review on dental management of pregnant patient
TRANSCRIPT
A Review on the principle of Dental Management of
the Pregnant patient
Dr A K M Tanzir Hasan
bull Pregnancy has been considered an impediment to dental treatment However preventive emergency and routine dental procedures are all suitable during various phases of a pregnancy with some treatment modifications and initial planning
Questions that a dentist may askbull Can I take x-raysbull Can I inject local anesthesia with
epinephrinebull What medications can I prescribebull Are topical agents safebull When should I perform necessary
proceduresbull Can I use mercury restorations
Stages of Pregnancybull1st Trimester (1-12 weeks)bullFetal organ formation and differentiationbullMost susceptible to adverse effects of teratogensbullAvoid all elective care but provide care as needed
Stages of Pregnancy
bull2nd Trimester (13-24 weeks)bullFetal growth and maturationbullSafest period to provide dental care
Stages of Pregnancy
bull3rd Trimester (25-40 weeks)bullFetal growth continuesbullFocus of concern is risk to upcoming birth process and safety and comfort of the pregnant woman
Physiologic Changes in Pregnancy
bull Complex hormonal interactions cause profound physiologic changes
bull Increase estrogen by 10 fold and progesterone by 30 folds
bull Increased hormonal secretion and fetal growth causes several systemic as well as physical changes in a pregnant women
Systemic changes in pregnancyCardiovascular system uarr in blood volume by an average of 45bull Anemia due to increased blood volume
(20 of women) darr in pulse by 10-15 beats per minute Systemic murmur occurs in 90 of
pregnancies disappears shortly after delivery
uarrcardiac output Supine hypotension syndrome may occur
FLAT SUPINE POSITIONING
bullNegatively impacts mother and infant
SUPINE HYPOTENSIONSYNDROME (Vena Cava Compression)
bull SUPINE POSITION AFTER 5TH MONTH
bull UTERUS COMPRESSES THE INFERIOR VENA CAVA
bull uarrVOL BLOOD IN THE LErsquoS bull darrRETURN TO THE HEARTbull REDUCED PERFUSION OF
UTERUS bull FETAL HYPOXIA
Supine Hypotension Syndrome
bull Obstruction of inferior vena cava and aorta from pressure of the large fetus
Symptoms Sweating Nausea Weakness Sense of lack of air
Supine Hypotension Syndrome
Other symptomsbull Drop in blood pressurebull Bradycardiabull Possible loss of consciousness
Prevention of Supine HypotensiveSyndrome
bullElevate right hip 10-12 cmbullWeight is taken off the major vessels
Treatment of Supine HypotensiveSyndrome
bullRoll patient onto her left side
How should the pregnant woman be positionedbull Flat position may
cause hypotension and hypoxia
bull Place a small pillow under right hip - left lateral displacement
bull Head above feet
Systemic changes in pregnancy
Diaphragm rises about 4 cm darr residual volume uarr awareness of a desire to breath is
common-may be interpreted as dyspnea Increased estrogen in blood causes
engorgement of the nasal capillaries and rhnitis in pregnant women
Frequent nosebleeds amp predisposition to upper respiratory infection
Respiratory system
Systemic changes in pregnancy
Gastrointestinal system Gastric emptying amp intestinal transit times
are delayed
Heart burn reflux common
Nausea and vomiting common
Systemic changes in pregnancy
For pregnant patient with Hyper-emesis gravidarium ( excessive and uncontrolled vomiting) morning appointments should be avoided
They should be seated in a semi-supine or comfortable position
In case of vomiting the procedure should be stopped immediately amp the patient should be repositioned upright
When vomiting is over rinsing mouth with cold water or mouthwash is recommended
Systemic changes in pregnancybull Urinary System uarr GFR amp renal plasma flow by as much as
50 Nocturia ndashto mobilize the dependent
edema which accumulate during the day uarr Frequency from uarr renal flow plus reduced
bladder capacity from uterine growth It is advisable to ask the patient to void the
bladder just prior to starting the dental procedure
Systemic changes in pregnancyEndocrine Changes uarrEstrogen uarr progesterone uarrhuman
gonadotropin uarr thyroxin steroid and insulin level Estrogen amp progesterone are insulin
