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Dentistry and the Pregnant Patient

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Dentistry and the Pregnant Patient
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Dentistry
Pregnant
Patient
and the
Daniel Ninan, dds
Assistant Professor
Dental Education Services
School of Dentistry
Loma Linda University
Loma Linda, California
With contributions from
R. Leslie Arnett, dds, ms
Sheila Bahn, md
Brinda Grapin, pharmd
Bates D. Moses, md
Berlin, Barcelona, Chicago, Istanbul, London, Milan, Moscow, New Delhi,
Paris, Prague, São Paulo, Seoul, Singapore, Tokyo, Warsaw
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This book is dedicated to my amazing family: Priscilla, Norman, Pat, Bonnie, Ben,
Barbara, David, Stacy, Debbie, Kayli, and Khloe. Thank you for always supporting my
pursuits. I also extend this dedication to those who have touched my life and inspired
me to make this world a better place.
Library of Congress Cataloging-in-Publication Data
Names: Ninan, Daniel, author.
Title: Dentistry and the pregnant patient / Daniel Ninan.
Description: Hanover Park, IL : Quintessence Publishing Co Inc, [2018] |
Includes bibliographical references and index.
Identifiers: LCCN 2017058024 (print) | LCCN 2017059740 (ebook) | ISBN
9780867157802 (ebook) | ISBN 9780867157796 (softcover)
Subjects: | MESH: Dental Care | Pregnant Women
Classification: LCC RK56 (ebook) | LCC RK56 (print) | NLM WU 29 | DDC
617.6--dc23
LC record available at https://lccn.loc.gov/2017058024
97%
© 2018 Quintessence Publishing Co, Inc
Quintessence Publishing Co, Inc
4350 Chandler Drive
Hanover Park, IL 60133
www.quintpub.com
5 4 3 2 1
All rights reserved. This book or any part thereof may not be reproduced, stored in a retrieval
system, or transmitted in any form or by any means, electronic, mechanical, photocopying, or
otherwise, without prior written permission of the publisher.
Editor: Marieke Zaffron
Design: Sue Zubek
Production: Angelina Schmelter
Printed in the USA
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Contents
Preface
1
vi
Perceptions About Dental Treatment
During Pregnancy 1
for Treating Pregnant
2 Considerations
Patients 5
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and the Impact on
3 Complications
Dental Care 19
Procedures and Treatment
4 Guidelines
57
of Drugs During
5 Administration
Pregnancy 77
6 Medications 85
7 Anesthetic Use 115
Appendices 133
Index 147
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Preface
My Introduction to the Treatment of
Pregnant Women
Early in life, I became aware of the fear and caution that can envelop health care practitioners
when they are placed in a situation where they have to evaluate and treat a pregnant woman. My
mother, a labor and delivery nurse, told me stories about her experiences. One time, the emergency room staff immediately transferred a patient to the labor and delivery unit upon finding out
she was pregnant—without even assessing the chief complaint that brought her to the emergency
room in the first place. It is likely that the emergency room staff had reservations about treating
a pregnant woman without first obtaining a specialist’s opinion. I have observed what appears
to be a similar fear from dental professionals who are reluctant to treat pregnant patients. Many
dentists may fear that they may cause harm to the unborn baby or the expectant mother.1
The Role of Dentistry During Pregnancy
As dental professionals, our duty is to find ways to provide necessary dental care as safely as
possible. Our ideal role is to work with a woman to help her get to a state of ideal oral health
before she becomes pregnant. This way, the need for invasive treatments during pregnancy
is minimized or prevented altogether. Researchers keep uncovering evidence that untreated
oral disease has the potential to be detrimental to both the expectant mother and the baby.
Poor oral health is associated with a number of pregnancy-related complications, including the
following:
•
•
•
•
•
•
Preterm delivery2
Low birth weight2,3
Preeclampsia2,4
Gestational diabetes3
Fetal loss5
Childhood caries as a result of maternal cariogenic bacterial load6
Unfortunately, there is a large proportion of pregnant women who have significant unmet oral
health care needs. Many women either fail to seek or are unable to receive dental treatment based
on concerns regarding its safety during pregnancy.
It is understandable for providers to have reservations about treating patients in need, and
careful consideration should be given to every circumstance. Currently, there is limited clinical
vi
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Preface
trial evidence to support or refute the premise that providing dental care is totally safe for the
pregnant woman. And while dental procedures have not been directly linked to fetal loss, it may
be of importance to note that most dental procedures induce bacteremias, and subgingival
bacteria has been reported to travel to the placenta and cause fetal demise.5,7
Even if all dental needs are addressed prior to pregnancy, unforeseen dental emergencies
may arise that require invasive and sometimes extensive treatment during pregnancy. It is also
important to note that nearly 50% of women have at least one unplanned pregnancy during the
course of their life. It is possible that a dentist may treat some patients who do not realize they
are already pregnant. Because of this, dental professionals should always consider the possibility of adverse fetal effect when treating a woman of childbearing age.
This book is a quick reference guide on how to maximize the safety of the pregnant woman
and her unborn child while providing dental care. Ultimately, my hope is that this will result in
better outcomes for both the expectant mother and her unborn baby.
Acknowledgments
I would first like to thank Quintessence Publishing for this opportunity. I would also like to say
thank you to everyone who helped. As with any list of people, there are always more whose
names are inadvertently omitted. I am very grateful to Dan Fischer and the many suggestions
he provided during this project. I do want to say thank you to Alexander Bahn, Natalie Barton,
Richard Lynch, Cathy Presland, and Penny Swift, as well as my family for their support and guidance while writing this book.
References
1. California Dental Association Foundation; American College of Obstetricians and Gynecologists, District IX.
Oral health during pregnancy and early childhood: Evidence-based guidelines for health professionals. J
Calif Dent Assoc 2010;38:391–403, 405–440.
2. Sanz M, Kornman K, Working group 3 of joint EFP/AAP workshop. Periodontitis and adverse pregnancy outcomes: Consensus report of the Joint EFP/AAP Workshop on Periodontitis and Systemic Diseases. J Periodontol 2013;84(4 suppl):S164–S169.
3. Kentucky Cabinet for Health and Family Services. Kentucky Pregnancy Risk Assessment Monitoring System
(PRAMS) Pilot Project: 2008 Data Report. http://chfs.ky.gov/NR/rdonlyres/888F8BBC-3DF7-47A4-B34E-8BD7BABA1E09/0/PRAMSREPORT08finalwithcovers.pdf. Accessed 15 January 2018.
4. Strafford KE, Shellhaas C, Hade EM. Provider and patient perceptions about dental care during pregnancy.
J Matern Fetal Neonatal Med 2008;21:63–71.
5. Han YW, Fardini Y, Chen C, et al. Term stillbirth caused by oral Fusobacterium nucleatum. Obstet Gynecol
2010;115:442–445.
6. Chaffee BW, Gansky SA, Weintraub JA, Featherstone JDB, Ramos-Gomez FJ. Maternal oral bacterial levels
predict early childhood caries development. J Dent Res 2014;93:238–244.
7. Hilgers KK, Douglass J, Mathieu GP. Adolescent pregnancy: A review of dental treatment guidelines. Pediatr
Dent 2003;25:459–467.
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vii
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CHAPTER
1
Perceptions
About Dental
Treatment During
Pregnancy
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Key Points
• Prenatal care providers often do not discuss oral health with their patients or
•
•
provide dental referrals.1
Dentists do not always provide treatment during pregnancy because of
poor perceptions of treatment safety.2
Pregnant women often do not seek dental care because they believe it is
unsafe.3 4
-
Most women do notsee a dentist duringtheir pregnancy, buttheconsequenceof nottreating
oral pathologies can be devastating.1 5 Perceptions of the safety of dental treatment during
pregnancy by patients, dental providers, and prenatal providers may all contribute to the lack
of oral health care during pregnancy.1,6
-
Prenatal Care Provider Perceptions
In 1992, it was reported that 91% of obstetricians did not want to be consulted before dental
treatment unless the treatment might induce a bacteremia.7 If they believed a bacteremia
might occur, 79% of the obstetricians wanted to be consulted prior to treatment.7 The conflict, which suggests insufficient understanding of dental treatment, is that most routine
dental procedures have been well documented to induce a transient bacteremia. Examples
of procedures that induce bacteremia include tooth extraction, gingivectomy, supra - and
subgingival scaling, ultrasonic scaling, and subgingival irrigation.8
In a 2012 study, it was reported that obstetricians were well informed on the relationship
between periodontal disease and pregnancy outcomes.1 However, at the same time, many
prenatal general practitioners and midwives may not understand the link between oral
health and overall health.1 The authors of the study also found that most of the time, prena tal care providers did not discuss oral health with their patients and that dental referrals were
often only made when the patient self- identified an oral health problem.1 Other researchers
1
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1 | Perceptions About Dental Treatment During Pregnancy
reported that only 26% of women were advised by their prenatal care provider to see
a dentist.2 While there has been an improvement in awareness of how oral health may
affect pregnancy, there is still a significant lack of dental referrals.
Dental Provider Perceptions
Many dentists are reluctant, or simply refuse, to see pregnant patients.1 In 2004, in
response to the increasing evidence that periodontal disease may contribute to
preterm birth and low–birth weight babies, the American Academy of Periodontology
began recommending that all women who were pregnant or planning to become
pregnant should undergo a periodontal examination.9 In 2006, the New York State
Department of Health published guidelines for oral health care during pregnancy.10
Despite this, researchers in 2008 found that 90% of dentists did not provide all necessary treatment to pregnant patients.2 Reasons dentists reported for withholding or
delaying treatment included fear of injuring the woman or fetus and fear of litigation.2
In 2010, the California Dental Association published evidence-based guidelines for
oral health care during pregnancy11 (see Appendix E). There is still room for the dental
profession to improve the delivery of oral health care to pregnant patients.
Patient Perceptions
In the United States, only 25% to 50% of women will receive any dental care while
pregnant, including prophylaxis.11 This is true even though 50% of pregnant women
have dental problems.12 Pregnant women do not seek dental care during pregnancy
for a number of reasons, including the following13:
•
•
•
•
They do not realize they have an oral disease.4
They believe poor oral health is normal during pregnancy.3,4
They believe dental treatment may harm the fetus.3,4
They are not informed that they should seek care.4
Pregnancy may be the only time women in the lower socioeconomic strata are eligible for dental benefits.3 At the same time, however, these women are less likely to utilize
services to receive dental care. For example, only 20% of the pregnant women enrolled
in California’s Medi-Cal Program in 2007 had a dental visit during their pregnancy.14
Conclusion
As these facts suggest, the main barrier to proper dental care during pregnancy is the
poor perception of patients, prenatal providers, and dental providers, all of whom
contribute to the lack of proper oral health care during pregnancy.
2
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References
References
1. George A, Shamim S, Johnson M, et al. How do dental and prenatal care practitioners perceive
dental care during pregnancy? Current evidence and implications. Birth 2012;39:238–247.
2. Michalowicz BS, DiAngelis AJ, Novak MJ, et al. Examining the safety of dental treatment in pregnant women. J Am Dent Assoc 2008;139:685–695.
3. Stevens J, Iida H, Ingersoll G. Implementing an oral health program in a group prenatal practice.
J Obstet Gynecol Neonatal Nurs 2007;36:581–591.
4. Dasanayake AP, Gennaro S, Hendricks-Muñoz KD, Chhun N. Maternal periodontal disease, pregnancy, and neonatal outcomes. MCN Am J Matern Child Nurs 2008;33:45–49.
5. Wong D, Cheng A, Kunchur R, Lam S, Sambrook PJ, Goss AN. Management of severe odontogenic
infections in pregnancy. Aust Dent J 2012;57:498–503.
6. Strafford KE, Shellhaas C, Hade EM. Provider and patient perceptions about dental care during
pregnancy. J Matern Fetal Neonatal Med 2008;21:63–71.
7. Shrout MK, Comer RW, Powell BJ, McCoy BP. Treating the pregnant dental patient: Four basic
rules addressed. J Am Dent Assoc 1992;123:75–80.
8. Achtari MD, Georgakopoulou EA, Afentoulide N. Dental care throughout pregnancy: What a dentist must know. Oral Health Dent Manag 2012;11:169–176.
9. Task Force on Periodontal Treatment of Pregnant Women, American Academy of Periodontology. American Academy of Periodontology statement regarding periodontal management of the
pregnant patient. J Periodontol 2004;75:495.
10. New York State Department of Health. Oral Health Care During Pregnancy and Early Childhood:
Practice Guidelines. Albany: New York State Department of Health, 2006. https://www.health.
ny.gov/publications/0824.pdf. Accessed 13 November 2017.
11. California Dental Association Foundation; American College of Obstetricians and Gynecologists,
District IX. Oral health during pregnancy and early childhood: Evidence-based guidelines for
health professionals. J Calif Dent Assoc 2010; 38:391–403, 405–440.
12. American Academy of Pediatric Dentistry. Guideline on Oral Health Care for the Pregnant Adolescent.
http://www.aapd.org/media/Policies_Guidelines/G_Pregnancy.pdf. Accessed 17 January 2018.
13. Al Habashneh R, Guthmiller JM, Levy S, et al. Factors related to utilization of dental services
during pregnancy. J Clin Periodontol 2005;32:815–821.
14. California HealthCare Foundation. Denti-Cal Facts and Figures: A Look at California’s Medicaid
Dental Program. Oakland: California HealthCare Foundation, 2007.
3
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CHAPTER
2
Considerations
for Treating
Pregnant
Patients
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Key Points
Bacteremia caused by dental treatment during pregnancy does not routinely
require antibiotic prophylaxis.
Providing routine dental treatment during pregnancy can improve maternal
oral health but does not necessarily improve pregnancy outcomes.
Perinatal provider consultation is not always necessary when providing rou tine dental care to a healthy pregnant woman.
TheTPAL ( term, premature, abortions, living children) recording system can be
used to screen for women with a history of high- risk pregnancy.
Emergency and urgent dental treatment can be done at any time. ( Depending
on the clinical situation, care can either be provided in the traditional outpa tient dental office or in a hospital.)
Necessary dental treatment is ideally provided early in the second trimester
(weeks 14 to 20 of pregnancy) .
Elective dental care is not expected to affect the health of the pregnant woman
or fetus during the time course of pregnancy and can be deferred until after
pregnancy.
Dental care provided during pregnancy ( eg, definitive dental treatment to sta bilize the dentition) may decrease the risk of aspiration of teeth or other ma terials during intubation if the patient undergoes general anesthesia during
pregnancy or at delivery.
Because many changes occur in the expectant mother and the baby during pregnancy, the
timing may affect what dental treatment should be done and how it should be provided.
There are always risks, benefits, and alternatives to dental treatments. In addition to the risk
to the mother, there is also the risk to the baby. Elowever, providing treatment that benefits
the mother may also benefit the baby.
5
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2 | Considerations for Treating Pregnant Patients
Categories of Dental Treatment
There are four categories of dental treatment: emergency, urgent, necessary, and
elective.
Emergency dental treatment
Emergency dental treatment is defined as treatment for conditions that require
immediate attention for the oral and/or systemic well-being of the patient. A dental
emergency is an acute injury or illness in which there is an immediate risk to a patient’s
life or long-term dental health. Examples include:
• Oral hemorrhage: This must be controlled or the patient may bleed to death.
• Ludwig angina: This is a potentially life-threatening infection of the floor of the
mouth that can compromise the patient’s ability to breathe.
• Traumatic injury: Depending on the severity, the patient may seek treatment in an
emergency room or urgent care center. However, patients who perceive the injury
as minor (eg, an avulsed tooth) may go to a dental office. In the case of an avulsed
tooth, there is a limited amount of time in which the tooth may be able to be reimplanted.
Urgent dental treatment
Urgent dental treatment would be considered treatment for conditions where
the patient is experiencing significant symptoms. A small delay in treatment is not
expected to significantly affect the treatment outcome. Examples include:
• Symptomatic irreversible pulpitis
• Cracked tooth syndrome
• Dental abscess (Note: Severe abscess and infection may require emergency treatment.)
Necessary dental treatment
Necessary dental treatment is treatment that may improve the health of the pregnant
woman or fetus during the time course of pregnancy. Examples include:
• Minor pain due to a fractured tooth
• Periodontally compromised teeth that may be avulsed and aspirated during intubation if the woman undergoes general anesthesia at delivery
• Caries that is either symptomatic or suspected to become symptomatic during the
time course of pregnancy
• Asymptomatic irreversible pulpitis
Elective dental treatment
Elective dental care is not expected to affect the health of the pregnant woman or
the fetus during the time course of pregnancy. Elective dental treatment does not
6
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Safety Considerations
necessarily treat oral pathologies. For example, it may be cosmetic in nature. Consider
deferring elective dental treatment until after pregnancy. Examples include:
• Oral pathologies that are difficult to treat during pregnancy and may spontaneous-
•
•
•
•
•
ly resolve after pregnancy
‒‒ For example, an asymptomatic pyogenic granuloma (of pregnancy) may recur if
removed during pregnancy.1,2
Cosmetic surgery
Veneers (no caries)
Tooth whitening
Small cracks in composites and amalgam with no caries
Tiny caries lesions
When to provide dental care
Ideally, all necessary dental treatment will have been completed prior to pregnancy.
In general, the safest option is to defer dental treatment until after pregnancy, when
there is no fetal risk. However, emergency and urgent dental care should be provided
at any time during pregnancy. Examples include providing care for acute infections
and abscesses.1,3–16 If treatment is necessary, give consideration to both the type of
treatment and the phase of pregnancy.
Deferring elective, nonessential, and postponable treatment until after pregnancy
eliminates the possibility that fetal risk may be associated with dental treatment.2
Pregnancy is finite and relatively short, lasting only 9 to 10 months in length, and most
oral pathologies are slowly progressing, non–life-threatening, and benign.2,10 Dental
care can often be postponed until either the second trimester or after delivery.10,17,18
Safety Considerations
Pregnancy itself is not a contraindication to dental care.19 According to the American
College of Obstetricians and Gynecologists,20 “Evidence has failed to show any improvement in outcomes after dental treatment during pregnancy. Nonetheless, these studies
did not raise any concern about the safety of dental services during pregnancy.” A healthy
pregnant woman having a normal pregnancy should have her urgent and emergency
dental needs taken care of at any time during pregnancy. 3–16 The decision of whether to
perform dental treatment in a hospital or an outpatient dental office setting will depend
on the patient’s health and the type and extent of the oral pathology.15
Consequences of dental treatment
When it comes to a developing fetus, the full impact of treatment is potentially not
known for many years. Severe complications of dental treatment can occur, though
they are rare.21,22 At the extreme, death has occurred in the dental office.23,24 Some
examples of severe iatrogenic-related complications include adverse reaction or
allergy to a medication as well as aspiration.
7
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2 | Considerations for Treating Pregnant Patients
Aspiration of dental instruments or dental materials is a life-threatening event and
can cause significant medical complications. Treatment may require a hospital-based
multidisciplinary team.21,22,25 Things as common as full-arch dental impressions may
place the patient at risk for aspirating the impression material, and swallowed objects
have the risk of causing perforation of the gastrointestinal tract.21,26,27
When treatment does not go as planned, additional treatment may be required.
This additional treatment may also place the fetus at increased risk. In addition, there
are psychologic risks that may affect both the patient and the dentist. For example,
the expectant mother may reach the conclusion that dental treatment was the cause
of an adverse pregnancy outcome. While uncommon, a woman may take legal action
against the provider in the absence of scientific evidence supporting her belief.3,28
Determining needs for treatment
Severe odontogenic infection provides a small risk of death to the pregnant woman,
and thereby the fetus. These cases require urgent referral and treatment in a hospital
capable of multidisciplinary treatment, including surgical, anesthetic, and obstetric
services.15 On the other hand, delaying elective treatment may prevent dental treatment from being correlated with fetal demise.6
Aspiration
One reason to provide dental treatment is to decrease the risk of aspiration that may
occur if a pregnant woman needs to be placed under general anesthesia either at
delivery or for some other reason during her pregnancy. Poor oral health may lead to
conditions that cause aspiration during intubation.4 Some examples of objects that
may be aspirated include:
•
•
•
•
Tooth fragments from severely decayed or fractured teeth
Periodontally compromised teeth that become dislodged
Temporary crowns
Other dental materials
Timing of treatment
In general, oral pathologies that may cause pain or infection during the time course
of pregnancy should be treated during pregnancy.20 (See “Recommendations by
Trimester” later in this chapter.) When possible, place definitive restorations during
pregnancy to minimize aspiration risk should intubation become necessary.4 Some
reasons to consider deferring dental treatment include the following:
• The patient has a medical condition that places her or the fetus at risk if she undergoes dental treatment.
• The patient has a history or elevated risk of miscarriage.
• Certain pathologies may recur when treated during pregnancy and resolve after
pregnancy. An example is a pregnancy-related pyogenic granuloma.1,2
8
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Safety Considerations
If the decision is made to defer dental treatment in the outpatient dental office
setting until after pregnancy, consider referring any necessary dental treatment to be
performed in a hospital setting.
Comprehensive dental treatment plan
Create a comprehensive dental treatment plan for the patient that includes3,4:
•
•
•
•
•
•
•
•
Chief complaint
Health history
History of substance use, including tobacco and alcohol
Clinical evaluation
Caries risk assessment
Periodontal disease risk assessment
Comprehensive periodontal examination (with periodontal charting)
Any maintenance therapy that may be needed during pregnancy
Perform diagnostic tests as needed to obtain definitive diagnoses as required for
dental treatment.
Medical consults
To minimize risk, it is important to assess the health of the woman and her pregnancy.5 A physician consult is not required when providing routine dental treatment
to a healthy pregnant woman, but it may serve as a tool to help educate the patient
that it is safe to receive dental care during pregnancy.3,4,9,14,16 Consider a consultation
with the patient’s prenatal care provider in the following situations:3,4,9,14,16
• When making the decision of whether or not to defer necessary dental treatment
until after pregnancy.
• When treatment may require use of nitrous oxide, intravenous sedation, or general
anesthesia.
• In the presence of comorbid medical conditions such as diabetes, pulmonary
problems, heart or valvular disease, hypertension, bleeding disorders, and heparintreated thrombophilia.
See Appendix A for sample physician consult forms.
Dental treatment–induced bacteremia
A transient bacteremia often follows dental treatment.3,6,29 It is not presently thought
that dental treatment–induced bacteremia warrants antibiotic prophylaxis in pregnant patients. While the effects of this bacteremia have not been well studied, clinical
trials have not reported adverse effects from a bacteremia that was induced by dental
treatment (see page 64).
9
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2 | Considerations for Treating Pregnant Patients
Pregnancy and Health Screening
Screening for pregnancy
About half of all pregnancies in the United States are unplanned.3,17,28,30,31 In fact, 48% of
unintended pregnancies occurred in a month when contraception was being used.32
Because a dentist may treat a woman of childbearing age who is unaware of her
own pregnancy, all women of childbearing age should be asked the following screening questions to assess the possibility of pregnancy6,17,33:
• Are you pregnant?
• Is there a possibility that you are pregnant and unaware of it?
• Are you trying to get pregnant?
Assessing reproductive history
Gravidity (gravida) refers to the number of times a woman has become pregnant,
regardless of the outcome.1,34–37 Parity (para) is a number that refers to pregnancy
outcomes. Parity is not always defined the same way. Two variations of parity are as
follows:
• The number of births after 20 weeks’ gestation. (This can also be phrased as the
number of births completed during the viable period.) When parity only refers to
births during the viable period, it may be accompanied by the term abortus, which
refers to the number of pregnancy losses prior to 20 weeks’ gestation. Abortus includes abortion, miscarriage, and ectopic pregnancy.1,37
• The total number of births, regardless of when they occurred during gestation.
When this method is used, parity is broken up into four components.34–36
‒‒ Term births, which occur after 37 weeks’ gestation
‒‒ Preterm births, which occur between 20 and 37 weeks’ gestation
‒‒ Abortions, which occur prior to 20 weeks’ gestation
‒‒ Living children
Multiple births (eg, twins, triplets) count as a single event in the above terms
because they occurred during a single pregnancy. This second method, known as
TPAL, can be used as a screening tool to identify a woman who has a history of highrisk pregnancy.5,35,36
GTPAL
The GTPAL (gravida, term, premature, abortions, living children) system contains five
numbers summarizing a woman’s reproductive history:
• G: Number of times a woman has become pregnant, regardless of the outcome
• T: Number of term births
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Pregnancy and Health Screening
• P: Number of premature births
• A: Number of abortions, miscarriages, or ectopic pregnancies
• L: Number of living children
Example 1:
If a woman is pregnant for the first time:
•
•
•
•
•
G: Number of times pregnant = 1
T: Number of term births = 0
P: Number of premature births = 0
A: Number of abortions, miscarriages, or ectopic pregnancies = 0
L: Number of living children = 0
This can be abbreviated as G1 T0 P0 A0 L0. In this example, the woman does not have
a history of poor pregnancy outcomes.
Example 2:
If a woman is currently pregnant and has been pregnant five times (including her current pregnancy) with one term delivery, two preterm deliveries, one miscarriage, and
three living children:
•
•
•
•
•
G: Number of times pregnant = 5
T: Number of term births = 1
P: Number of premature births = 2
A: Number of abortions, miscarriages, or ectopic pregnancies = 1
L: Number of living children = 3
This can be abbreviated as G5 T1 P2 A1 L3. In this example, the woman has a history of
poor pregnancy outcomes. Because of this, the oral health care provider may consider
consulting with the patient’s perinatal care provider.5
Assessing oral health
For the oral health assessment, ask questions similar to the following3,4:
•
•
•
•
•
•
Where and when did you last visit a dentist?
Are your gums swollen? Do they bleed?
Do you have any toothache or pain?
Do you have any problems eating or chewing food?
Do you have any other problems in your mouth?
Do you have any signs or symptoms of a high-risk pregnancy (eg, high blood pressure, prior miscarriages, recent cramping, or bleeding)?
• How many weeks pregnant are you? What trimester are you in? When is your due
date?*
• Do you have any concerns or questions about receiving oral health care during your
pregnancy?
11
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2 | Considerations for Treating Pregnant Patients
• During your pregnancy, have you been vomiting? If so, how frequently?
• Have you been receiving care for your pregnancy?
*If a woman does not know the answers to these questions, her due date can be
estimated by using Naegele’s rule. The due date can be estimated by subtracting 3
months from the first day of the woman’s last menstrual period (LMP) and adding 7
days. For example, if the first day of a patient’s LMP was October 10, 3 months prior
would be July 10. Adding 7 days yields an estimated due date of July 17.38 If needed,
consult with the woman’s prenatal care provider.
Recommendations by Trimester
See Table 2-1 for a summary of dental treatment recommendations during normal
pregnancy.
First trimester recommendations: Conception through week 13
The first trimester is considered the most critical time period of gestation because
organogenesis is occurring during this time.3,6,14,29 The majority of spontaneous abortions (85%) occur during the first trimester.6 Therefore, dental treatment should be
limited to emergency and urgent dental treatment. When possible, provide definitive
treatment.1,11,12,39 Avoid routine radiographs, but take selective radiographs as needed
to diagnose oral diseases that require immediate treatment.4,6–8,11,12 Periodontal prophylaxis can be done, but the second trimester is the preferred time to provide a
dental prophylaxis.4,8
Provide patient education and anticipatory guidance that includes educating the
patient about oral changes during pregnancy and also what to expect after pregnancy.1,3 Provide oral hygiene instructions for plaque control.1,3
Second trimester recommendations: Week 14 through week 26
The second trimester, specifically weeks 14 to 20, is the preferred time to provide dental treatment during pregnancy.1–14,20,29,40,43 There is less risk of pregnancy loss during
this time frame when compared with the first trimester, and organogenesis is complete. Because the fetus is smaller than it will be at term and the uterus is below the
umbilicus until about week 20, the woman will likely be more comfortable compared
with later in pregnancy.
Provide dental treatment to control active oral diseases and urgent pathologies.1,3–13,20,40,43 Provide scaling, polishing, and curettage as clinically indicated.8 Avoid
routine radiographs, but take select radiographs when needed.6,8,11 From the middle
of the second trimester on, position the patient on her left side during treatment to
minimize the risk of supine hypotension.3,5,14 See page 31 for more information.
12
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Ninan_CH02.indd 13
35–Delivery
Third trimester
27–34
Emergency and urgent dental treatment should be performed promptly at any time during pregnancy.1,3–16
Patient education should be given at any time during pregnancy (see chapter 4).1,3
Emergency and
urgent treatment
Patient education
Provide oral hygiene instructions.
Educate the patient about oral changes during pregnancy.
Provide nutritional education.
Provide anticipatory guidance.
Avoid routine radiographs. Take select radiographs as needed.8,11,14
*Note that the ideal weeks for dental treatment are an approximation and may not be appropriate for every patient.
•
•
•
•
Limit radiographs to what is required
for immediate treatment.4,6–8,11,12
Radiographs
Treatment
should be
deferred.
Nitrous oxide may be considered when topical and local anesthetic are
inadequate for treatment that should not be deferred until after pregnancy.
Consult with the patient’s prenatal care provider prior to administering nitrous
oxide.3,4,6–9,16,19
Periodontal
prophylaxis, if
clinically indicated.7,8
Postpone routine
dental treatment
until after pregnancy.7,8,39
If possible, avoid nitrous oxide in
the first trimester.6–8
The second trimester is the preferred time to perform periodontol
treatment. Treatment may include
prophylaxis, scaling, polishing, and
curettage.1–13,20,40
When possible,
provide dental
treatment before the middle
of the third
trimester.1,8
Nitrous oxide
Periodontal
prophylaxis, if
clinically indicated.2,6–8
Provide dental treatment to control
active oral diseases. Treatment may
include caries control and periodontal therapy. If possible, conditions
that may become symptomatic
during the third trimester should be
proactively treated.1–13,20,40
The second trimester is the
preferred time to perform dental
treatment.
Treatment
should be
deferred.
The ideal time
Treat the patient using left uterine displacement (see
for dental treat- page 31).3,5,14
ment.4,7,9,13,14,29
21–26
Second trimester
14–20
Periodontal
treatment
9–13
First trimester
Limit dental treatment to emergency and urgent needs.11,12,39 (The first
10 weeks of pregnancy are when
teratogenic risk is greatest.5)
1–8
Dental treatment
Weeks of pregnancy
Table 2-1 | S
ummary of dental treatment recommendations during normal pregnancy*
Dental care is usually
deferred. Consider waiting a
few weeks to provide dental
treatment. The woman is
likely to be in a hypercoagulable state for at least 2–3
weeks after delivery.5 This
high-risk period may last
until 25 days after delivery.5
The patient may be on prophylactic anticoagulative
therapy, which increases
the risk of bleeding.10,41,42
Accidental intravascular injection of epinephrine may
increase the risk of activating coagulation.5 The risk
of pulmonary embolism in
the immediate postpartum period is greater than
during pregnancy.5,41 In
addition, 25% of eclamptic
seizures occur 7 to 10 days
postpartum.6
2–3 postpartum
Immediate postpartum
Recommendations by Trimester
13
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2 | Considerations for Treating Pregnant Patients
Provide patient education, including oral hygiene instructions and anticipatory
guidance to inform the patient about oral changes during pregnancy and also what to
expect after pregnancy.1,3
In the sixth month of pregnancy, it has been suggested that the expectant mother
should start using a daily mouth rinse of 0.05% sodium fluoride and 0.12% chlorhexidine. The purpose is to improve maternal oral health through the reduction of
caries-causing bacteria. This in turn may delay colonization of caries-causing bacteria
in the infant after delivery.7
Third trimester recommendations: Week 27 until delivery
By the third trimester, the end of pregnancy is nearing. In general, the safest option is
to defer dental treatment until after pregnancy. If treatment is necessary, it is better
to provide dental care in the first half of the third trimester.1 Dental care should be
deferred from the middle of the third trimester until a few weeks postpartum.7,8,29
Provide oral hygiene instructions and anticipatory guidance on what to expect after
pregnancy.1,3 If dental treatment is performed, provide dental care that is needed to
improve the health of the expectant mother and baby during pregnancy.1,3–16 When
needed, take select radiographs.8,11,14 Consider short dental appointments to minimize
patient discomfort that may be present because of her enlarged uterus. Also, patients
should be positioned on their left side to minimize the risk of supine hypotension.3,5,14
See page 31 for more information.
Immediate postpartum recommendations
Dental care is usually best deferred until a few weeks after giving birth. Unless the
woman has had significant blood loss during delivery, she is in a hypercoagulable
state for at least 2 to 3 weeks after delivery.5 Epinephrine may increase the risk of coagulation.5 See pages 122–123 for further information.
Conclusion
When a patient is pregnant, additional consideration may be needed when providing
dental care. While a consult with the patient’s prenatal care provider is not required
for routine dental treatment for a healthy pregnant woman, there are circumstances
and treatment options where such a consultation is recommended.3,4,9,14,16 Even when
treatment is not provided, patient education can still be given and a trusting relationship with the patient can be established for future care.
14
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References
References
1. Niessen LC. Women’s health. In: Patton LL (ed). The ADA Practical Guide to Patients with Medical
Conditions. Ames, Iowa: Wiley-Blackwell, 2012:399–424.
2. Sonis ST, Fazio RC, Fang LST. Principles and Practice of Oral Medicine, ed 2. Philadelphia: Saunders, 1995.
3. California Dental Association Foundation; American College of Obstetricians and Gynecologists,
District IX. Oral health during pregnancy and early childhood: Evidence-based guidelines for
health professionals. J Calif Dent Assoc 2010;38:391–403, 405–440.
4. New York State Department of Health. Oral Health Care During Pregnancy and Early Childhood:
Practice Guidelines. https://www.health.ny.gov/publications/0824.pdf. Accessed 13 November
2017.
5. Fayans EP, Stuart HR, Carsten D, Ly Q, Kim H. Local anesthetic use in the pregnant and postpartum patient. Dent Clin North Am 2010;54:697–713.
6. Hilgers KK, Douglass J, Mathieu GP. Adolescent pregnancy: A review of dental treatment guidelines. Pediatr Dent 2003;25:459–467.
7. American Academy of Pediatric Dentistry. Guideline on Oral Health Care for the Pregnant Adolescent. http://www.aapd.org/media/Policies_Guidelines/G_Pregnancy.pdf. Accessed 17 January
2018.
8. Suresh L, Radfar L. Pregnancy and lactation. Oral Surg Oral Med Oral Pathol Oral Radiol Endod
2004;97:672–682.
9. Steinberg BJ, Hilton IV, Iada H, Samelson R. Oral health and dental care during pregnancy. Dent
Clin North Am 2013;57:195–210.
10. Flynn TR, Susarla SM. Oral and maxillofacial surgery for the pregnant patient. Oral Maxillofac Surg
Clin North Am 2007;19:207–221.
11. Kandan PM, Menaga V, Raja R, Kumar RR. Oral health in pregnancy (guidelines to gynaecologists,
general physicians & oral health care providers). J Pak Med Assoc 2011;61:1009–1014.
12. Ritter AV, Southerland JH. Pregnancy and oral health. J Esthet Restor Dent 2007;19:373–374.
13. Task Force on Periodontal Treatment of Pregnant Women, American Academy of Periodontology. American Academy of Periodontology statement regarding periodontal management of the
pregnant patient. J Periodontol 2004;75:495.
14. Achtari MD, Georgakopoulou EA, Afentoulide N. Dental care throughout pregnancy: What a dentist must know. J Oral Health Dent Manag 2012;11:169–176.
15. Wong D, Cheng A, Kunchur R, Lam S, Sambrook PJ, Goss AN. Management of severe odontogenic
infections in pregnancy. Aust Dent J 2012;57:498–503.
16. Oral Health Care During Pregnancy Expert Workgroup. Oral health care during pregnancy: A national consensus statement. Washington, DC: National Maternal and Child Oral Health Resource
Center, 2012.
17. Donaldson M, Goodchild JH. Pregnancy, breast-feeding and drugs used in dentistry. J Am Dent
Assoc 2012;143:858–871.
18. Moore PA. Selecting drugs for the pregnant dental patient. J Am Dent Assoc 1998;129:1281–1286.
19. Cengiz SB. The pregnant patient: Considerations for dental management and drug use. Quintessence Int 2007;38:e133–e142.
20. The American College of Obstetricians and Gynecologists. Oral Health Care During Pregnancy
and Through the Lifespan. Committee Opinion Number 569. https://www.acog.org/Resources-And-Publications/Committee-Opinions/Committee-on-Health-Care-for-UnderservedWomen/Oral-Health-Care-During-Pregnancy-and-Through-the-Lifespan. Accessed 13 November
2017.
