A pregnant patient poses a unique set of management considerations for the dentist. The primary concern of the dentist must be to render dental care to the mother without adversely affecting the developing fetus. Although routine dental care of pregnant patients is generally safe to perform, some potentially harmful elements could include ionizing radiation and drug administration. Hence, the dentist should aim at minimizing or avoiding exposure of the patient to potentially harmful procedures.
During first trimester, fatigue is a common physiologic finding. A tendency towards syncope and postural hypotension has been noted. During the second trimester, patients have a sense of well-being and relatively few symptoms. During the third trimester, increasing fatigue and discomfort may be reported.
During late pregnancy, a phenomenon known as supine hypotensive syndrome may occur that manifests as an abrupt fall in blood pressure, bradycardia, sweating, nausea, weakness and air-hunger when the patient is in a supine position. Symptoms are caused by impaired venous return to the heart that results from compression of inferior venacava by the gravid uterus. This leads to decreased blood pressure, reduced cardiac output and impairment or loss of consciousness. The remedy for the problem is to roll the patient over onto her left side, which lifts the uterus off the venacava. Blood pressure should rapidly return to normal.
During pregnancy, expectant mother’s appetite is increased and thus contributes to increased weight gain. Also, the expectant mother may experience taste alterations and an increased gag response. This gag reflex may pose a hindrance to the dentist during the dental treatment.
In order to avoid spontaneous abortion (miscarriage) during dental treatment, fetal hypoxia and exposure of fetus to teratogens should be avoided.
Dental Management of a Pregnant Patient;
• During management of a pregnant patient, there are no definite rules or strict guidelines. The dentist should assess the general health of the patient through a thorough medical history.
• Dentist should make inquiries regarding current physician, medications taken, and use of tobacco, alcohol, or illicit drugs, h/o gestational diabetes, miscarriages, hypertension and morning sickness.
• If possible, the dentist should contact the patient’s obstetrician or physician to discuss her medical status, dental needs, and proposed dental treatment. This will help the dentist to plan treatment and also helps to develop a rapport with the patient regarding caring approach of the dentist towards herself and her baby. Since pregnancy is a special event in a woman’s, it is very important that the dentist establish a good patient/dentist relationship which will encourage openness, honesty and trust between the patient and dentist. This kind of relationship will greatly reduce stress and anxiety for both patient and dentist.
• Measure the vital signs i.e. blood pressure, pulse, and respiration. Systolic pressure values at or above 140mmHg and diastolic pressure at or above 90mmHg are signs of hypertension.
• Preventive program should include the following, so as to reduce the oral streptococcal levels in the pregnant mother;
-Diet counseling, with emphasis on limiting the intake of refined carbohydrates and carbonated soft drinks.
-Coronal scaling and polishing or root curettage may be performed whenever necessary.
-Preventive plaque-control measures which includes daily rinses with 0.12% chlorhexedine throughout pregnancy.
Treatment Timing;
• Elective dental care is best avoided during the first trimester because of potential vulnerability of the fetus. The second trimester is the safest period during which to provide routine dental care.
• Extensive reconstruction or significant surgical procedures are best postponed until after delivery.
• After the middle of the third trimester, elective dental care should be postponed.
• Prolonged time in dental chair should be avoided to prevent the complication of supine hypotension.
• If supine hypotension develops, roll the patient onto left side, so as to facilitate return of circulation to the heart.
• In short, scheduling short appointments, allowing the patient to assume a semi reclined position, and encouraging frequent changes of position can minimize problems.
Dental Radiography
• Irradiation should be avoided during pregnancy, especially during the first trimester, because the developing fetus is particularly susceptible to radiation damage.
• However, if it becomes necessary for accurate diagnosis and treatment, the dentist should take following precautions.
-Fast exposure techniques like high-speed film and digital imaging.
-Filtration.
-Collimation.
-Use of lead aprons which is most important. When lead apron is used during dental radiography, gonadal and fetal radiation is less than 0.01 microsieverts.
Drug Administration;
During pregnancy, the principal concern regarding drug administration is that a drug may cross the placental barrier and be toxic or teratogenic to the fetus. Also, any drug that is a respiratory depressant may cause maternal hypoxia, resulting in fetal hypoxia, injury or death.
Ideally, no drug should be administered during pregnancy, especially during the first trimester. But, it is not always possible to adhere to this rule. Most of the commonly used drugs in dental practice can be given during pregnancy with relative safety, although a few exceptions are notable. Below is a suggested approach to drug usage for pregnant patients.
Anesthetics;
• Local anesthetics (etidocaine, lidocaine and prilocaine) administered with epinephrine are considered relatively safe for use during pregnancy.
• But, however prilocaine, articaine and bupivacaine should be used with caution, because high dose prilocaine and articaine pose a risk of methemoglobinemia whereas, toxic doses of bupivacaine may have embryocidal effects.
Analgesics;
• The analgesic of choice during pregnancy is acetaminophen.
• Aspirin and non-steroidal anti-inflammatory drugs convey risks for constriction of the ductus arteriosis, as well as for post-partum hemorrhage and delayed labor, especially when agents are administered during the third trimester.
• Prolonged use or high doses of opioids are associated with congenital abnormalities and respiratory depression. Hence, the opioid containing drugs should be avoided.
Antibiotics;
• Penicillin, erythromycin (except in estolate form), and cephalosporin (first and second generation) are considered safe for the expectant mother as well as the developing fetus. An increased dose or more frequent administration may be required if an infection is not readily brought under control with antibiotic use.
• The use of tetracycline is contraindicated during pregnancy. Tetracycline binds to hydroxyappetite, causing brown discoloration of teeth, hypo plastic enamel, inhibition of bone growth, and other skeletal abnormalities.
Drug use during breast feeding;
When a nursing mother requires the administration of a drug in the course of dental treatment, a potential problem arises, because the administered drug may enter the breast milk and be transferred to the nursing infant, in whom exposure may result in adverse effects.
Drugs contraindicated during breast feeding are the sedatives/hypnotics i.e. barbiturates and benzodiazepines. Barbiturates may cause neonatal respiratory depression.
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