer JT. Fluid and electrolytes in pregnancy. Clin Obstet Gynecol 1994;37:3-15. 3. Duvekot JJ, Peeters LLH. Renal hemodynamics and volume homeostasis in pregnancy. Obstet Gynecol Surv 1994;49:830-9. 4. Barron WM, Lindheimer MD. Medical disorders during pregnancy. 2nd ed. St Louis: Mosby; 1995. p. 129. 5. Thornburg KL, Jacobson SL, Giraud GD, Morton MJ. Hemodynamic changes in pregnancy. Semin Perinatol 2000;24:11-4. 6. Fiese R, Herzog S. Issues in dental and surgical management of the pregnant patient. Oral Surg Oral Med Oral Pathol 1988;65:292-7. 7. Martin C, Varner MW. Physiologic changes in pregnancy:surgical implications. Clin Obstet Gynecol 1994;37:241-55.

8. Clark SL, Cotton DB, Lee W, Bishop C, Hill T, Southwick J, et al. Central hemodynamic assessment of normal term pregnancy. Am J Obstet Gynecol 1989;161:1439-42. 9. Mabie WC, Di Sessa TG, Crocker LG, Sibai BM, Arheart KL. A longitudinal study of cardiac output in normal human pregnancy. Am J Obstet Gynecol 1994;170:849-56. 10. Clapp JF 3rd, Capeless E. Cardiovascular function before, during, and after the first and subsequent pregnancies. Am J Cardiol 1997;80:1469-73. 11. Duvekot JJ, Peeters LL. Maternal cardiovascular hemodynamic adaptation to pregnancy. Obstet Gynecol Surv 1994;49(Suppl): S1-14.

12. Bhagwat AR, Engel PJ. Heart disease and pregnancy. Cardiol Clin 1995;13:163-78. 13. Lanni SM, Tillinghast J, Silver H. Hemodynamic changes and baroreflex gain in the supine hypotensive syndrome. Am J Obstet Gynecol 2002;187:1636-41. 14. Little JW, Falace DA, Miller CS, Rhodus NL. Dental management of the medically compromised patient. 6th ed. St Louis: Mosby; 2002. p. 303. 15. Garcia-Rio F, Pino JM, Gomez L, Alvarez-Sala R, Villasante C, Villamor J. Regulation of breathing and perception of dyspnea in healthy pregnant women. Chest 1996;110:446-53. 16. McAuliffe F, Kametas N, Costello J, Rafferty GF, Greenough A, Nicolaides K. Respiratory function in singleton and twin pregnancy. BJOG 2002;109:765-9. 17. Clapp JF 3rd, Seaward BL, Sleamaker RH, Hiser J. Maternal physiologic adaptations to early human pregnancy. Am J Obstet Gynecol 1988;159:1456-60. 18. ODay MP. Cardio-respiratory physiological adaptation of pregnancy. Semin Perinatol 1997;21:268-75. 19. Contreras G, Gutierrez M, Beroiza T, Fantin A, Oddo H, Villarroel L, et al. Ventilatory drive and respiratory muscle function in pregnancy. Am Rev Respir Dis 1991;144:837-41. 20. Turner M, Aziz SR. Management of the pregnant oral and maxillofac

21. Sifakis S, Pharmakides G. Anemia in pregnancy. Ann N Y Acad Sci 2000;900:125-36. 22. Branch DW. Physiologic adaptations of pregnancy. Am J Reprod Immunol 1992;28:120-2. 23. Burrows RF, Kelton JG. Incidentally detected thrombocytopenia in healthy mothers and their infants. N Engl J Med 1988;319: 142-5. 24. Hanly JG. Antiphospholipid syndrome: an overview. CMAJ 2003;24(168):1675-82. 25. Heilmann L, von Tempelhoff GF, Pollow K. Antiphospholipid syndrome in obstetrics. Clin Appl Thromb Hemost 2003;9: 143-50. 26. Sherman P, Flaxman SM. Nausea and vomiting of pregnancy in an evolutionary perspective. Am J Obstet Gynecol 2002; 185(Suppl):s190-7. 27. Koch KL. Gastrointestinal factors in nausea and vomiting of pregnancy. Am J Obstet Gynecol 2002;185(Suppl):s198-203. 28. Koch KL, Frissora CL. Nausea and vomiting during pregnancy. Gastroenterol Clin N Am 2003;32:201-34. 29. Baron TH, Ramirez B, Richter JE. Gastrointestinal motility disorders during pregnancy. Ann Intern Med 1993;118: 366-75. 30. Richter JE. Gastroesophageal reflux disease during pregnancy. Gastroenterol Clin N Am 2003;32:235-61.