15
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2 | Considerations for Treating Pregnant Patients
21. Abusamaan M, Giannobile WV, Jhawar P, Gunaratnam NT. Swallowed and aspirated dental
prostheses and instruments in clinical dental practice. A report of five cases and proposed management algorithm. J Am Dent Assoc 2014;145:459–463.
22. Chiu YH, Lu WH, How CK, Chen JD. Dental bridge aspiration. Resuscitation 2009;80:157–158.
23. Owen M, Shelton DL, Gorner J. Woman dies at dental office: School principal getting root canal.
Chicago Tribune. December 19, 2007.
24. Lee HH, Milgrom P, Starks H, Burke W. Trends in death associated with pediatric dental sedation
and general anesthesia. Paediatr Aneasth 2013;23:741–746.
25. Mahmoud M, Imam S, Patel H, King M. Foreign body aspiration of a dental bridge in the left mainstem bronchus. Case Rep Med 2012;2012:798163.
26. Cameron SM, Whitlock WL, Tabor MS. Foreign body aspiration in dentistry: A review. J Am Dent
Assoc 1996;127:1224–1229.
27. Obinata K, Satoh T, Towfik AM, Nakamura M. An investigation of accidental ingestion during dental procedures. J Oral Sci 2011;53:495–500.
28. National Maternal and Child Oral Health Policy Center. Improving the Oral Health of Pregnant
Women and Young Children: Opportunities for Policymakers. https://www.astdd.org/docs/
improving-the-oral-health-of-pregnant-and-young-children-aug-2012.pdf. Accessed 14 November 2017.
29. Michalowicz BS, DiAngelis AJ, Novak J, et al. Examining the safety of dental treatment in pregnant
women. J Am Dent Assoc 2008;139:685–695.
30. Centers for Disease Control and Prevention. Folic Acid: Recommendations. http://www.cdc.gov/
ncbddd/folicacid/recommendations.html. Accessed 26 January 2018.
31. US Food and Drug Administration. Pregnancy and Lactation Labeling (Drugs) Final Rule.
http://www.fda.gov/Drugs/DevelopmentApprovalProcess/DevelopmentResources/Labeling/
ucm093307.htm. Accessed 17 January 2018.
32. Moos MK, Dunlop AL, Jack BW, et al. Healthier women, healthier reproductive outcomes: Recommendations for the routine care of all women of reproductive age. Am J Obstet Gynecol
2008;199(6 suppl 2):S280–S289.
33. American Academy on Pediatric Dentistry Council on Clinical Affairs Committee on the Adolescent. Guideline on oral health care for the pregnant adolescent. Pediatr Dent 2008–2009;30(7
suppl):102–106.
34. Bernstein HB, VanBuren G. Normal pregnancy. In: DeCherney AH, Nathan L, Laufer N, Roman AS
(eds). Current Diagnosis & Treatment: Obstetrics & Gynecology, ed 11. New York: McGraw-Hill,
2013:141–153.
35. Bardsley C. Normal pregnancy. In: Tintinalli JE, Stapczynski J, Ma O, Cline DM, Cydulka RK, Meckler
GD (eds). Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, ed 7. New York:
McGraw-Hill, 2011:690.
36. Kawada C, Hochner-Celnikier D. Gynecologic history, examination, and diagnostic procedures.
In: DeCherney AH, Nathan L, Laufer N, Roman AS (eds). Current Diagnosis & Treatment: Obstetrics
& Gynecology, ed 11. New York: McGraw-Hill, 2013:555–573.
37. Fortin AH VI, Dwamena FC, Frankel RM, Smith RC (eds). Complete write-up of Mrs. Jones’ initial
evaluation. In: Smith’s Patient-Centered Interviewing: An Evidence-Based Method, ed 3. New
York: McGraw-Hill, 2012:259–268.
38. Lynch CD, Zhang J. The research implications of the selection of a gestational age estimation
method. Paediatr Perinat Epidemiol 2007;21(suppl 2):86–96.
39. Ressler-Maerlender J, Krishna R, Robison V. Oral health during pregnancy: Current research. J
Womens Health (Larchmt) 2005;14:880–882.
40. Dasanayake A, Gennaro S, Hendricks-Muñoz KD, Chhun N. Maternal periodontal disease, pregnancy, and neonatal outcomes. MCN Am J Matern Child Nurs 2008;33:45–49.
16
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References
41. Saha SA, Rao RK. Pulmonary embolic disease. In: Crawford MH (ed). Current Diagnosis & Treatment: Cardiology, ed 4. New York: McGraw-Hill, 2014:379–395.
42. Bourjeily G, Mazer J, Levinson A. Pulmonary disorders and pregnancy. In: Grippi MA, Elias JA,
Fishman JA, Kotloff RM, Pack AI, Senior RM (eds). Fishman’s Pulmonary Diseases and Disorders,
ed 5. New York: McGraw-Hill, 2015:1479–1495.
43. George A, Shamim S, Johnson M, et al. How do dental and prenatal care practitioners perceive
dental care during pregnancy? Current evidence and implications. Birth 2012;39:238–247.
17
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CHAPTER
3
Complications
and the Impact
on Dental Care
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2/28/18 11:45 AM
Key Points
Oral manifestations of pregnancy -related changes may adversely affect a
woman ’s oral health.
The oral health care provider may identify conditions that need further evalu ation by the patient’s prenatal care provider.
Elevated blood pressure places a pregnant woman at risk of preeclampsia ( or
eclampsia) and should be evaluated by the patient’s prenatal care provider.
Heart conditions sometimes require antibiotic prophylaxis, but pregnancyinduced heart murmurs generally do not.
From midpregnancy onward, place the woman in left uterine displacement
( LUD) positioning when providing dental treatment to minimize the disruption
of maternal and placental blood flow.
Respiratory changes should be taken into account when administering inhaled anesthesia to the pregnant woman.
Sedation places pregnant women at increased risk of aspiration.
Medications that are cleared by renal excretion may need to have the dosage
increased to account for the increased rate of renal clearance.
Birth defects may develop at any stage in fetal development. No stage of fetal
development is completely safe from teratogens that may be introduced by
medical or dental treatment.
Dental treatment is usually deferred during embryogenesis because this is
when the fetus is most susceptible to developing birth defects.
Teratogens may not be identified until many years after exposure.
Postmarketing surveillance is important because teratogenic effects may not
become apparent until after a medication is released onto the market.
Adolescents are at increased risk for medical complications during pregnancy.
Informed consent may be more difficult to obtain when the pregnant minor
has different opinions from her legal guardian and /or when the legal guardian
is unaware of the pregnancy.
19
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3 | Complications and the Impact on Dental Care
Pregnancy-Related Changes
During pregnancy, a woman undergoes significant physical and physiologic changes.
The woman’s immune system is weakened, allowing for the development of different
oral pathologies.1 Many of the changes during pregnancy are mediated by hormones:
There is a 10-fold increase in estrogen and a 30-fold increase in progesterone during
pregnancy.1,2 This leads to altered periodontal microvascularization. Increased hormones are also associated with increased levels of bacteria.1
A common misconception about pregnancy is that teeth are weakened during
pregnancy.3–5 However, calcium is not taken away from teeth during pregnancy;
the increased risk for dental caries is due to dietary changes, particularly increased
snacking on carbohydrate-rich foods and the consumption of smaller, more frequent
carbohydrate-rich meals. This carbohydrate-rich diet feeds oral bacteria, leading to
an increase in dental plaque, acidity, and tooth decay. In addition, changes in oral
hygiene, morning sickness, and changes to the maternal immune system may also
affect oral health.1,6–10 In general, the incidence of gingivitis and periodontal disease
increases during pregnancy. Higher disease levels appear to be correlated with
increased age, lower levels of education, and multiparity (having more than one
child).1
Impact on dental treatment
During pregnancy, there are a number of changes to the patient that may affect her
dental treatment. Table 3-1 summarizes various medical concerns that may affect the
patient’s dental treatment, organized alphabetically first by system or category and
then by condition or symptom. The table is followed by a detailed analysis of each
condition, including a brief introduction along with some background knowledge.
There is also a description of how the condition may be detected; sometimes the only
indication of the condition is awareness of the patient’s pregnancy. The third section
discusses implications of the condition. Information in this section falls into one of
three categories:
1. The condition has no effect on dental treatment. The information presented is intended to reassure the clinician that no dental treatment modification is necessary.
2. If the patient has the condition, dental treatment modification may sometimes or
always be required.
3. The condition itself may require treatment; eg, a hypoglycemic episode caused by
an underlying condition of gestational diabetes needs to be treated independently
of dental care.
20
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Ninan_CH03.indd 21
28
29
29
30
30
Increased heart rate
Hypertension (elevated
blood pressure)
Hypotension in early
pregnancy
Pregnancy-induced heart
murmurs
Supine hypotensive
syndrome
32
27
Eclampsia
Gestational diabetes
26
Preeclampsia
Endocrine
24
Cardiopulmonary arrest
Circulatory
24
See
page
Dental anxiety
Condition or symptom
Behavioral health
System or category
Description/dental implication
(cont)
Gestational diabetes places the patient at higher risk for complications during pregnancy.12 Treating
periodontal disease may improve glycemic control.8 This may decrease the chance of the patient
developing type 2 diabetes mellitus.14 It may also decrease the chance of fetal anomalies.14
The supine position can cause decreased placenta perfusion and fetal hypoxia.13 From midgestation
onward, avoid placing the pregnant patient in a completely supine position.3,8
Typically, the murmurs do not require antibiotic prophylaxis for subacute bacterial endocarditis.3
Minor variations are not thought to affect dental treatment.
If the blood pressure is either ≥ 140/90 mmHg or 30/15 mmHg higher than before pregnancy, then refer the patient to her prenatal care provider for evaluation because of increased risk of complications
such as preeclampsia.3
Minor variations are not thought to affect dental treatment.
Eclamptic seizures are considered a medical emergency.3
In 2010, the California Dental Association stated that preeclampsia is not a contraindication to dental
care.8 A patient with preeclampsia or eclampsia may be at increased risk of seizure if lidocaine is
accidently administered intravascularly.12
AED can be used.11 Manual LUD should be done when aortocaval compression may be suspected
(eg, > 20 weeks gestation, morbidly obese, or uterus is above the umbilicus).11
In the presence of dental anxiety, consider short appointments and defer elective treatment until after
pregnancy.8
Table 3-1 | Select pregnancy-related changes and the impact on dental treatment
Pregnancy-Related Changes
21
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Ninan_CH03.indd 22
Mother-to-infant
transmission of oral
pathogens
Decreased IgG blood
levels
Immune
37
Thromboembolic disease
39
39
38
37
Hypercoagulable state
(immediate postpartum)
Hepatic (liver)
dysfunction
36
35
Nutritional deficiencies
Hypercoagulable state
(during pregnancy)
34
Nausea and vomiting
during pregnancy
(morning sickness)
36
34
Hyperemesis gravidarum
Antiphospholipid
syndrome
33
See
page
Gastroesophageal reflux
and pyrosis (heartburn)
Condition or symptom
Hepatic
Hematologic
Gastrointestinal
System or category
(cont)
The mother is the most common source of the infant’s oral pathogenic bacteria.8 Provide anticipatory
guidance for the care of her future infant.
May lead to oral pathogen proliferation and can contribute to sustained oral infections such as periodontal disease.8
Liver dysfunction may cause or precede a number of significant medical conditions.2 Minor variations
in liver function are not thought to affect dental treatment. Consulting with the patient’s prenatal care
provider may help clarify if changes in liver function indicate the presence of an additional medical
condition.
Patients are at an increased risk of thromboembolic disease because they are in a hypercoagulable
state.16,18,19 Accidental intravascular injection may increase the risk of activating coagulation.12
For at least the first 2–3 weeks after delivery, the woman will often be in a hypercoagulable state.12
Consider the need to provide treatment during this time versus 2 or 3 weeks later.
During pregnancy, the woman is in a hypercoagulable state, which places her at increased risk for
thromboembolic disease.2,16
Consider providing dental care to these patients in a hospital setting.2
Energy required for the fetus and placenta often leads to nutritional deficits in pregnant women. Two
common deficiencies are iron and folate.
Nausea and vomiting may need to be taken into consideration when prescribing medications.15
Vomiting may occur during dental treatment. Instruct the patient on proper oral care after vomiting.
A severe form of nausea and vomiting during pregnancy.8,17 The patient has an increased risk of loss of
surface enamel via acid erosion.3 Provide oral care instructions to be followed after vomiting.
The enlarging uterus places pressure on the stomach and can lead to heartburn (increased gastric
reflux), nausea and vomiting, rapid satiety (feeling full), and increased risk of aspiration.8,15,16 Excess
stomach acid in the oral cavity can lead to enamel erosion.8 Women should be given instructions similar
to NVP instructions. GI changes may also affect the patient’s ability to tolerate dental treatment.
Description/dental implication
Table 3-1 (cont) | Select pregnancy-related changes and the impact on dental treatment
3 | Complications and the Impact on Dental Care
22
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Ninan_CH03.indd 23
44
44
45
46
Changes in upper
respiratory mucosa
Dyspnea
(shortness of breath)
Hyperventilation
Respiratory capacity
Respiratory
(cont)
Melasma (“mask of pregnancy”)2,20
Spider angioma8
Palmar erythema (reddening of the palmar aspect of the hands)8
As the pregnancy progresses, there is decreased functional residual capacity and an increase in tidal
volume, and certain comorbid conditions can contribute to decreased vital capacity.3,8,20 These changes may need to be taken into consideration when administering inhaled anesthesia.
A hyperventilating patient may present with mild respiratory alkalosis, which may include symptoms
of dizziness and mental confusion.16 22
As pregnancy progresses, the incidence of dyspnea increases.16 Because of this, a woman’s ability to
comfortably tolerate dental treatment may decline throughout her pregnancy.
This may place the woman at increased risk of nosebleeds, which may occur in the dental office, and
upper respiratory tract infection.2,16 Periodontal pathogens may be associated with upper respiratory
tract infections.21
If contractions do not cease, contact the patient’s perinatal care provider to determine if labor has
started.12
An increased glomerular filtration rate may require an adjustment in the dosing of medications
cleared by renal excretion.15,16,2,20 Because of the increased frequency of urination, consider advising
the patient to empty her bladder just prior to the start of a dental procedure.2,16
Consider a palliative approach for dry mouth treatment. The patient can drink more water or chew
sugarless or xylitol-containing gum to increase salivation.9
Typically located on the labial aspect of the interdental papilla.2 May resolve spontaneously after
delivery.3 May recur if removed during pregnancy.8
Pregnancy gingivitis is characterized by dark red, swollen, smooth gingiva that bleeds easily.8 Marginal
gingiva and interdental papillae are often affected.2 Periodontal disease is not caused by pregnancy;
however, it may be worsened by pregnancy.2
Can be caused by gastric acid exposure to the teeth from morning sickness, vomiting, or gastric
reflux.9
•
•
•
Normal dermatologic changes may be observed during the extraoral examination and may include:
AED, automated external defibrillator; GI, gastrointestinal; IgG, immunoglobulin G; LUD, left uterine displacement; NVP, nausea and vomiting during pregnancy.
43
Braxton-Hicks contractions or false labor
Reproductive
42
Salivary changes
43
42
Pyogenic granuloma
(pregnancy tumor)
Renal changes
41
Pregnancy gingivitis and
gingival hyperplasia
Renal and urinary
41
Perimylolysis (enamel
erosion or decalcification)
Oral
40
Dermatologic changes
Integumentary
pathogens
Pregnancy-Related Changes
23
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3 | Complications and the Impact on Dental Care
Behavioral Health
Dental anxiety
Pregnancy is associated with higher levels of anxiety which may in turn cause increased
stress during dental appointments.8 Dental fear fluctuates differently throughout and
after the pregnancy for expectant mothers and fathers.23 Expectant mothers may have
a decrease in dental fear toward late pregnancy that then increases slightly after childbirth. For expectant mothers, dental fear does not correlate with either depression or
anxiety. In comparison, expectant fathers were found to experience increased dental
fear on behalf of the mothers during pregnancy, and this was correlated with depression and anxiety.23
Presentation
A patient’s anxiety may be directly observed through her behavior, or she may reveal
it through conversation.
Consideration and management
In the presence of high levels of dental anxiety, consider short appointments and
deferring elective treatment until after pregnancy.8 It is possible that the willingness
of the woman to undergo treatment may be affected by the dental fear the expectant
father may be feeling on her behalf. If this is the case, it may be helpful to educate the
expectant father on the risks and benefits of dental treatment during pregnancy.
Circulatory
Cardiopulmonary arrest
The incidence of cardiac arrest during pregnancy is 1 in 12,000.11 Because of respiratory changes and the decreased ability to buffer pH to compensate for respiratory
problems, anoxia can rapidly occur in the pregnant patient during respiratory arrest.24
During severe hypoxia, the fetus has several protective measures. Fetal cardiac
output is altered to increase gas exchange through increasing blood flow to the placenta.24 Fetal blood is also redirected to vital organs, thereby protecting them from
severe damage. Fetal red blood cells (RBCs) contain more fetal hemoglobin than
maternal hemoglobin, and fetal hemoglobin has a stronger affinity for oxygen and
binds oxygen more strongly than maternal hemoglobin.24
Presentation
The patient is unresponsive and either not breathing or not breathing normally (eg,
agonal breaths).11 If a definite pulse is detected, perform rescue breathing at a rate
of 1 breath every 5 to 6 seconds. Every 2 minutes, check if a pulse is present. If no
pulse is present, or if uncertain 10 seconds of checking, begin high-quality chest
compressions.11
24
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Circulatory
Consideration and management
The American Heart Association (AHA) recommends a few modifications to cardiopulmonary resuscitation (CPR) to allow for changes that occur during pregnancy (Fig
3-1).11 Automated external defibrillators (AEDs) may be used without any modification
during pregnancy.11 Pregnant patients have increased oxygen demand because of the
fetus, so it is recommended to provide supplemental oxygen to the patient.24
Unresponsive
No breathing or no normal breathing
Uterus is at or above the umbilicus
Activate emergency response system:
• BLS response: minimum 3 additional staff + code cart
• ACLS: maternal code team activation
• Second responder: get AED immediately and apply
Check pulse:
Definite pulse within 10 seconds?
Definite
pulse
• Using bag-mask: give 1 breath
every 5–6 seconds
• Recheck pulse every 2 minutes
No pulse
or unsure
Document time
Start high-quality chest compressions*
Apply AED
Perform appropriate airway management†
Shockable
• Give 1 shock
• Resume CPR immediately for 2 minutes
Perform continuous manual LUD
Not shockable
• Resume CPR immediately for 2 minutes
• Check rhythm every 2 minutese
• Fluid resuscitation if PEA
Appropriate airway management for pregnancy:
*Chest compressions in pregnancy:
†
• Use a firm backboard
• Place patient supine
• Place hands in center of chest (as in
nonpregnant patient)
• Compress at a rate of at least 100/min
• Compress at a depth of at least 2 inches (5 cm)
• Perishock pause < 10 seconds
• Allow complete chest recoil after each
compression
• Minimize interruptions
• Perform continuous manual LUD
• Open airway by using head tilt–chin lift maneuver (if
not a trauma victim)
• Administer 100% O2 at ≥ 15 L/min
• When available, perform bag-mask ventilation:
– Seal mask, ensure no leak around mask; twohanded technique preferred
– Deliver each rescue breath over 1 second
– Give 2 breaths for every 30 compressions
–Give a sufficient tidal volume to produce visible
chest rise or fog within face mask
–If not seen, reopen airway and improve seal
–Consider using oral airway
• Avoid excessive ventilation
Fig 3-1 Cardiac arrest in pregnancy in-hospital basic life support (BLS) algorithm: simultaneous C-AB-U (chest compressions/current-airway-breathing-uterine displacement). ACLS, advanced cardiovascular life support; LUD, left uterine displacement; PEA, pulseless electric activity. (Reprinted with permission from the American Heart Association.11)
25
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3 | Complications and the Impact on Dental Care
As the pregnancy progresses, aortocaval compression can occur by the gravid
uterus, preventing adequate return circulation during CPR.11,24 Resuscitation attempts
will likely fail if aortocaval compression is present during CPR.25,26 One method to
address the problem of aortocaval compression is to tilt the woman’s body to her
left side. However, if the woman’s body is tilted, her heart can shift laterally, which
can decrease the effectiveness of chest compressions, possibly preventing successful
resuscitation.11 During dental treatment, the dental provider may place a pillow or a
wedge under the woman to position her into LUD. The provider should be aware that
pillows or wedges tend to slip during CPR.25
The preferred method to relieve aortocaval compression is to have continuous
manual LUD for all pregnant women where the uterus may be causing aortocaval compression during CPR.11 Continuous manual LUD can be done by having someone either
pull or push the gravid uterus to the left to relieve aortocaval compression.11 Care should
be taken to avoid pressing down on the woman, thereby inadvertently causing aortocaval compression.11 Manual LUD should be done under the following circumstances11:
• Gestational age at least 20 weeks
• Uterus is palpated at or above the umbilicus
• Difficult to assess the uterus (eg, morbidly obese patients)
Emergency cesarean delivery may be required.24 Arrange emergency transportation
that can handle both the patient and the fetus.24
If the patient recovers, position her in the full left lateral decubitus position if possible
until emergency medical services (EMS) arrive to transport her to a hospital.11
Preeclampsia
Preeclampsia occurs in 3% to 7% of women and usually presents after week 20 of
pregnancy.3,8,12,27 It may be caused by or preceded by liver dysfunction.2 Periodontal
disease has been found to be associated with preeclampsia in pregnant women.8
Factors in diagnosis include the following:
• Hypertension, including pregnancy-induced12,27 (blood pressure above 140/90 mmHg
on two readings that are at least 4 hours apart)27
• Proteinuria12,27
• Edema3,27
The exact cause is not known.3,27 Predisposing factors include:
•
•
•
•
•
•
Family or personal history of preeclampsia27
Age (younger than 20 or older than 35 years)3
Primigravida (pregnant for the first time)3,8,27
Diabetes3,27
Preexisting hypertension or preexisting vascular disorders8
High prepregnancy blood pressure or weight (the higher these values, the higher
the risk for preeclampsia)8
26
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Circulatory
Risk factors include:
• Multiple gestations (eg, twins or triplets)8,27
• Change in paternity from previous pregnancy8,27
• Different parental ethnicity8
Severe preeclampsia is associated with:
•
•
•
•
Blood pressure > 160/1108
Pulmonary edema8
Less than 5 g proteinuria over a 24-hour period8
Increased risk of fetal intrauterine growth restriction (IUGR)8,27
Preeclampsia can lead to life-threatening complications:
• Placental abruption, where the placenta separates from the inner uterine wall prior
to delivery27
• HELLP syndrome (hemolysis, elevated liver enzymes, and low platelet count)3,27
• Preeclampsia may progress to eclampsia3,27
Delivery is the only cure for preeclampsia.27
Presentation
While taking the patient’s medical history, or through conversation, the patient may
reveal she has preeclampsia. Elevated blood pressure may be present.12,27
Consideration and management
In 2010, the California Dental Association published the statement that preeclampsia
is not a contraindication to dental care.8 However, patients with preeclampsia may
be taking certain medications and may therefore require additional consideration
when providing dental treatment. Physicians may treat some subgroups with aspirin,
antiplatelet agents, calcium, and heparin.8 Other treatment options include antihypertensives, corticosteroids, or anticonvulsant medications.27 Ensure that all patients
provide a complete list of prescription and over-the-counter medicines prior to any
dental procedures.
A patient with preeclampsia or eclampsia may be at increased risk of seizure when
lidocaine is accidentally administered intravascularly.12 Consider consulting with the
patient’s prenatal care provider when preeclampsia is either present or suspected.
Eclampsia
Eclampsia includes convulsive seizures or coma that does not have another etiology
and occurs during preeclampsia.3,12 More than 80% of women with eclampsia are
young women who are pregnant for the first time (primigravida).3
27
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3 | Complications and the Impact on Dental Care
The pathogenesis includes the following12:
• Uterine spiral arteries, which supply nutrients to the placenta and fetus, do not dilate. This decreases placental perfusion.12,28
• Increased maternal vasopressor sensitivity.
• Coagulation cascade activation with concomitant microthrombi.
• Decreased intravascular volume.
There is increased risk of:
•
•
•
•
•
•
•
Cerebral hemorrhage12
Aspiration pneumonia3
Hypoxia3
Encephalopathy3
Thromboembolisms3
Poor perinatal outcome (diabetic patients)8
Maternal and/or fetal dealth (Maternal death is often due to gastric aspiration, and
fetal death is often due to hypoxia.3)
• Eclamptic seizures are considered a medical emergency.3
‒‒ 25% occur before labor.
‒‒ 50% occur during labor.
‒‒ 25% occur 7 to 10 days postpartum.
Treatment of eclampsia may include:
•
•
•
•
•
Delivery (best treatment)3
Medication for seizure prophylaxis3
Medication to control blood pressure3
Antiplatelet therapy (including aspirin and heparin)8
Calcium supplements8
Presentation
Eclampsia may present as a seizure in the dental office.
Consideration and management
Eclamptic seizures are considered a medical emergency.3 Most eclamptic seizures
(75%) occur in the time frame from labor to 10 days postpartum.3 Deferring elective
dental treatment during this time frame reduces the risk of an eclamptic seizure occurring during dental treatment. Be aware that the patient’s medical provider(s) may
have prescribed medication that can interfere with dental treatment. For example,
antiplatelet therapy (eg, aspirin or heparin) may increase bleeding risk during surgery.
Increased heart rate
Cardiac output increases 30% to 50% during pregnancy to meet the metabolic needs
of the pregnant woman and fetus.2,3,20,29 This is due to an increase in stroke volume
28
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Circulatory
and also a 20% to 30% increase in heart rate.12,20 Most of the increased cardiac output occurs during the first 10 weeks of pregnancy. Afterward, there continues to be a
gradual increase in cardiac output until week 24, at which time the changes in cardiac
output level off.12
Presentation
During pregnancy, the patient’s heart rate may be elevated by about 10 to 20 beats
per minute.2
Consideration and management
Minor variations in heart rate, consistent with what is expected during pregnancy, are
not thought to have a significant effect on dental treatment.
Hypertension (increased blood pressure)
Hypertensive disorders occur in about 7% to 10% of pregnancies.3,12 Preexisting hypertension is when a woman has hypertension before the 20th week of pregnancy.2,3 This
is indicated by either a systolic blood pressure ≥ 140 mmHg or a diastolic blood pressure ≥ 90 mmHg.
Pregnancy-induced hypertension is when a woman becomes hypertensive for the
first time during the second half of pregnancy.3 This is indicated by either a systolic
blood pressure ≥ 30 mmHg above the prepregnancy systolic blood pressure or a diastolic blood pressure ≥ 15 mmHg above the prepregnancy diastolic blood pressure.
Presentation
Vital signs should be recorded prior to providing dental treatment.30 While obtaining
vital signs, it may be observed that the patient has elevated blood pressure at the
dental appointment3:
30 mmHg above prepregnancy
≥ 140 mmH
or
15 mmHg above prepregnancy
≥ 90 mmH
Consideration and management
When available, it is important to compare pregnancy blood pressure readings with
prepregnancy blood pressure readings. If this is not done, a pathologic increase in
blood pressure that is still below 140/90 may not be detected.3 Regardless of the
cause, women with hypertension should be referred to their prenatal care provider
for evaluation because they are at increased risk for preeclampsia, which may lead to
fatal complications during pregnancy.2 (See previous section on preeclampsia.)
Hypotension (decreased blood pressure) in early pregnancy
A decrease in blood pressure may be caused by peripheral vasodilation and venodilation.16 Blood pressure reaches the lowest point sometime between weeks 16 and
24 of pregnancy.16,31 These changes are mediated by progesterone, prostaglandins,
and nitric oxide. Progesterone mediates relaxation of venous smooth muscle, which
causes a drop in systemic vascular resistance.16 After 16 weeks, blood pressure may
increase and gradually return to baseline by the end of the second trimester.2
29
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3 | Complications and the Impact on Dental Care
Presentation
The patient may have decreased blood pressure at the dental appointment. Diastolic
blood pressure may decrease 7 to 10 mmHg during early pregnancy.3 The pregnant
patient may also experience syncope (fainting) in the dental office.3
Consideration and management
Minor variations in blood pressure, consistent with what is expected during pregnancy, are not thought to have an effect on dental treatment. If the patient faints,
position her on her left side, elevate her legs, and administer oxygen. If she does not
recover, call emergency medical services.3
Pregnancy-induced heart murmurs
Myocardial contractility increases throughout pregnancy. This leads to mild ventricular hypertrophy. The left atrium also increases in size as a result of the increased
cardiac output and increased blood volume.8 In 90% of women, these changes cause a
functional S3 systolic heart murmur.2,16,20 These symptoms often resolve after delivery.2
Presentation
A patient may state that she has a heart murmur on her health history, or she may
reveal it through conversation.
Consideration and management
Pregnancy-induced heart murmurs typically do not require antibiotic prophylaxis for
subacute bacterial endocarditis.3 Depending on the information available, a physician
consult regarding the heart murmur may be advisable.3
Supine hypotensive syndrome
As early as week 20, adverse effects from the aortic and venal caval (aortocaval) compression may occur when the pregnant woman is placed in the supine position.13 By
week 30 of pregnancy, 98% of women naturally avoid sleeping in the supine position.13 When the woman is placed in the supine position, fetal monitoring has shown
fetal heart rates transition from normal to nonreassuring heart rates, which include
tachycardia, bradycardia, and other variations.13,32 Placing the pregnant woman in the
supine position may cause abdominal contents to compress the diaphragm, which
may in turn cause difficulty breathing.3 About 25% of pregnant woman experience
modest hypoxemia while supine.3 During the third trimester, 30% of women will have
aortocaval compression when placed in the supine position.12
Supine hypotensive syndrome may affect 8% to 20% of pregnant women and occurs
mainly from the late second trimester (midpregnancy) to the end of pregnancy.2,8 Near
term, 10% of pregnant women may show signs of shock (tachycardia and pallor) when
in the supine position.3,13
30
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Circulatory
In the supine position, utero compression of the maternal inferior vena cava can
cause maternal symptoms of3,12:
•
•
•
•
•
•
•
•
•
•
Nausea2,7,8,33
Dizziness2
Lightheadedness12
Hypotension2,8,12,15,16
Pallor8
Syncope (fainting)2,12,15,16
Bradycardia (decreased heart rate)15,16
Tachycardia (increased heart rate)12
A 14% reduction in cardiac output12
Compression of the descending aorta (can lead to decreased blood to the common
iliac arteries)12
• Compression of the inferior vena cava (reduces venous return to the heart, decreases stroke volume, stimulates the baroreceptors reflex to maintain cardiac output)16
• Decreased placenta perfusion13
• Fetal hypoxia13
Consideration and management
From midgestation onward, the pregnant woman is at increased risk of hypotension
when placed in the supine position.8 Avoid placing the pregnant patient in a completely supine position.3,8 Even if a patient does not have the symptoms of supine
hypotensive syndrome, there still may be a significant disruption in her uteroplacental
blood flow.16
Preventing or treating supine hypotensive syndrome can usually be done through
positioning the patient into LUD (Fig 3-2). If the following patient-positioning instructions are ineffective at relieving hypotension, administer 100% oxygen12:
1. Roll the patient to her left side in the range of 5 to 15 degrees.12 This can be done by
elevating the woman’s right hip 10 to 12 cm (approximately 4 to 5 inches), or have
the woman roll to the left side.
2. Place a wedge-shaped pillow, a small pillow, or a folded blanket under the woman’s right side.2,3,16 A woman with an unusually large uterus (eg, conditions such as
polyhydramnios or multiple gestations) may require up to 30 degrees of uterine
displacement.13
3. If these steps do not relieve hypotension, place the woman in a full left lateral position; this displaces the uterus so it does not compress the inferior vena cava.12,16
In 90% of women, LUD relieves fetal symptoms.13 In 10% of women, fetal monitoring
shows that fetal symptoms only resolve after placing the woman in right uterine
displacement.13
31
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3 | Complications and the Impact on Dental Care
a
b
Fig 3-2 (a) When the pregnant woman is supine, the fetus may press against the abdominal aorta
and inferior vena cava. (b) Placing the woman into LUD relieves this compression. (Courtesy of Natalie
Joy Barton, Thornton, Colorado.)
Endocrine
Gestational diabetes
Diabetes mellitus (DM) refers to the group of metabolic diseases in which the body
has prolonged high levels of blood sugar.14 Pregnancies where the mother has both
diabetes and preeclampsia have increased risk of poor perinatal outcome.8,34 Patients
whose blood glucose levels have large, less predictable variations often require
multiple hospitalizations and are sometimes referred to as having labile or brittle diabetes.35,36 The three main types of DM are as follows:
1. Type 1 DM, or insulin-dependent DM, is when the body does not produce sufficient
insulin. This category comprises 5% to 10% of diabetics.14
2. Type 2 DM, or non–insulin dependent DM, is when the body does not properly respond to insulin. This category comprises 85% to 90% of diabetics.14
3. Gestational diabetes (GD) occurs in pregnant women who do not have a prior history of diabetes.12,34 GD resembles type 2 DM.14
Estrogen and progesterone act as insulin antagonists and lead to insulin resistance.
To compensate, a pregnant woman’s insulin level is often elevated. Women who are
unable to produce sufficient insulin to overcome the antagonistic effects of estrogen
and progesterone develop GD.2 Risk factors for developing GD include obesity and a
family history of type 2 DM.2,34 It is estimated that about 9% of women will have GD.37
Immediately after pregnancy, 5% to 10% of women who had GD will have diabetes.38
GD may occur in seemingly healthy women with no prior history of diabetes, and the
risk of recurrence in future pregnancies is about 60%.12 After pregnancy, there is a 40%
to 60% chance of developing diabetes later in life.14 GD leads to an increased risk of
miscarriage, congenital malformations, preterm birth, pyelonephritis, preeclampsia,
in utero meconium, fetal heart rate abnormalities, cesarean delivery, and stillbirth.12
Treatment often includes3,34:
32
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Gastrointestinal
• Dietary modifications
• Insulin therapy
• Frequent glucose monitoring
Glucose intolerance leads to hyperglycemia and the risk of12:
•
•
•
•
Premature placental aging
Uteroplacental deficiencies
Delayed fetal lung maturation
Birth defects, including cardiac abnormalities
Presentation
While obtaining the patient’s health history, or through conversation, she may indicate that she has GD.
Consideration and management
If a patient’s hemoglobin A1c (HbA1c) level is greater than 8%, her diabetes is considered to be poorly controlled.39 If a patient’s diabetes is not well-controlled, consider
delaying elective dental treatment until her diabetes is better controlled.39
GD places the expectant mother at higher risk for additional complications during
pregnancy. Because diabetics may have poorly regulated blood glucose levels, they are
at greater risk of having a hypoglycemic episode while in the dental office. It is recommended that dental offices have a protocol for treating both conscious and unconscious
patients who have hypoglycemia.14 Treating periodontal disease in patients with GD
may improve glycemic control during pregnancy.8 This may decrease the chance of the
mother developing type 2 DM as well as the development of fetal anomalies.14
Gastrointestinal
Gastroesophageal reflux and pyrosis (heartburn)
A pregnant woman is predisposed to have heartburn and gastroesophageal reflux. This
occurs in up to 70% of pregnant women.2,16 The enlarging uterus and corresponding
displacement of abdominal contents is responsible for some of the gastrointestinal
(GI) changes in pregnant women.15 As the uterus enlarges, pressure is placed on the
stomach and can lead to:
• Delayed gastric emptying7,15 (The decreased rate of gastric emptying can also be
•
•
•
•
•
caused by other factors including narcotics, onset of labor, pain, or trauma.2,8)
Rapid satiety (feeling full)8
‒‒ Rapid satiety may lead the woman to eat small, frequent carbohydrate-rich
meals, which provides cariogenic conditions.7–9
A “full stomach”9
Increased intragastric pressure2
Nausea and vomiting15 (see pages 34–35)
Increased risk of aspiration of gastric contents16
33
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3 | Complications and the Impact on Dental Care
The woman is further predisposed to having gastroesophageal reflux (heartburn) because of changes to her lower gastroesophageal sphincter, which include
decreased resting pressure (from increased levels of circulating progesterone and
estrogen) and decreased muscle tone.2,8,15,16 Gastroesophageal reflux places the dentition at increased risk for acid erosion.8
Presentation
Evidence of acid erosion may be visible during the dental examination. The patient
may also reveal that she has gastroesophageal reflux on the health history or through
conversation. The patient may experience nausea in the dental office, which may
affect her ability to tolerate dental treatment. Excess stomach acid in the oral cavity
can lead to enamel erosion, which may be present.8
Consideration and management
If the patient experiences nausea in the dental office, it may affect her ability to tolerate dental treatment. A caries risk assessment can be used to uncover the patient’s
dietary habits (see Appendix B for caries risk assessments), and patient-specific nutritional counseling can be provided (see chapter 4). If enamel decalcification or other
signs of acid erosion are present, refer to the section on perimylolysis (see page 41).
