Dental considerations in pregnant women

Dental Considerations in Pregnant womenDr. Tanmay Singh PathaniBDS, MPH8/27/20151

Contents IntroductionPeriod of pregnancyPhysiologyCommon Complaints in PregnancyComplicationsClinical FindingsDental ManagementDrug AdministrationOral Complications And ManifestationObstetrical Emergencies in Dental OfficeBibliography

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Introduction8/27/20153

IntroductionPregnancy is a major event in any woman's life.

A pregnant patient is not considered medically compromised but consists of a unique set of management for the dentist. 8/27/20154

Dental care should be given in such a way that it does not adversely effect the fetus .

Hormonal changes during the period of pregnancy causes changes in the body as well as the oral cavity.

All elective dental procedures can be delayed till postpartum to avoid any risk to the developing fetus.

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It is still very important to maintain the pregnant woman's current state of dental health and pregnancy is the ideal opportunity to begin a preventive dental program.

Its also important to educate the pregnant patient about the common problems noticed during pregnancy.

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Period of Pregnancy8/27/20157

Period of PregnancyGENERAL OVERVIEWNormal pregnancy last for about forty weeksand it can be divided into three stages-:

ZygoteIt is from the time of fertilization to implantation.

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Embryonic PeriodIt is from the second week to the eight week.

Fetal Period-:It is from the eight week upto parturition.

For practical purpose pregnancy may be divided into three trimesters-:First TrimesterSecond TrimesterThird Trimester

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1.First TrimesterDuring the first trimester formation of organs and system occurs. The fetus is most susceptible to malformations during this period. There is an increased risk of effects by Teratogens. 8/27/201510

2.Second Trimester The majority of formation is complete and chances of malformation are less. The organogenesis is complete. It is considered to be a more safe period.

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3. Third TrimesterThe uterus expands with the growing fetus and placenta. The fetus come to lie directly over the inferior vena cava, femoral vessels and the Aorta.

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The First Trimester (0-12 Weeks)The Second Trimester (13-28 Weeks)The Third Trimester (29-40 Weeks)

Physiology 8/27/201514

Physiology Endocrine Endocrine changes are the most significant basic alterations that occur with pregnancy.

This is due to the production of maternal and placental hormones.

Modification in activity of target organs.

Most hormones rise at pregnancy.

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Increase in maternal hormones estrogen & progesterone Placental hormones are secreted.

Prolactin increases.

Follicle stimulating hormones decreases

ACTH, TSH, GH Increases to accommodate the increase in BMR.

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2.Cardiovascular SystemBlood volume increase 40%Cardiac output increase 30% to 40%Red blood cell volume increase to 15% to 20%Corresponding to increase in blood volume

High flow/low resistance circulation. Tachycardia Heart murmurs. A benign systolic murmur develops in 90% of pregnant women & disappears shortly after delivery- (physiologic).

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Blood changes -: AnemiaWBC increase due to neturophelia.Fibrinogen, factor VII, VIII, IX, X & FSP increase hyper coagulation thrombosis.Pregnancy can worsen anemia particularly sickle cell anemia

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8/27/2015193.Supine Hypotensive syndrome Third trimester 10~15%Compression of inferior vena cava & aortaDecrease venous return to heartDecrease uteroplacental perfusion and fetal distress

Supine Hypotensive Syndrome8/27/201520

Comparison of Supine and Left Lateral Position8/27/201521

Left Lateral Position8/27/201522

Manifests by an abrupt fall in BP, -Bradycardia -Sweating - Nausea - Weakness -Air hunger

4.Respiratory SystemReduced expiratory reserve volume Increased rate of respiration.Dysponea at supine position.Hyperemia and edema of respiratory tract.

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5.Kidney and LiverRenal blood flow & glomerular filtration rate increases about 50% from 4th to 7th months of gestation.Creatinine levels drop & increase frequency of urination.Blood flow to maternal liver is essentially unchanged during pregnancyDuring pregnancy - kidney & liver of mother & fetus are primary organs responsible for drug detoxification.

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6.DIET Increase appetite & craving for unusual food.Taste alterations & increased gag response.90% of pregnant women vulnerable to nausea & vomiting.Glycosuria & impaired glucose tolerance gestational diabetes.

7. Facial pigmentation ( chloasma or melasma gravidarum)

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Common Complaints in Pregnancy8/27/201526

Common Complaints in Pregnancy

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Complications8/27/201528

ComplicationsInfectionGlucose abnormalitiesHypertensionRare complication (5%)-PreclampsiaAlbuminuriaEdema Pre-eclampsia progresses Eclampsia If seizures & coma develop.Malignant hypertensionBlurred visionSeizuresComaSpontaneous abortion

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Clinical Findings8/27/201530

Clinical FindingsWEIGHT GAINAMENORRHOEAABDOMINAL PROTUBERANCEANAEMIAFATIGUEPERIPHERAL OEDEMAVENOUS STASISTACHYCARDIATACHYAPNOEANAUSEA & VOMITINGANXIOUSNESS, NERVOUSNESSIn 3rd trimester FATIGUE& MILD DEPRESSION

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Dental Management8/27/201532

Dental Management

1.DiagnosisAbsence of an expected menstrual period.Test Latex inhibition test.Pelvic examination uterine enlargement.Confirmation By evidence of fetal heart tones & ultrasound detection.