31. Marrero JM, Goggin PM, de Caestecker JS, Pearce JM, Maxwell JD. Determinants of pregnancy heartburn. Br J Obstet Gynaecol 1992;99:731-4. 32. Hamaoui E, Hamaoui M. Nutritional assessment and support during pregnancy. Gastroenterol Clin N Am 2003;32:59-121. 33. King JC. Physiology of pregnancy and nutrient metabolism. Am J Clin Nutr 2000;71(suppl):1218s-25s. 34. Casanueva E, Pfeffer F, Fernandez-Gaxiola AC, GutierrezValenzuela V, Rothenberg SJ. Iron and folate status before pregnancy and anemia during pregnancy. Ann Nutr Metab 2003; 47:60-3. 35. Chng CL, Morgan M, Hainsworth I, Kingham JG. Prospective study of liver dysfunction in Southwest Wales. Gut 2002;51: 876-80. 36. Rahman TM, Wendon J. Severe hepatic dysfunction in pregnancy. QJM 2002;95:343-57. 37. Knox TA, Olans LB. Liver disease in pregnancy. N Engl J Med 1996;335:569-76. 38. Saftlas AF, Olson DR, Franks AL, Atrash H, Pokras R. Epidemiology of preeclampsia and eclampsia in the United States, 1979e1986. Am J Obstet Gynecol 1990;163:460-5. 39. Walker JJ. Pre-eclampsia. Lancet 2000;356:1260-5.

40. Davidson JM. Renal disorders in pregnancy. Curr Opin Obstet Gynecol 2001;13:109-14. 41. Dafnis E, Sabatini S. The effect of pregnancy on renal function: physiology and pathophysiology.AmJMedSci 1992;303:184-205. 42. Davison JM, Shiells EA, Philips PR, Lindheimer MD. Serial evaluation of vasopressin release and thirst in human pregnancy. Role of human chorionic gonadotrophin in the osmoregulatory changes of gestation. J Clin Invest 1988;81:798-806. 43. Glinoer D, de Nayer P, Bourdoux P, Lemone M, Robyn C, van Steirteghem A, et al. Regulation of maternal thyroid during pregnancy. J Clin Endocrinol Metab 1990;71:276-87. 44. Wilson SG, Retallack RW, Kent JC, Worth GK, Gutteridge DH. Serum free 1,25-dihydroxyvitamin D and the free 1,25- dihydroxyvitamin D index during a longitudinal study of human pregnancy and lactation. Clin Endocrinol 1990;32:61322. 45. Rasmussen N, Frolich A, Hornnes PJ, Hegedus L. Serum ionized calcium and intact parathyroid hormone levels during pregnancy and postpartum. Br J Obstet Gynaecol 1990;97:857-9. 46. Guyton AC. Textbook of medical physiology. 8th ed. Philadelphia: W B Saunders; 1991. p. 915e28. 47. Trainer PJ. Corticosteroids and pregnancy. Semin Reprod Med 2002;20:37580. 48. Soory M. Hormonal factors in periodontal disease. Dent Update 2000;27:3803.