Hyperemesis gravidarum
Hyperemesis gravidarum is a severe form of nausea and vomiting during pregnancy.8,17
It occurs in 0.3% to 2% of pregnancies.2,8,17 There is an increased risk of loss of surface
enamel via acid erosion from the vomiting.3
Presentation
The patient may indicate she has this condition on her health history. The patient may
also become nauseated or vomit during the dental appointment. Evidence of acid
erosion may be visible.
Consideration and management
Avoid morning appointments for patients with this condition.16 Advise the patient to
avoid citrus drinks and fatty foods because they may delay gastric emptying or cause
gastric upset.2,16 Sipping small amounts of electrolyte-containing liquids such as
sports drinks may minimize vomit-induced dehydration.2
During treatment, position the patient in a semisupine or comfortable position.2 If
vomiting occurs during dental treatment, immediately stop the treatment and reposition the patient into an upright position.2 When finished vomiting, the patient should
rinse her mouth as per the instructions in the following section.
Nausea and vomiting during pregnancy (morning sickness)
Nausea and vomiting during pregnancy (NVP), also known as morning sickness, occurs
in 50% to 90% of all pregnancies during the first trimester.3 The condition starts about
5 weeks after the last menstrual period and peaks between weeks 8 and 12 of pregnancy, after which symptoms often gradually decline.2
34
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Gastrointestinal
NVP may be partially caused by increased levels of estrogen and human chorionic gonadotropin.3 Physicians sometime treat NVP with antiemetics, sedatives, or
vitamins.3 Doxylamine and pyridoxine (eg, Diclegis, Duchesnay) is currently the only
FDA-approved medication to treat morning sickness.40 It has an FDA pregnancy risk
category of A40,41 (see Table 5-1).
Presentation
While NVP is common, it may not manifest while the patient is in the dental office.
However, educating the patient may help improve her oral health.
Consideration and management
Nausea and vomiting may need to be taken into consideration when prescribing medications.15 Instruct the expectant mother on the proper oral care after vomiting. To
neutralize acidity after vomiting, do one of the following:
• Rinse mouth with cold water.2
• Rinse mouth with a cup of water containing a teaspoon of sodium bicarbonate
(baking soda).3,4,7,8,33,42–44
• Rinse with mouthwash.2
• Apply a casein phosphopeptide amorphous calcium phosphate paste to the teeth
(eg, Recaldent CPP-ACP, which is in MI Paste [GC America]).45
Minimize dental erosion by instructing patients to:
• Avoid brushing the teeth for about 1 hour after vomiting to minimize erosion by
stomach acid exposure.9,44 This delay allows for saliva to dilute and buffer acids and
to start to remineralize the teeth.46
• Use a soft or super soft toothbrush.44
• When scheduling the patient, consider asking what time of day she feels best.42
Nutritional deficiencies
The increased energy required for the fetus and placenta to grow often leads to nutritional deficits. The pregnant woman is often placed on nutritional supplements to
counteract this need.2 Fetal erythropoiesis (production of red blood cells) requires
iron.8 Amino acid and nucleic acid synthesis both require folate.2
Presentation
While iron and folate deficiencies may not be directly observable, they may come up
during conversations about diet and how diet affects oral health.
Consideration and management
Reinforce dietary recommendations (see pages 66–67).
35
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3 | Complications and the Impact on Dental Care
Hematologic
Antiphospholipid syndrome
Antiphospholipid syndrome (APLS) is a disease where antiphospholipid antibodies
bind to phospholipids and may cause thrombosis and fetal loss.2,47 Women with APLS
are at significant risk for thromboembolism during pregnancy. They may be placed on
anticoagulant therapy to prevent thrombus formation.2,47
Presentation
The patient may list the medical diagnosis and medication being taken on the health
history or reveal it through conversation.
Consideration and management
Because APLS carries increased risk of thromboembolism and likelihood of increased
bleeding, it is recommended to provide dental care to these patients in a hospital
setting.2
Hypercoagulable state
During pregnancy
Coagulation is controlled by the balance between clotting and anticlotting factors.
During pregnancy, the balance shifts to a more hypercoagulable state, and coagulation changes are most pronounced in the third trimester.2,12 This hypercoagulable
state is caused by both a decrease in anticlotting factors and an increase in coagulation factors 2,12,16 (Table 3-2).
Table 3-2 | Clotting and anticlotting factors that change during pregnancy2,12,16
Clotting or
anticlotting
Change
I (fibrinogen)
Clotting
Increases
V (proaccelerin)
Clotting
Increases
VII (proconvertin)
Clotting
Increases
VIII (antihemophilic)
Clotting
Increases
IX (Christmas factor)
Clotting
Increases
X (Stuart-Prower factor)
Clotting
Increases
von Willebrand factor
Clotting
Increases
Factor
XI (plasma thromboplastin antecedent)
Anticlotting
Decreases
XIII (fibrin-stabilizing factor)
Anticlotting
Decreases
Fibrinolytic protein C
Anticlotting
Decreases
Presentation
On the health history or through conversation, the patient may indicate that she is
pregnant.
36
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Hematologic
Consideration and management
The patient’s hypercoagulable state places her at increased risk for thromboembolic
disease.16 Because of this, there is an increased risk that the patient may have a thromboembolism while in the dental office. (See the following section on thromboembolic
disease for additional information.)
Immediate postpartum period
A hypercoagulable state often exists for 2 to 3 weeks after delivery. This high-risk
period may last until 25 days after delivery.12 This hypercoagulable state may be less
intense in women who suffered significant blood loss during delivery.12
When the placenta is removed, there is an increase in maternal circulation of tissue
factor (TF). The increased levels of TF may activate coagulation and lead to thrombosis.12 For treatment, the patient’s perinatal care provider may prescribe prophylactic
anticoagulative therapy.16
Presentation
The woman may inform the dental practitioner that she recently had a baby. On the
health history form, consider including a question similar to the following:
☐ I recently had a baby. Delivery date: __/__/____
Consideration and management
When treating a woman in the immediate postpartum period, it is important to be
aware that the patient may be in a heightened state of coagulability and also that the
physician may have placed the patient on anticoagulant therapy.12 Consider the need
to provide treatment during this time versus waiting a few weeks.
Thromboembolic disease
Changes in clotting factors place all pregnant women at increased risk for venous
thromboembolism.8 During pregnancy, women have at least five times the risk of
thromboembolism.16,18,19 This increased risk is caused by their hypercoagulable state,
and uterine compression of the venous return from the lower extremity also leads
to venous stasis and predisposes a woman to thrombus formation.16 The risk of pulmonary embolism during the immediate postpartum period is greater than the risk
during pregnancy.12,18 About 0.1% of pregnant women form a thrombus. Of these,
about 20% develop a pulmonary embolism, which has a 12% to 15% mortality rate.16
Presentation
The patient may indicate that she is pregnant on the health history, or she may disclose this information through conversation.
Consideration and management
Because pregnant women are at increased risk of thromboembolic disease, they are at
a slightly increased risk of having a thromboembolism while in the dental office.16 The
37
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3 | Complications and the Impact on Dental Care
patient may be on anticoagulant therapy, which may increase risk for bleeding.16,18,19
The epinephrine in local anesthetic administered intramuscularly is not thought to
significantly increase risk.12 Accidental intravascular injection may increase the risk of
activating coagulation.12 (For further information, see pages 122–123).
Hepatic
Hepatic (liver) dysfunction
Approximately 3% of pregnant patients may experience pregnancy-related abnormal liver tests.2 There may be decreased levels of protein and albumin (secondary to
increased plasma volume).2,16 Levels of the following may be elevated:
•
•
•
•
•
Bilirubin
Serum aspartate aminotransferase (AST)
Serum alanine aminotransferase (ALT)
Cholesterol and triglycerides
Alkaline phosphatase (from the 5th month of pregnancy until delivery) because
placental alkaline phosphatase leaks into the maternal blood2
Liver dysfunction may cause or precede the following2:
•
•
•
•
Preeclampsia
Eclampsia
HELLP syndrome
Obstructive cholestasis
‒‒ In this condition, bile is unable to flow from the liver to the duodenum. While the
cause is unknown, it is significantly affected by genetics.39
• Acute fatty liver disease of pregnancy2
‒‒ This is a potentially fatal disease that usually occurs in the third trimester and affects 1 in 13,000 pregnancies. It has an estimated maternal mortality of 18% and
infant mortality of 13% to 18%. In 20% to 40% of cases, complications include
preeclampsia.48
Presentation
Through either the health history or conversation, the patient may reveal hepatic dysfunction during pregnancy.
Consideration and management
Minor variations in liver function are not thought to interfere with providing necessary
dental treatment during pregnancy. Depending on the circumstances, a medical consult may be indicated to find out if there is the presence of a more severe diagnosis
that may need to be taken into account when providing treatment.
38
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Immune
Immune
Decreased immunoglobulin G levels
In the second half of the second trimester, immunoglobulin G (IgG) blood levels are
decreased. Decreased IgG levels can lead to oral pathogen proliferation. This may
allow for sustained oral infections such as periodontal disease.8
Presentation
The patient may indicate she is pregnant on the health history form. Patients may also
have increased oral infection such as periodontal disease.8
Consideration and management
Emphasize the importance of excellent at-home oral hygiene care including proper
technique for brushing, flossing, and using mouth rinse (see page 65).
Mother-to-infant transmission of oral pathogens
The mother is the most common source of the infant’s oral pathogenic bacteria.8
Infants born via cesarean deliveries have been found to be infected with maternal
Streptococcus mutans 12 months earlier than infants delivered vaginally.8,49 At present,
it is unclear why this correlation is present.8,49
S mutans can be acquired in the following ways8 (Fig 3-3):
• Vertical transmission from mother (or caregiver) to child.
• Horizontal transmission from child to child.
Mother
Caregiver
Vertical
transmission
Child
Child
Horizontal transmission
Fig 3-3 Transmission of S mutans.
Presentation
The patient may indicate she is pregnant on the health history form.
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3 | Complications and the Impact on Dental Care
Consideration and management
Because maternal oral bacterial load can be used to predict the development of childhood caries, providing oral care to reduce the bacterial load prior to childbirth may
help reduce childhood caries.50 Also, provide the expectant mother with anticipatory
guidance for the oral care of her future infant (see page 68).
Integumentary
Dermatologic changes
Observable extraoral changes can reveal medical conditions that impact oral health and
dental treatment. Normal pregnancy can also manifest itself with changes to the skin.
Presentation
The following is a list of some common dermatologic changes that may occur during
pregnancy.
• Melasma (“mask of pregnancy”).2,20 This is caused by an increase in facial pigmen-
tation. It presents as bilateral brown patches in the middle of the face and occurs
in about 73% of women, usually beginning during the first trimester. It is thought
to be caused by increased estrogen and progesterone and typically resolves after
delivery.
• Spider angioma.8 This is characterized by swollen blood vessels that are slightly
below the skin surface. They often have a central red spot with radiating reddish
extensions that may resemble a spider’s web. This condition is thought to be
caused by increased estrogen levels.
• Palmar erythema (reddening of the skin in the palmar aspect of the hands).8
Consideration and management
In the presence of pregnancy, these are normal variations that may be observed
during the extraoral examination. While these dermatologic changes are not thought
to have any effect on dental treatment, the underlying pregnancy may require modifications to dental treatment.
Some women remain unaware of their own pregnancy for significantly longer than
other women. Teenagers who are pregnant may deny the pregnancy if asked in front
of their parents. In cases where the woman is either unaware of or hiding the presence
of pregnancy, these dermatologic changes may reveal the presence of pregnancy or
another underlying medical condition. Depending on the situation, a medical referral
for further evaluation may reveal an underlying medical condition that may indicate
modifications to dental treatment.
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Oral
Oral
Perimylolysis (erosion/decalcification of tooth enamel)
This can be caused by gastric acid exposure to the teeth from morning sickness, vomiting, or gastric reflux.9 Also, because of changes in appetite, pregnant women often
eat snacks with increasing frequency, and this frequent carbohydrate snacking is
associated with an increase in caries.44
Presentation
Tooth acid erosion may be present during the clinical examination.
Consideration and management
When erosion is present, consider prescribing daily use of a fluoride mouth rinse or
gel.9 There are two general forms of fluoride: acidulated phosphate fluoride (APF)
and neutral sodium fluoride. APF provides increased enamel fluoride uptake and is
more efficient at reducing tooth demineralization than neutral sodium fluoride.51,52
APF may cause deterioration of the superficial layer of dental restorations because
it can acid-etch the surface of porcelain.53 Different manufacturers’ composites are
affected differently.52,54 (It has also been reported that acidic food and drink may cause
deterioration of restorative materials.55) Neutral sodium fluoride is less efficient at
enamel fluoride uptake when compared with APF and significantly deteriorate dental
restorations.51,52
Advise women that eating foods with high sugar content places them at increased
caries risk, and raise awareness that some sources of sugar intake may be unexpected.9
For example, some over-the-counter (OTC) antacids used for heartburn induced
by pregnancy may have a high sugar content. Long-term frequent use of sugarcontaining antacids increases caries risk. Emphasize both dietary recommendations
and oral hygiene instructions (see chapter 4).
Pregnancy gingivitis and gingival hyperplasia
Pregnancy gingivitis and/or gingival hyperplasia occurs in 50% to 100% of pregnancies.3,8,15 Generalized tooth mobility in the absence of periodontal disease may also
occur. After pregnancy, resolution is usually spontaneous.8
Pregnancy gingivitis is characterized by dark red, swollen, smooth gingiva that
bleeds easily.8 It is usually observed starting in the 2nd month of pregnancy and typically peaks in the 8th month of pregnancy.3 Changes in hormones mediate changes in
oral inflammatory processes. Increased circulating estrogens also increase capillary
permeability. These changes predispose the expectant mother to both pregnancy gingivitis and pregnancy gingival hyperplasia.16
Marginal gingiva and interdental papillae are often affected.2 Periodontal disease is
not caused by pregnancy, but it may be worsened by pregnancy.2
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3 | Complications and the Impact on Dental Care
Presentation
Dark red, swollen, smooth gingiva that bleeds easily may be present during pregnancy.8
Consideration and management
Advise patients on the importance of good oral hygiene to prevent or minimize the
effects of pregnancy gingivitis. Dental prophylaxis can also be performed (see chapter 4).
Pyogenic granuloma (pregnancy tumor, epulis gravidarum,
or pregnancy granuloma)
About 5% of pregnant women are likely to experience a pyogenic granuloma.2,3
Pyogenic granuloma is thought to be the result of the following factors2:
• Increased circulating estrogen and progesterone, which leads to increased localized angiogenesis
• Gingival irritation by plaque or other local factors
Pyogenic granuloma is more common in the first or second trimester of a woman’s
first pregnancy; however, it may occur any time throughout pregnancy.3
Presentation
This condition typically presents on the labial aspect of the interdental papilla.2 Rapid
growth is common; however, it rarely grows larger than 2 cm in diameter.8 This condition is usually painless.3,42
Consideration and management
If painful or otherwise symptomatic, the pyogenic granuloma can be removed
during pregnancy, but it may recur.8 After pregnancy, it may spontaneously resolve or
regress.3,8
Salivary changes
Be aware of the possibility of reduced salivary flow during pregnancy. One study
reported that 44% of pregnant women may experience persistent xerostomia.9 This
is thought to be caused by hormonal changes.9 Changes in salivary composition
include2,16:
•
•
•
•
•
Decreased sodium
Decreased pH and increased risk of tooth demineralization
Increased potassium
Increased protein
Increased salivary estrogen
Increased salivary estrogen levels may cause an increased proliferation and desquamation of the oral mucosa, along with an increased amount of gingival crevicular
fluid.2,16 Desquamated oral mucosa may be a source of nutrition for bacteria.2,16
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Reproductive
Salivary hormone levels can be used to approximate levels of plasma hormones
and may be predictive of preterm birth.2 Salivary estrogen levels have been found to
be higher in women with preterm births as compared with women who carry to term;
salivary progesterone has been found to be lower in women with preterm births as
compared with women who carry to term.56,57
Presentation
The pregnant patient may report differences in salivary flow during her pregnancy.
Consideration and management
Consider a palliative approach for dry mouth treatment. The patient can drink more
water or chew sugarless gum or gum containing xylitol to increase salivation.9 Educate
the patient on the importance of oral hygiene.
Renal and Urinary
Renal changes
During pregnancy, there is a 50% increase in the glomerular filtration rate.2,20 In addition, there is a 50% to 80% increase in renal plasma flow caused by the increased
blood volume. These changes lead to a slight increase in creatinine clearance and
increased urea and uric acid excretion.2,16,20 There is an increased risk of urinary stasis
and urinary tract infection.2,16,20
The frequency of urination may increase during the second half of pregnancy.2,16
One contributing factor is human chorionic gonadotropin, which can lead to changes
in osmoregulation.2 Only 1% to 2% of pregnant women have hypotonic bladder, urinary stasis, and/or pyelonephritis.2
Presentation
On the health history, the patient may indicate she is pregnant. Or she may report that
she is taking an antibiotic for urinary tract infection.
Consideration and management
Consider advising the patient to empty her bladder just prior to the start of a dental
procedure.2,16 The dosing of medications that are cleared by renal excretion may need
to be adjusted to account for increased rates of renal clearance.15,16
Reproductive
Braxton-Hicks (practice) contractions or false labor
False labor may start in the second trimester.12 It is most common in the third
trimester.12
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3 | Complications and the Impact on Dental Care
Presentation
False labor is described as having infrequent, unpredictable, and uncomfortable
(rather than painful) contractions with irregular intensity. Contractions do not
increase in intensity or frequency but taper off and disappear.12 Uterine muscles typically tighten for 30 to 60 seconds, though contractions can last for up to 2 minutes.12
Consideration and management
Contractions are typically alleviated by changing the patient’s position, rhythmic
breathing, hydration, or urination.12 If contractions do not cease with these methods,
contact the patient’s perinatal care provider to determine if labor has started.12
In the presence of suspected miscarriage or preterm labor, contact EMS and the
patient’s perinatal care provider immediately. Symptoms may include vaginal bleeding or discharge with or without strong contractions.2,3 Recline the patient, position
her on her left side, and administer oxygen if needed.2,3
Respiratory
Changes in upper respiratory mucosa
Circulating estrogens may lead to engorged nasal capillaries, causing airway edema.2
Severe rhinitis (irritation and inflammation of the nasal mucous membrane) may
occur in 30% of pregnant women, which places them at risk of2:
• Frequent nosebleeds2,16
• Predisposition for upper respiratory tract infection2,16
Presentation
The patient may have a nosebleed (epistaxis) in the dental office. If this occurs, dental
treatment may need to be suspended until the bleeding is controlled. If the nosebleeds are frequent or unable to control, a referral for medical evaluation may be
appropriate.
Consideration and management
Because periodontal pathogens may be associated with upper respiratory tract
infection, controlling periodontal disease might decrease the chances of developing
respiratory infections.21 It is important to educate the pregnant woman on maintaining meticulous oral hygiene. If general anesthesia is used, avoid nasal intubation.15
Dyspnea (shortness of breath)
By the middle of the second trimester, 50% of women have dyspnea, and this increases
to 75% of women by the middle of the third trimester.16 During periods of shortness
of breath, the combination of decreased oxygen reserve coupled with an increased
oxygen demand place the pregnant woman and fetus at increased risk of hypoxia.2
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Respiratory
Pregnant patients experience a number of respiratory changes during pregnancy.
They experience a decreased oxygen reserve because they have a 15% to 20%
decrease in the functional residual capacity at term, combined with a 15% increase
in oxygen consumption by the pregnant uterus when compared with baseline oxygen
consumption.8,12 In addition, they also experience a 30% to 40% increase in the total
amount of air breathed in and out during normal breathing (tidal volume).8
Presentation
The woman may have shortness of breath in the dental office.
Consideration and management
Dyspnea may affect a woman’s ability to comfortably tolerate dental treatment.
Respiratory changes may be of significance if general anesthesia is used.8
Hyperventilation
While hyperventilation may occur during the first trimester, the risk of hyperventilation
increases throughout pregnancy.3,20 About 42% of women may experience hyperventilation in their third trimester.12,16 If a pregnant woman has significant hyperventilation,
there may be a corresponding decrease in fetal oxygenation.12
Causes of hyperventilation include:
• Decreased resting arterial carbon dioxide tension (< 30 mmHg)12
• Increased renal bicarbonate excretion12
• Progesterone acting as a respiratory stimulant12,20
Presentation
Hyperventilation may cause a pregnant woman to present with mild respiratory alkalosis.16 Symptoms of respiratory alkalosis may include anxiety, dizziness, and mental
confusion.22
Consideration and management
If the patient is hyperventilating, attempt to calm and reassure her. Explain that
rapid, deep breathing can cause physical symptoms that can lead to more rapid deep
breathing. Suggested initial treatment includes:
• Repeat a cadence such as “in…out…in…out…” to help the patient voluntarily slow
down her breathing.58
• Have the patient close her mouth and breathe through her nose.59
• Encourage the patient to only take one breath every 5 seconds.60
The traditional treatment of having the patient breathe into a paper bag has
resulted in death when used on patients who were hypoxemic or had myocardial
infarction.61 Patients with hyperventilation may benefit from addressing any underlying psychologic stress.22 Because of this, it may be important to minimize stressful
situations during the dental visit.
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3 | Complications and the Impact on Dental Care
Respiratory capacity
There may be a 15% to 20% decrease in functional residual capacity in the pregnant
woman at term.3,8,20 In addition, there can be a 30% to 40% increase in tidal volume in
the pregnant woman at term.8,20 Vital capacity in the upright position has little change
during normal pregnancy.8 Decreased vital capacity can occur as a result of obesity,
cardiovascular dysfunction, or pulmonary dysfunction.8
Presentation
The patient may not be able to inhale as deeply as before.
Consideration and management
Respiratory changes can be a cause of concern when administering inhaled anesthesia to the pregnant woman, especially late in pregnancy (see pages 128–129).
Fetal Development Risks
For simplicity, this book uses the term fetus to refer to everything from the fertilized
egg through the stages of embryonic and fetal development up to birth. Throughout
the different stages of fetal development, different parts of the fetus go through different amounts of risk for developmental defects. There is no time when the fetus is
completely safe from developing defects.
Birth defects
Minor birth defects are present in 14% to 40% of live births.62 This wide range of prevalence may result from the lack of a uniform definition of exactly what a “minor defect”
is. Major birth defect, or congenital malformation, occurs in about 4% of live births.62
Birth defects account for about 21% of all infant deaths and are the leading cause of
infant mortality.63 It is thought that about 2% to 3% of birth defects are caused by exposure to drugs and chemicals.64 Most drugs cross to the placenta via simple diffusion.12
Fetal anomalies can be separated into the following three categories63:
1. Malformations: Structures that form incorrectly.
2. Disruptions: Destructive processes that alter structures that are already formed.
3. Deformations: Mechanical forces that mold or shape portions of the fetus over time.
Teratogen
Principles of teratology
A teratogen is something that has been found to cause birth defects.63 The factors that
contribute to the ability of something to produce birth defects are also known as the
principles of teratology. Susceptibility of the teratogen depends partly on the fetal genotype and also on the maternal genome. Maternal metabolism of drugs and immune
system function (resistance to infection) both play a role in susceptibility of the fetus
to a teratogen.63
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Fetal Development Risks
The stage of fetal development when the exposure occurs affects the impact of the
exposure on the fetus.63 Embryogenesis is from the 3rd to the 8th week of fetal development after fertilization. This is when the fetus is most susceptible to birth defects.
Each organ system may have multiple periods or moments when exposure to a teratogen may lead to a defect in that organ system. The severity of the birth defect can
depend on both the dose and the duration of exposure to a teratogen.
Teratogens have specific mechanisms by which they induce birth defects.
Teratogens can cause abnormal development that may result in63:
•
•
•
•
Death
Malformation
Growth retardation
Functional disorders
A drug is classified as a teratogen if it has the potential to produce a developmental
abnormality. A common example is thalidomide. If 50 mg of thalidomide is given on
the 26th day of pregnancy, there is a significant risk to the embryo.62 However, thalidomide does not always harm the fetus. If the same 50 mg of thalidomide is given during
the 10th week of pregnancy, structural malformations are not expected. Similarly, 1
mg of thalidomide given any time during pregnancy is not expected to have an effect
on the fetus or embryo.62
The timing of teratogen exposure
The most critical period for brain development is 3 to 16 weeks postconception.
(However, the brain may still be affected by teratogens after this period.)62 Cleft lip
development is most sensitive during weeks 5 and 6. Enamel development is most
sensitive during the end of week 6 through week 8: Enamel hypoplasia and staining
can occur because of problems during this time frame. Tooth development is sensitive from week 9 onward. Cleft palate development is most sensitive during the end of
week 6 through the beginning of week 9.62
FDA postmarketing drug surveillance
Because there is often little information about the potential for a drug to be a teratogen,
postmarketing surveillance during pregnancy is critical to learn about drug-related
fetal effects.62 It may take a significant amount of time to discover that a drug may be
harmful during pregnancy because some teratogenic effects are not clinically apparent until many years after birth. For example, thalidomide was used for about 4 years
before the medical community realized that it was the cause of severe birth defects. It
took more than 20 years to link malformations with warfarin—this resulted in an entire
generation believing the drug was safe.62
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3 | Complications and the Impact on Dental Care
Types of teratogens
Dentistry potentially overlaps with a number of these categories of teratogens. Because
dentistry addresses certain maternal diseases, providing dental care may reduce teratogen exposure. On the other hand, there may be concern that dental care may be unsafe
because it includes potentially teratogenic components (eg, x-rays, medications, and
dental materials). Teratogens can be placed into a number of different categories.
•
•
•
•
•
•
•
•
Infectious agents (eg, rubella, cytomegalovirus, herpes simplex, varicella)
Physical agents (eg, x-rays, hyperthermia)
Chemical agents (eg, thalidomide, phenytoin, lithium, alcohol)
Hormones
Maternal disease
Nutritional deficiencies
Hypoxia
Heavy metals (eg, organic mercury and lead)
See chapter 4 for more information on how each of these affects dental treatment
during pregnancy.63
Fetal development
Predifferentiation is defined as the first 2 weeks after fertilization, or 2 to 4 weeks after
the last menstruation.6,12,62 During this period, there is a resistance to teratogenic
effects.6,12,62 However, there may be problems with zygote cleavage or blastocyst
implantation or early spontaneous abortion of the embryo.62
The embryonic period (embryogenesis)
The embryonic period is from 5 to 10 weeks after last menstruation, or 3 to 8 weeks
after fertilization.63 Major organogenesis occurs during weeks 2 through 8 after fertilization (which corresponds with weeks 4 through 10 after last menstruation).3 During this
period, major malformations can occur.63 This is the time period when the embryo is
most at risk for teratogenesis.3,8,65
The fetal period (fetogenesis)
The fetal period goes from week 11 after last menstruation to birth (or week 9 after fertilization to birth.)63 Few structural defects or malformations occur during this period.
However, deformations and disruptions can occur in this period. Central nervous system development remains vulnerable to teratogens throughout pregnancy.
Fetal loss
Between 50% and 75% of all spontaneous abortions occur during the first trimester,
or the time from conception up to the 14th week of gestation.2 A fetus with a major
chromosomal abnormality usually does not last to the 14th week of pregnancy.12
During weeks 14 through 23 of pregnancy, risk of pregnancy loss is 1% to 2%.12 Causes
for fetal loss during the second trimester include inflammation of fetal membranes,
inflammation of the umbilical cord, and viral infection of the placenta.12
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Adolescent Pregnancy
Premature birth
Premature birth has been linked to the presence of periodontal disease.5 Infants prematurely born at 22 to 25 weeks have about a 50% chance of survival.12 If it is born at
week 23 to 25, the infant will likely require a minimum of 4 to 5 months of inpatient
care. These infants are at a high risk of death or disability (Table 3-3).66
Table 3-3 | P
remature baby chance of
survival66
Week of gestation at
birth
23
Chance of survival
0%–53%
24
3%–70%
25
29%–85%
The Nursing Infant
If a prescription is given near the end of pregnancy, it is possible that the mother will
deliver and begin breastfeeding while still taking the same prescription. When the
dental patient is a mother who is nursing an infant, there are some additional considerations that should be taken into account. The nursing infant has the potential
to be exposed to whatever the mother has been exposed to. This is because many
medications that the mother may take have the potential to be transferred to the
infant through human breast milk. If a nursing infant starts experiencing adverse
effects, consider if the adverse effects could be caused by something the mother is
taking. For example, if maternal antibiotics are transferred to the infant, the infant
may have GI disruption from changes in the infant’s GI bacterial population. This may
lead to symptoms such as diarrhea.67 Similarly, aspirin may interfere with the infant’s
platelets.3 At the extreme, infant death may occur if an infant is exposed to largerthan-usual amounts of morphine in human breast milk of mothers who are ultrarapid
metabolizers of codeine.68 Depending on the medication, the mother may need to
avoid nursing for the period of time when the nursing infant may be exposed to a
potentially detrimental or dangerous agent.
Adolescent Pregnancy
Adolescent pregnancy is similar to adult pregnancy. However, there are several
complicating factors. First, pregnant adolescents have more medical complications
during pregnancy compared with adult patients.3,9 Second, there are legal considerations that affect who can consent to dental treatment for the pregnant adolescent.
This can get complicated if the pregnant adolescent wants to keep her pregnancy a
secret from her parents.9
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Despite the decline in teen birth rates, the United States still has more teen births
than other developed countries.69 In 2014, there were 249,078 babies born to girls who
were 15 to 19 years old in the United States. Of these births, 17% were from women
who already had at least one baby.69 Eighty-three percent of adolescent pregnancies
and births are from low-income families.9 In 2010, 55% of adolescent pregnancies
ended in live birth, 15% in miscarriage, and 30% in abortions.69
The neonatal death rate in adolescent mothers is nearly triple the rate for adults,
and the mortality rate for the pregnant adolescent is nearly double the rate for adults.
Medical complications are also more common in 11- to 15-year-old girls when compared with 20- to 22-year-old women. These complications include9:
•
•
•
•
•
•
•
Low–birth weight infants
Premature delivery
Anemia
Gestational diabetes
Sexually transmitted diseases
Premature labor
Pregnancy-induced hypertension, which increases the risk of bleeding during procedures
A healthy diet that includes adequate nutrients is important during an adolescent
pregnancy (see pages 66–67).
Legal considerations
Informed consent includes discussing the risks and benefits to both the unborn baby
and the expectant mother herself. If a minor is pregnant, awareness of the pregnancy
is necessary to adequately discuss the risks and benefits. In cases where the minor
can provide her own informed consent, there is no conflict. However, depending on
the situation, conflict may be present when informed consent must be obtained by
the minor’s parent or legal guardian. Table 3-4 shows areas of possible conflict that
can arise when a pregnant minor comes in for dental treatment.
Laws regarding consent vary from state to state.3,9 In some states, parental consent is
required for nonemergency dental services for children 17 years and younger who are
pregnant.9 For the parent to understand the risks and benefits of the proposed treatment, the parent must be aware of the pregnancy.3,9 If the parent is not aware of the
pregnancy, the pregnant adolescent may be entitled to confidentiality regarding the
pregnancy.9 Some states have “mature minor” laws (eg, Mature Minor Doctrine3,9) that
allow pregnant adolescents to consent for their own health care in cases where the
dentist determines the minor is competent to provide the necessary informed consent.
Other states allow emancipation of minors, and emancipated minors can provide their
own consent.3,9 In some instances, states only allow the minor to provide consent for
her baby upon delivery, and they do not allow her to provide consent for her own treatment.3 Dentists should become familiar with the laws specific to where they practice
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Conclusion
and where the patient resides.9 If you have questions, consider contacting your professional liability insurance company or an attorney for specific advice.
Table 3-4 | A
reas of possible conflict when a pregnant minor comes in for dental
treatment
Parent or guardian wants
treatment for minor
Minor wants
treatment
Minor does not
want treatment
Parent or guardian does not want
treatment for minor
Aware of
pregnancy
Unaware of
pregnancy
Aware of
pregnancy
Unaware of
pregnancy
Both parties
want treatment.
Both parties
want treatment.
Both parties
have adequate
information
to provide informed consent.
The parent/
guardian has
inadequate information to provide informed
consent for the
minor.
There is conflict
regarding who
wants treatment
for the minor.
There is conflict
regarding who
wants treatment
for the minor.
Both parties
have adequate
information
to provide informed consent.
The parent/
guardian has
inadequate information to provide informed
consent for the
minor.
There is conflict
regarding who
wants treatment
for the minor.
There is conflict
regarding who
wants treatment
for the minor.
Both parties
have adequate
information
to provide informed consent.
The parent/
guardian has
inadequate information to provide informed
consent for the
minor.
Because the
parent/guardian
and minor both
do not want
treatment, there
is no conflict.
Because the
parent/guardian
and minor both
do not want
treatment, there
is no conflict.
Both parties
have adequate
information
to provide informed consent.
The parent/
guardian has
inadequate information to provide informed
consent for the
minor.
Conclusion
During pregnancy, there are many significant changes that occur in a woman that
may require modification to dental treatment. Changes in dental anxiety may require
modification regarding what is included on the treatment plan and when treatment
will be completed as well as extra reassurance to the patient and the presentation
of additional information when obtaining informed consent. Variations in her vital
signs may either be normal pregnancy-related physiologic changes or may indicate
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3 | Complications and the Impact on Dental Care
the presence of pathology that should be brought to the attention of the patient’s
prenatal care provider. Changes in pharmacokinetics and teratogenic risk may alter
the selection, dosage, and frequency of medications that are prescribed or administered. Oral conditions directly related to pregnancy may develop and require
treatment. These include perimylolysis (enamel erosion/decalcification), pregnancy
gingivitis, gingival hyperplasia, pyogenic granuloma, and salivary changes. As the
pregnancy progresses, patient positioning should be modified from supine to LUD to
minimize adverse impact due to possible decreased circulation for both the expectant
mother and unborn baby. Pregnancy-related medical conditions such as hypoglycemia (from gestational diabetes), nosebleeds, Braxton-Hicks contractions (false labor),
hyperventilation, dyspnea (shortness of breath), and morning sickness may need to
be initially managed by the dental professional. It is also important to educate the
expectant mother with nutritional counseling, oral hygiene instruction, and anticipatory guidance (see chapter 4).
References
1. Strafford KE, Shellhaas C, Hade EM. Provider and patient perceptions about dental care during
pregnancy. J Matern Fetal Neonatal Med 2008;21:63–71.
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2004;97:672–682.
3. Hilgers KK, Douglass J, Mathieu GP. Adolescent pregnancy: A review of dental treatment guidelines. Pediatr Dent 2003;25:459–467.
4. Stevens J, Iida H, Ingersoll G. Implementing an oral health program in a group prenatal practice.
J Obstet Gynecol Neonatal Nurs 2007;36:581–591.
5. Cibulka NJ, Forney S, Goodwin K, Lazaroff P, Sarabia R. Improving oral health in low-income
pregnant women with a nurse practitioner-directed oral care program. J Am Acad Nurse Pract
2011;23:249–257.
6. Cengiz SB. The pregnant patient: Considerations for dental management and drug use. Quintessence Int 2007;38:e133–e142.
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ny.gov/publications/0824.pdf. Accessed 13 November 2017.
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2018.
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G, Rosen MA (eds). Shnider and Levinson’s Anesthesia for Obstetrics, ed 4. Philadelphia: Lippincott Williams & Wilkins, 2002:3–18.
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References
14. Kidambi S, Patel SB. Diabetes mellitus: Considerations for dentistry. J Am Dent Assoc
2008;139(suppl):8S–18S.
15. Wong D, Cheng A, Kunchur R, Lam S, Sambrook PJ, Goss AN. Management of severe odontogenic
infections in pregnancy. Aust Dent J 2012;57:498–503.