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2. Medical ConsiderationsDetermination of general health with through a thorough history.Current physician.History of Gestational Diabetes.MiscarriageHypertension Morning sicknessContacting patients obstetrician for discussionabout -;1.Medical status 2.Dental need3.Proposed dental treatment 8/27/201534

3. General GuidelinesDetailed history about the number of times patient has been pregnant, number of children conceived, history of abortion ( spontaneous and elective).Appointments to be kept short and the best chair position is sitting up or left lateral position with the head of the chair elevated.Elective dental treatment should be deferred to post term.Dental radiographs are best avoided. If unavoidable then second trimester is preferred.Prescription of drugs to be done with care. 8/27/201535

4. Preventive Program

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5. Treatment Timing

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Good Plaque control.Elective dental care is best avoided during the first trimester because of potential vulnerability.Second trimester is the safest period in which routine dental care can be provided.Control of any active disease.Eliminate potential problems that could occur later in pregnancy or in immediate post partum period.Early part of third trimester is still good time to provide routine dental care.Postpone elective dental care in third trimester.

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6. Dental RadiographsAvoided especially during 1st trimesterSafety Fast exposure technique (E speed film)FiltrationCollimation (Rectangular Collimation)Lead ApronsHigh kilo voltageConstant beamsRadiographs to be used selectively and only when necessaryMandibular Radiographs are considered more safe as vertical angulations is negative and tube head pointed upwards.

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Comparative Radiation Exposure To Fetal or Embryonic TissueSource of RadiationAbsorbed Exposure (cGy)Upper GIT Series

Chest Radiograph

Skull Radiograph

Daily Background radiation

Full Mouth Dental Series0.330

0.008

0.004

0.0004

0.00001

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7. PrematurityPremature infants may have orofacial defects.Enamel hypoplasia due to trauma, infections, metabolic and nutritional disorders.Laryngoscopy can damage the unerupted maxillary anterior teeth and oropharyngeal tube can cause grooving of anterior maxillary ridge.8/27/201541

Drug Administration8/27/201542

Drug AdministrationIdeally, no drug should be administered during pregnancy especially 1st trimester.

ALL DRUGS SHOULD BE AVOIDED UNLESS POTENIAL BENEFIT OUT WEIGHS POTENTIAL RISKS.

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Principles of prescribing during pregnancy Whenever possible use non drug therapy.Prescribe drugs only when definitely needed choose the drug having best safety record over time.Avoid newer drugs.As far as possible, avoid medication in initial 1o weeks of gestation Use the lowest effective dose.Use drug for the shortest period necessary.If possible give drug intermittently.

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PHARMACOKINETICS IN PREGNANCY

>Drug Absorption Slower drug absorptionParenteral drug administrationDrug compliance poor

>Drug Metabolism Hepatic drug metabolizing enzymes are inducedRapid metabolic degradation

>Drug Excretion Renal plasma flow increases by 100% & glomerular filtration rate by 70%Rapid elimination

Most commonly used drugs in dental practice can be given during pregnancy with relative safety.

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Food and Drug Admistration Classification SystemControlled studies showed no risk to the fetus. This group limited to multivitamins and prenatal vitamins , not mega vitamins.

Either animal studies have shown no fetal effects , but there is no controlled human studies during pregnancy, or animal studies have shown adverse effect that was not confirmed in controlled studies during first trimester. Penicillins are in this family.

There are no adequate studies, or animal studies have shown adverse effect , but controlled studies in women are not available. Potential benefit must be greater than the risk to the fetus if these medications are used.

A

B

C8/27/201546

Evidence of fetal risk is proven, but potential benefit must be thought to be outweigh the risks.

Proven fetal risk clearly outweighs any potential benefits.

D

X

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Drug Administration During PregnancyDRUGFDA CategoryUse During PregnancyRiskUse During Breast-feeding1. Local Anesthetics LidocaineBYes-YesPrilocaineBYes-YesMepivacainetCUse with caution consult physicianFetal bradycardiaYes

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DRUGFDA CategoryUse During PregnancyRiskUse During Breast-feeding1.Analgesics AsprinC/D3Avoid in 3rd trimesterPost partum hemorrhage constriction ductus arteriosussAvoidAcetaminophenBYes-YesIbuprofen B Caution avoid in second half of pregnancy Delayed labour Yes

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DRUGFDA CategoryUse During PregnancyRiskUse During Breast-feeding1.Antibiotics Penicillin B Yes Yes ErythromycinBYes avoid estolate form-Yes Cephalosporin BYes - YesTetracyclineDAvoidTooth discoloration bone deformitiesAvoidMetronidazoleBYesMutagenicYes

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DRUGsFDA CategoryUse During PregnancyRiskUse During Breast-feeding1.Sedatives/Hypnotics Barbiturates D AvoidNeonatal Respiratory DepressionAvoidBenzodiazepines D/X AvoidOral clefts Avoid2.CorticosteroidsPrednisoneBYesDelaylabourYes

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Anesthetics: LA + EPINEPHRINE= SAFE

Conscious sedation Diazepam or Midazolam are hazardous. 1st trimester and last month of third trimester Anxiolytic: nitrous oxideInterferes with vitamin B12 and folate metabolismChronic nitrous oxide-oxygen inhalation cellular abnormalities in animals.

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GUIDELINES:Restrict use to second and third trimester.

Limit duration of exposure