49. Hugoson A. Gingivitis in pregnant women. A longitudinal clinical study. Odontol Revy 1971;22:65-84. 50. Neville BW, Damm DD, Allen CM, Bouquot JE. Oral & Maxillofacial Pathology. 3rd ed. Philadelphia: W B Saunders; 2002. p. 329-30, 447-9. 51. Tilakaratne A, Soory M, Ranasinghe AW, Corea SM, Ekanayake SL, de Silva M. Periodontal disease status during pregnancy and 3 months postpartum in rural population of Sri-Lankan women. J Clin Periodontol 2000;27:787-92. 52. Laine M, Tenovuo J, Lehtonen OP, Ojanatko-Harri A, Vilja P, Tuohimaa P. Pregnancy e related changes in human whole saliva. Arch Oral Biol 1988;33:913-7. 53. Yuan K, Wing LY, Lin MT. Pathogenetic roles of angiogenic factors in pyogenic granulomas in pregnancy are modulated by female sex hormones. J Periodontol 2002;73:701-8. 54. Evans RD, Briggs PF. Tooth-surface loss related to pregnancyinduced vomiting. Prim Dent Care 1994;1:24-6. 55. Salvolini E, Di Giorgio R, Curatola A, Mazzanti L, Fratto G. Biochemical modifications of human whole saliva induced by pregnancy. Br J Obstet Gynaec 1998;105:656-60. 56. Mauldin JG, Newman RB. Preterm birth risk assessment. Semin Perinatol 2001;25:215-22. 57. Heine RP, McGregor JA, Goodwin TM, Artal R, Hayashi RH, Robertson PA, et al. Serial salivary estriol to detect an increased risk of preterm birth. Obstet Gynecol 2000;96:490-7.

58. Kauh YC, Zachian TF. Melasma. Adv Exp Med Biol 1999;455: 4919. 59. Wong RC, Ellis CN. Physiologic skin changes in pregnancy. J Am Acad Dermatol 1984;10:929-40. 60. Errickson CV, Matus NR. Skin disorders of pregnancy. Am Fam Physician 1994;49:605-10. 61. Lopez NJ, Smith PC, Gutierrez J. Periodontal therapy may reduce the risk of preterm low birth weight in women with periodontal disease: a randomized controlled trial. J Periodontol 2002;73:911-24. 62. McGaw T. Periodontal disease and preterm delivery of lowbirthweight infants. J Can Dent Assoc 2002;68:165-9. 63. Richards AG. Dental x-ray protection. Dent Clin North Am 1968;631-41. 64. 1990 Recommendations of the International Commission on Radiological Protection. Ann ICRP 1991;21:1-201. 65. Hall EJ. Radiation, the two-edged sword: cancer risks at high and low doses. Cancer J 2000;6:343-50. 66. Diethelm L, Xu H. Diagnostic imaging of the lung during pregnancy. Clin Obstet Gynecol 1996;39:36-55.

67. Brent RL. The effects of embryonic and fetal exposure to x-rays, microwaves and ultrasound. ClinObstetGynecol 1983;26:484-510. 68. National Council on Radiation Protection. NCRP report no.128, 1998. Bethesda, Md: Author. 69. Wasylko L, Matsui D, Dykxhoorn SM, Reider MJ. Weinberg S. A review of common dental treatments during pregnancy: implications for patients and dental personnel. J Can Dent Assoc 1998;64:434-9. 70. Freeman JP, Brand JW. Radiation doses of commonly used dental radiographic surveys. Oral Surg Oral Med Oral Pathol 1994;77:285-9. 71. Kircos LT,Angin LL, Lorton L.Order ofmagnitude dose reduction in intraoral radiography. J Am Dent Assoc 1987;114:344-7. 72. Updegrave WJ. Simplified and standardized intraoral radiography with reduced tissue irradiation. J Am Dent Assoc 1972;85:861-9. 73. Wood RE, Harris AM, van der Merwe EJ, Nortje CJ. The leaded apron revisited: does it reduce gonadal radiation dose in dental radiology? Oral Surg Oral Med Oral Pathol 1991;71:642-6. 74. An update on radiographic practices: information and recommendations. ADA Council on Scientific Affairs. J Am Dent Assoc 2001;132:234-8.