16. Flynn TR, Susarla SM. Oral and maxillofacial surgery for the pregnant patient. Oral Maxillofac Surg
Clin North Am 2007;19:207–221.
17. Outlaw WM, Ibdah JA, Koch KL. Hyperemesis Gravidarum and Maternal Liver Disease. http://
www.ncbi.nlm.nih.gov/books/NBK6104/#!po=2.63158. Accessed 18 January 2018.
18. Saha SA, Rao RK. Pulmonary embolic disease. In: Crawford MH (ed). Current Diagnosis & Treatment: Cardiology, ed 4. New York: McGraw-Hill, 2014:379–395.
19. Bourjeily G, Mazer J, Levinson A. Pulmonary disorders and pregnancy. In: Grippi MA, Elias JA,
Fishman JA, Kotloff RM, Pack AI, Senior RM (eds). Fishman’s Pulmonary Diseases and Disorders,
ed 5. New York: McGraw-Hill, 2015:1479–1495.
20. Gomella LG, Haist SA. Blood gases and acid-base disorders. In: Gomella LG, Haist SA (eds). The
Famous Scut Monkey Handbook: Clinician’s Pocket Reference, ed 11. New York: McGraw-Hill,
2007:163–178.
21. Bansal M, Khatri M, Taneja V. Potential role of periodontal infection in respiratory diseases: A
review. J Med Life 2013;6:244–248.
22. DuBose TD Jr. Acidosis and alkalosis. In: Longo D, Fauci A, Kasper D, Hauser S, Jameson J,
Loscalzo J (eds). Harrison’s Principles of Internal Medicine, ed 18. New York: McGraw-Hill,
2012:363–373.
23. Tolvanen M, Hagqvist O, Luoto A, et al. Changes over time in adult dental fear and correlation to
depression and anxiety: A cohort study of pregnant mothers and fathers. Eur J Oral Sci 2013;121(3
part 2):264–269.
24. Campbell TA, Sanson TG. Cardiac arrest and pregnancy. J Emerg Trauma Shock 2009;2:34–42.
25. Goodwin AP, Pearce AJ. The human wedge. A manoeuvre to relieve aortocaval compression
during resuscitation in late pregnancy. Anaesthesia 1992;47:433–434.
26. Rees GA, Willis BA. Resuscitation in late pregnancy. Anaesthesia 1988;43:347–349.
27. The American College of Obstetricians and Gynecologists. Definition of Term Pregnancy. Committee Opinion Number 579. http://www.acog.org/-/media/Committee-Opinions/Committee-on-Obstetric-Practice/co579.pdf?dmc=1&ts=20150409T12. Accessed 28 November 2017.
28. Pijnenborg R, Vercruysse L, Hanssens M. The uterine spiral arteries in human pregnancy: Facts
and controversies. Placenta 2006;27:939–958.
29. Sonis ST, Fazio RC, Fang LST. Principles and Practice of Oral Medicine, ed 2. Philadelphia: Saunders, 1995.
30. Malamed SF. Handbook of Local Anesthesia, ed 6. St Louis: Elsevier, 2013.
31. Tolstrup K. Cardiovascular disease in pregnancy. In: Crawford MH (ed). Current Diagnosis & Treatment: Cardiology, ed 4. New York: McGraw-Hill, 2014:474–493.
32. Sweha A, Hacker TW, Nuovo J. Interpretation of the electronic fetal heart rate during labor. Am
Fam Physician 1999;59:2487–2500.
33. Oral Health Care During Pregnancy Expert Workgroup. Oral Health Care During Pregnancy: A National Consensus Statement. Washington, DC: National Maternal and Child Oral Health Resource
Center, 2012.
34. National Institute of Diabetes and Digestive and Kidney Diseases. Gestational Diabetes. https://
www.niddk.nih.gov/health-information/diabetes/overview/what-is-diabetes/gestational. Accessed 18 January 2018.
35. McCulloch DK. The Adult Patient with Brittle Diabetes Mellitus. http://www.uptodate.com/contents/the-adult-patient-with-brittle-diabetes-mellitus. Accessed 18 January 2018.
36. Genetic and Rare Diseases Information Center. Brittle Diabetes. http://rarediseases.info.nih.gov/
gard/11900/brittle-diabetes/. Accessed 18 January 2018.
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37. DeSisto CL, Kim SY, Sharma AJ. Prevalence estimates of gestational diabetes mellitus in the United States, Pregnancy Risk Assessment Monitoring System (PRAMS), 2007-2010. Prev Chronic Dis
2014;11:E104.
38. Centers for Disease Control and Prevention. National Diabetes Statistics Report, 2014: Estimates
of Diabetes and Its Burden in the United States. http://www.thefdha.org/pdf/diabetes.pdf. Accessed 28 November 2017.
39. Niessen LC. Women’s health. In: Patton LL (ed). The ADA Practical Guide to Patients with Medical
Conditions. Ames, Iowa: Wiley-Blackwell, 2012:399–424.
40. Duchesnay USA. The FDA rates Diclegis® as pregnancy category A, the highest safety rating possible. https://www.diclegis.com/en/diclegis/how-safe-is-diclegis. Accessed 28 November 2017.
41. Diclegis (doxylamine succinate and pyridoxine hydrocholoride) delayed-release tablets, for oral
use [package insert]. Bryn Mawr, PA: Duchesnay, 2013.
42. Steinberg BJ, Hilton IV, Iada H, Samelson R. Oral health and dental care during pregnancy. Dent
Clin North Am 2013;57:195–210.
43. The American College of Obstetricians and Gynecologists. Oral Health Care During Pregnancy
and Through the Lifespan. Committee Opinion Number 569. https://www.acog.org/Resources-And-Publications/Committee-Opinions/Committee-on-Health-Care-for-Underserved-Women/Oral-Health-Care-During-Pregnancy-and-Through-the-Lifespan. Accessed 13 November
2017.
44. Kandan PM, Menaga V, Raja R, Kumar RR. Oral health in pregnancy (guidelines to gynaecologists,
general physicians & oral health care providers). J Pak Med Assoc 2011;61:1009–1014.
45. Okuda WH. Minimally invasive dentistry and its impact on esthetic restorative dentistry. Gen Dent
2013;61:24–26.
46. Buzalaf MA, Hannas AR, Kato MT. Saliva and dental erosion. J Appl Oral Sci 2012;20:493–502.
47. Clowse MEB, Saiton B. Pregnancy and rheumatic diseases. In: Imboden JB, Hellmann DB, Stone
JH (eds). Current Diagnosis & Treatment: Rheumatology, ed 3. New York: McGraw-Hill, 2013:533–
539.
48. Ukomadu C. Hepatic complications of pregnancy. In: Greenberger NJ, Blumberg RS, Burakoff R
(eds). Current Diagnosis & Treatment: Gastroenterology, Hepatology, & Endoscopy, ed 2. New
York: McGraw-Hill, 2012:105–110.
49. Pattanaporn K, Saraithong P, Khongkhunthian S, et al. Mode of delivery, mutans streptococci
colonization, and early childhood caries in three- to five-year-old Thai children. Community Dent
Oral Epidemiol 2013;41:212–223.
50. Chaffee BW, Gansky SA, Weintraub JA, Featherstone JDB, Ramos-Gomez FJ. Maternal oral bacterial levels predict early childhood caries development. J Dent Res 2014;93:238–244.
51. Benderli Y, Gökçe K, Kazak M. Effect of APF gel on micromorphology of resin modified glassionomer cements and flowable compomers. J Oral Rehabil 2005;32:669–675.
52. Yeh ST, Wang HT, Liao HY, et al. The roughness, microhardness, and surface analysis of nanocomposites after application of topical fluoride gels. Dent Mater 2011;27:187–196.
53. Canay S, Hersek N, Ertan A. Effect of different acid treatments on a porcelain surface. J Oral Rehabil 2001;28:95–101.
54. Hosoya Y, Shiraishi T, Puppin-Rontani RM, Powers JM. Effects of acidulated phosphate fluoride
gel application on surface roughness, gloss and colour of different type resin composites. J Dent
2011;39:700–706.
55. Ohara N, Koizumi H, Matsumoto Y, Nakayama D, Ogino T, Matsumura H. Surface roughness and
gloss of indirect composites etched with acidulated phosphate fluoride solution. Acta Odontol
Scand 2009;67:313–320.
56. Olsen RN, Dunsmoor-Su R, Capurro D, McMahon K, Gravett MG. Correlation between spontaneous preterm birth and mid-trimester maternal serium estriol. J Matern Fetal Neonatal Med
2014;27:376–380.
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References
57. Priya B, Mustafa MD, Guleria K, Vaid NB, Banerjee BD, Ahmed RS. Salivary progesterone as a
biochemical marker to predict early preterm birth in asymptomatic high-risk women. BJOG
2013;120:1003–1011.
58. Buttaravoli P. Minor Emergencies: Splinters to Fractures, ed 2. Philadelphia: Mosby, 2007.
59. RelayHealth. Hyperventilation Syndrome [patient handout]. McKesson Health Solutions, 2014.
60. WebMD. Hyperventilation: Home Treatment. http://www.webmd.com/a-to-z-guides/tc/hyperventilation-home-treatment#1. Accessed 26 January 2018.
61. Callaham M. Hypoxic hazards of traditional paper bag rebreathing in hyperventilating patients.
Ann Emerg Med 1989;18:622–628.
62. US Department of Health and Human Services, Food and Drug Administration. Reviewer Guidance: Evaluating the Risks of Drug Exposure in Human Pregnancies. https://www.fda.gov/downloads/Drugs/.../Guidances/ucm071645.pdf. Accessed 28 November 2017.
63. Sader TW. Langman’s Medical Embryology, ed 8. Baltimore: Lippincott Williams & Wilkins, 2000.
64. Donaldson M, Goodchild JH. Pregnancy, breast-feeding and drugs used in dentistry. J Am Dent
Assoc 2012;143:858–871.
65. Michalowicz BS, DiAngelis AJ, Novak J, et al. Examining the safety of dental treatment in pregnant
women. J Am Dent Assoc 2008;139:685–695.
66. Smith LK, Draper ES, Field D. Long-term outcome for the tiniest or most immature babies: Survival rates. Semin Fetal Neonatal Med 2014;19:72–77.
67. Wynn RL, Meiller TF, Crossley HL (eds). Drug Information Handbook for Dentistry, ed 23. Hudson,
OH: Lexi-Comp, 2018.
68. Synalgos-DC (Aspirin, Caffeine, and Hydrocodeine Bitartrate) [package insert]. Atlanta: Caraco
Pharma, 2013.
69. US Department of Health and Human Services. Trends in Teen Pregnancy and Childbearing: Teen
Births. http://www.hhs.gov/ash/oah/adolescent-health-topics/reproductive-health/teen-pregnancy/trends.html. Accessed 18 January 2018.
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CHAPTER
4
Procedures
and Treatment
Guidelines
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Key Points
Radiographs that are clinically indicated and properly taken are considered
both safe and necessary for the treatment of pregnant women.
The American Dental Association (ADA) recommends delaying radiographs until after pregnancy when possible.
Radiation exposure may be minimized by deferring radiographs until after delivery if treatment will nottake place until this time.
Composite resin and amalgam restorations are considered safe when treating
dental pathology during pregnancy.
Mercury released from dental amalgam is of less concern than naturally ocurring methylmercury that can be ingested from other sources.
Scaling and root planing ( SRP) is thought to be safe to perform during pregnancy.
Oral changesthatcan occurduring pregnancy make it especially importantfor
the expectant mother to maintain meticulous oral hygiene.
Instructions for oral care after vomiting will help expectant mothers who experience nausea and vomiting during pregnancy ( NVP) .
Nutritional counseling is important to help the expectant mother minimize
dental caries, optimize health, and promote healthy fetal development.
Anticipatory guidance will help prevent oral diseases as well as provide early
identification and intervention of oral health pathologies that the infant may
experience.
Dental Radiographs
Radiographs should only be taken when it is thought that the diagnostic yield will affect
patient care.li2 Dental radiographs expose patientsto an extremely small amount of radiation.
This small amount minimizes the risk of harm to the patientand thefetus, butthe riskcannot
be completely eliminated.3-7 However, the diagnostic information from clinically indicated,
properly taken dental radiographs is generally considered to outweigh the risk of harm.1
Digital radiographs expose the patient to a fraction of the radiation required for traditional
film radiographs.8,9
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Background information
Dental x-rays are a form of ionizing radiation that is regulated at both state and federal levels.1 While large exposures of radiation have historically caused fetal harm (eg,
early medical use of pelvic radiotherapy during pregnancy, atomic bomb survivors in
Hiroshima and Nagasaki), the tiny amounts delivered from modern dental x-ray equipment pose little risk.3,7,8
Stochastic and deterministic effects of radiation
The effects of radiation can be broken down into two categories. Stochastic effects are
independent of the radiation dosage. An example of a stochastic effect is radiationinduced cancer. In contrast, deterministic effects do have a threshold dose. Radiation
below a threshold dose does not have clinically appreciable effects. On the other hand,
once radiation is above a threshold dose, the severity of the injury increases as the
dose of radiation increases. Examples of deterministic effects include skin erythema
and cataracts. Deterministic effects are rarely observed with diagnostic radiology.7
Risk of radiation to the thyroid
The thyroid is more sensitive to radiation until about age 20 years.1 Even with the
proper technique, the primary dental x-ray beam may expose the thyroid to radiation.1 Researchers in one study found an association between dental radiographs and
term low–birth weight infants.10 Protective thyroid collars should be used to minimize
this risk.11
Effect of radiation on the fetus
The effect of radiation on the fetus depends on two factors: the gestation of the fetus
and the dose of radiation. During the first trimester, the fetus is most sensitive to radiation because fetal cells are actively dividing. During the second and third trimesters,
the fetus is less sensitive to radiation.3,7,12
If the estimated threshold dosage of teratogenicity is correct, the risk of teratogenesis from dental x-ray exposure should be virtually nonexistent (< 0.1%).3 The risk of
spontaneous abortion or malformation is 1,000 times greater.8 The amount of additional radiation from dental x-rays compared with everyday life is about the same as
the increased amount of cosmic radiation that a person living in Denver experiences
compared with a person living at sea level. Yet there has not been a higher incidence
of fetal abnormalities found in Denver populations when compared with the rest of
the United States.3
The American College of Radiology and the American College of Obstetricians and
Gynecologists have both made the statement that the radiation dose for a single
diagnostic procedure is insufficient to cause harm to a developing embryo or fetus.13,14
With properly functioning modern equipment, it is unlikely that the abdominal area
will be exposed to x-rays when taking dental radiographs. Because of this, the benefit
of shielding the abdominal area with a lead apron is likely to be primarily psychologic.
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Dental Radiographs
However, the ADA currently recommends the use of a lead apron to shield both the
thyroid and the abdominal areas.3
Insurance and other administrative requirements for
dental radiographs
Radiographs taken solely for administrative purposes unnecessarily expose the
patient to radiation and are inappropriate, unethical, and in violation of both ADA
and US Food and Drug Administration (FDA) policies.11 Depending on the situation,
consider contacting the insurance company and asking what its radiographic requirements are for pregnant patients. The insurance company may have special allowances
for pregnant patients. For example, California’s Medi-Cal Dental Program specifically
waives the requirement of arch radiographs for pregnant patients for a number of
procedures.15
Effect on dental treatment
The benefit of taking necessary dental radiographs to diagnose and treat disease
that requires immediate treatment is thought to outweigh the risk, particularly for
otherwise healthy expectant mothers.1 The ADA and FDA guidelines state that before
conducting a radiographic examination, a dentist should do the following2:
• Conduct a clinical examination.
• Consider the patient’s oral and medical histories.
• Consider the patient’s vulnerability to environmental factors that may affect her
oral health.
• Prescribe an individualized radiographic examination.
Both the ADA and the National Council on Radiation Protection and Measurements
recommend that if treatment will be done after delivery, dental radiographs should
also be taken after delivery.1,16
Reasons to take radiographs during pregnancy
Because both incomplete and inaccurate diagnosis can lead to inadequate or
inappropriate treatment, appropriate dental radiographs should be taken during
pregnancy.3 Radiographs should be taken when the standard of care includes radiographs and when treatment cannot wait until after delivery.8,16,17 However, radiographs
should only be taken when there is an expectation that the diagnostic yield will affect
patient care.1,2
The dentist has the responsibility to adhere to the ALARA (as low as reasonably
achievable) principle and minimize the radiation exposure of the patient.2,13 See
Appendix C for further information on when radiographs should be taken. Some ways
to minimize radiation exposure include:
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• Avoid radiographs during pregnancy, especially during the first trimester, unless
•
•
•
•
•
there is a clinical reason.17
Take bitewing instead of panoramic radiographs.3
Use high-speed film or digital x-rays. Image receptors or film speeds slower than the
American National Standards Institute speed group E should be avoided.3
Use rectangular collimation instead of circular collimation.3
Use a properly collimated beam.3
Use a lead apron that covers the abdomen and has a protective thyroid collar on
the neck.16
Dental Materials
Dentists are fortunate to have a profession where they are able to quickly improve
the quality of people’s lives every day. However, this comes with the responsibility to
have an awareness of the impacts of restoring teeth using various dental materials.
At this time, little is known about the safety of using dental fillings during pregnancy.
Research has found that both amalgam and composite fillings can affect the human
body, but this research has been insufficient to determine how this may affect fetal
development. In general, it is thought that the benefit outweighs the risk when treating symptomatic oral conditions or conditions that may become symptomatic during
pregnancy.18
Fetal exposure to dental materials
The use of rubber dam for isolation during restorative procedures helps to minimize
maternal ingestion, aspiration, and inhalation of dental materials.9,11,13,18 Although
little is known about the safety of using dental materials during pregnancy, the FDA
classifies dental fillings (including encapsulated amalgam, gold, and composite fillings) as a class II medical device (moderate risk).9,11,19 If the FDA pregnancy rating for
drugs were applied to dental fillings, they would likely be classified as Category B or
C11 (see Table 5-1).
Dental amalgam
Fetal exposure to mercury through dental amalgam
Organic mercury (found in the environment) and inorganic mercury (found in dental
materials) are two general forms of mercury that are both well-known neurotoxins.9,20
Exposure to inorganic mercury from dental materials typically occurs at a much
lower rate than exposure to organic mercury from the environment.9 Dental amalgam
contains about 50% inorganic mercury.13,21 A person with amalgam restorations is
exposed to mercury vapor (Hg0) throughout the life of the restorations, but the threshold level in which Hg0 exposure causes neurotoxicity is not known.21 The World Health
Organization (WHO)22 estimates maximum total safe mercury intake to be 2 µg/kg/d,
and the amount of mercury released from dental amalgams in the mouth is estimated
to be approximately 10 µg/d. Factoring in body weight, this is well under the WHO’s
estimated maximum.13
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Dental Materials
Despite this current evidence, Germany, Austria, and Canada have chosen to restrict
the placing of amalgam restorations in pregnant women. Other countries, including
Sweden and Denmark, are choosing to phase out amalgam altogether due to environmental concerns.11
Fetal accumulation of mercury
Hg0 may be inhaled and absorbed into the bloodstream and crosses the placental
barrier.13 Mercury concentration in umbilical cord blood is similar to that of the expectant mother, and higher concentrations have been found in fetal kidneys compared
with fetal brains.20 Fetal brain accumulation of Hg appears to be less than that found in
the pregnant woman’s brain.21 This appears to be because the fetal liver converts Hg0
into Hg++, which does not cross the blood-brain barrier as easily as Hg0.
Mercury vapor
Hg0 may be released and systemically absorbed during the following events:
• When placing and removing amalgam restorations.9
• When bruxing or chewing on amalgam restorations.9
• When whitening teeth with products that use or generate hydrogen peroxidein the
presence of amalgam restorations.1,9
Aside from rare hypersensitivity reactions, the following organizations have made
statements that current evidence does not support the concern that dental amalgams
are unsafe23:
•
•
•
•
•
•
•
•
•
•
•
•
ADA19
Alzheimer’s Association
American Academy of Pediatrics
Autism Society of America
US Environmental Protection Agency
Mayo Clinic
National Multiple Sclerosis Society
FDA
New England Journal of Medicine
International Journal of Dentistry
National Council Against Health Fraud
National Institute of Dental and Craniofacial Research (NIDCR, part of the National
Institutes of Health)
• American Cancer Society
• WebMD
The number of amalgam fillings in the mother has not been correlated with mercury concentration in human breast milk.20
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Effect on dental treatment
Studies have not found adverse reproductive effects resulting from the placement,
removal, or presence of dental amalgam.13 In the absence of pathology, deferring the
elective replacement of dental amalgam restorations with composite restorations
may further minimize fetal exposure to mercury. Consider deferring the use of toothwhitening products that use or generate hydrogen peroxide until after pregnancy
because they may cause inorganic mercury to be released from dental amalgams.1,9
Composite resin
Composite resins are made up of polymerized resin (methacrylate monomers) and
inorganic filler.9 Research on methacrylate monomers shows that after polymerization, some monomers may be released into the oral cavity and also diffuse through
dentin to the dental pulp.9 Bisphenol A (BPA) is a chemical that can be used to make
hard plastics and dental composite resins (Fig 4-1a). High concentrations of BPA have
been shown to cause health problems, and there is a concern that BPA may be present
when using dental sealants and composite restorations.25–27 This concern originates
in a 1996 study that found BPA present in benzoporphyrin derivative monoacid ring
A (BPDMA)-based composite resins (Fig 4-1b).27 These researchers also found BPA
and BPDMA to be estrogenic.29 This study is sometimes incorrectly applied to nonBPDMA-based composite resins.27 It is possible that a patient may be exposed to
small amounts of BPA either through an impurity retained in the manufacturing process or via breakdown of a material such as bisphenol A–dimethacrylate (bis-DMA).25
BPDMA-based composite resins undergo a hydrolysis reaction in saliva that breaks
BPDMA into BPA.25 On the other hand, bisphenol A–glycidyl methacrylate (bis-GMA)
based composite resins do not break down into BPA in saliva (Fig 4-1c).25 Dental manufacturers have been aware of and used bis-GMA in the manufacture of some dental
resins since the 1960s.27 Dental manufacturers can use high-quality sources of bis-GMA
with no detectable BPA.27
Effect on dental treatment
There are no known short-term health risks with the placement of dental sealants or
composite resins. However, there is also insufficient information available to determine if there are any effects of long-term exposure.9 Dental composite resins have not
been shown to adversely affect health through exposure to BPA.25
If you have questions regarding a specific restorative material, check the Material
Safety Data Sheet (MSDS), the Safety Data Sheet (SDS), or the Globally Harmonized
System of Classification and Labelling of Chemicals (GHS), or contact the dental manufacturer of that material.
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SRP and Prophylaxis During Pregnancy
H
O
O
O
H
O
O
O
a
24
b
BPA
28
BPDMA or bis-DMA
O
O
H
O
O
O
O
H
O
c
bis-GMA30
O
Fig 4-1 (a) Chemical structure of BPA. (b) BPDMA’s ester linkage has resonance-stabilized intermediates. In saliva, a hydrolysis reaction converts BPDMA into BPA.25 (c) bis-GMA has a stable ether linkage
that does not undergo a salivary hydrolysis reaction.25
SRP and Prophylaxis During Pregnancy
Periodontal disease is correlated with a variety of adverse pregnancy outcomes. These
adverse outcomes may include low birth weight (LBW), preterm birth (PTB), small size
for gestational age, pregnancy-induced hypertension, and fetal loss.31–33 The causeeffect relationships between pregnancy and periodontal disease have not yet been
established; periodontal disease may lead to pregnancy complications, pregnancy
may worsen periodontal disease, or the two may build off each other.34–36
Ideally, a woman should be free of periodontal disease prior to becoming pregnant. Nonsurgical periodontal therapy such as SRP may benefit the patient.36 There
is conflicting evidence as to whether the fetus will benefit if the patient undergoes
periodontal treatment. After one early meta-analysis found fetal benefit, health plans
increased dental coverage.37 However, multiple subsequent meta-analyses that had
access to additional research did not find fetal benefit when nonsurgical periodontal
therapy was performed during pregnancy.34,35,38–42
There may be certain categories of high-risk pregnancies where there is possible
fetal benefit to receiving periodontal therapy during pregnancy.38 Further research is
needed to confirm and identify which women may benefit from receiving periodontal
treatment during pregnancy.38 Fetal benefit may be linked to the success of periodontal therapy.43 The timing of periodontal therapy during the pregnancy may affect
whether or not there is fetal benefit.40
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4 | Procedures and Treatment Guidelines
Periodontal therapy will induce a transient bacteremia in the woman.33 It may be
important to note that subgingival bacteria was reported to travel to the placenta and
cause fetal demise in one case.44 Because this incident did not involve dental treatment, alone it is insufficient to reach a conclusion of how dental treatment may affect
pregnancy. This case occurred at term (39 weeks, 5 days).44 In comparison, periodontal treatment is usually scheduled early during the second trimester.45 The authors
reporting this incident suggest antibiotic prophylaxis in the presence of multiple
infections.44
Because clinical trials have not provided evidence of short-term adverse effects in
healthy patients, dental prophylaxis and SRP are both thought to be safe during pregnancy.42,46 A current literature review did not produce any long-term studies examining
the safety of dental treatment on the pregnant patient.
Effect on dental treatment
Researchers suggest that it is safe to provide SRP and dental prophylaxis during pregnancy.35 The first half of the second trimester has traditionally been thought to be
the safest time for SRP. One research study found no increased risk of adverse medical events when SRP is done during this time frame.46 Additional factors such as the
woman’s health and her ability to tolerate treatment may need to be taken into consideration when recommending treatment options.
Antibiotic prophylaxis is not routinely recommended to address the treatmentinduced bacteremia during pregnancy. Antibiotic prophylaxis may be given for other
clinically indicated reasons, such as the presence of multiple infections.44
When anesthetic agents are needed, consider pregnancy category B anesthetics.
Consider lidocaine or a lidocaine/prilocaine combination (eg, Oraqix [Dentsply]) for
topical anesthesia. Consider lidocaine with 1:100,000 epinephrine for local anesthesia. See chapter 7 for further details.
At-Home Oral Care
Dental treatment is only one piece of the patient’s overall oral health. In addition, it is
important to teach pregnant patients how to take care of their oral hygiene at home so
that they can take an active role in maintaining their oral health. As part of educating
the patient on at-home oral care, it is important to provide oral hygiene instructions
and explain how diet affects oral health.
Because of the oral changes that occur during pregnancy, including the increased
prevalence of gingivitis, it is especially important for the patient to maintain meticulous oral hygiene throughout her pregnancy.
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At-Home Oral Care
Brushing, flossing, and mouthwash
Toothbrush instructions
Each person in a family should have his or her own toothbrush, and toothbrushes
should not be shared.9 Toothbrushes should be replaced at the first sign of wear, or
every 3 to 4 months.18,47 Toothbrushes with soft bristles should be chosen.48
Toothpaste selection
Toothpaste, or dentifrice, is designed to aid in the removal of plaque and bacterial
biofilm by improving the mechanical cleaning that a toothbrush can provide. The ADA
Seal of Acceptance for toothpastes is more rigorous than the FDA’s requirements for
manufacturers who make toothpaste.49 In addition to the mild abrasive that toothpastes typically contain, they may contain a number of other ingredients depending
on the purpose of the toothpaste. For example, desensitizing toothpastes may contain potassium nitrate or strontium chloride.49 If the toothpaste helps to reduce the
accumulation of calculus, then it may include an ingredient such as pyrophosphates,
triclosan, or zinc citrate.49 A stain-removing toothpaste may have abrasives that are
made of modified silica abrasives or enzymes.49
Brushing technique
While the specific brushing technique may need to be modified for the specific patient,
some general recommendations can be used as a starting point. All patients should
brush their teeth at least twice a day for 2 minutes.41,48 It is particularly important for
them to brush their teeth and use dental floss before going to bed.9 They should use a
toothpaste that contains fluoride, brush with gentle pressure, and position the toothbrush at a 45-degree angle to the gums and the teeth.41,48,50 It is important to brush
the outer, inner, and occlusal surfaces of the teeth as well as the gingival sulcus.47 In
addition, patients should also brush their tongue to remove bacteria.47
Use of interdental cleaners
In general, patients should use an interdental cleaner such as dental floss at least
once a day.9,11,18,47,50 The selection of the appropriate interdental cleaner and the proper
technique need to be customized to the specific needs of the individual patient. Both
the ADA and the American Dental Hygienists Association have good patient education
resources to help instruct the patient in proper flossing techniques (see Appendix E).
Use of mouthwash
In addition to brushing and flossing, patients should also use mouthwash.5 By rinsing
with a fluoride-containing alcohol-free mouth rinse right before going to bed, patients
can help to remineralize their teeth.18 While the amount of alcohol absorbed during
proper use of an alcohol-based mouth rinse may be negligible, recommending an
alcohol-free mouthwash preempts the possible situation where someone comes to
the conclusion that alcohol in the mouthwash caused a problem during pregnancy.
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For additional information about at-home oral care, patients can also be referred
to the ADA’s website.
Oral care after vomiting
Vomiting increases acidity in the mouth and also places digestive enzymes (pepsin and trypsin) in the oral cavity, which may transiently increase the risk for tooth
demineralization and erosion.51 The patient should avoid brushing for about 1 hour
after vomiting because brushing teeth immediately after vomiting can worsen tooth
demineralization.5 To help neutralize acidity and minimize dental erosion, the woman
should do one of the following immediately after vomiting:
• Rinse with water.11
• Rinse with water with baking soda (sodium bicarbonate). Use an 8-oz cup of water
containing 1 tsp baking soda.9
• Rinse with a fluoride-containing mouthwash.5,9
• Apply or gently brush casein phosphopeptide amorphous calcium phosphate
paste (eg, MI Paste [GC America]) onto the teeth.5
Reinforce medical recommendations
Advise patients to avoid alcohol, tobacco (including secondhand smoke), and recreational drugs during pregnancy.9
Nutritional Counseling
Eating healthy is good for both the patient’s body and her teeth. The Academy of
Nutrition and Dietetics has additional information on nutrition during pregnancy and
also provides a resource to locate a dietitian (see Appendix E).
Eat healthy foods
In addition to taking prenatal vitamins, pregnant patients should be encouraged to
eat a variety of healthy foods such as fruits, vegetables, whole-grain foods, beans,
nuts, milk, unsweetened yogurt, cheese, cottage cheese, meats, fish, and eggs.9,18 They
should eat foods that are high in protein; calcium; phosphorus; and vitamins A, C, and
D.9 For snacks, suggest small amounts of noncariogenic foods that are rich in protein,
such as cheese.9 If nausea prevents the patient from eating very much, suggest eating
small quantities of healthy food throughout the day.9,18
Avoid foods that are high in sugar
Reducing the amount of foods that are high in sugar such as candy, desserts, and
dried fruit is recommended.18 Eating foods that are rich in fermentable carbohydrates
or sugars, such as cookies, crackers, and chips, increases the risk of caries. Frequent
snacking with these foods also increases caries risk.9
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Nutritional Counseling
Limit foods that contain mercury
Pregnant women should be educated that mercury is a naturally occurring element
that is prevalent in the environment. This environmental exposure is more likely to
be harmful than exposure from amalgam fillings. Environmental exposure to organic
mercury (methylmercury, MeHg or [CH3Hg]+) has caused developmental delay, microcephaly, and severe brain damage.51 The FDA recommends that pregnant women
avoid eating fish that accumulate mercury such as shark, swordfish, king mackerel,
and tilefish.52 However, fish with lower levels of mercury (eg, halibut and albacore
tuna) can be consumed at 4 oz per week, and the FDA actually recommends eating 8
to 12 oz per week of a variety of other fish and seafood (eg, salmon, shrimp, tilapia).52
Drinks
Pregnant women should drink optimally fluoridated water, which the US Public Health
Service has defined as 0.7 mg/L.18,53 Alcoholic beverages should not be consumed
during pregnancy.9,18 Between meals, the patient should replace juice, fruit-flavored
drinks, and carbonated beverages with either water or milk.18 The recommended daily
fruit intake should be met by eating fruit rather than by drinking fruit juice.9 During
meals, pregnant patients should reduce or eliminate drinking of the following9,18:
•
•
•
•
Juice
Soda, including diet soda (acids weaken tooth enamel)
Sports drinks
Carbonated drinks
Xylitol
Chewing xylitol-containing gum or eating xylitol-containing products is one method
to reduce cariogenic bacteria and improve oral health. (See page 69 for more
information.)
Folate
Adequate folate reduces the chance of cleft lip and palate.9 The US Public Health
Service and Centers for Disease Control and Prevention recommend that all women of
childbearing age consume 0.4 mg of folic acid (a synthetic version of folate) every day
to reduce the chance of birth defects should they become pregnant.32 Some foods are
specifically fortified with folate or folic acid, and some foods naturally include folate,
including18:
•
•
•
•
Asparagus, broccoli, lettuce, spinach, and other green leafy vegetables
Legumes such as peas, lentils, and beans
Papaya, oranges, strawberries, cantaloupe, and bananas
Tomato and orange juice
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Anticipatory Dental Guidance
Anticipatory guidance to the expectant mother should be provided during pregnancy to help her prepare for taking care of her infant. As a starting point, she should
continue following the general dietary recommendations and at-home oral hygiene
instructions described previously. In addition, the expectant mother should be educated with what to expect and what steps she can take to make sure both herself and
her infant will have good oral health. The American Academy of Pediatric Dentistry
(AAPD) and the ADA have excellent resources and a collection of clinical practice
guidelines (see Appendix E).
Minimize transmission of cariogenic bacteria
Educate the patient that saliva-sharing behavior such as the following may spread
oral disease—including caries—to the infant9,11,41,54,55:
•
•
•
•
•
Kissing the baby on the mouth
Sharing a spoon while tasting baby food
Cleaning a dropped pacifier with your mouth
Licking your finger to wipe the baby’s mouth
Allowing children to share toys, pacifiers, and other items that children may place
in their mouths
• Allowing older children to share straws, cups, or eating utensils
Minimize cariogenic bacteria in people who are
around the infant
A mother’s saliva is the main source of her children’s oral bacteria. A mother with high
levels of cariogenic bacteria is more likely to pass the cariogenic bacteria on to her
infant.9 Providing dental treatment to the mother and also to those around the infant
will decrease the number of cariogenic bacteria that may be transferred to the infant.
The purpose of providing dental treatment is to improve the oral health of those
around the infant, which in turn minimizes the transfer of cariogenic bacteria to the
infant.9 After pregnancy, encourage the woman to continue with dental care.9
Maternal use of xylitol
Restorative dentistry by itself does not decrease the bacterial load sufficiently to prevent transmission to the infant—antibacterial treatment is also necessary. Antibacterial
treatment may include fluoride, chlorhexidine, and xylitol usage.9 Xylitol may be more
effective than fluoride or chlorhexidine at reducing Streptococcus mutans levels in the
mother and subsequently preventing caries in her children.56 The anticaries effect of
xylitol appears to last for years.56
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Anticipatory Dental Guidance
Xylitol gum
A 70% reduction in caries in 5-year-old children was observed when mothers chewed
xylitol-containing gum four times per day.57 In this study, mothers had an average daily
dose of 6 to 7 g of xylitol from 3 months after delivery until her child was 2 years old.57
Based on research, the suggested dose and frequency of xylitol-containing gum is to
chew it three to seven times per day with a total xylitol intake of 4 to 10 g per day.9,56,58–60
It is important to note that most readily available consumer gum often does not have
sufficient xylitol to provide a caries-protective effect.58
Xylitol side effects
Consuming 3 to 60 g of xylitol per day has resulted in patients experiencing abdominal distress and osmotic diarrhea.56 Others have reported that osmotic diarrhea may
occur when xylitol is consumed at four to five times that required for caries prevention,
which is a total of 6 to 10 g of xylitol per day.58
Oral care for the infant
Emphasize the importance of the child’s primary dentition.9 Parents and other caregivers should regularly lift their child’s lip and look for white or brown spots on their
teeth.9 Also, instruct them to ask their baby’s health professional about his or her oral
health.18 The AAPD recommends that infants should be seen by a dentist after the
eruption of their first tooth but no later than 12 months of age, preferably between 6
and 12 months of age.61
Breastfeeding
Breastfeeding is associated with a number of health benefits. Children who are exclusively breastfed for the first 6 months of life have been found to have between a 41%
and 72% decreased prevalence of moderate to severe malocclusion.62 Support a
woman’s decision to breastfeed.9 If she has difficulty or questions, she can be referred
to her physician or a lactation consultant. One resource for finding a lactation consultant is the International Lactation Consultant Association (see Appendix E).
Reconstituting infant formula
Optimally fluoridated water can occasionally be used when reconstituting infant formula, but regular use of fluoridated water for such purpose may result in the child
developing enamel fluorosis.9,63,64 The ADA’s evidence-based dentistry website has further information on this issue (see Appendix E).
Dietary recommendations
Food that contains sugar should be limited to mealtimes. If food is eaten between
meals, it should be noncariogenic and nutritious.9 If the child is given a bottle or sippy
cup in between meals or at bedtime, it should only contain water.9 Children should
consume fresh fruit instead of fruit juice to meet the recommended daily fruit intake.9
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Caries risk assessment
By age 1 year, a child’s risk of oral disease should be assessed.9 Both the ADA and the
AAPD provide caries risk assessment tools, which are outlined in Appendix B. A caries
risk assessment takes into consideration a number of different factors that have been
associated with dental caries:9
•
•
•
•
•
•
•
•
•
Inadequate or inappropriate fluoride exposure
Past or current caries of the child, his or her siblings and parents, or other caregivers
Restorations placed within the past 2 years
Inadequate age-appropriate oral hygiene by parents or caregivers
Developmental delays or disabilities
Clinical findings of plaque accumulation
Clinical signs of decalcification (white spot lesions)
Medications that contain sugar
Medications that inhibit salivary flow:
‒‒ Anticholinergics
‒‒ Asthma medications
‒‒ Seizure medications
‒‒ Attention-deficit hyperactivity disorder medications
‒‒ Antibiotics administered in a sugary syrup
• Use of a nighttime bottle or sippy cup with anything other than water
• Frequent exposure to fermentable carbohydrates
Professionally applied topical fluoride treatment
Professionally applied topical fluoride treatment is recommended for children with
high or increased caries risk. For all children regardless of caries risk, the AAPD recommends a professional topical fluoride treatment at least every 6 months.63 The ADA
recommends fluoride varnish every 3 to 6 months.65
Silver diamine fluoride
In recent years, silver diamine fluoride (SDF) has been gaining attention as a potential
caries-arresting medicament. Of the graduate pediatric dentistry training programs
surveyed, most were either already teaching SDF or planning on implementing the
use of SDF into their training programs.66 In 2014, the FDA approved SDF to be used for
desensitization in adults.66 The off-label use for caries control in young children has
been demonstrated in a large clinical trial.66 A single SDF application has 47% to 90%
effectiveness in arresting caries.67 However, to maintain caries arrest, reapplication of
SDF may be necessary. Bond strength of resin composite to dentin is not affected by
prior application of SDF.67–69
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Anticipatory Dental Guidance
Some of the adverse effects that have been noted with SDF include the following67:
•
•
•
•
Metallic/bitter taste
Temporary staining of skin
Mucosal irritation lesions
Dark-staining caries lesions (The AAPD has recommended the use of photographs
that show SDF-related staining.)
Billing, coding, and reimbursement for caries-arresting medicaments, including
SDF, are still in the early stages. In 2016, the ADA introduced current dental terminology (CDT) code D1354.70 In 2017, the ADA further redefined this code D1354 as “interim
caries arresting medicament application – per tooth” to indicate that this code should
be used per tooth.70
According to the AAPD Policy Statement on the Use of SDF for Pediatric Dental
Patients,71 the AAPD supports the following:
• The use of SDF as part of an ongoing caries-management plan with the aim of optimizing individualized patient care.
• Third-party reimbursement for fees associated with SDF.
• More practice-based research to be conducted on SDF to evaluate its efficacy.
Cleaning the infant’s teeth
Instruct the infant’s caregiver to wipe the infant’s teeth after each feeding with a soft
cloth or toothbrush with soft bristles; this practice should begin as soon as the first
tooth erupts.9 Parents should be sure to brush their child’s teeth before bedtime.9 An
adult will need to supervise the brushing of a child’s teeth until the child is about 7
years old. The transition to the child brushing his or her own teeth can occur only
when he or she is able to brush effectively.9
Toothpaste for the infant
The ADA Council on Scientific Affairs recommends using fluoride-containing toothpaste based on the risk of developing caries.72 General recommendations are outlined
in Box 4-1:
Box 4-1 | Recommended amounts of fluoridated toothpaste for children
ADA recommendations72
AAPD recommendations63
•
•
•
Use a smear of toothpaste from eruption of the first tooth until age 3 years.
Increase to a pea-sized amount at
age 3 years and continue with this
amount until age 6 years.
•
Use a smear of toothpaste from eruption of the first tooth until age 2 years.
Increase to a pea-sized amount at age
2 years and continue with this amount
until age 5 years.
71
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4 | Procedures and Treatment Guidelines
From the eruption of the first tooth to 2 or 3 years of age, use a smear of fluoridecontaining toothpaste. The purpose of starting with the eruption of the first tooth is to
maximize the caries-protective benefit that fluoride provides. The delay in using peasized amounts of fluoride-containing toothpaste is to minimize risk of fluorosis if the
child swallows the toothpaste. The greatest risk of fluorosis for the permanent central
incisors occurs approximately at 2 years of age. From age 3 to 6 years, use a pea-sized
amount of fluoride-containing toothpaste (Fig 4-2).
Fig 4-2 Use a small amount of toothpaste for young children.
(Reprinted with permission from Terry.73)
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7. Nguyen CP, Goodman LH. Fetal risk in diagnostic radiology. Semin Ultrasound CT MR 2012;33:4–10.
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9. California Dental Association Foundation; American College of Obstetricians and Gynecologists,
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Health Issues. Chicago: ADA Council on Access, Prevention, and Interprofessional Relations, 2006.
17. Ritter AV, Southerland JH. Pregnancy and oral health. J Esthet Restor Dent 2007;19:373–374.
18. Oral Health Care During Pregnancy Expert Workgroup. Oral health care during pregnancy: A national consensus statement. Washington, DC: National Maternal and Child Oral Health Resource
Center, 2012.
19. American Dental Association. Statement on Dental Amalgam. http://www.ada.org/en/aboutthe-ada/ada-positions-policies-and-statements/statement-on-dental-amalgam. Accessed 22
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20. Luglie PF, Campus G, Chessa G, et al. Effect of amalgam fillings on the mercury concentration in
human amniotic fluid. Arch Gynecol Obstet 2005;271:138–142.
21. Watson GE, Lynch M, Myers GJ, et al. Prenatal exposure to dental amalgam. Evidence from the
Sychelles Child Development Study main cohort. J Am Dent Assoc 2011;142:1283–1294.
22. World Health Organization. Exposure to Mercury: A Major Public Health Concern. http://www.
who.int/phe/news/Mercury-flyer.pdf. Accessed 14 November 2017.
23. American Dental Association. Dental Amalgam: What Others Say. www.ada.org/en/press-room/
press-kits/dental-filings-press-kit/dentalamalgam-what-others-say. Accessed 22 Janaury 2018.
24. National Center for Biotechnology Information. Bisphenol A. http://pubchem.ncbi.nlm.nih.gov/
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25. Chen L, Suh BI. Bisphenol A in dental materials: A review. JSM Dent 2013;1:1004.
26. Bonefeld-Jørgensen EC, Long M, Hofmeister MV, Vinggaard AM. Endocrine-disrupting potential
of bisphenol A, bisphenol A dimethacrylate, 4-n-nonylphenol, and 4-n-octylphenol in vitro: New
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27. Fischer D. Ultradent’s Vigilance with BPA. https://www.ultradent.com/zh-cn/Dental-Products/
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ncbi.nlm.nih.gov/compound/Bisphenol_A_dimethacrylate. Accessed 22 January 2018.
29. Olea N, Pulgar R, Pérez P, et al. Estrogenicity of resin-based composites and sealants used in
dentistry. Environ Health Perspect 1996;104:298–305.
30. National Center for Biotechnology Information. Bis-GMA. http://pubchem.ncbi.nlm.nih.gov/
compound/15284. Accessed 22 January 2018.
31. Offenbacher S, Katz V, Fertik G, et al. Periodontal infection as a possile risk factor for preterm low
birth weight. J Periodontol 1996;67(10 suppl):1103–1113.
32. Vergnes JN, Sixou M. Preterm low birth weight and maternal periodontal status: A meta-analysis.
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33. Xiong X, Buekens P, Fraser WD, Beck J, Offenbacher S. Periodontal disease and adverse pregnancy outcomes: A systematic review. BJOG 2006;113:135–143.
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34. Baccaglini L. A meta-analysis of randomized controlled trials shows no evidence that periodontal treatment during pregnancy prevents adverse pregnancy outcomes. J Am Dent Assoc
2011;142:1192–1193.
35. Bobetsis YA, Barros SP, Offenbacher S. Exploring the relationship between periodontal disease
and pregnancy complications. J Am Dent Assoc 2006;137(suppl):7–13.
36. Sanz M, Kornman K, Working group 3 of joint EFP/AAP workshop. Periodontitis and adverse pregnancy outcomes: Consensus report of the Joint EFP/AAP Workshop on Periodontitis and Systemic Diseases. J Periodontol 2013;84(4 suppl):s164–s169.
37. McQueen MP. Health plans expand dental benefits. The Wall Street Journal. September 19, 2006.
https://www.wsj.com/articles/SB115862887605767077. Accessed 13 November 2017.
38. Kim AJ, Lo AJ, Pullin DA, Thornton-Johnson DS, Karimbux NY. Scaling and root planing treatment for periodontitis to reduce preterm birth and low birth weight: A systematic review and
meta-analysis of randomized controlled trials. J Periodontol 2012;83:1508–1519.
39. Polyzos NP, Polyzos IP, Zavos A, et al. Obstetric outcomes after treatment of periodontal disease
during pregnancy: Systematic review and meta-analysis. BMJ 2010;341:c7017.
40. Uppal A, Uppal S, Pinto A, et al. The effectiveness of periodontal disease treatment during pregnancy in reducing the risk of experiencing preterm birth and low birth weight: A meta-analysis. J
Am Dent Assoc 2010;141:1423–1434.
41. Michalowicz BS, Gustafsson A, Thumbigere-Math V, Buhlin K. The effects of periodontal treatment on pregnancy outcomess. J Am Dent Assoc 2013;84(4 suppl):S195–S208.
42. The American College of Obstetricians and Gynecologists. Oral Health Care During Pregnancy
and Through the Lifespan. Committee Opinion Number 569. https://www.acog.org/Resources-And-Publications/Committee-Opinions/Committee-on-Health-Care-for-Underserved-Women/
Oral-Health-Care-During-Pregnancy-and-Through-the-Lifespan. Accessed 13 November 2017.
43. Jeffcoat M, Parry S, Sammel M, Clothier B, Catlin A, Macones G. Periodontal infection and preterm
birth: Successful periodontal therapy reduces the risk of preterm birth. BJOG 2011;118:250–256.
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48. American Dental Association. Brushing Your Teeth. http://www.mouthhealthy.org/en/az-topics/b/brushing-your-teeth. Accessed 22 January 2018.
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50. For the dental patient: Oral health during pregnancy. J Am Dent Assoc 2011;142:574.
51. Schlueter N, Glatzki J, Klimek J, Ganss C. Erosive-abrasive tissue loss in dentine under simulated
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52. US Food and Drug Administration. Eating Fish: What Pregnant Women and Parents Should Know.
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53. US Department of Health and Human Services Federal Panel on Community Water Fluoridation.
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pregnant women with a nurse practitioner-directed oral care program. J Am Acad Nurse Pract
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56. American Academy on Pediatric Dentistry. Policy on the Use of Xylitol. http://www.aapd.org/media/Policies_Guidelines/P_Xylitol.pdf. Accessed 22 January 2018.
57. Isokangas P, Söderling E, Pienihäkkinen K, Alanen P. Occurrence of dental decay in children after
maternal consumption of xylitol chewing gum, a follow-up from 0 to 5 years of age. J Dent Res
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58. Ly KA, Milgrom P, Rothen M. Xylitol, sweeteners, and dental caries. Pediatr Dent 2006;28:154–163.
59. National Maternal and Child Oral Health Policy Center. Improving the Oral Health of Pregnant Women and Young Children: Opportunities for Policymakers. https://www.astdd.org/docs/improvingthe-oral-health-of-pregnant-and-young-children-aug-2012.pdf. Accessed 14 November 2017.
60. Mäkinen KK. Sugar alcohols, caries incidence, and remineralization of caries lesions: A literature
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61. American Academy of Pediatric Dentistry Clinical Affairs Committee, American Academy on Pediatric Dentistry Council on Clinical Affairs. Guideline on periodicity of examination, preventive
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62. Peres KG, Cascaes AM, Peres MA, et al. Exclusive breastfeeding and risk of dental malocclusion.
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63. American Academy of Pediatric Dentistry. Guideline on fluoride therapy. Pediatr Dent
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64. Berg J, Gerweck C, Hujoel PP, et al. Evidence-based clinical recommendations regarding fluoride
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65. Weyant RJ, Tracy SL, Anselmo TT, et al. Topical fluoride for caries prevention: Executive summary
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69. Selvaraj K, Sampath V, Sujatha V, Mahalaxmi S. Evaluation of microshear bond strength and nanoleakage of etch-and-rinse and self-etch adhesives to dentin pretreated with silver diamine fluoride/potassium iodide: An in vitro study. Indian J Dent Res 2016;27:421–425.
70. American Dental Association. D1354 – ADA Guide to Reporting Interim Caries Arresting Medicament Application. http://www.ada.org/~/media/ADA/Publications/Files/D1354_ADAGuidetoReportingInterimCariesArrestingMedicamentApplication_v1_2017Jul15.pdf?la=en. Accessed 14
November 2017.
71. American Academy of Pediatric Dentistry. Policy on the Use of Silver Diamine Fluoride for Pediatric Dental Patients. http://www.aapd.org/media/Policies_Guidelines/P_SilverDiamine.pdf.
Accessed 14 November 2017.
72. American Dental Association Councel on Scientific Affairs. Fluoride toothpaste use for young children. J Am Dent Assoc 2014;145:190–191.
73. Terry DA. What’s in Your Mouth? Chicago: Quintessence, 2013:6.
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CHAPTER
5
Administration
of Drugs During
Pregnancy
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Key Points
• Women who aretryingto become pregnantshould be advised ofthe potential
•
risk (s) of any medications they may be taking.
When prescribing a medication forthe pregnant patient, select the safest medication and prescribe for the minimum necessary duration and dosage.1 2
The US Food and Drug Administration ( FDA) has defined five pregnancy categories that can be used when making decisions on which medication to prescribe3-5:
A and B can be administered during pregnancy.
C can be used with caution during pregnancy. (When prescribing these
medications, the dentist may consider consulting with the patient’s prenatal care provider.)
D and X should be avoided during pregnancy.
Risk does not necessarily progress from A to X.
Drugs within the same category do not necessarily provide the same level
of risk.
The Pregnancy and Lactation Labeling Rule ( PLLR) is being phased in to allow
prescribers access to better information for making decisions.
,
•
•
The FDA considers a number of the medications commonly used in dentistry to be relatively
safe.6 However, a risk- benefit evaluation should be considered before prescribing or administering any medication to a pregnant patient.1 If a woman is trying to become pregnant,
she should be advised of the potential risk if she becomes pregnant while taking a medica tion.3 When selecting a medication to administer or prescribe, the dentist should consider
the following1’2:
• Evaluate the potential risk and benefit to expectant mother and her unborn baby.
• Choose the medication most likely to be safest.
• Minimize the duration and dosage.
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5 | Administration of Drugs During Pregnancy
Factors that affect bioavailability of drugs to the fetus
Maternal plasma has a higher capacity to bind drugs than fetal plasma, but this difference has not been shown to be significant for toxicity.7 Drugs that compete for plasma
protein binding may be more bioavailable to fetal plasma, and fetal acidemia may
lead to increased drug absorption and retention in the placenta.7 Only free, unbound
drugs are able to travel to the placenta.7 During pregnancy, several factors predispose
the patient to fetal exposure to unbound drugs:8
•
•
•
•
•
•
•
Decreased serum concentration required for drug binding
Increased drug distribution volume
Decreased maximum plasma concentration
Decreased plasma half-life
Increased lipid solubility
Increased clearance of drugs
Delayed gastric emptying (which may in turn increase drug bioavailability)9
The injection for nerve blocks occurs right next to blood vessels, and the chance of
accidental intravascular injection is present. Accidental intravascular injection may
introduce a drug systemically. With proper technique, the chance of accidental intravascular injection is minimized.7,10 Studies on pregnant women have been conducted
over very short time frames with respect to the human lifetime. As such, it may take
many years before adverse effects that might manifest late in life become apparent.
For example, if in-utero exposure to a drug caused a minor decrease in intelligence or
fertility, it may not be noticed for many years, if at all.1
Nursing mothers
A single prescription may overlap pregnancy, birth, and nursing. It is important to be
aware that the nursing infant is exposed to most maternal drugs via breast milk.4,8
Because of this, if it is anticipated that a woman may be nursing while taking a prescription medication, it is best to educate her on the possible risks of nursing while
taking said medication.
FDA Pregnancy Risk Categories
FDA pregnancy risk categories (PRCs) are a useful tool in determining which medications to provide to the pregnant patient (Table 5-1). Based on feedback that these
categories are oversimplified and may lead to poorly informed clinical decisions, the
FDA has replaced PRCs with the Pregnancy and Lactation Labeling Rule (PLLR) for
prescription drugs.11,12
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FDA Pregnancy Risk Categories
Table 5-1 | F
DA pregnancy categories11
A
Adequate, well-controlled studies in pregnant women have failed to demonstrate a risk
to the fetus in the first trimester of pregnancy, and there is no evidence of a risk in later
trimesters.
If this drug is used during pregnancy, the possibility of fetal harm appears remote. Because studies cannot rule out the possibility of harm, however, this drug should be used
during pregnancy only if clearly needed.
B
Animal reproduction studies have failed to demonstrate a risk to the fetus, and there are
no adequate and well-controlled studies in pregnant women.
or
Animal reproduction studies have shown an adverse effect (other than decrease in
fertility), but adequate and well-controlled studies in pregnant women have failed to
demonstrate a risk to the fetus during the first trimester and there is no evidence of risk in
later trimesters.
Because animal reproduction studies are not always predictive of human response and
because the studies in humans cannot rule out the possibility of harm, this drug should
be used in pregnancy only if clearly needed.
C
There are no adequate and well-controlled studies in humans, and either there are no
animal reproduction studies or animal reproduction studies have shown an adverse effect
on the fetus.
It is also not known whether this drug can cause fetal harm when administered to a pregnant woman or if it can affect reproduction capacity. The benefits from the use of the drug
in pregnant women may be acceptable despite its potential risks. This drug should be
used during pregnancy only if the potential benefit justifies the potential risk to the fetus.
D
There is positive evidence of human fetal risk based on adverse reaction data from investigational or marketing experience or studies in humans, but the potential benefits from
the use of the drug in pregnant women may be acceptable despite its potential risks.
X
Studies in animals or humans have demonstrated fetal abnormalities, or there is positive
evidence of fetal risk based on adverse reaction reports from investigational or marketing
experience (or both). The risk of the use of the drug in a pregnant woman clearly outweighs any possible benefit.
Limitations with the PRCs
The FDA has chosen to phase out the PRCs for prescription medications because the
PLLR will better support the needs of clinicians to safely treat patients.11 However, clinicians will likely still encounter the PRCs in their practice during the transition to the
PLLR, and the PRCs will remain for over-the-counter medications. By identifying the
limitations of the PRCs, the clinician will have a greater understanding of the implications of using them to prescribe or administer medications to the pregnant patient.
The following section is a selected summary of issue 104, volume 73 of the 2008
issue of the Federal Register.11 The PRC classification system may incorrectly convey
that drug risk categories increase from A to X as drugs are determined to carry greater
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5 | Administration of Drugs During Pregnancy
risk. Categories C, D, and X may all have similar risk, but they are categorized differently based on different risk-benefit considerations. This classification system may
also incorrectly lead the practitioner to conclude that the drugs from the same category have similar risk for developmental toxicity. Currently, drugs with known risk can
be placed in the same category as drugs with no known risk.
The PRC labeling does not take the following into account:
• Whether the risk is based on effects that have been observed in human versus animal studies
• Statistical significance and study design
• Degree of risk based on dose, duration, frequency, route of exposure, or gestational
timing
This labeling also does not address inadvertent exposure to a drug. Because about
50% of pregnancies are unplanned, there is significant potential for inadvertent drug
exposure. Labeling does not adequately address the full range of potential developmental toxicities, which may include:
•
•
•
•
Fetal death
Structural malformations
Perturbations of fetal growth
Functional deficits
There should be a mechanism to routinely update the Pregnancy subsection of
labeling to include human exposure information as it becomes available.
PLLR
The FDA is phasing out pregnancy categories A, B, C, D, and X.12 The new system, PLLR,
provides a risk summary of the drug being used during pregnancy and lactation as
well as how it may affect reproductive potential. It is important to be aware that the
PLLR only applies to prescription medications, not over-the-counter medications.12
The PLLR applies the following three sections to drug labeling:
• Section 8.1: Pregnancy (includes labor and delivery)
• Section 8.2: Lactation (includes nursing mothers)
• Section 8.3: Females and Males of Reproductive Potential
In the PLLR, Section 8.1, Pregnancy, includes the information from both the old section 8.1, Pregnancy, and the old section 8.2, Labor and Delivery. The original section
8.3, Nursing Mothers, has been renumbered and renamed as Section 8.2, Lactation. A
new section 8.3, Females and Males of Reproductive Potential, is also introduced under
this rule.12 Table 5-2 provides an overview of the new labeling.
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FDA Pregnancy Risk Categories
In the past, the PRCs provided a simplified single-letter representation of risk. This
new labeling replaces this single-letter representation with a more informative narrative summary that gives the provider additional information that previously was not
easily accessible. This should help the provider to make a better benefit-versus-risk
assessment, which in turn should allow for better prescribing decisions.
Table 5-2 | S
ummary of new PLLR for prescription drugs
Old
labeling12
8.1 Pregnancy
New
labeling13
8.2 Labor and
Delivery
8.3 Nursing Mothers
8.1 Pregnancy
Pregnancy Exposure Registry*
8.2 Lactation
Risk Summary†
Information regarding the pregnancy and exposure registry information for this drug. The FDA
has a list of registries (see Appendix E).
Summarizes information on the
presence of a drug and/or its
active metabolite(s) in human
milk, the effects of a drug and/
Risk Summary†
or its active metabolite(s) on the
• Statement that the drug is contraindicated breastfed child, and the effects
during pregnancy*
of a drug and/or its active me• Risk statement based on human data
tabolite(s) on milk production
• Risk statement based on animal data
Clinical Considerations*
• Risk statement based on pharmacology*
• Background birth defects and miscarriage (Provides information to further
rates
inform prescribing and risk-
8.3 Females
and Males of
Reproductive
Potential
Pregnancy
Testing*
Recommendations
or requirements for
pregnancy testing
before, during, or
after drug therapy.
Contraception*
Recommendations
or requirements for
contraception before, during, or after
drug therapy.
Clinical Considerations*
benefit counseling.)
•
Minimizing exposure
Infertility*
Monitoring for adverse reactions Human and/or animal data suggesting
Data*
drug-associated
Describes the data that provide
effects on fertility.
the scientific basis for the
•
•
•
•
Disease-associated maternal and/or embryo/
fetal risk
Dose adjustments during pregnancy and the
postpartum period
Maternal adverse reactions
Fetal/neonatal adverse reactions
Labor or delivery
Data*
•
•
information presented in the
Risk Summary and Clinical
Considerations
Describes the data that provide the scientific
basis for the information presented in the Risk
Summary and Clinical Considerations
*Section can be omitted if not applicable.
†Required subheading.
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5 | Administration of Drugs During Pregnancy
Because there is more information to read, this labeling system will likely increase
the amount of time necessary to make prescribing decisions.12,14 Therefore, if the provider rushes this process, it may lead to an incomplete assessment, possibly resulting
in increased risk to the patient.14
The PRCs are still provided for medications discussed in this book because the PLLR
is currently being phased in. All prescription drugs and biologic products submitted
for FDA approval after June 30, 2015, use the new PLLR format.12 Prescription drugs
approved on or after June 30, 2001, will be phased in over a period of 3 to 5 years.12
Prescription drugs approved prior to June 30, 2001, have a 3-year period in which to
remove the PRC.12
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References
References
1. Moore PA. Selecting drugs for the pregnant dental patient. J Am Dent Assoc 1998;129:1281–1286.
2. American Academy of Pediatric Dentistry. Guideline on Oral Health Care for the Pregnant Adolescent.
http://www.aapd.org/media/Policies_Guidelines/G_Pregnancy.pdf. Accessed 25 January 2018.
3. Donaldson M, Goodchild JH. Pregnancy, breast-feeding and drugs used in dentistry. J Am Dent
Assoc 2012;143:858–871.
4. Hilgers KK, Douglass J, Mathieu GP. Adolescent pregnancy: A review of dental treatment guidelines. Pediatr Dent 2003;25:459–467.
5. Lodi KB, Carvalho LF, Koga-Ito CY, Carvalho VA, Rocha RF. Rational use of antimicrobials in dentistry during pregnancy. Med Oral Patol Oral Cir Bucal 2009;14:E15–E19.
6. Michalowicz BS, DiAngelis AJ, Novak J, et al. Examining the safety of dental treatment in pregnant
women. J Am Dent Assoc 2008;139:685–695.
7. Fayans EP, Stuart HR, Carsten D, Ly Q, Kim H. Local anesthetic use in the pregnant and postpartum patient. Dent Clin North Am 2010;54:697–713.
8. Suresh L, Radfar L. Pregnancy and lactation. Oral Surg Oral Med Oral Pathol Oral Radiol Endod
2004;97:672–682.
9. California Dental Association Foundation; American College of Obstetricians and Gynecologists,
District IX. Oral health during pregnancy and early childhood: Evidence-based guidelines for
health professionals. J Calif Dent Assoc 2010;38:391–403.
10. Cengiz SB. The pregnant patient: Considerations for dental management and drug use. Quintessence Int 2007;38:e133–e142.
11. US Food and Drug Administration. Content and format of labeling for human prescription
drug and biological products; requirements for pregnancy and lactation labeling. Fed Regist
2008;73(104):30831–30868.
12. US Food and Drug Administration. FDA Pregnancy and Lactation Labeling (Drugs) Final Rule.
http://www.fda.gov/Drugs/DevelopmentApprovalProcess/DevelopmentResources/Labeling/
ucm093307.htm. Accessed 25 January 2018.
13. US Food and Drug Administration. Outline of Section 8.1–8.3 on Drug Labeling. https://www.fda.
gov/Drugs/DevelopmentApprovalProcess/DevelopmentResources/Labeling/ucm425415.htm.
Accessed 5 November 2017.
14. Pernia S, DeMaagd G. The new pregnancy and lactation labeling rule. P T 2016;41:713–715.
83
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CHAPTER
6
Medications
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Key Points
Acetaminophen ( Tylenol, Janssen Pharmaceuticals) may be one of the safer
analgesics to use during pregnancy, provided the dosing is low enough to minimize hepatotoxicity.
Acetaminophen combination drugs may be considered if acetaminophen
alone is insufficient.
Codeine has potential problems with hypo - and hypermetabolism.
Opioids should be limited to short- term usage during pregnancy.
Nonsteroidal anti-inflammatory drugs ( NSAIDs) are not routinely prescribed
during pregnancy, and use should be limited to 48 to 72 hours and only during
the second trimester.
Antibiotics commonly used in dentistry are generally considered safe (when
compared with the risk of nontreatment) for healthy pregnant women with no
other contraindications. These include:
Penicillin
Amoxicillin
Amoxicillin plus clavulanic acid
Dicloxaci llin
Cephalexin
Erythromycin
Azithromycin
Clindamycin
Tetracyclines may cause developmental tooth staining and should be avoided, unless there is no other reasonable option.1.2
Many commonly used pain medications are not considered safe during pregnancy. A consultation with the patient ’s prenatal care provider may be warranted prior to prescribing certain pain medications.
-
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6 | Medications
Nonsteroidal Anti-Inflammatory Drugs
NSAIDs inhibit prostaglandin synthesis, which may lead to the following risks3,4:
• Delayed labor. Prostaglandins act on the endometrial lining and help induce labor.
Inhibiting prostaglandin synthesis may delay labor, prolong labor (dystocia), and
prolong pregnancy.3–6
• Miscarriage.4,6
• Premature closure of the ductus arteriosus in the fetal heart. (This can cause pulmonary hypertension, respiratory problems, renal dysfunction, and hemostatic
abnormalities.)3,4,6
Cyclooxygenase-2 (COX2) inhibitors are a category of NSAIDs that act on the COX2
enzyme. The COX2 enzyme is involved in one of the major pain and inflammation pathways and is involved with the conversion of arachidonic acid into prostaglandin H2.6
Considerations during pregnancy
In general, NSAIDs are not recommended during pregnancy.5,7,8 NSAIDs that are more
frequently used in pregnancy include ibuprofen, naproxen, and ketoprofen.5 If NSAIDs
are prescribed, some general considerations include the following:
•
•
•
•
Use the lowest effective dose.4
Minimize the duration of use and limit use to 48 to 72 hours.7–9
Avoid use in the first trimester, third trimester, and just after delivery.3,5,8
Consider the pregnancy risk category (PRC):
‒‒ Some consider NSAIDs, such as ibuprofen and naproxen, to be PRC B during the
first and second trimester.6
‒‒ COX2 inhibitors are classified as PRC C.6
‒‒ NSAIDs are classified as PRC D during the third trimester.6
Considerations for nursing mothers
COX2 inhibitors have a long half-life and should be avoided in breastfeeding mothers.6
The package insert for ibuprofen recommends to either stop nursing or to stop taking
the medication.10 While some consider ibuprofen to be safe during breastfeeding, small
amounts of NSAIDs are found in breast milk, thereby placing the infant at slight risk.4,6
Opioids
Opioids are centrally acting analgesics and should be used with caution.3,6 Be aware
of the potential for addiction and drug abuse when prescribing opioids.6 Opioids pass
from the pregnant woman to the fetus.4 While short duration of low-dose narcotics
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Dental Analgesics
has not been shown to cause fetal anomalies, chronic use of opioids during pregnancy may lead to the following5,6:
•
•
•
•
•
•
Premature delivery
Growth retardation
Physical dependency (fetal and maternal)
Neonatal narcotic withdrawal syndrome
Depression of fetal central nervous system
Depression of fetal respiratory system
Considerations during pregnancy
When indicated, certain opioid analgesics can be used during both pregnancy and lactation.4 The dentist may consider consulting with the patient’s prenatal care provider
prior to prescribing opioids.6 When acetaminophen provides insufficient analgesia,
consider prescribing acetaminophen combination drugs.6 Some drugs that are commonly added to acetaminophen include codeine, oxycodone, and hydrocodone.
Considerations for nursing mothers
Opioids pass into breast milk.4 Prescribing opioids for a shorter period of time and
using smaller doses provides the least risk for the nursing infant.11
Dental Analgesics
This section is intended to serve as a quick reference providing information to aid
the clinician in determining what pain medications to use for the pregnant patient
(Table 6-1). This is not intended to replace an up-to-date drug reference, which should
be consulted when prescribing any medication. A risk-benefit analysis, possibly in
conjunction with the patient’s prenatal care provider, should always be done prior
to prescribing medication. In general, acetaminophen (plain) may be one of the safer
medications.7 When something stronger is needed, an acetaminophen combination
drug may be considered.
Sample prescriptions are given for illustrative purposes only and sample dosing
and instructions are for the healthy nonpregnant patient. They are not intended to
replace the information found in up-to-date drug references or information provided
by the manufacturer of the medication. See Appendix D for additional information on
prescribing medications, including sig abbreviations.
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6 | Medications
Table 6-1 | Summary of select pain-management medications during pregnancy
Drug
Celecoxib
PRC
C (< 30 w)
D (≥ 30 w)
Ibuprofen
C/D
(≥ 30 w)
Comments
See page
Contraindicated if the patient has a sulfa drug
allergy.
92
Avoid in late pregnancy.
93
Acetaminophen
B
Reduce the dose if the patient has liver disease.
OTC maximum labeled dose is 3 g/day.
94
Acetaminophen
+ codeine
C
Reduce the dose if the patient has liver disease.
There is potential for hyper- or hypocodeine
metabolism.
94
Hydrocodone +
acetaminophen
C
Avoid shortly before delivery, or neonatal respiratory depression may occur.
96
Hydrocodone +
ibuprofen
C
Dose may need to be reduced in patients with liver
disease. Should not be used in the third trimester.
97
Oxycodone +
acetaminophen
C
Dose may need to be reduced in patients with liver
disease. Not recommended around the time of
labor and delivery.
99
Meperidine
C
Prolonged use is not recommended.
100
Hydromorphone
C
Contraindicated during labor and delivery.
101
w, weeks.
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Dental Analgesics
Aspirin (acetylsalicylic acid)
Generic name
Aspirin
FDA pregnancy category
C/D
Therapeutic class
Salicylate
Pregnancy notes
In general, aspirin-containing products should be avoided during pregnancy.8 During the first
two trimesters, aspirin is considered PRC C, but during the third trimester, it is considered PRC
D.6 Aspirin should be avoided in the first and third trimesters.4,7
Physicians sometimes use low-dose aspirin to treat patients with certain medical conditions,
such as antiphospholipid syndrome, during pregnancy12 (see page 36). Aspirin can cross to the
fetus.13 Aspirin inhibits prostaglandin synthesis and may cause the following4:
•
•
•
•
•
Postponed labor and prolonged pregnancy4
Delivery complications6
Premature closure, or constriction, of the fetal ductus arteriosus, which may cause fetal pulmonary hypertension4,6
Antepartum maternal/fetal hemorrhage6
Postpartum maternal/fetal hemorrhage6
Long-term aspirin use may be associated with maternal anemia.6 High doses of aspirin may be
associated with perinatal mortality, delayed intrauterine growth, and teratogenic effects.6
Aspirin may also be responsible for increased instances of spontaneous abortion or fetal gastroschisis (anterior abdominal wall defect that allows abdominal contents to protrude out).11
Risks with aspirin in the third trimester include low birth weight, increased incidence of intracranial hemorrhage in premature infants, stillbirth, neonatal death, anemia, and oligohydramnios (amniotic fluid deficiency).13
If aspirin is taken within 1 week of labor and delivery, excessive blood loss may occur at delivery.13 Aspirin used several days before labor and delivery may cause intracranial hemorrhage in
the newborn infant.4
Nursing notes
Aspirin is excreted in human milk.4,13 Nursing mothers should not take aspirin because it can
interfere with the infant’s platelet function.4,6,7
Aspirin has been detected in human breast milk. The nursing infant is at increased risk for
problems with platelet functioning. The nursing infant is also at increased risk for getting Reye
syndrome (acute brain damage and liver dysfunction).
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6 | Medications
Codeine
Because there are genetic variations of codeine metabolism, consider asking the
patient if she has taken a codeine-containing drug before and of whether or how she
thought it helped her.
Ultrarapid codeine converters
Rapid metabolizers of codeine may experience life-threatening symptoms of overdose
even when taking codeine at labeled doses.14 Having an extra CYP2D6 gene leads to
higher enzyme levels, which increases the metabolism of codeine into morphine15,16
(Table 6-2).
Table 6-2 | Estimated CYP2D6 ultrarapid converter phenotype prevalence16
Population
Prevalence
Chinese and Japanese
0.5%–1.0%
Hispanic
0.5%–1.0%
Caucasian
1%–10%
African American
3%
North African, Ethiopian, and Arab
16%–28%
Poor codeine metabolizers
Poor codeine metabolizers have different CYP2D6 alleles. Codeine provides little to
no analgesia when given to these people. About 8% of white people, and possibly a
higher percentage in other ethnic groups, are poor codeine metabolizers.15
Generic name
Codeine
FDA pregnancy category
C3
Pregnancy notes
Nursing notes
Animal studies suggest that maternal codeine
use may lead to low infant birth weight.3 A
prospective study found that codeine may be
associated with multiple congenital defects
including heart and circulatory defects, cleft
lip, and cleft palate.3,6
Infant death may occur when infants are
exposed to larger-than-usual amounts of
morphine in the breast milk of mothers who
are ultrarapid metabolizers of codeine.16 If the
mother is nursing, she should be instructed
to immediately contact the baby’s doctor, go
to a local emergency room, or contact the
local emergency services (911) if the baby
shows any signs of morphine toxicity, which
may include increased sleepiness, difficulty
breastfeeding, or difficulty breathing.