75. Rayburn WF. Recommending medications during pregnancy: an evidence based approach. Clin Obstet Gynecol 2002;45:1-5. 76. Rathmell JP, Viscomi C, Ashburn MA. Management of nonobstetric pain during pregnancy and lactation. Anesth Analg 1997;85:1074-87. 77. Teratology society public affairs committee. FDA classification of drugs for teratogenic risk. Teratology 1994;49:446-7. 78. Moore PA. Selecting drugs for the pregnant dental patient. J Am Dent Assoc 1998;129:1281-6. 79. Haas DA. An update on analgesics for the management of acute postoperative dental pain. J Can Dent Assoc 2002;68:476-82. 80. Haas DA, Pynn BR, Sands TD. Drug use for the pregnant or lactating patient. Gen Dent 2000;48:54-60. 81. Committee on Drugs, American Academy of Pediatrics. The transfer of drugs and other chemicals into human milk. Pediatrics 1994;93:137-50. 82. Nielsen GL, Sorensen HT, Larsen H, Pedersen L. Risk of adverse birth outcome and miscarriage in pregnant users of nonsteroidal anti-inflammatory drugs: population based observational study and case-control study. BMJ 2001;322:266-70. 83. Janssen N, Genta M. The effects of immunosuppressive and antiinflammatory medications on fertility, pregnancy, and lactation. Arch Intern Med 2000;16:610-9.

84. Ostensen M. Nonsteroidal anti-inflammatory drugs during pregnancy. Scand J Rheumatol Suppl 1998;107:128-32. 85. USPDI -Drug information for the health care professional. 22nd ed. Greenwood Village, CO: Micromedex; 2002. p. 152-79. 86. Denson DD, Coyle DE, Thompson GA, Santos D, Turner PA, Myers JA, et al. Bupivacaine protein binding in the term parturient: effects of lactic acidosis. Clin Pharmacol Ther 1984;35:702-9. 87. Dillon DE, Wagner CL, Wiest D, Newman RB. Drug therapy in the nursing mother. Obstet Gynecol Clin North Am 1997;24: 675-96. 88. Dashe JS, Gilstrap LC. Antibiotic use in pregnancy. Obstet Gynecol Clin North Am 1997;24:617-29. 89. American College of Rheumatology. Ad hoc Committee on Clinical Guidelines. Guidelines for monitoring drug therapy in rheumatoid arthritis. Arthritis Rheum 1996;39:723-31. 90. Ng PC. The fetal and neonatal hypothalamic-pituitary-adrenal axis. Arch Dis Child Fetal Neonatal Ed 2000;82:F250-4. 91. Crowley P. Antenatal corticosteroidscurrent thinking. BJOG 2003;110(Suppl 20):77-8. 92. ACOG committee opinion: antenatal corticosteroid therapy for fetal maturation. Obstet Gynecol 2002;99:871-3. 93. Ost L, Wettrell G, Bjorkhem I, Rane A. Prednisolone excretion in human milk. J Pediatr 1985;106:1008-11.

94. Rowland AS, Baird DD, Shore DL, Weinberg CR, Savitz DA, Wilcox AJ. Nitrous oxide and spontaneous abortion in female dental assistants. Am J Epidemiol 1995;141:531-8. 95. McGlothlin JD, Jensen PA, Fischbach TJ, Hughes RT, Jones JH. Control of anesthetic gases in dental operatories. Scand J Work Environ Health 1992;18(Suppl 2):103-5. ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY Volume 97, Number 6 Suresh and Radfar 681

96. Rosen MA. Nitrous oxide for relief of labor pain: a systematic review. Am J Obstet Gynecol 2002;186(Suppl Nature):S110-6. 97. Sands TD, Pynn BR. Management considerations for the pregnant or nursing emergency patient. Ont Dent 1998;75: 17-9. 98. Daya S. Recurrent spontaneous early pregnancy loss and low dose aspirin. Minerva Ginecol 2003;55:441-9. 99. Sinclair C. Handbook of obstetrical emergencies. 1st ed. Philadelphia: WB Saunders; 1996. p. 29-39, 69. 100. Tarsitano BF, Rollings RE. The pregnant dental patient: evaluation and management. Gen Dent 1993;41:226-34. 101. Livingston MH, Dlllinger TM, Holder R. Consideration in the management of the pregnant patient. SCD Special Care in Dentistry 1998;18:183-8.

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