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Dental Analgesics
Naproxen
Generic name
Naproxen
Brand names
Naprelan (Almatica Pharma), Naprosyn
(Atnahs), Aleve (Bayer), Anaprox (Atnahs)
FDA pregnancy category
C17
Therapeutic class
NSAID, prostaglandin inhibitor
Pregnancy notes
Nursing notes
Naproxen should be avoided during pregnancy
to minimize the adverse effects of NSAIDs.17
This concern is especially true during late pregnancy. Naproxen should not be used during
the first or third trimester.7,18 If naproxen is used,
it should be limited to 48 to 72 hours.7
About 1% of the maternal plasma concentration of naproxen has been found in human
milk.17 Side effects in breastfeeding infants
may include drowsiness and vomiting.12
There are contradictory recommendations
during nursing. One recommendation is that
Naproxen may be associated with increased
the nursing mother should temporarily disneonatal risks:
continue nursing while on this medication.17
to be compatible
• Necrotizing entercolitis (portions of the intes- Others consider naproxen
7
with
breastfeeding.
tines undergo death)
•
•
Ductus arteriosus may be patent or have premature closure
Intracranial hemorrhage
In late pregnancy, naproxen has been linked
to persistent pulmonary hypertension, renal
dysfunction, and abnormal prostaglandin E
levels. Naproxen should be avoided around
the time of labor and delivery because of the
following effects:
•
•
•
•
May contribute to dystocia (difficult labor)
May increase risk of uterine hemorrhage
May inhibit uterine contractions
May adversely affect fetal circulation
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6 | Medications
Celecoxib
Celecoxib is a sulfa drug and is contraindicated for patients who are allergic to sulfa
drugs.19
Generic name
Celecoxib
Brand name
Celebrex (Pfizer)
FDA pregnancy category
< 30 weeks: C
≥ 30 weeks: D
Therapeutic class
COX2 inhibitor
Pregnancy notes
Nursing notes
Animal studies showed increased incidence
of ventricular septal defect, misshapen sternebrae, and diaphragmatic hernias when given
celecoxib during organogenesis. Celecoxib
should only be taken when the benefit to the
patient is expected to outweigh the risk to the
fetus.
Celecoxib has been found to be excreted in
human breast milk. The manufacturer recommends using caution when administering to
patients who are nursing.
Sample prescription
Rx: Celecoxib 200 mg
Disp: 15 capsules
Sig: Take 2 capsules by mouth stat, then 1 capsule every 12 hours as needed for pain.
Alternate sig: Take 2 capsules po stat, then 1 capsule q12h prn pain.
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Dental Analgesics
Ibuprofen
Generic name
Ibuprofen
Brand names
Advil (Pfizer), Motrin (Johnson & Johnson)
FDA pregnancy category
< 30 weeks: C12
≥ 30 weeks: D12
Pregnancy notes
Nursing notes
Avoid using ibuprofen in the first and third
trimesters, and avoid using ibuprofen for
longer than 48 to 72 hours.7 Ibuprofen should
be avoided in late pregnancy because it
may cause premature closure of the ductus
arteriosus.18
The manufacturer recommends against
administering ibuprofen for patients who are
nursing and advises that there is the potential
for serious adverse reactions in infants who
nurse from women taking ibuprofen.10
Note: Others consider ibuprofen to be compatible with breastfeeding.4
Sample prescription
Rx: Ibuprofen 600 mg
Disp: 28 tablets
Sig: Take 1 tablet by mouth every 8 hours, as needed for pain.10
Alternate sig: Take 1 tab po tid prn pain.
Other
The maximum dose for a nonpregnant adult is 3,200 mg/24 hours. Increasing the total daily
dosage from 2,400 mg to 3,200 mg increases the potential risk and may not provide a better
response.
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Acetaminophen (N-acetyl-para-aminophenol)
Dosing may need to be reduced in patients with renal or hepatic impairment.12 Consuming
alcohol while taking acetaminophen increases the risk of developing hepatotoxicity.12
Patients should be instructed to not take more than 3 g of acetaminophen per day
unless directed by a health care professional who may recommend a maximum dose
of 4 g per day.
Generic name
Acetaminophen (N-acetyl-para-aminophenol or
acetaminophen or paracetamol)
Brand names
Tylenol (Johnson & Johnson), Acephan (G&W
Laboratories), Excedrin Tension Headache
(GlaxoSmithKline), Mapap (Major Pharmaceuticals)
FDA pregnancy category
B4,6
Pregnancy notes
Nursing notes
Acetaminophen appears to be safe and has
been widely used as an analgesic during
pregnancy.5 Some consider acetaminophen
as the analgesic of choice for the short-term
management of the pregnant patient’s orofacial pain.6,7
Acetaminophen is present in human milk.12
However, acetaminophen is generally thought
to be safe for use at any stage of pregnancy
and in nursing mothers.4
When given in high doses, it may be associated with maternal anemia and fetal renal
disease.4 Frequent use during pregnancy may
be associated with early childhood asthma
and wheezing.12 Advise patients to make sure
that the total acetaminophen from all sources
does not exceed the maximum daily limit.12
Sample prescription
Rx: Acetaminophen
Disp: (Available OTC)
Sig: Take 325 to 650 mg by mouth every 4 to 6 hours. Do not exceed 4 g/day.12
Alternate sig: Take 1,000 mg po tid. Do not exceed 4 g/day.
Acetaminophen + codeine 14
This combination comes in two forms:
• Tylenol with Codeine #3 contains 300 mg of acetaminophen and 30 mg of codeine
• Tylenol with Codeine #4 contains 300 mg of acetaminophen and 60 mg of codeine
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Dental Analgesics
If the patient uses multiple medications that contain acetaminophen, she should
be cautioned on the potential for acetaminophen overdose.20 Some people are ultrarapid metabolizers of codeine and are at risk of experiencing overdose symptoms14
(see page 90).
Generic name
Acetaminophen + codeine
Brand name
Tylenol with Codeine #3
FDA pregnancy category
C12
Pregnancy notes
Nursing notes
Codeine passes to the fetus.14
Both acetaminophen and codeine are excreted in human milk.12
Sample prescription
Rx: Tylenol #3
Disp: 28 tablets
Sig: Take 1 to 2 tablets by mouth every 4 to 6 hours as needed for pain.
Alternate sig: Take 1–2 tabs po q4–6h prn pain.
Active ingredients
Acetaminophen (300 mg)
Codeine (30 mg)
Aspirin + caffeine + dihydrocodeine
Generic name
Aspirin + caffeine + dihydrocodeine
Brand name
Synalgos-DC (Sun Pharmaceutical Industries)
FDA pregnancy category
This drug does not currently have an FDA
pregnancy category assigned to it.16
Pregnancy notes
Nursing notes
There is currently insufficient information to
know the possible adverse fetal effects.16 A
prospective study found that codeine may be
associated with multiple congenital defects
including heart and circulatory defects, cleft
lip, and cleft palate.3
Because of the risk of serious adverse reactions in the nursing infant, it is not recommended in nursing mothers unless the benefit
clearly outweighs the risks.
Infant death may occur when infants are
exposed to larger-than-usual amounts of
morphine in the breast milk of mothers who
are rapid metabolizers of codeine.
Ingredients
Aspirin (356.4 mg)
Caffeine (30 mg)
Dihydrocodeine (16 mg)
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6 | Medications
Tramadol + acetaminophen
Generic name
Tramadol + acetaminophen
Brand name
Ultracet (Janssen Pharmaceuticals)21
FDA pregnancy category
C21
Pregnancy notes
Nursing notes
Acetaminophen and tramadol both cross to
the placenta.12 Tramadol has been reported
to be possibly linked with neonatal seizures,
neonatal withdrawal syndrome, fetal death,
and stillbirth.21
Because the safety of Ultracet in nursing
mothers has not been studied, it is not
recommended for nursing mothers. One study
showed that 16 hours after a single maternal
IV dose of tramadol, 0.1 % of the maternal
dose was present in human breast milk.
Active ingredients
Acetaminophen (325 mg)
Tramadol hydrochloride (37.5 mg)
Hydrocodone + acetaminophen
There are several different brand-name drugs offering hydrocodone and acetaminophen. Table 6-3 compares several formulations of Norco (Allergan) and Vicodin (AbbVie).
Table 6-3 | Different forms of hydrocodone plus acetaminophen
Drug
Hydrocodone
Acetaminophen
Norco
5.0 mg
325 mg
7.5 mg
325 mg
10.0 mg
325 mg
Vicodin
5.0 mg
300 mg
Vicodin ES
7.5 mg
300 mg
Vicodin HP
10.0 mg
300 mg
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Dental Analgesics
Generic name
Hydrocodone + acetaminophen
Brand names
Norco, Lorcet (Forest Pharmaceuticals), Lortab
(Akorn, Inc), Vicodin
FDA pregnancy category
C
Pregnancy notes
Nursing notes
Use may lead to fetal physical dependency and
neonatal withdrawal symptoms at delivery.22
The intensity does not always correlate with
maternal duration or dose. Vicodin given to the
expectant mother shortly before delivery may
cause neonatal respiratory depression.
Acetaminophen is excreted in human breast
milk.22 Because of the limited studies and the
possibility of serious adverse reactions in the
nursing infant, nursing is not recommended
while the mother is taking hydrocodone +
acetaminophen.
Sample prescription
Rx: Vicodin (5 mg/300 mg)
Disp: 16 tablets
Sig: Take 1 to 2 tablets by mouth every 4 to 6 hours as needed for pain. Do not exceed 8 tablets
in 24 hours.22
Alternate sig: Take 1–2 tabs po q4–6h prn pain, not to exceed 8 tabs in 24 hours.
Hydrocodone + ibuprofen
There are at least two different brand-name drugs offering hydrocodone and ibuprofen. Table 6-4 shows a comparison of two.
Generic name
Hydrocodone + ibuprofen
Brand names
Ibudone (Poly Pharmaceuticals),
Vicoprofen (AbbVie)
FDA pregnancy category
C
Pregnancy notes
Nursing notes
Vicoprofen should not be used in late pregnancy (third trimester) because it may lead
to the fetal ductus arteriosus prematurely
closing.
Because of the limited studies and the
possibility of serious adverse reactions in the
nursing infant, nursing is not recommended
while the mother is taking Vicoprofen.24
Sample prescription
Rx: Vicoprofen
Disp: 16 tablets
Sig: Take 1 tablet by mouth every 4 to 6 hours as needed for pain. Do not exceed 5 tablets in
24 hours.22
Alternate sig: Take 1 tab po q4–6h prn pain (do not exceed 5 tabs in 24 hours).
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6 | Medications
Table 6-4 | Different forms of hydrocodone plus ibuprofen
Ibudone
23
Vicoprofen
24
Hydrocodone
Ibuprofen
5.0 mg
200 mg
10.0 mg
200 mg
7.5 mg
200 mg
Oxycodone + aspirin
Generic name
Oxycodone + aspirin
Brand names
Endodan (Endo Pharmaceuticals), Percodan
(Endo Pharmaceuticals)
FDA pregnancy category
D12
Oxycodone: B
Aspirin: C/D
Pregnancy notes
Nursing notes
Oxycodone has not been found to be teratogenic or toxic to the fetus in rat and rabbit
studies. Oxycodone can cross to the fetus and
may cause neonatal respiratory depression,
fetal physical drug dependency, and withdrawal symptoms after birth. Percodan is not
recommended just prior to labor and delivery
because it may depress the newborn respiratory system.13
Because of the risk of adverse reactions to the
nursing infant, the mother should normally
either discontinue nursing or discontinue use
of this drug.13
See aspirin section on page 89 for more
information.
Oxycodone is found in human breast milk and
may cause sedation and respiratory depression in the nursing infant. There have been
reports of somnolence and lethargy in babies
of nursing mothers who have been taking an
oxycodone/acetaminophen combination drug.
Aspirin has been detected in human breast
milk. The nursing infant is at increased risk for
problems with platelet functioning. The nursing infant is also at increased risk for getting
Reye syndrome (acute brain damage and liver
dysfunction).
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Oxycodone + acetaminophen
Percocet (Endo Pharmaceuticals) comes in several different strengths25 (Table 6-5).
Table 6-5 | Different strengths of Percocet
Oxycodone/acetaminophen
(mg)
Max daily dose
(tabs)
2.5/325
12
5.0/325
12
7.5/325
8
10.0/325
6
Generic name
Oxycodone + acetaminophen
Brand name
Percocet
FDA pregnancy category
C25
Pregnancy notes
Nursing notes
Opioids can cross to the fetus and may cause
neonatal respiratory depression.25 Fetal
exposure to opioids may cause the neonate
to suffer symptoms of severe drug withdrawal,
which may be life-threatening.12 This drug is
not recommended for use by women around
the time of labor and delivery because it may
lead to depressed respiratory function of the
newborn.
Small amounts of both acetaminophen
and oxycodone have been found in human
breast milk.18,23 There have been reports of
somnolence and lethargy in babies of nursing
mothers who have been taking an oxycodone/
acetaminophen combination drug. The nursing infant is at risk of sedation and respiratory
depression. The manufacturer recommends
that the nursing mother not take Percocet.
Sample prescription
Note: Sample prescription based on the manufacturer’s labeling of the usual adult dose of 2.5
mg/325 mg tablets.
Rx: Percocet 2.5 mg
Disp: 20 tablets
Sig: Take 1 to 2 tablets by mouth every 6 hours as needed for pain.
Alternate sig: Take 1–2 tabs po q6h prn pain.
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6 | Medications
Meperidine
Generic name
Meperidine
Brand name
Demerol (Pfizer)
FDA pregnancy category
C26
Pregnancy notes
Nursing notes
While meperidine may be used in pregnancy, prolonged use of meperidine is not
recommended.7,9 Meperidine has not been
researched in animal reproductive studies.26
Meperidine crosses the placenta and accumulates in the fetus, and it should not be used
around the time of labor and delivery because
it can travel from the pregnant woman to the
fetus, where it may depress respiratory and
psychophysiologic functions.12 The newborn
infant may require resuscitation.26
Meperidine can be found in human breast
milk. This may place the nursing infant at risk
for serious adverse reactions. It is recommended that a nursing mother either discontinue nursing or switch medications.
Note: Others consider meperidine to be compatible with breastfeeding.4
Sample prescription26
Note: Sample prescription based on the package insert stating the usual adult dose is 50 to 150 mg.
Rx: Demerol 50 mg
Disp: 16 tablets
Sig: Take 1 tablet every 3 to 4 hours by mouth as needed for pain.
Alternate sig: Take 1 tab q3–4h po route prn pain.
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Dental Antibiotics
Hydromorphone
Generic name
Hydromorphone
Brand name
Dilaudid (Fresenius Kabi)
FDA pregnancy category
C12
Pregnancy notes
Nursing notes
Hydromorphone crosses the placenta and is
present in the fetus.27 Animal studies show
increased incidence of exencephaly (cephalic
disorder where brain tissue protrudes outside
of the skull) and cranioschisis (failure of the
skull to completely fuse) when given during
organogenesis. Dilaudid is contraindicated
during labor and delivery.
Because drugs in this class may be present in
human milk, nursing should be discontinued
while the mother is taking this medication.27
Sample prescription
Note: Dilaudid comes in 2-mg, 4-mg, and 8-mg tablets. Sample prescription is based on the
package insert.
Rx: Dilaudid 2 mg
Disp: 16 tablets
Sig: Take 1 tablet by mouth every 4 to 6 hours as needed for pain.
Alternate sig: Take 1 tablet po q4–6h prn pain.
Dental Antibiotics
This section is intended to serve as a quick reference, providing information to aid the
clinician in determining what antibiotic to use for the pregnant patient. It is important
to be aware that some antibiotics have altered pharmacokinetics during pregnancy.
This may cause changes in drug effectiveness during pregnancy.
This information is not intended to replace information found in up-to-date drug
references or information provided by the manufacturer of the medication, which
should be consulted when prescribing medication. Sample prescriptions are given
for illustrative purposes only and sample dosing and instructions are for the healthy
nonpregnant patient. Prescription examples are only provided for PRC B antibiotics.
Table 6-6 provides a brief overview of some of the different antibiotic families, and
Table 6-7 lists some of the antibiotics commonly used in dentistry.
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Table 6-6 | Families of antibiotics commonly used in dentistry
Family
Action
Comments
Penicillins
Inhibits bacterial cell wall
synthesis.1
Examples: penicillin, amoxicillin, oxacillin,
cloxacillin, dicloxacillin, methicillin,
ampicillin
Cephalosporins
Inhibits bacterial cell wall
synthesis.1
First generation: cefazolin, cephalexin,
cefadroxil, and cefradine
Second generation: cefuroxime, cefprozil,
and cefmetazol
Third generation: cefotaxime, cefdinir, ceftriaxone, cefoperazone, and ceftazidime
Fourth generation: cefepime and cefpiroma
Acts on the 50S ribosomal
subunit, which inhibits tRNA
translocation.1
Examples: erythromycin, clarithromycin,
roxithromycin, and azithromycin1
Lincosamines
Acts on the 50S ribosomal
subunit to inhibit tRNA translocation.1
Clindamycin is the only lincosamine
indicated for pregnant women.1
Tetracyclines
Bacteriostatic: Binds ribosom- Examples include tetracycline and doxyal 30S subunit, inhibiting RNA cycline, which are PRC D1
aminoacyl transferase.1
Tetracyclines have been linked to dental
developmental problems such as staining
and hypomineralization. Tetracyclines
should be avoided during pregnancy and
also in nursing mothers.1,4
Quinolones
Converts bacterial gyrase and
topoisomerase IV into toxic
enzymes that fragment the
bacterial chromosome.28
Macrolides
Macrolide antibiotics may cause a
prolonged QT interval (irregular heart
rhythm).12
Example: ciprofloxacin28
Quinolones act via a different mechanism
than penicillins, cephalosporins, aminoglycosides, macrolides, and tetracyclines.29 Microorganisms resistant to these
classes of antibiotics may be susceptible
to quinolones.29 There is no known crossresistance between ciprofloxacin and
other antimicrobial classes.29
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Dental Antibiotics
Table 6-7 | Antibiotics commonly used in dentistry
Drug
See page
Comments
Penicillin V potassium
103
May require higher dose or increased dosing frequency
during second and third trimesters.
Amoxicillin
104
Decreased peak serum concentration and decreased
half-life during pregnancy.
Amoxicillin +
clavulanic acid
105
Decreased peak serum concentration and decreased
half-life during pregnancy. Not recommended for use
in women with preterm premature rupture of fetal
membrane.
Dicloxacillin
105
Animal studies have not shown harm to the fetus.30,31
Cephalexin
106
Pregnancy does not appear to alter peak concentrations of cephalexin.32
Clarithromycin
106
PRC C. Inform pregnant patients of potential harm to
the fetus.
Erythromycin
107
Avoid the estolate form. This drug has multiple drug
interactions.
Azithromycin
108
Azithromycin may lead to irregular heart rhythm in the
patient that can be fatal.
Clindamycin
109
Pregnancy does not appear to alter the pharmacokinetics.
Ciprofloxacin
110
PRC C. Teratogenic risk is unlikely, but clindamycin
should be reserved for patients with no other treatment options.
Penicillin V potassium
Generic name
Penicillin V potassium
FDA pregnancy category
B18
Antibiotic family
Penicillins
Pregnancy notes
Nursing notes
Penicillin can cross the placenta and enter the
amniotic fluid.33 Maternal penicillin use is generally thought to be safe and does not increase
the risk of adverse fetal effects.18 During the
second and third trimesters of pregnancy, the
pharmacokinetics of penicillin may be altered.
This may require the use of a larger dose or
increased dosing frequency to obtain the same
effect. One study suggested increasing dosage
frequency to every 6 hours (q6h).34
Infants have been reported to have loose
stools and rash after nursing from women
who have taken penicillin.12
Sample prescription
Rx: Penicillin V potassium 500 mg
Disp: 40 tablets
Sig: Take 1 tablet by mouth 4 times per day until gone.35
Alternate sig: Take 1 tab po qid until gone.
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Amoxicillin
Generic name
Amoxicillin
Brand names
Amoxil (GlaxoSmithKline), Moxatag (Vernalis
Therapeutics)
FDA pregnancy category
B18,36
Antibiotic family
Penicillins
Pregnancy notes
Nursing notes
In general, maternal amoxicillin use has not
shown an increased risk of adverse fetal
effects.18 Maternal exposure to amoxicillin may
increase fetal risk of cleft lip or cleft palate.37
One study found that use of amoxicillin in
early pregnancy is a causative factor for molar
incisor hypomineralization.38 Amoxicillin may
have the potential to disrupt the mineralization
of dentin.39 Pregnancy-induced physiologic
changes include increased clearance due to:
The manufacturer recommends caution
when using amoxicillin in mothers who are
nursing.36 Amoxicillin has been found in breast
milk and may lead to infant allergic sensitization or risk of altering infant bowel flora.12,36,40
•
•
Decreased peak (maximum) serum concentration (Cmax)
Decreased amoxicillin half-life
Sample prescription
Rx: Amoxicillin 500 mg
Disp: 30 tablets
Sig: Take 1 tablet by mouth 3 times per day until gone.41
Alternate sig: Take 1 tab po tid until gone.
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Dental Antibiotics
Amoxicillin + clavulanic acid
Generic name
Amoxicillin + clavulanic acid
Brand names
Amoclan (Hexal), Augmentin (GlaxoSmithKline)
FDA pregnancy category
B40
Antibiotic family
Penicillins
Pregnancy notes
Nursing notes
Refer to page 104 for details about amoxicillin.
Amoxicillin is present in human breast milk.
The manufacturer recommends caution in
nursing.40
Augmentin may be associated with increased
risk of bowel disorders such as neonatal
necrotizing enterocolitis. It is not recommended for use in women with preterm premature
rupture of fetal membrane, as it may be
associated with increased risk of neonatal
necrotizing entercolitis.42
Sample prescription
Rx: Augmentin 500 mg
Disp: 30 tablets
Sig: Take 1 tablet by mouth 3 times per day until gone.40
Alternate sig: Take 1 tab po tid until gone.
Dicloxacillin
Generic name
Dicloxacillin
FDA pregnancy category
B30
Antibiotic family
Penicillins
Pregnancy notes
Nursing notes
Small amounts of dicloxacillin have been
found to cross from the pregnant woman to
the fetus during late pregnancy, but animal
studies have not shown harm to the fetus.30,31
The manufacturer recommends caution when
using dicloxacillin in nursing mothers.30 Other
penicillins are excreted in human milk and are
considered safe during breastfeeding.33 There
is a risk of altering infant bowel flora.
Sample prescription
Rx: Dicloxacillin 500 mg
Disp: 40 capsules
Sig: Take 1 capsule by mouth every 6 hours until gone.30
Alternate sig: Take 1 capsule po q6h until gone.
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Cephalexin
Generic name
Cephalexin
Brand name
Keflex (Shionogi)
FDA pregnancy category
B43
Antibiotic family
Cephalosporins
Pregnancy notes
Nursing notes
Maternal cephalexin can be found at therapeutic levels in amniotic fluid and in the
fetal circulation.12 Cephalexin has not been
associated with increased risk of teratogenic
events.43 Pregnancy does not appear to alter
peak concentrations of cephalexin.32
Use caution in nursing.43 Cephalexin is
excreted in human milk, and the maximum
breast milk concentration occurs about 4
hours after a single dose. About 8 hours after
a single dose, cephalexin is no longer present.
A nursing infant is at risk of having bowel flora
altered.
Sample prescription
Rx: Cephalexin 500 mg
Disp: 40 capsules
Sig: Take 1 capsule by mouth 4 times per day until gone.12
Alternate sig: Take 1 capsule po qid until gone.
Clarithromycin
Generic name
Clarithromycin
Brand name
Biaxin (AbbVie)
FDA pregnancy category
C44
Antibiotic family
Macrolides
Pregnancy notes
Nursing notes
Animal studies have shown adverse fetal
effects. The manufacturer recommends
that clarithromycin should only be used in
pregnant women when there is no appropriate alternative therapy.44 If pregnancy occurs
while the patient is taking clarithromycin, the
manufacturer recommends informing the
patient of the possible harm to the fetus.
The manufacturer recommends caution if
administering clarithromycin to a nursing
woman.12 Clarithromycin is excreted in human
milk.44 Nursing infants have been reported to
have decreased appetite, diarrhea, rash, and
somnolence.
Additional warnings
Clarithromycin may cause a prolonged QT interval (irregular heart rhythm).12 For further information, see the FDA warning for azithromycin.2
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Dental Antibiotics
Erythromycin
Generic name
Erythromycin
FDA pregnancy category
B45
Antibiotic family
Macrolides
Pregnancy notes
Nursing notes
Erythromycin crosses to the placenta.12
Adverse effects include abdominal pain.12 The
enteric coating may decrease the risk of causing an upset stomach.41 Avoid the estolate
form during pregnancy and breastfeeding.1,18
The estolate form may be more hepatotoxic during pregnancy than the nonestolate
form.18 The estolate form is associated with
cholestatic hepatitis during pregnancy.46
Erythromycin is excreted in human breast
milk, so use caution in nursing.
Sample prescription45
Rx: Erythromycin base 250 mg
Disp: 40 tablets (enteric coated)
Sig: Take 1 tablet by mouth 4 times per day until gone.45
Alternate sig: Take 1 tab by po qid until gone.
Additional warnings45
Multiple drug interactions and fatalities have been reported. When prescribing, refer to an
up-to-date drug reference for further information. Erythromycin may cause a prolonged QT interval (irregular heart rhythm).12 For further information, see the FDA warning for azithromycin.2
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Azithromycin
Generic name
Azithromycin
Brand name
Zithromax (Pfizer)
FDA pregnancy category
B47
Antibiotic family
Macrolides
Pregnancy notes
Nursing notes
When compared with other antibiotics,
azithromycin does not cross the placenta
to the fetus as easily.5 It is recommend for
use in pregnant women who are allergic to
penicillin.4 Limited information suggests that
azithromycin may be a cause for infantile
pyloric stenosis, which is the narrowing of the
opening that goes from the stomach to the
duodenum. The serum half-life of azithromycin is not affected in early pregnancy; at term,
serum half-life is decreased.32
The manufacturer recommends caution
during nursing.12 Azithromycin is excreted in
human breast milk. Altered bowel flora, diarrhea, rash, somnolence, and decreased appetite have been reported in nursing infants.
The serum concentration for the pregnant
woman is different for the first 48 hours as
compared with nonpregnant women. After
48 hours, concentrations were found to be
similar. High concentrations of azithromycin
are present in the myometrium (uterine wall’s
middle layer) and also adipose tissue.32
Sample prescription
Note: Zithromax is packaged in a Z-Pak.
Rx: Zithromax (Z-Pak)
Disp: 1 pack (6 × 250 mg tablets)
Sig: Take 2 tablets by mouth on day 1, and 1 tablet on days 2 through 5.47
Additional warnings
FDA warning: “… azithromycin (Zithromax or Zmax) can cause abnormal changes in the
electrical activity of the heart that may lead to a potentially fatal irregular heart rhythm.
Patients at particular risk for developing this condition include those with known risk factors
such as existing QT interval prolongation, low blood levels of potassium or magnesium, a
slower than normal heart rate, or use of certain drugs used to treat abnormal heart rhythms,
or arrhythmias. … Health care professionals should consider the risk of fatal heart rhythms
with azithromycin when considering treatment options for patients who are already at risk for
cardiovascular events.”2
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Dental Antibiotics
Clindamycin
Generic name
Clindamycin
Brand name
Cleocin (Pfizer)
FDA pregnancy category
B48,49
Antibiotic family
Lincosamines
Pregnancy notes
Nursing notes
Clindamycin crosses the placenta to the
fetus.12 Maternal use of clindamycin has not
been associated with adverse fetal effects.48,49
The pharmacokinetics do not appear to be
altered during pregnancy.12
Clindamycin is excreted in human breast
milk.48,49 While some authors suggest that clindamycin is safe for use during breastfeeding,
the manufacturer recommends against using
clindamycin for nursing mothers.11
Sample prescription48,49
Rx: Clindamycin 300 mg
Disp: 40 capsules
Sig: Take 1 capsule by mouth 4 times per day until gone.48,49
Alternate sig: Take 1 capsule po qid until gone.
Additional warnings
While all antibiotics have risk for pseudomembranous colitis, clindamycin may be more likely
to induce pseudomembranous colitis.48,49
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Ciprofloxacin
Generic name
Ciprofloxacin
Brand name
Cipro (Bayer)
FDA pregnancy category
C
Antibiotic family
Quinolones
Pregnancy notes
Nursing notes
An expert review of published data concluded
that it is unlikely that substantial teratogenic
risk exists when therapeutic doses of ciprofloxacin are taken during pregnancy.29 Several
small postmarketing epidemiologic studies
suggest that ciprofloxacin is safe during pregnancy. However, further research is needed to
confirm these initial findings. Animal studies
have shown that quinolones (including ciprofloxacin) cause arthropathy in weight-bearing
joints in juveniles, resulting in lameness.
Ciprofloxacin is excreted in human breast
milk.29 The manufacturer recommends
against breastfeeding while the mother is
taking ciprofloxacin.
Additional warnings
Excerpt from a 2016 FDA safety announcement: “We have determined that fluoroquinolones
should be reserved for use in patients who have no other treatment options … because the
risk of these serious side effects generally outweighs the benefits in these patients. For some
serious bacterial infections, the benefits of fluoroquinolones outweigh the risks, and it is appropriate for them to remain available as a therapeutic option. … Stop fluoroquinolone treatment
immediately if a patient reports serious side effects, and switch to a non-fluoroquinolone
antibacterial drug to complete the patient’s treatment course.”50
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References
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2. US Food and Drug Administration. FDA Drug Safety Communication: Azithromycin (Zithromax or
Zmax) and the Risk of Potentially Fatal Heart Rhythms. http://www.fda.gov/downloads/Drugs/
DrugSafety/UCM343347.pdf. Accessed 30 January 2018.
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4. Suresh L, Radfar L. Pregnancy and lactation. Oral Surg Oral Med Oral Pathol Oral Radiol Endod
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8. American Academy of Pediatric Dentistry. Guideline on Oral Health Care for the Pregnant Adolescent. http://www.aapd.org/media/Policies_Guidelines/G_Pregnancy.pdf. Accessed 26 January
2018.
9. Oral Health Care During Pregnancy Expert Workgroup. Oral health care during pregnancy: A national consensus statement. Washington, DC: National Maternal and Child Oral Health Resource
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10. Ibuprofen: Ibuprofen Tablet, Film Coated [package insert]. Bachepalli, India: Dr. Reddy’s Laboratories Limited, 2007.
11. Donaldson M, Goodchild JH. Pregnancy, breast-feeding and drugs used in dentistry. J Am Dent
Assoc 2012;143:858–871.
12. Wynn RL, Meiller TF, Crossley HL (eds). Drug Information Handbook for Dentistry, ed 23. Hudson,
OH: Lexi-Comp, 2018.
13. Percodan (Oxycodone and Aspirin Tablets, USP) [package insert]. Chadds Ford, PA: Endo Pharmaceuticals, 2010.
14. Acetaminophen and Codeine Phosphate tablet [package insert]. Concord, NC: McKesson Corporation, 2011.
15. Crowley KE. Anesthetic issues and anxiety management in the female oral and maxillofacial surgery patient. Oral Maxillofac Surg Clin North Am 2007;19:141–152.
16. Synalgos-DC (Aspirin, Caffeine, and Hydrocodeine Bitartrate) [package insert]. Atlanta: Caraco
Pharma, 2013.
17. Naprosyn [package insert]. San Francisco: Genentech, 2010.
18. Moore PA. Selecting drugs for the pregnant dental patient. J Am Dent Assoc 1998;129:1281–1286.
19. Celebrex [package insert]. New York: Pfizer, 2013.
20. Medline Plus. Acetaminophen. http://medlineplus.gov/druginfo/meds/a681004.html. Accessed
30 January 2018.
21. Ultracet (Tramadol Hydrochloride/Acetaminophen Tablets) [package insert]. Raritan, NJ:
Ortho-McNeil Pharmaceutical, 2011.
22. Vicodin (Hydrocodone Bitartrate and Acetaminophen Tablets, USP) [package insert]. North Chicago, IL: AbbVie, 2013.
111
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6 | Medications
23. Ibudone (Hydrocodone Bitartrate and Ibuprofen) Tablet, Film Coated [package insert]. Mobile,
AL: Poly Pharmaceutical, 2009.
24. Vicoprofen (Hydrocodone Bitartrate and Ibuprofen Tablets) 7.5mg/200mg [package insert].
North Chicago, IL: Abbott Laboratories, 2008.
25. Percocet (Oxycodone and Acetaminophen Tablets, USP) [package insert]. Chadds Ford, PA: Endo
Pharmaceuticals, 2006.
26. Demerol (Meperidine Hydrochloride, USP) [package insert]. Bridgewater, NJ: Sanofi-Aventis,
2011.
27. Dilaudid Oral Liquid and Dilaudid Tablets (Hydromorphone Hydrochloride) [package insert].
North Chicago, IL: Abbott Laboratories, 2007.
28. Aldred KJ, Kerns RJ, Osheroff N. Mechanism of quinolone action and resistance. Biochemistry
2014;53:1565–1574.
29. Cipro [package insert]. West Haven, CT: Bayer, 2004.
30. Dicloxacillin Sodium: Dicloxacillin Sodium Capsule [package insert]. Sellersville, PA: Teva Pharmaceuticals, 2011.
31. Depp R, Kind AC, Kirby WM, Johnson WL. Transplacental passage of methicillin and dicloxacillin
into the fetus and amniotic fluid. Am J Obstet Gynecol 1970;107:1054–1057.
32. Lexicomp Online. http://www.wolterskluwercdi.com/lexicomp-online. Accessed 26 January 2018.
33. Nathan L, Bawdon RE, Sidawi JE, Stettler RW, McIntire DM, Wendel GD Jr. Penicillin levels following the administration of benzathine penicillin G in pregnancy. Obstet Gynecol 1993;82:338–342.
34. Heikkilä AM, Erkkola RU. The need for adjustment of dosage regimen of penicillin V during pregnancy. Obstet Gynecol 1993;81:919–921.
35. Penicillin V Potassium [package insert]. Fort Lee, NJ: Dava Pharmaceuticals, 2011.
36. Amoxil (Amoxicillin Capsules, Tablets, Chewable Tablets, and Powder for Oral Suspension) [package insert]. Research Triangle Park, NC: GlaxoSmithKline, 2006.
37. Lin KJ, Mitchell AA, Yau WP, Louik C, Hernández-Díaz S. Maternal exposure to amoxicillin and the
risk of oral clefts. Epidemiology 2012;23:699–705.
38. Laisi S, Ess A, Sahlberg C, Arvio P, Lukinmaa P, Alaluusua S. Amoxicillin may cause molar incisor
hypomineralization. J Dent Res 2009;88:132–136.
39. Kumazawa K, Sawada T, Yanagisawa T, Shintani S. Effect of single-dose amoxicillin on rat incisor
odontogenesis: A morphological study. Clin Oral Investig 2012;16:835–842.
40. Augmentin (Amoxicillin and Clavulanate Potassium Tablet, Film Coated. Amoxicillin and Clavulanate Potassium Powder for Suspension) [package insert]. Bridgewater, NJ: Dr. Reddy’s Laboratories, 2013.
41. Jacobsen PL. The Little Dental Drug Booklet: Handbook of Commonly Used Dental Medications,
ed 20. Hudson, OH: Lexicomp, 2013.
42. Keyon SI, Taylor DJ, Tarnow-Mordi W, ORACLE Collaborative Group. Broad-spectrum antibiotics for preterm, prelabour rupture of fetal membranes: The ORACLE I randomised trial. Lancet
2001;357(9261):979–988.
43. Keflex Capsules: Cephalexin, USP [package insert]. Germantown, MD: Advancis Pharmaceutical
Corporation, 2006.
44. Biaxin Filmtab (Clarithromycin Tablets, USP) Biaxin XL Filmtab (Clarithromycin ExtendedRelease Tablets) Biaxin Granules (Clarithromycin for Oral Suspension, USP) [package insert]. North
Chicago, IL: Abbott Laboratories, 2013.
45. Erythromycin Base Filmtab – Erythromycin Tablet, Film Coated [package insert]. Zanesville, OH:
Cardinal Health, 2009.
46. Kandan PM, Menaga V, Raja R, Kumar RR. Oral health in pregnancy (guidelines to gynaecologists,
general physicians & oral health care providers). J Pak Med Assoc 2011;61:1009–1014.
112
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References
47. Zithromax (Azithromycin Tablets) and (Azithromycin for Oral Suspension) [package insert]. New
York: Pfizer, 2013.
48. Cleocin HCl (Clindamycin Hydrochloride Capsules, USP) [package insert]. New York: Pharmacia
& Upjohn, 2009.
49. Clindamycin Hydrochloride: Clindamycin Hydrochloride Capsule [package insert]. Concord, NC:
McKesson Corporation; 2009.
50. US Food and Drug Administration. FDA Drug Safety Communication: FDA Updates Warnings for
Oral and Injectable Fluoroquinolone Antibiotics due to Disabling Side Effects. https://www.fda.
gov/downloads/Drugs/DrugSafety/UCM513019.pdf. Accessed 29 November 2017.
113
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CHAPTER
7
Anesthetic Use
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Key Points
Maximum dosages of anesthetic should be decreased during pregnancy because more anesthetic is free ( unbound) , which in turn exposes the fetus to
more anesthetic.1-3
Longer- acting anesthetics may provide greater risk to the fetus than shorter
acting anesthetics.4
Dental cartridges may contain more than the labeled 1.7 mL, so it is recommended to use 1.8 mL when calculating the maximum dosage of local anesthetic.5
When selecting a topical or local anesthetic, consider selecting a pregnancy
risk category ( PRC) B option such as lidocaine, prilocaine, or the combination
of lidocaine and prilocaine.
Lidocaine is the local anesthetic with the longest track record and is the most
commonly used local anesthetic.i
Epinephrine is thought to be a safer vasoconstrictor reagardingthe fetus when
compared to levonordefrin.1
PRC B topical anesthetics include:
Prilocaine
Lidocaine
Lidocaine and prilocaine combination
PRC C anesthetics:
Benzocaine
Tetracaine
Articaine
Bupivacaine
- Mepivacaine
When topical and local anesthetics are insufficient, consider consulting with
the patient’s prenatal care provider about the use of nitrous oxide.6-11
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This chapter is intended to provide additional details on the use of dental local and
topical anesthetics during pregnancy. It includes background information and some
unique circumstances that may be present while treating the pregnant patient.
Table 7-1 shows the FDA pregnancy categories of the topical and local anesthetics
that are commonly used in dentistry.
Table 7-1 | Common dental topical anesthetics
Anesthetic
Amide
Ester
Pregnancy category
Topical
12–18
Lidocaine
x
B
Lidocaine and prilocaine combination (eg, Oraqix)
x
B
Benzocaine
x
C
Tetracaine
x
C
Benzocaine/butamben/tetracaine combination
x
C/unassigned/C
x
C
Local19–32
Articaine
Bupivacaine
x
C
Lidocaine with or without epinephrine
x
B
Mepivacaine
x
C
Prilocaine
x
B
Calculating the Amount of Local Anesthetic
in a Dental Cartridge
Because a 1.7-mL dental cartridge may actually contain more than the labeled
amount, the American Academy of Pediatric Dentistry recommends using 1.8 mL
when calculating the maximum dosage of local anesthetic for all patients.5
For every 100 mL of solution that contains 2% local anesthetic, there are 2 g (2,000 mg)
local anesthetic.33 With this ratio of 20 mg/mL, the amount of anesthetic in a 1.8-mL dental
cartridge can be calculated as 36 mg.33
2% anesthetic = 2 g anesthetic = 2,000 mg anesthetic = 20 mg anesthetic
100 mL
1 mL
100 mL
20 mg anesthetic × 1.8
mL
mg
anesthetic
= 36
1 mL
dental cartridge
dental cartridge
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Allergies and Psychogenic Reactions
Allergies and Psychogenic Reactions
Local and topical anesthetics can be divided into the categories of esters and amides
based on their molecular structure.34 This distinction between amide and ester anesthetics is important when dealing with a possible allergic reaction to anesthetics. While
topical amide and ester anesthetics are available, only amide local dental anesthetic
cartridges are available in the United States. Because most allergic reactions to local
anesthetics are to ester anesthetic, not amide, it is more likely that the patient will be
allergic to a topical anesthetic than a local anesthetic.1 The suspected allergen in ester
anesthetics is the metabolite para-aminobenzoic acid.1 Articaine has an ester linkage;
however, it quickly breaks down into an inactive metabolite.1
Dental anesthetic cartridges may contain compounds such as epinephrine or
levonordefrin (eg, Neo-Cobefrin, Cook-Waite), which are vasoconstrictors. If a vasoconstrictor is present, the dental anesthetic cartridge will also include an antioxidant.1
The antioxidant is often either sodium bisulfite or metabisulfite. A bisulfite allergy is
thought to be much more common than a true allergy to the local anesthetic.1
It is estimated that 59% to 77% of adverse reactions to local anesthetics are due
to psychogenic causes.35 Symptoms of psychogenic reactions may include dizziness, pallor, nausea, palpitations, fainting, vasovagal syncope, and other autonomic
responses. Psychogenic reactions usually begin within 1 to 2 minutes of administration of the local anesthetic. Other less common causes of adverse reactions include
allergy and inadvertent intravascular injection.35
Effect on dental treatment
The most common cause of an adverse reaction to a local or topical anesthetic is a
psychogenic reaction.35 If it is suspected that a patient may have a true allergy to an
anesthetic, the patient can be referred for allergy testing prior to treatment.1
Table 7-2 lists which anesthetic might be considered if the patient has an allergy.
Table 7-2 | Dental anesthetic allergies and solutions1
Allergy to:
Consider trying:
Ester anesthetics
Amide anesthetic
Amide anesthetic
Ester anesthetic
Antioxidant (sodium bisulfite or
metabisulfite)
Anesthetic free of antioxidant. (Because this antioxidant is
added when a vasoconstrictor is added, these anesthetics
will have no vasoconstrictor.)
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7 | Anesthetic Use
Methemoglobinemia
Methemoglobinemia occurs when the oxidation state of iron in the hemoglobin molecule changes from Fe2+ (ferrous state) to Fe3+ (ferric state).34 This prevents hemoglobin
from transporting oxygen.4,18 Depending on the severity, the patient may exhibit a
range of symptoms of lack of oxygen and respiratory distress.34 Symptoms are not
relieved with administration of 100% oxygen because not all hemoglobin molecules
are properly functioning. Methylene blue is often used to treat methemoglobinemia.
While rare, methemoglobinemia can lead to death.34
Effect on dental treatment
Certain topical and local anesthetics used in dentistry may increase the risk for
acquired methemoglobinemia.18 (These risks are noted when specific anesthetics are
discussed in the following sections.) Because symptoms may occur 3 to 4 hours after
exposure, the patient may no longer be in the dental office.34
Topical Anesthetics
This section is intended to serve as a quick reference providing information to aid the
clinician in determining what topical anesthetic(s) to use. It is intended to be used as
a starting point, not to replace an up-to-date drug reference or the clinical judgment
of a licensed health care professional.
Lidocaine (topical)
Generic name
Lidocaine (topical)
FDA pregnancy category
B12,13
Pregnancy notes
Nursing notes
No evidence of fetal harm has been observed
in studies with rats at up to 6.6 times the
recommended human dose.12,13
Unknown if excreted in human breast milk.
Lidocaine is thought to be safe for the nursing
infant.12,13,36
Additional warnings
In children under 3 years of age, cardiopulmonary arrest and death may occur when not used
in accordance with recommended dosage and administration.12,13
Other
Common form: 2% lidocaine oral topical solution (viscous)
Anesthetic type: Amide
Metabolism: Liver
Excretion: Kidneys (both active drug and metabolites)
Half-life (elimination): 1.5 to 2 hours after IV injection
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Topical Anesthetics
Lidocaine + prilocaine combination
Generic name
Lidocaine + prilocaine combination
Brand name
Oraqix (Dentsply Sirona)
FDA pregnancy category
B14
Pregnancy notes
Nursing notes
Animal reproductive studies have not
revealed evidence of fetal harm due to the
combination of lidocaine and prilocaine (eg,
Oraqix).14
May be excreted in human breast milk. The
manufacturer recommends caution when
administering to mothers who are nursing.14
Based on separate entries, the LactMed database indicates that dental topical application
of lidocaine and prilocaine is unlikely to affect
the nursing infant.36,37
Additional warnings
Lidocaine and prilocaine toxicities are thought to be additive.14
Prilocaine should be avoided in patients with a history of congenital or acquired methemoglobinemia.4
Other
Anesthetic type: Amide
Metabolism: Liver
Excretion: Kidneys
Half-life (elimination):
•
•
Lidocaine: 3.6 ± 1.3 h
Prilocaine: 2.8 ± 1.0 h
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7 | Anesthetic Use
Benzocaine
Generic name
Benzocaine
FDA pregnancy category
C15
Pregnancy notes
Nursing notes
Benzocaine is sometimes recommended as
a topical anesthetic that is safe to use during
pregnancy. Fetal complications have not been
observed in the limited studies that have
included benzocaine as a topical anesthetic.1,38,39 When choosing a topical anesthetic,
the practitioner should be aware that benzocaine is FDA PRC C and that PRC B topical
anesthetics are available.
Maternal dental topical application is unlikely
to have a negative effect on the nursing
infant.40
Additional warnings
Benzocaine should be avoided in patients with a history of congenital or acquired methemoglobinemia.4
Other
Common form: 20% benzocaine gel41
Anesthetic type: Ester15
Metabolism: Pseudocholinesterases15
Tetracaine
Generic name
Tetracaine
FDA pregnancy category
C16
Pregnancy notes
Nursing notes
Caution is advised when using tetracaine on
the pregnant patient.4
Maternal dental topical application is unlikely
to have a negative effect on the nursing
infant.42
Additional warnings
Tetracaine should be avoided in patients with a history of congenital or acquired methemoglobinemia.4
Other
Common form: 2% tetracaine
Anesthetic type: Ester
Metabolism: Liver and plasma by pseudocholinesterases
Duration: 45 minutes
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Local Anesthetics
Benzocaine/butamben/tetracaine
Generic name
Benzocaine/butamben/tetracaine
Brand name
Cetacaine (Cetylite)
FDA pregnancy category
Benzocaine: C17,18
Butamben: Unassigned17,18
Tetracaine: C17,18
Pregnancy notes
Nursing notes
It is not known if this combination of topical
anesthetics may have adverse fetal effects.18
Benzocaine: Maternal dental topical application is unlikely to have a negative effect on the
nursing infant.40
Butamben: There has not been sufficient
research on the effect of maternal use on the
nursing infant.
Tetracaine: Maternal dental topical application is unlikely to have a negative effect on the
nursing infant.42
Additional warnings
Benzocaine and tetracaine should be avoided in patients with a history of congenital or
acquired methemoglobinemia.4
Other
Anesthetic type: Esters
Metabolism: Plasma cholinesterases
Excretion: Kidneys (inert metabolites)
Duration: 30 to 60 minutes43
Active ingredients
14% benzocaine
2% butamben
2% tetracaine HCl
Onset
Duration
Rapid
Quick
Intermediate
Intermediate
Slow
Extended
Local Anesthetics
Fetal exposure to local anesthetics during pregnancy
Local anesthetic administered to a pregnant woman also freely passes to the
fetus.1,2,4,44 Fetal toxicity depends on the amount of anesthetic that the fetus receives.1
The amount of local anesthetic reaching the fetus is usually thought to be insufficient
to create an adverse reaction. Factors that appear to affect the passage of local anesthetic from the patient to the fetus include the following1:
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7 | Anesthetic Use
•
•
•
•
•
Dose
Route of administration (eg, intramuscular, accidental intravascular)
Presence or absence of a vasoconstrictor
Maternal protein binding
Fetal protein binding
Local anesthetics without a vasoconstrictor have been shown to affect uterine
smooth muscle.1 In vitro studies have shown that large amounts of lidocaine can
cause contractions. However, these adverse effects have not been observed in vivo
when using clinically acceptable amounts of lidocaine.1
Amide local anesthetics require 1-acid glycoprotein for metabolism, and during
pregnancy, there is a decreased amount of 1-acid glycoprotein.1,2 This means that it is
expected that pregnant women will have more plasma-free local anesthetic after administration. In turn, the fetus will be exposed to more local anesthetic, which increases the
risk of fetal toxicity.1,2 This increased possibility of fetal toxicity is thought to be of greater
risk with long-acting local anesthetics, such as bupivacaine. Because of this increased
possibility of local anesthetic toxicity during pregnancy, consider administering a
reduced dose to pregnant women.1,2 A 2015 publication45 reported that dental anesthetics and treatment during pregnancy were not found to increase major teratogenic risk;
however, the study did not indicate which types of anesthetics were researched.
Effect on dental treatment
Local anesthetics administered to the pregnant patient can cross to the fetus, where
they may lead to fetal depression.44 Care should also be taken to avoid accidental
intravascular injection, which may cause complications such as convulsions, coma,
and respiratory arrest.1,4,19,21,38 In the presence of certain medical conditions such as
preeclampsia or eclampsia, inadvertent intravascular injection increases the possibility of inducing a seizure.1 Avoid longer-acting anesthetics such as bupivacaine if a
shorter-acting anesthetic would be adequate, because longer-acting anesthetics may
provide greater risk to the fetus.1,2,4
As with most medications, lidocaine has not undergone adequate well-controlled
studies in pregnant women to establish safe use during pregnancy.25 However, based
on its track record, lidocaine with epinephrine may be the anesthetic of choice during
pregnancy.1 Epinephrine is thought to be a safer vasoconstrictor for the fetus when
compared with levonordefrin.1 Lidocaine with epinephrine is considered safe to
use when providing necessary dental treatment during pregnancy.9,11 To minimize
possible fetal risk, it is recommended to use the minimum effective dose of local
anesthetic.45 Because local anesthetic toxicity may be higher in pregnancy, it has been
recommended to proportionally reduce the maximum dosage of local anesthetics.5
Local anesthetic use during the immediate postpartum period
During the immediate postpartum period (at least the first 2 to 3 weeks after delivery), the patient will often be in a hypercoagulable state. Some studies suggest that
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Local Anesthetic Quick Guide
the condition can last for up to 25 days after delivery, and possibly longer.1 Because
of the hypercoagulable state, the perinatal care provider may prescribe prophylactic
anticoagulation medication. Epinephrine may also worsen the hypercoagulable state.
Epinephrine may activate coagulation by increasing thrombin and clotting factor VIII
levels. The amount of epinephrine from the local anesthetic is thought to be minimal
during normal intramuscular injections. However, an accidental intravascular injection may have the potential to introduce a significant amount of epinephrine.1
Effect on dental treatment
Because the woman may be in a hypercoagulable state, consider if the need to provide dental treatment is urgent or if the patient can wait a few weeks. Use good local
anesthetic administration technique, including aspiration to minimize accidental
intravascular injection.1,2,10 Be aware that the patient’s physician may have placed her
on an anticoagulation medication.1
Local anesthetic use during lactation
While a true allergy to lidocaine is rare, adding epinephrine as a vasoconstrictor
requires the addition of preservatives to the dental cartridge.1 During lactation, an
infant can have an adverse reaction to these preservatives.1
Effect on dental treatment
Be aware of the possibility that a nursing infant may have an adverse reaction to a
local anesthetic administered to the mother.1 If there is a concern that a significant
amount of the drug might be passed on to the infant, consider suggesting that feeding
be accomplished with stored milk or formula. The shorter the half-life of the medication, the sooner the mother can return to nursing her child.
Local Anesthetic Quick Guide
This section is intended to serve as a quick reference providing information to aid
the clinician in determining what local anesthetic(s) to use for the pregnant patient.
It is not intended to replace an up-to-date drug reference, which should be consulted
when prescribing any medication. Please see the following sections for the maximum
recommended dosages of individual anesthetics for pregnant patients.
Intravenous lipid emulsion (ILE) is used to treat local anesthetic toxicity.46 It is suspected that ILE may aid in removing lipophilic drug molecules from target receptors.46
It has been recommended that the dental profession consider ILE as a treatment for
local anesthetic toxicity.47 ILE is included here to raise awareness of its possible use in
treating local anesthetic overdose.
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7 | Anesthetic Use
Lidocaine
Generic name
Lidocaine
Brand names
Lignospan (Septodont), Xylocaine (Fresenius
Kabi)
FDA pregnancy category
B12,13
Pregnancy notes
Nursing notes
Inadvertent intravascular injection may expose the fetus or uterus to significant levels of
epinephrine.1 Lidocaine is the local anesthetic
with the longest track record and is the most
commonly used local anesthetic.
The manufacturer recommends caution and
states that it is unknown if lidocaine is present
in human breast milk.25–27 The American
Academy of Pediatrics considers lidocaine to
be safe for breastfeeding mothers.1
Maximum dosage during pregnancy
The manufacturer states that the maximum adult dosage of 2% lidocaine with 1:100,000 epinephrine is 7 mg/kg (3.2 mg/lb) with a maximum dose of 500 mg.26
It has been suggested that during pregnancy, this should be reduced to 4.4 mg/kg (2.0 mg/lb)
with a maximum dose of 300 mg or 8.3 dental cartridges.3
Other
Common forms25–27:
•
•
2% lidocaine with 1:100,000 epinephrine
2% lidocaine with 1:50,000 epinephrine
Anesthetic type: Amide1
Metabolism: Liver1
Excretion: Kidneys (both active drug and metabolites)
Half-life (elimination): 1.5 to 2 hours
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Local Anesthetic Quick Guide
Mepivacaine
Generic name
Mepivacaine
Brand names
Carbocaine (Cook-Waite), Scandonest
(Septodont), Polocaine (Dentsply Sirona)
FDA pregnancy category
C
Pregnancy notes
Nursing notes
Risk of fetal bradycardia (decreased fetal heart
rate)10,44
Use caution, as it is unknown if mepivacaine is
present in human breast milk.
Epinephrine is thought to be a safer vasoconstrictor for the fetus than levonordefrin.1
Maximum dosage during pregnancy
The manufacturer states that the maximum adult dosage of mepivacaine is 3 mg/lb, with a
maximum dose of 400 mg.30
It has been suggested that during pregnancy, this should be reduced to 4.4 mg/kg (2.0 mg/lb),
with a maximum dose of 300 mg.3 For the 2% concentration, this is 8.3 dental cartridges. For
the 3% concentration, this is 5.5 dental cartridges.
Other
Common forms28–30:
•
•
3% mepivacaine plain
2% mepivacaine with 1:20,000 levonordefrin
Anesthetic type: Amide
Metabolism: Liver (principle location of metabolism) → bile → intestines → kidneys
Excretion: Kidney (mostly eliminated within 30 hours)
Half-life (elimination)28–31:
•
•
Adults: 1.9 to 3.2 hours
Neonates: 8.7 to 9 hours
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Prilocaine
Generic name
Prilocaine
Brand name
Citanest (Dentsply Sirona)
FDA pregnancy category
B
Pregnancy notes
Nursing notes
Possible risk of fetal methemoglobinemia.1
Unknown if found in human breast milk.
Maximum dosage during pregnancy
The manufacturer states that the maximum adult dose is 600 mg, or 8 cartridges. For patients
weighing less than 150 lbs (70 kg), the maximum dosage is 8 mg/kg (4 mg/lb).3,32
It has been suggested that during pregnancy, this should be reduced to 6.0 mg/kg (2.7 mg/lb),
with a maximum dose of 300 mg or 5.5 dental cartridges.
Additional warnings
Prilocaine should be avoided in patients with a history of congenital or acquired methemglobinemia.
Other
Common forms:
•
•
4% prilocaine plain
4% prilocaine with 1:200,000 epinephrine32
Anesthetic type: Amide12,13
Metabolism: Liver and kidneys12,13
Excretion: Kidneys32
Half-life (elimination): 10 to 150 minutes32
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Local Anesthetic Quick Guide
Bupivacaine
Generic name
Bupivicaine
Brand names
Marcaine (Pfizer), Sensorcaine (Fresenius
Kabi), Vivacaine (Septodont)
FDA pregnancy category
C
Pregnancy notes
Nursing notes
Risk of fetal bradycardia. May have an
increased risk of fetal toxicity when compared
with other shorter-acting local anesthetics.2
10,44
Unknown if present in human breast milk.21–24
Maximum dosage during pregnancy
The manufacturer states that the maximum adult dosage is 1.3 mg/kg (0.6 mg/lb), with a maximum dose of 90 mg, or 10 dental cartridges.32
(Note: This suggested maximum dose is the same for pregnant women.)
Additional warnings
Bupivacaine is not recommended for children under 12 years.21–24
Other
Common forms: 0.5% bupivacaine with 1:200,000 epinephrine21–24
Anesthetic type: Amide
Metabolism: Liver
Excretion: Kidneys
Half-life (elimination):
•
•
Adults: 1.2 to 4.6 hours
Infants: 6 to 22 hours
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Articaine
Generic name
Articaine
Brand name
Septocaine (Septodont)
FDA pregnancy category
C
Pregnancy notes
Nursing notes
Animal studies show risk of fetal harm.
Unknown if present in human breast milk.
Only use during pregnancy if the benefit will
likely outweigh the fetal risk.
Safe use on children under the age of 4 years
has not been established. To minimize the
chance of this drug getting to the infant,
nursing mothers may pump and discard
breast milk for 4 hours (based on the plasma
half-life).19,20
Safe use on children under the age of 4 years
has not been established.19,20
Maximum dosage during pregnancy
It has been suggested that during pregnancy, the maximum dosage should be 7.0 mg/kg (3.2
mg/lb), with a maximum dose of 500 mg or 7 dental cartridges.3 (This is the same maximum
dosage information as recommended for a healthy nonpregnant patient.48)
Other
Common forms:
•
•
4% articaine with 1:100,000 epinephrine19
4% articaine with 1:200,000 epinephrine20
Anesthetic type: Amide
Metabolism:
•
•
Primarily by plasma carboxyesterase
5% to 10% in the liver by p450 isoenzyme system
Excretion: Kidneys
Half-life (elimination):
•
•
1:100,000 epinephrine: 43.8 minutes
1:200,000 epinephrine: 44.4 minutes
Nitrous Oxide
There is controversy surrounding the use of nitrous oxide in pregnant women. Nitrous
oxide can travel to the placenta and may interfere with DNA synthesis or cause vasoconstriction, decreasing uterine blood flow.10,38 The use of nitrous oxide has also been
implicated in spontaneous abortion in women with occupational exposure.44 Because
of potential contraindications, nitrous oxide use is restricted to situations where local
and topical anesthesia are insufficient to provide treatment that is both necessary
and nondeferrable.
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References
When used alone, nitrous oxide has an excellent safety record.6 As a single agent,
nitrous oxide does not depress ventilation.6 When combined with other medications
that depress ventilation (eg, sedatives or opioids), a greater-than-expected respiratory
depression may occur.6 Consider treating pregnant women who require sedation with
general anesthesia in a hospital.11
Effect on dental treatment
Nitrous oxide has a greater effect on pregnant women than nonpregnant women. It
takes a lower dosage of nitrous oxide to have the same effect.6,9,11 If possible, avoid
using nitrous oxide during the first trimester.1,2,7,10 If nitrous oxide is administered, it will
ideally be in the second or third trimester and administered with at least 50% oxygen
and for less than 30 minutes.2,38
Avoid prolonged treatments with nitrous oxide to minimize fetal exposure to
nitrous oxide.6,44 Use standard nitrous oxide administration protocols in dentistry,
and continuously monitor vital signs when administering nitrous oxide.6 Use a scavenging system to minimize gas escape and indirect exposure to nitrous oxide during
administration.6,38
References
1. Fayans EP, Stuart HR, Carsten D, Ly Q, Kim H. Local anesthetic use in the pregnant and postpartum patient. Dent Clin North Am 2010;54:697–713.
2. Suresh L, Radfar L. Pregnancy and lactation. Oral Surg Oral Med Oral Pathol Oral Radiol Endod
2004;97:672–682.
3. Flynn TR, Susarla SM. Oral and maxillofacial surgery for the pregnant patient. Oral Maxillofac
Surg Clin North Am 2007;19:207–221.
4. Donaldson M, Goodchild JH. Pregnancy, breast-feeding and drugs used in dentistry. J Am Dent
Assoc 2012;143:858–871.
5. Council on Clinical Affairs, American Academy of Pediatric Dentistry. Guideline on use of local
anesthesia for pediatric dental patients. Pediatr Dent 2015;37(5):71–77.
6. California Dental Association Foundation; American College of Obstetricians and Gynecologists,
District IX. Oral health during pregnancy and early childhood: Evidence-based guidelines for
health professionals. J Calif Dent Assoc 2010;38:391–403.
7. American Academy of Pediatric Dentistry. Guideline on Oral Health Care for the Pregnant Adolescent. http://www.aapd.org/media/Policies_Guidelines/G_Pregnancy.pdf. Accessed 26 January
2018.
8. Oral Health Care During Pregnancy Expert Workgroup. Oral Health Care During Pregnancy: A National Consensus Statement. Washington, DC: National Maternal and Child Oral Health Resource
Center, 2012.
9. Steinberg BJ, Hilton IV, Iada H, Samelson R. Oral health and dental care during pregnancy. Dent
Clin North Am 2013;57:195–210.
10. Hilgers KK, Douglass J, Mathieu GP. Adolescent pregnancy: A review of dental treatment guidelines. Pediatr Dent 2003;25:459–467.
11. New York State Department of Health. Oral Health Care During Pregnancy and Early Childhood:
Practice Guidelines. Albany: New York State Department of Health, 2006. https://www.health.ny.gov/
publications/0824.pdf. Accessed 13 November 2017.
129
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7 | Anesthetic Use
12. Lidocaine: Lidocaine Ointment [package insert]. Hawthorne, NY: Taro Pharmaceuticals, 2005.
13. Lidocaine Hydrochloride: Lidocaine Hydrochloride Anhydrous Solution [package insert].
Amityville, NY: Hi-Tech Pharmacal, 2011.
14. Oraqix (Lidocaine and Prilocaine Periodontal Gel) 2.5% / 2.5% [package insert]. York, PA: Dentsply
Pharmaceutical, 2010.
15. Benzocaine Topical Dosage. http://www.drugs.com/dosage/benzocaine-topical.html. Accessed
30 January 2018.
16. Tetracaine. http://www.drugs.com/monograph/tetracaine.html. Accessed 18 January 2014.
17. Cetacaine Anesthetic: Benzocaine, Butamben, and Tetracaine Hydrochloride Solution [package
insert]. Pennsauken, NJ: Cetylite Industries, 2013.
18. Cetacaine Topical Anesthetic: Benzocaine, Butamben, and Tetracaine Hydrochloride Gel [package insert]. Pennsauken, NJ: Cetylite Industries, 2010.
19. Septocaine® with Epinephrine 1:100,000, Septocaine® with Epinephrine 1:200,000 (Articaine Hydrochloride 4% (40 mg/mL) with Epinephrine 1:100,000 or 1:200,000 Injection) [package insert].
Louisville, CO: Septodont, 2010.
20. Posicaine 200 (Articaine Hydrochloride 4% with Epinephrine 1:200,000) [package insert].
Elmhurst, IL: Henry Schein, 2008.
21. Marcaine® 0.5% with Epinephrine 1:200,000 Injection (as Bitartrate) (Bupivacaine Hydrochloride
and Epinephrine Injection, USP) [package insert]. Cambridge, Canada: Cook-Waite, 2007.
22. Sensorcaine(r) Bupivacaine Hydrochloride Injection USP [package insert]. Wilmington: AstraZeneca, 2015.
23. Vivacaine Bupivicaine HCl 0.5% and Epinephrine 1:200,000 Injection (as Bitartrate) [package insert]. Cambridge, Canada: Novocol Pharmaceutical of Canada, 2009.
24. Surgicaine Bupivacaine HCl 0.5% and Epinephrine 1:200,000 Injection (as Bitartrate) [package
insert]. Cambridge, Canada: Novocol Pharmaceutical of Canada, 2009.
25. Octocaine (Lidocaine Hydrochloride and Epinephrine Injection, USP) [package insert].
Cambridge, Canada: Novocol Pharmaceutical of Canada, 2007.
26. Lidocaine HCl 2% and Epinephrine 1:50,000 Lidocaine HCl 2% and Epinephrine 1:100,000 (Lidocaine Hydrochloride and Epinephrine Injection, USP) [package insert], Cambridge, Canada:
Novocol Pharmaceutical of Canada, 2011.
27. Lignospan (Lidocaine Hydrochloride and Epinephrine Injection, USP) [package insert].
Cambridge, Canada: Novocol Pharmaceutical of Canada, July 2011. :2-3.
28. Isocaine 3% Plain (Mepivacaine Hydrochloride Injection, USP) Isocaine 2% (with Levonordefrin 1:20,000) (Mepivacaine Hydrochloride and Levonordefrin Injection, USP) [package insert].
Cambridge, Canada: Novocol Pharmaceutical of Canada, 2010.
29. Carbocaine 3% Injection (Mepivacaine Hydrochloride Injection, USP) Carbocaine 2% with
Neo-Cobefrin 1:20,000 Injection (Mepivacaine Hydrochloride and Levonordefrin Injection, USP)
[package insert]. Cambridge, Canada: Novocol Pharmaceutical of Canada, 2009.
30. Scandonest 3% Plain (Mepivacaine Hydrochloride Injection, USP) Scandonest 2% L (with Levonordefrin 1:20,000) (Mepivacaine Hydrochloride and Levonordefrin Injection, USP) [package
insert]. Cambridge, Canada: Novocol Pharmaceutical of Canada, 2009.
31. Polocaine: Mepivacaine Hydrochloride Injection, Solution; Polocaine: MPF, Mepivacaine Hydrochloride Injection, Solution [package insert]. Schaumburg, IL: APP Pharmaceuticals, 2008.
32. Citanest Forte: Prilocaine Hydrochloride and Epinephrine Bitartrate Injection, Solution [package
insert]. York, PA: Dentsply Pharmaceutical, 2012.
33. Saraghi M, Moore PA, Hersh E V. Local anesthetic calculations: Avoiding trouble with pediatric
patients. Gen Dent 2015;63:48–52.
34. Malamed SF. Handbook of Local Anesthesia, ed 6. St Louis: Elsevier, 2013.
35. Jacobsen RB, Borche JE, Bindslev-Jensen C. Hypersensitivity to local anaesthetics. Allergy
2005;60:262–264.
130
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References
36. Toxicology Data Network. Lidocaine. http://toxnet.nlm.nih.gov/cgi-bin/sis/search2/r?dbs+lactmed:
@[email protected]+363. Accessed 30 November 2017.
37. Toxicology Data Network. Prilocaine. http://toxnet.nlm.nih.gov/cgi-bin/sis/search2/r?dbs+lactmed:@[email protected]+713. Accessed 30 November 2017.
38. Cengiz SB. The pregnant patient: Considerations for dental management and drug use. Quintessence Int 2007;38:e133–e142.
39. Michalowicz BS, DiAngelis AJ, Novak J, et al. Examining the safety of dental treatment in pregnant
women. J Am Dent Assoc 2008;139:685–695.
40. Toxicology Data Network. Benzocaine. http://toxnet.nlm.nih.gov/cgi-bin/sis/search2/r?dbs+lactmed:@[email protected]+845. Accessed 30 January 2018.
41. Ultradent. Ultracare Oral Anesthetic Gel. https://www.ultradent.com/en-us/Dental-ProductsSupplies/Prepare/Oral-Anesthetic-Gel/Ultracare/Pages/default.aspx. Accessed 30 January 2018.
42. Toxicology Data Network. Tetracaine. http://toxnet.nlm.nih.gov/cgi-bin/sis/search2/r?dbs+lactmed:@[email protected]+714. Accessed 30 January 2018.
43. Cetylite Industries. Cetacaine Topical Anesthetic Prescribing Information. http://cetylite.com/sites/
default/files/resources/Cetacaine%20Prescribing%20Information_0.pdf. Accessed 21 May 2017.
44. Moore PA. Selecting drugs for the pregnant dental patient. J Am Dent Assoc 1998;129:1281–1286.
45. Hagai A, Diav-Citrin O, Shechtman S, Ornoy A. Pregnancy outcome after in utero exposure to local
anesthetics as part of dental treatment. J Am Dent Assoc 2015;146:572–580.
46. Muller SH, Diaz JH, Kaye AD. Clinical applications of intravenous lipid emulsion therapy. J Anesth
2015;29:920–926.
47. Ciechanowicz S, Patil V. Lipid emulsion for local anesthetic systemic toxicity. Anesthesiol Res
Pract 2012;2012:131784.
48. Haas DA. An update on local anesthetics in dentistry. J Can Dent Assoc 2002;68:545–551.
131
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Appendices
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Appendix A
134
Appendix B
136
Appendix C
141
Appendix D
143
Appendix E
144
Sample Consult Forms
Caries Risk Assessment Forms
FDA Recommendations for Prescribing Dental
Radiographs
Prescription Writing Overview
Recommended Web Resources
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Appendix A: Sample Consult Forms
Appendix A: Sample Consult Forms
A1: Dentist to perinatal provider
I authorize the release of my medical information in order to get a medical consultation.
Patient’s name:
Date of birth: /
Patient’s signature:
Date:
/ /
/
To be filled out by the dentist:
The above patient has come to my office for dental treatment. Her health history indicated pregnancy with
an estimated delivery date of / / as well as the following medical conditions:
☐ Anemia
☐ Anticoagulation therapy
☐ Asthma
☐ Hypertension
☐ Hyperemesis gravidarum
☐ Preeclampsia
☐ Diabetes: Type 1 / Type 2 / Gestational (Please circle type.)
☐ Other:
Dental care to address oral disease and infection during a low-risk pregnancy often includes the following:
• Dental x-rays (taken with lead abdominal and neck shielding) as necessary for oral evaluation.
• Pain and infection may be addressed at any time during the pregnancy, but treatment will be provided
during the second trimester when possible.
• Dental cleaning (prophylaxis/scaling and root planing).
• Restorative dentistry to treat dental caries.
• Extractions or oral surgery as needed to address disease.
• Standard medications may be used as indicated:
‒ Topical and local anesthetic (eg, lidocaine with or without epinephrine)
‒ Antibiotics such as penicillin, amoxicillin cephalosporin, clindamycin, erythromycin
(nonestolate form)
‒ Analgesics such as acetaminophen or acetaminophen with codeine
Description of proposed dental treatment:
To be filled out by the perinatal provider:
Are you recommending any precautions or modifications to dental treatment?
☐ No
☐ Yes. Please describe and include reason:
Physician’s signature:
Print name:
Date:
Office address:
City, state, zip:
Phone:
Fax:
/
-
/
-
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Appendix A
A2: Perinatal provider to dentist
I authorize the release of my medical information in order to get a medical consultation.
Patient’s name:
Date of birth:
/ /
Patient’s signature:
Date:
/ /
To be filled out by the perinatal provider:
My patient is pregnant with an estimated delivery date of
ment at this time for the following reason(s):
☐ Routine examination and cleaning
☐ Pain or discomfort
☐ Bleeding gums
☐ Other:
/
/
. She would like to seek dental treat-
Known allergies:
☐ None
☐ Yes (list):
Additional medical conditions:
☐ None
☐ Yes (list):
The patient may have routine dental care to address oral disease and infection during pregnancy. This may
include (but is not limited to) the following:
• Dental x-rays (taken with lead abdominal and neck shielding) as necessary for oral evaluation.
• Dental cleaning (prophylaxis/scaling and root planing).
• Restorative dentistry to treat dental caries.
• Extractions or oral surgery as needed to address disease.
• Medications as needed to treat oral disease:
‒ Topical and local anesthetic (eg, lidocaine with or without epinephrine)
‒ Antibiotics such as penicillin, amoxicillin, cephalosporin, clindamycin, erythromycin
(nonestolate form)
‒ Analgesics such as acetaminophen or acetaminophen with codeine
Are you recommending any precautions or modifications to dental treatment?
☐ No
☐ Yes
Comments:
To be filled out by the dentist:
Date of oral evaluation:
/
/
Description of oral disease and planned treatment:
Dentist’s signature:
Print name:
Date:
Office address:
City, state, zip:
Phone:
Fax:
/
/
-
-
135
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Appendix B: Caries Risk Assessment Forms
Appendix B: Caries Risk Assessment Forms
B1: American Academy of Pediatric Dentistry
Table 1 | Caries Risk Assessment Form for 0 to 3-Year-Olds59,60 (for Physicians and Other
Non-Dental Health Care Providers)
Factors
High Risk
Low Risk
Biological
Mother/primary caregiver has active cavities
Yes
Parent/caregiver has low socioeconomic status
Yes
Child has >3 between-meal sugar-containing snacks or
beverages per day
Yes
Child is put to bed with a bottle containing natural or added
sugar
Yes
Child has special health care needs
Yes
Child is a recent immigrant
Yes
Protective
Child receives optimally fluoridated drinking water or
fluoride supplements
Yes
Child has teeth brushed daily with fluoridated toothpaste
Yes
Child receives topical fluoride from health professional
Yes
Child has dental home/regular dental care
Yes
Clinical Findings
Child has white spot lesions or enamel defects
Yes
Child has visible cavities or fillings
Yes
Child has plaque on teeth
Yes
Circling those conditions that apply to a specific patient helps the health care worker and parent understand the factors that contribute to or protect from caries. Risk assessment categorization of low or high
is based on preponderance of factors for the individual. However, clinical judgment may justify the use of
one factor (eg, frequent exposure to sugar-containing snacks or beverages, visible cavities) in determining overall risk.
Overall assessment of the child’s dental caries risk:
High ❑
Low ❑
Copyright © 2016-17 American Academy of Pediatric Dentistry and reproduced with their permission.
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Appendix B
Table 2 | Caries Risk Assessment Form for 0 to 5-Year-Olds59,60 (for Dental Providers)
Factors
High Risk
Moderate Risk
Low Risk
Biological
Mother/primary caregiver has active caries
Yes
Parent/caregiver has low socioeconomic
status
Yes
Child has >3 between-meal sugarcontaining snacks or beverages per day
Yes
Child is put to bed with a bottle containing
natural or added sugar
Yes
Child has special health care needs
Yes
Child is a recent immigrant
Yes
Protective
Child receives optimally fluoridated
drinking water or fluoride supplements
Yes
Child has teeth brushed daily with
fluoridated toothpaste
Yes
Child receives topical fluoride from health
professional
Yes
Child has dental home/regular dental care
Yes
Clinical Findings
Child has >1 decayed/missing/filled surfaces
Yes
Child has active white spot lesions or
enamel defects
Yes
Child has elevated mutans streptococci
levels
Yes
Child has plaque on teeth
Yes
Circling those conditions that apply to a specific patient helps the practitioner and parent understand
the factors that contribute to or protect from caries. Risk assessment categorization of low, moderate, or
high is based on preponderance of factors for the individual. However, clinical judgment may justify the
use of one factor (eg, frequent exposure to sugar-containing snacks or beverages, more than one dmfs) in
determining overall risk.
Overall assessment of the child’s dental caries risk:
High ❑
Moderate ❑
Low ❑
Copyright © 2016-17 American Academy of Pediatric Dentistry and reproduced with their permission.
137
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Appendix B: Caries Risk Assessment Forms
Table 3 | Caries Risk Assessment Form for > 6-Year-Olds60–62 (for Dental Providers)
Factors
High Risk
Moderate Risk
Low Risk
Biological
Patient is of low socioeconomic status
Yes
Patient has >3 between-meal sugarcontaining snacks or beverages per day
Yes
Patient has special health care needs
Yes
Patient is a recent immigrant
Yes
Protective
Patient receives optimally fluoridated
drinking water
Yes
Patient brushes teeth daily with fluoridated
toothpaste
Yes
Patient receives topical fluoride from health
professional
Yes
Additional home measures (eg, xylitol,
MI paste, antimicrobial)
Yes
Patient has dental home/regular dental care
Yes
Clinical Findings
Patient has >1 interproximal lesion
Yes
Patient has active white spot lesions or
enamel defects
Yes
Patient has low salivary flow
Yes
Patient has defective restorations
Yes
Patient wearing an intraoral appliance
Yes
Circling those conditions that apply to a specific patient helps the practitioner and patient/parent
understand the factors that contribute to or protect from caries. Risk assessment categorization of low,
moderate, or high is based on preponderance of factors for the individual. However, clinical judgment
may justify the use of one factor (eg, >1 interproximal lesion, low salivary flow) in determining overall risk.
Overall assessment of the dental caries risk:
High ❑
Moderate ❑
Low ❑
Copyright © 2016-17 American Academy of Pediatric Dentistry and reproduced with their permission.
138
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Appendix B
B2: American Dental Association
Caries Risk Assessment Form (Age 0-6)
Patient Name:
Birth Date:
Date:
Age:
Initials:
Low Risk
Contributing Conditions
Moderate Risk
High Risk
Check or Circle the conditions that apply
I.
Fluoride Exposure (through drinking water,
supplements, professional applications,
toothpaste)
II.
Sugary Foods or Drinks (including juice, carbonated or non-carbonated soft drinks, energy
drinks, medicinal syrups)
III.
Eligible for Government Programs
(WIC, Head Start, Medicaid or SCHIP)
IV.
Caries Experience of Mother, Caregiver and/
or other Siblings
No carious lesions in
last 24 months
❑
Carious lesions in
last 7-23 months
❑
V.
Dental Home: established patient of record in
a dental office
Yes
❑
No
❑
I.
Special Health Care Needs (developmental,
physical, medical or mental disabilities that
prevent or limit performance of adequate oral
health care by themselves or caregivers)
I.
Visual or Radiographically Evident Restorations/Cavitated Carious Lesions
No new carious lesions or restorations
in last 24 months
❑
Carious lesions or
restorations in last
24 months
❑
II.
Non-cavitated (incipient) Carious Lesions
No new lesions in
last 24 months
❑
New lesions in last
24 months
❑
III.
Teeth Missing Due to Caries
No
❑
Yes
❑
IV.
Visible Plaque
No
❑
Yes
❑
V.
Dental/Orthodontic Appliances Present (fixed
or removable)
No
❑
Yes
❑
VI.
Salivary Flow
Yes
❑
No
❑
Primarily at
mealtimes
❑
Frequent or
prolonged between
meal exposures/day
❑
No
❑
General Health Conditions
Yes
❑
Carious lesions in
last 6 months
❑
Check or Circle the conditions that apply
Yes
❑
No
❑
Clinical Conditions
Overall assessment of dental caries risk:
Bottle or sippy cup
with anything other
than water at bed time
❑
Check or Circle the conditions that apply
Visually
adequate
❑
❑ Low
Visually
inadequate
❑
❑ Moderate
❑ High
Instructions for Caregiver:
Copyright © 2018 American Dental Association. All rights reserved. Reprinted with permission.
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Appendix B: Caries Risk Assessment Forms
Caries Risk Assessment Form (Age >6)
Patient Name:
Birth Date:
Date:
Age:
Initials:
Low Risk
Contributing Conditions
I.
Fluoride Exposure (through drinking water,
supplements, professional applications,
toothpaste)
II.
Sugary Foods or Drinks (including juice, carbonated or non-carbonated soft drinks, energy
drinks, medicinal syrups)
III.
Caries Experience of Mother, Caregiver and/or
other Siblings (for patients ages 6-14)
IV.
Dental Home: established patient of record,
receiving regular dental care in a dental office
Moderate Risk
Check or Circle the conditions that apply
Yes
❑
No
❑
Frequent or
prolonged between
meal exposures/day
❑
Primarily at
mealtimes
❑
No carious lesions in
last 24 months
❑
Carious lesions in
last 7-23 months
❑
Yes
❑
No
❑
General Health Conditions
Carious lesions in
last 6 months
❑
Check or Circle the conditions that apply
I.
Special Health Care Needs (developmental,
physical, medical or mental disabilities that prevent or limit performance of adequate oral health
care by themselves or caregivers)
No
❑
II.
Chemo/Radiation Therapy
No
❑
III.
Eating Disorders
No
❑
Yes
❑
IV.
Medications that Reduce Salivary Flow
No
❑
Yes
❑
V.
Drug/Alcohol Abuse
No
❑
Yes
❑
Clinical Conditions
Yes (over age 14)
❑
Yes (ages 6-14)
❑
Yes
❑
Check or Circle the conditions that apply
I.
Cavitated or Non-Cavitated (incipient)
Carious Lesions or Restorations (visually or
radiographically evident)
II.
Teeth Missing Due to Caries in past 36
months
No
❑
III.
Visible Plaque
No
❑
Yes
❑
IV.
Unusual Tooth Morphology that compromises
oral hygiene
No
❑
Yes
❑
V.
Interproximal Restorations - 1 or more
No
❑
Yes
❑
VI.
Exposed Root Surfaces Present
No
❑
Yes
❑
VII.
Restorations with Overhangs and/or Open
Margins; Open Contacts with Food Impaction
No
❑
Yes
❑
VIII.
Dental/Orthodontic Appliances (fixed or
removable)
No
❑
Yes
❑
IX.
Severe Dry Mouth (Xerostomia)
No
❑
Overall assessment of dental caries risk:
High Risk
No new carious lesions or restorations
in last 36 months
❑
❑ Low
1 or 2 new carious lesions or restorations
in last 36 months
❑
3 or more carious lesions or restorations
in last 36 months
❑
Yes
❑
Yes
❑
❑ Moderate
❑ High
Patient Instructions:
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Appendix C
Appendix C: US Food and Drug Administration
Recommendations for Prescribing Dental
Radiographs
These recommendations are subject to clinical judgment and may not apply to every
patient. They are to be used by dentists only after reviewing the patient’s health history and
completing a clinical examination. Even though radiation exposure from dental radiographs
is low, once a decision to obtain radiographs is made, it is the dentist’s responsibility to follow
the ALARA principle (as low as reasonably achievable) to minimize the patient’s exposure.
Type of encounter
Patient age and dental developmental stage
Child with Primary
Dentition (prior to
eruption of first
permanent tooth)
Child with
Transitional
Dentition (after
eruption of first
permanent tooth)
Adolescent with
Permanent
Dentition (prior to
eruption of third
molars)
Adult, Dentate
or Partially
Edentulous
Adult, Edentulous
New patient* being evaluated for oral diseases
Individualized
radiographic exam
consisting of selected periapical/occlusal views and/or
posterior bitewings
if proximal surfaces
cannot be visualized or probed.
Patients without
evidence of disease
and with open
proximal contacts
may not require a
radiographic exam
at this time.
Recall patient* with clinical
caries or at increased risk
for caries†
Posterior bitewing exam at 6- to 12-month intervals if proximal
surfaces cannot be examined visually or with a probe
Posterior bitewing
exam at 6- to
18-month intervals
Not applicable
Recall patient* with no
clinical caries and not at
increased risk for caries†
Posterior bitewing exam at 12- to 24-month
intervals if proximal surfaces cannot be
examined visually or with a probe
Posterior bitewing
exam at 24- to
36-month intervals
Not applicable
Recall patient* with
periodontal disease
Clinical judgment as to the need for and type of radiographic images for the evaluation
of periodontal disease. Imaging may consist of, but is not limited to, selected bitewing
and/or periapical images of areas where periodontal disease (other than nonspecific
gingivitis) can be demonstrated clinically.
Patient (new and recall) for
monitoring of dentofacial
growth and development,
and/or assessment of dental/skeletal relationships
Clinical judgment as to need for and type
of radiographic images for evaluation
and/or monitoring of dentofacial growth
and development or assessment of
dental and skeletal relationships
Patient with other circumstances including, but not
limited to, proposed or existing implants, other dental
and craniofacial pathoses, restorative/endodontic needs,
treated periodontal disease
and caries remineralization
Clinical judgment as to need for and type of radiographic images for evaluation and/or monitoring of these
conditions
Ninan_Appendices.indd 141
Individualized
radiographic exam
consisting of posterior bitewings with
panoramic exam or
posterior bitewings
and selected periapical images.
Individualized radiographic exam consisting of posterior bitewings with panoramic
exam or posterior bitewings and selected
periapical images. A full-mouth intraoral
radiographic exam is preferred when the
patient has clinical evidence of generalized oral disease or a history of extensive
dental treatment.
Posterior bitewing
exam at 18- to
36-month intervals
Same as children,
plus panoramic or
periapical exam to
assess developing
third molars
Individualized
radiographic
exam, based on
clinical signs and
symptoms.
Not applicable
Usually not indicated for monitoring
of growth and development. Clinical
judgment as to the need for and type
of radiographic image for evaluation of
dental and skeletal relationships.
141
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Appendix C: US Food and Drug Administration Recommendations
*Clinical situations for which radiographs may be indicated include, but are not
limited to:
• Positive historical findings:
‒‒ Previous periodontal or endodontic treatment
‒‒ History of pain or trauma
‒‒ Familial history of dental anomalies
‒‒ Postoperative evaluation of healing
‒‒ Remineralization monitoring
‒‒ Presence of implants, previous implant-related pathosis, or evaluation for implant placement
• Positive clinical signs/symptoms:
‒‒ Clinical evidence of periodontal disease
‒‒ Large or deep restorations
‒‒ Deep caries lesions
‒‒ Malposed or clinically impacted teeth
‒‒ Swelling
‒‒ Evidence of dental/facial trauma
‒‒ Mobility of teeth
‒‒ Sinus tract (“fistula”)
‒‒ Clinically suspected sinus pathosis
‒‒ Growth abnormalities
‒‒ Oral involvement in known or suspected systemic disease
‒‒ Positive neurologic findings in the head and neck
‒‒ Evidence of foreign objects
‒‒ Pain and/or dysfunction of the temporomandibular joint
‒‒ Facial asymmetry
‒‒ Unexplained bleeding
‒‒ Unexplained sensitivity of teeth
‒‒ Unusual eruption, spacing, or migration of teeth
‒‒ Unusual tooth morphology, calcification, or color
‒‒ Unexplained absence of teeth
‒‒ Clinical tooth erosion
‒‒ Peri-implantitis
†
Factors increasing risk for caries may be assessed using the ADA Caries Risk
Assessment forms (0– 6 years of age and > 6 years of age).
142
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Appendix D
Appendix D: Prescription Writing Overview
Typical elements of a prescription
•
•
•
•
•
•
Doctor’s name, address, and phone number
Patient’s name, address, and date of birth
Date
Rx: Drug name, dosage, form, and size
Disp: How much of the drug to be dispensed
Sig: Directions for how the patient should take the drug
‒‒ Include route of administration.
‒‒ Include when to stop taking. For example, “as needed for pain” or “until gone.”
‒‒ Consider including the purpose of the medication to help educate the patient.
For example, take “to treat oral infection.”
‒‒ Example: “Take one tablet by mouth three times a day until finished to treat infection.”
• Fill generic (OK to substitute with generic) / Fill as written (Do not substitute)
• Doctor’s signature, state license number, Drug Enforcement Agency number (as required)
Common prescription writing abbreviations
When in doubt, write it out.
Abbreviation
i, ii, iii
b
Meaning
one, two, three
Abbreviation
q
twice
Meaning
four (note: same abbreviation as “every”)
twice a day
qAM
in the morning
d
day
qhs
at bedtime
h
hours
qid
four times a day
po
by mouth/orally
qPM
in the evening
prn
as needed
stat
immediately
bid
q
every (eg, q6h means every
6 hours)
t
tid
three
three times a day
143
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Appendix E: Recommended Web Resources
Appendix E: Recommended Web Resources
Academy of Nutrition and Dietetics
The Academy of Nutrition and Dietetics’s award-winning eatright.org brings consumers the latest science-based nutrition information. This site offers additional
information on nutrition during pregnancy and provides a resource to locate a dietitian. All content on the eatright websites is copyrighted by the Academy of Nutrition
and Dietetics.
http://www.eatright.org
American Academy of Pediatric Dentistry
Caries risk assessment
http://www.aapd.org/media/Policies_Guidelines/G_CariesRiskAssessment.pdf
Guideline on informed consent
http://www.aapd.org/media/Policies_Guidelines/G_InformedConsent.pdf
Guideline on oral health care for the pregnant adolescent
http://www.aapd.org/media/Policies_Guidelines/G_Pregnancy.pdf
Guideline on periodicity of examination, preventive dental services, anticipatory guidance/counseling, and oral treatment for infants, children, and adolescents
http://www.aapd.org/media/Policies_Guidelines/G_Periodicity.pdf
All items on the aapd.org website are copyright of the American Academy of Pediatric
Dentistry.
American Dental Association
Caries risk assessment tools, ages 0 to 6
http://www.ada.org/en/~/media/ADA_Foundation/GKAS/Files/topics-caries-educationalunder6-GKAS
Caries risk assessment tools, ages over 6
http://www.ada.org/en/~/media/ADA/Science%20and%20Research/Files/topic_caries_over6
Information on reconstituting infant formula with fluoridated water
http://ebd.ada.org/~/media/EBD/Files/ADA_Evidence-based_Infant_Formula_Chairside_
Guide.ashx
Collection of clinical practice guidelines
http://ebd.ada.org/en/evidence/guidelines
Guidelines on flossing
http://www.ada.org/~/media/ADA/Science%20and%20Research/Files/watch_materials_floss.
pdf?la=en
Guidelines on brushing
http://www.mouthhealthy.org/en/az-topics/b/brushing-your-teeth
144
Unless otherwise indicated, all items on the ada.org website are protected by copyright of the American Dental Association.
Ninan_Appendices.indd 144
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Appendix E
California Dental Association
Evidence-based oral health guidelines
https://www.cdafoundation.org/portals/0/pdfs/poh_guidelines.pdf
All contents of the CDA Foundation web site: Copyright © 2002-2017 CDA Foundation,
all rights reserved.
The International Lactation Consultant Association
This site provides a resource for a woman to find a lactation consultant.
http://www.ilca.org/home
The contents of all materials contained on ILCA’s website are owned by ILCA (unless
otherwise indicated) and are protected by US and international copyright laws.
National Maternal and Child Oral Health Resource Center
Home page
https://www.mchoralhealth.org/
Oral health care during pregnancy: a national consensus statement
https://www.mchoralhealth.org/materials/consensus_statement.php
All OHRC-produced resources, including materials and websites, are copyrighted and
protected by Georgetown University’s copyright policies, unless otherwise stated.
New York State Department of Health
Oral health care during pregnancy and early childhood practice guidelines
https://www.health.ny.gov/publications/0824.pdf
NIH National Library of Medicine
The LactMed Database contains information on drugs and other chemicals to which
breastfeeding mothers may be exposed and the possible adverse effects in the nursing infant.
https://toxnet.nlm.nih.gov/newtoxnet/lactmed.htm
US Food and Drug Administration
List of pregnancy exposure registries
https://www.fda.gov/ScienceResearch/SpecialTopics/WomensHealthResearch/ucm134848.htm
The selection of patients for dental radiographic examinations
http://www.fda.gov/Radiation-EmittingProducts/RadiationEmittingProductsandProcedures/
MedicalImaging/MedicalX-Rays/ucm116504.htm
Pregnancy and lactation labeling (drugs) final rule
http://www.fda.gov/Drugs/DevelopmentApprovalProcess/DevelopmentResources/Labeling/
ucm093307.htm
145
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Index
Ninan_Index.indd 146
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Index
Page references followed by “t” denote tables and “f” denote figures.
A
AADP. See American Academy of Pediatric
Dentistry.
AAP. See American Academy of
Periodontology.
Abortus, 10
Academy of Nutrition and Dietetics, 145
Acetaminophen, 88t, 94–95
Acetaminophen + codeine, 88t, 94–95
Acetylsalicylic acid, 89
ACOG. See American College of Obstetricians
and Gynecologists.
ADA. See American Dental Association.
Adolescent pregnancy, 49–51
AED. See Automated external defibrillator.
AHA. See American Heart Association.
ALARA principle, 59
Alcohol, 67
Alkaline phosphatase, 38
Allergies, 117–118
Amalgam, 60–62
American Academy of Pediatric Dentistry, 71,
136, 144
American Academy of Periodontology, 2
American College of Obstetricians and
Gynecologists, 7, 58
American College of Radiology, 58
American Dental Association
caries risk assessment forms, 139–140
toothpaste recommendations of, 71
web resources of, 144
American Heart Association, 25
Amide anesthetics, 117t, 122
Amoclan. See Amoxicillin + clavulanic acid.
Amoxicillin, 102t, 104
Amoxicillin + clavulanic acid, 102t, 105
Analgesics
acetaminophen, 88t, 94–95
acetaminophen + codeine, 88t, 94–95
aspirin, 89
aspirin + caffeine + dihydrocodeine, 95
celecoxib, 88t, 92
codeine, 90
hydrocodone + acetaminophen, 88t, 96–97
hydrocodone + ibuprofen, 88t, 97
hydromorphone, 88t, 101
ibuprofen, 88t, 93
meperidine, 88t, 100
naproxen, 91
oxycodone + acetaminophen, 88t, 99
oxycodone + aspirin, 98
summary of, 87, 88t
tramadol + acetaminophen, 96
Anesthetics
allergies to, 117–118
local. See Local anesthetics.
psychogenic reactions to, 117–118
topical, 116t, 118–121
Antibiotics
cephalosporins, 102t
lincosamines, 102t
macrolides, 102t
penicillins, 102t
prophylactic uses of, 64
quinolones, 102t
summary of, 101, 102t–103t
tetracyclines, 102t
Anticipatory guidance
for cariogenic bacteria, 68
in first trimester, 12
in third trimester, 14
Antiphospholipid syndrome, 22t, 36
Anxiety, dental, 21t, 24, 51
Aortocaval compression, 21t, 26, 30, 31, 32f
APLS. See Antiphospholipid syndrome.
Articaine, 116t, 117, 128
ASA. See Acetylsalicylic acid.
Aspiration, 8–9
Aspirin, 49, 89, 98
Aspirin + caffeine + dihydrocodeine, 95
At-home oral care, 64–66
Augmentin. See Amoxicillin + clavulanic acid.
Automated external defibrillator, 21t, 25
Azithromycin, 103t, 108
B
Bacteremia, 1, 5, 9, 64
Bacteria, cariogenic, 68
Behavioral health, 21t
Benzocaine, 116t, 120
Benzocaine/butamben/tetracaine, 116t, 121
Birth defects, 46
Bisphenol A, 62, 63f
Bisphenol A–glycidyl methacrylate, 62, 63f
Blood pressure, 29–30
BPA. See Bisphenol A.
Braxton-Hicks contractions, 23t, 43–44
Breast milk, 49
147
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Index
Breastfeeding, 69. See also Nursing.
Brushing, 65
Bupivacaine, 116t, 127
C
California Dental Association
oral health guidelines, 2
preeclampsia guidelines, 27
web resources of, 145
Carbocaine. See Mepivacaine.
Cardiac output
fetal, 24
maternal, 29
Cardiopulmonary arrest, 21t, 24–26, 25f
Cardiopulmonary resuscitation, 25f, 25–26
Caries
childhood, 40
professionally applied topical fluoride for,
70–71
Caries risk assessment
description of, 34
forms for, 136–140
in infant, 70
Cariogenic bacteria, 68
CDT. See Current dental terminology.
Celecoxib, 88t, 92
Cephalexin, 103t, 106
Cephalosporins, 102t
Cesarean delivery, 26
Chlorhexidine, 14
Ciprofloxacin, 110
Circulatory system, 21t, 24–32
Citanest. See Prilocaine.
Clarithromycin, 106
Cleft lip/palate, 47, 67
Cleocin. See Clindamycin.
Clindamycin, 103t, 109
Clotting factors, 36t
Coagulation, 14, 36–37
Codeine, 90
Composite resins, 62, 63f
Comprehensive dental treatment plan, 9
Consent, informed, 50
Consults, medical
description of, 9
forms used in, 134–135
COX2 inhibitors. See Cyclooxygenase-2
inhibitors.
CPR. See Cardiopulmonary resuscitation.
Creatinine clearance, 43
Current dental terminology, 71
Cyclooxygenase-2 inhibitors, 86
D
Delayed gastric emptying, 33–34
Dental anxiety, 21t, 24, 51
Dental care
barriers to, 2
postpartum, 14
when to provide, 7
Dental emergency, 6
Dental erosion, 34–35
Dental instruments, aspiration of, 9
Dental materials
amalgam, 60–62
aspiration of, 9
composite resin, 62, 63f
fetal exposure to, 60
Dental provider’s perceptions, 2
Dental referrals, 1, 134, 135
Dental treatment
bacteremia caused by, 9
categories of, 6–7
comprehensive plan for, 9
consequences of, 7–8
deferral of, 9
in minors, 51t
needs for, 8
pregnancy-related changes’ effect on,
20–23, 21t–22t
radiographs effect on, 59
timing of, 8–9
trimester-based recommendations for,
12–14, 13t
Dentifrice. See Toothpaste.
Dermatologic changes, 23t, 40
Deterministic effects, of radiation, 58
Diabetes mellitus, 21t, 32–33
Diastolic blood pressure, 29
Dicloxacillin, 103t, 105
Doxylamine and pyridoxine, 35
Drugs. See Anesthetics; Medications.
Due date estimations, 12
Dyspnea, 23t, 44–45
E
Eclampsia, 21t, 27–29
Elective dental treatment, 6–7
Embryogenesis, 48
Emergency dental treatment, 6, 13t
Enamel
erosion/decalcification of, 23t, 41
fetal development of, 47
Endocrine system, 21t, 32–33
Epinephrine, 14, 123
148
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Index
Epistaxis. See Nosebleed.
Epulis gravidarum, 42
Erythromycin, 103t, 107
Ester anesthetics, 117t
Estrogen, 20, 32, 41, 43
F
False labor, 23t, 43–44
FDA. See Food and Drug Administration.
Fetal development
anomalies of, 46
birth defects, 46
normal, 48
teratogen effects on, 46–48
Fetal erythropoiesis, 35
Fetal gastroschisis, 89
Fetal red blood cells, 24
Fetogenesis, 48
Fetus
brain development in, 47
cardiac output in, 24
definition of, 46
dental material exposure by, 60
dental treatment effects on, 8–9
drug bioavailability to, 78
heart rate in, 31
hypoxia compensatory measures from, 24
local anesthetic exposure to, 121–122
loss of, 48
mercury exposure to, from amalgam,
60–61
periodontal therapy effects on, 63
radiation effects on, 58–59
First trimester, 12, 13t
Flossing, 65
Fluoride
in toothpaste, 72
topical, professionally applied, 70–71
in water, 67
Fluorosis, 72
Folate, 67
Food and Drug Administration
dental radiograph guidelines, 141–142
Pregnancy and Lactation Labeling Rule,
78, 80–82, 81t
pregnancy risk categories, 78–82
web resources of, 145
Foods, 66–67
G
Gastroesophageal reflux, 22t, 33–34
Gastrointestinal system, 22t, 33–35
Gastroschisis, 89
Gestational diabetes, 21t, 32–33
Gingival crevicular fluid, 42
Gingival hyperplasia, 23t, 41–42
Gingivitis, 20, 23t, 41–42, 64
Glomerular filtration rate, 23t, 43
Glucose intolerance, 33
GTPAL, 10–11
H
Heart murmurs, 21t, 30
Heart rate
fetal, 31
increased, 21t, 29
Heartburn, 22t, 33–34
HELLP syndrome, 27
Hematologic system, 22t, 36–38
Hemoglobin A1c, 33
Hepatic dysfunction, 22t, 38
Hepatic system, 22t, 38
Hormones, 20, 32, 41, 43.
Hydrocodone + acetaminophen, 88t, 96t, 97
Hydrocodone + ibuprofen, 88t, 97
Hydromorphone, 88t, 101
Hypercoagulable state, 3t, 14, 22t, 36–37,
122–123
Hyperemesis gravidarum, 22t, 34
Hyperglycemia, 33
Hypertension, 21t, 29
Hyperventilation, 23t, 45
Hypoglycemia, 33
Hypotension, 21t, 29–30
Hypoxia, 24
I
Iatrogenic-related complications, 8
Ibudone. See Hydrocodone + ibuprofen.
Ibuprofen, 88t, 93
ILE. See Intravenous lipid emulsion.
Immune system, 22t, 39–40
Immunoglobulin G, 22t, 39
Infant
caries risk assessment in, 70
cariogenic bacteria exposure, 68
cleaning of teeth, 71
dietary recommendations for, 69
maternal medication transfer to, during
nursing, 49
oral care for, 69
toothpaste for, 71–72, 71t, 72f
Infant formula, 69
Inferior vena cava compression, 31, 32f
149
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Index
Informed consent, 50
Inorganic mercury, 60
Integumentary system, 23t, 40
Interdental cleaners, 65
Interdental papilla, 41–42
Intravenous lipid emulsion, 123
K
Keflex. See Cephalexin.
L
Lactation
FDA Pregnancy and Lactation Labeling
Rule, 78, 80–82, 81t
local anesthetic use during, 123
Last menstrual period, for due date
estimation, 12
Left uterine displacement, 21t, 26, 30–32,
32f, 52
Levonordefrin, 123
Lidocaine
characteristics of, 116t, 124
with epinephrine, 122–123
topical, 118
Lidocaine + prilocaine, 119
Lincosamines, 102t
Liver dysfunction, 22t, 38
Local anesthetics
amide, 122
in dental cartridge, 116
epinephrine in, 38
fetal exposure to, 121–123
intravenous lipid emulsion for toxicity
caused by, 123
during lactation, 123
placental transfer of, 122–123
in postpartum period, 122–123
toxicity to, 123
types of, 116t
Loss, fetal, 48
LUD. See Left uterine displacement.
M
Macrolides, 102t
Marcaine. See Bupivacaine.
“Mask of pregnancy.” See Melasma.
“Mature minor” laws, 50
Medical consults
description of, 9
forms used in, 134–135
Medications
analgesics. See Analgesics.
bioavailability of, to fetus, 78
FDA pregnancy risk categories for, 78–82
nonsteroidal anti-inflammatory drugs, 86
during nursing, 78
opioids, 87
over-the-counter, 79
placental passage of, 78
prescription writing for, 143
selection of, 77
Melasma, 23t, 40
Meperidine, 88t, 100
Mepivacaine, 116t, 125
Mercury
in amalgam, 60–61
in foods, 67
Mercury vapor, 61
Methemoglobinemia, 118
Minors, 49–51, 51t
Morning sickness, 22t, 34–35
Mother-to-infant transmission of oral
pathogens, 22t, 39f, 39–40
Mouthwash, 65
Moxatag. See Amoxicillin.
Multiple births, 10
Myocardial contractility, 30
N
Naproxen, 91
National Maternal and Child Oral Health
Resource Center, 145
Nausea and vomiting during pregnancy
description of, 22t, 34–35
oral care after, 66
Necessary dental treatment, 6
Necrotizing enterocolitis, 91
Nerve blocks, 78
New York State Department of Health, 2, 145
Nitrous oxide
description of, 128–129
trimester-based recommendations for,
13t, 129
Nonsteroidal anti-inflammatory drugs, 86
Norco. See Hydrocodone + acetaminophen.
Nosebleed, 44
NSAIDs. See Nonsteroidal anti-inflammatory
drugs.
Nursing
FDA Pregnancy and Lactation Labeling
Rule, 78, 80–82, 81t
health benefits of, 69
maternal medication transfer to infant
during, 49
medication use during, 78
150
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Index
opioid use during, 87
Nutritional counseling, 66–67
Nutritional deficiencies, 22t, 35
NVP. See Nausea and vomiting during
pregnancy.
O
Obstructive cholestasis, 38
Opioids, 87
Oral care
at-home, 64–66
for infant, 69
Oral cavity, 23t, 41–43
Oral health
assessment of, 11–12
California Dental Association evidencebased guidelines for, 2
prenatal care provider discussions about, 1
Oral hygiene, in third trimester, 14
Oral pathogens, mother-to-infant
transmission of, 22t, 39f, 39–40
Oral pathologies, 8
Organic mercury, 60, 67
Organogenesis, 48
Over-the-counter medications, 79
Oxycodone + acetaminophen, 88t, 99
Oxycodone + aspirin, 98
P
Palmar erythema, 23t, 40
Parity, 10
Patient education, 12–14, 13t
Patient perceptions, 2
Patient positioning
left uterine displacement, 21t, 26, 30–32,
32f, 52
in second trimester, 12
supine position, 30
Penicillin V potassium, 102t, 103
Penicillins, 102t
Perceptions
dental provider, 2
patient, 2
prenatal care provider, 1–2
Percocet. See Oxycodone + acetaminophen.
Perimylolysis, 23t, 41
Periodontal disease
description of, 1, 20
gestational diabetes and, 33
preeclampsia and, 26
pregnancy outcomes affected by, 63
respiratory infections and, 44
Periodontal treatment, 13t
Physiologic changes, 20–23, 21t–22t
Placental abruption, 27
PLLR. See Pregnancy and Lactation Labeling
Rule.
Polocaine. See Mepivacaine.
Postpartum period
dental care in, 14
hypercoagulable state in, 37, 122–123
local anesthetic use in, 122–123
PRCs. See Pregnancy risk categories, FDA.
Predifferentiation, 48
Preeclampsia, 21t, 26–27
Preexisting hypertension, 29
Pregnancy and Lactation Labeling Rule, 78,
80–82, 81t
Pregnancy granuloma, 42
Pregnancy risk categories, FDA, 78–82
Pregnancy tumor, 42
Pregnancy-induced hypertension, 29
Premature birth, 49
Prenatal care provider perceptions, 1–2
Prescription writing, 143
Prilocaine, 116t, 126
Principles of teratology, 46
Progesterone, 20, 30, 32, 43
Prophylaxis, dental, 63–64
Psychogenic reactions, 117–118
Pulmonary embolism, 37
Pyogenic granuloma, 23t, 42
Pyrosis, 22t, 33–34
Q
Quinolones, 102t
R
Radiation exposure, 57–59
Radiographs
administrative requirements for, 59
dental treatment effects of, 59
FDA recommendations for, 141–142
indications for, 57, 141–142
insurance requirements for, 59
radiation exposure from, 57–59
reasons for taking, 59–60
trimester-based recommendations for,
12, 13t
Rapid satiety, 33
Renal system, 23t, 43
Reproductive history, 10
Reproductive system, 23t, 43–44
Respiratory alkalosis, 45
151
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Index
Respiratory capacity, 23t, 46
Respiratory system, 23t, 44–46, 45
Root planing. See Scaling and root planing.
S
Safety considerations, 7–9
Salivary changes, 23t, 42–43
Scaling and root planing, 63–64
Scandonest. See Mepivacaine.
Screening
oral health, 11–12
reproductive history, 10
SDF. See Silver diamine fluoride.
Second trimester, 12–14, 13t
Seizures, eclamptic, 28–29
Sensorcaine. See Bupivacaine.
Septocaine. See Articaine.
Shortness of breath. See Dyspnea.
Silver diamine fluoride, 70–71
Sodium bisulfite, 117t
Sodium fluoride, 14
Spider angioma, 23t, 40
Spontaneous abortion, 12, 48, 58
SRP. See Scaling and root planing.
Stochastic effects, of radiation, 58
Streptococcus mutans, 39, 39f, 68
Subacute bacterial endocarditis, 30
Supine hypotension, 12
Supine hypotensive syndrome, 21t, 30–31
Supine position, 30, 32f
Systolic blood pressure, 29
T
Teenage pregnancy. See Adolescent
pregnancy.
Teeth
development of, 47
infant’s, cleaning of, 71
Teratogens, 46–48, 52, 58
Tetracaine, 116t, 120
Tetracyclines, 102t
TF. See Tissue factor.
Thalidomide, 47
Third trimester, 14, 31
Thromboembolic disease, 22t, 36–38
Thyroid gland, 58
Tissue factor, 37
Toothbrushes, 65
Toothpaste
for children, 71t, 71–72, 72f
fluoride-containing, 72
in pregnancy, 65
Topical anesthetics, 116t, 118–121
TPAL, 10
Tramadol + acetaminophen, 96
Treatment. See Dental treatment.
Tylenol. See Acetaminophen; Acetaminophen
+ codeine.
Type 1 diabetes mellitus, 32
Type 2 diabetes mellitus, 21t, 32
U
Upper respiratory mucosa, 23t, 44
Urgent dental treatment, 6, 13t
Urinary system, 23t, 43
Urination, 43
Uterine spinal arteries, 28
V
Vicodin. See Hydrocodone + acetaminophen.
Vicoprofen. See Hydrocodone + ibuprofen.
Vital capacity, 46
Vivacaine. See Bupivacaine.
Vomiting. See Nausea and vomiting during
pregnancy.
W
Water, 67
Web resources, 144–145
World Health Organization mercury intake
standards, 60
X
Xylitol, 67–69
Z
Zithromax. See Azithromycin.
152
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