antagonists uarr level of these hormones lead to insulin resistance Thus insulin levels are elevated in pregnant in pregnant patient to compensate this resistance
About 45 of women fail to produce sufficient amount of insulin to overcome this antagonist action amp thus develop gestational diabetes
Systemic changes in pregnancy
Hematological changebull uarr red RBC uarrESR darrHbbull uarrWBCbull uarr circulatory catecholamin amp cortisol lead
to leucositosis bull uarr Coagulation factors except factor XI amp
XIII (anticloting factor) bull so pregnancy is a hypercoagulable state amp
uarr risk for thromboembolism
Systemic changes in pregnancy
bull Pregnant women with anti-phospholipid syndrome are at uarr risk for thrombo-embolisim
bull They are placed on subcutaneous low molecular weight heparin (LMWH)
bull These patients must be hospitalized for dental care
Pregnancy RelatedOral Health Problems
bull Pregnancy Gingivitisbull Pregnancy Epulis bull Increased Tooth Mobilitybull Dental Cariesbull Erosionbull Dental Problems in relation to Labor
and Delivery
Oral Problems in Pregnancy
bullPregnancy GingivitisbullMost common oral manifestation (50-100 of women)bullCaused by hormonal and vascular changes of pregnancy
Pregnancy Gingivitis Pathophysiology
bull Elevated circulating estrogen increases capillary permeability
bull Preexisting gingivitis may predispose to pregnancy gingivitis
Pregnancy Gingivitis
bullOccurs commonly in the 2nd to 8th monthsbullTendency to bleed very easilybullTreatment Scaling root-planing currettage OHI
Pregnancy Granuloma
bullOccurs in up to 5 of womenbullMost common in buccal maxillary anterior areasbullUsually starts in an area of gingivitis
Pregnancy Granuloma (continued)
bullRapid growth up to 2 cmbullSingle tumor-like growthbullusually in interdental papillaebullPurplish to bluish in color may be ulcerated- bleeds easily
Gum Problems - Pregnancy Granuloma
Gum Problems - Pregnancy Granuloma
Gum Changes - Pregnancy Granuloma
Pregnancy Granuloma (continued)
Treatment
bull Scaling and root planingbull Excision if it is too large or bleeds too
easilybull May regress spontaneously after
pregnancy
Candidiasis
bullWipes offbullUsually asymptomatic but may burnbullTreatment topical or systemic antifungals
Pregnancy MythsbullldquoA mother loses a tooth for every babyrdquobullNo evidence that aphthous ulcers are any more common in pregnancy
Other Oral Conditions in Pregnancy
bull Dry mouthbull Excessive salivationbull Tooth erosions associated with
severe GERD or hyperemesis
Changes During Pregnancy that Affect Oral Health
bull Hormonal Affects
ndash Increased tooth mobility
ndash Saliva changes
ndash Increased bacteria
ndash Gingival problems
Saliva changesbull Decreased buffers
bull Decreased minerals
bull Decreasing flow first and last trimester
bull Increased flow second trimester
bull More acidic
Increased Bacteriabull Increased acidity
ndash Increase in decay-causing bacteriabull Increased Snacking
ndash Morning sicknesslow blood sugarndash Between-meal snacks
bull Increase in amount and frequency of starchescarbohydrates ndash Crackers are commonly recommendedndash Promotes decay-causing bacteria
Changes During Pregnancy that Affect Oral Healthbull Morning sickness
ndash Difficulty with hygienebull Gingival diseasebull Tooth decay
ndash Vomitingbull Esophogeal Reflux (heartburn)bull Acid exposure
ndash Irritation of the gumsndash Weakening of tooth enamelndash Dental erosion
Enamel erosion caused by frequent vomiting
Treatment for Acid Exposure
bull Do NOT brush immediately after vomiting
bull Rinse ndash Water with baking sodandash Antacidndash Plain water
bull Eat some cheese
Oral Diseases Can Effect Pregnancy
bull Preterm low birth weight (LBW) linked to periodontal disease
bull Thorough calculus (tartar) removal in pregnant women with periodontitis may reduce pre-term births
Periodontal Disease and Preterm LaborbullMaternal periodontal disease is associated with increased risk of preterm laborbullAnaerobic oral gram-negative bacteria cause inflammatory responsebullInflammatory response stimulates prostaglandin and cytokine production to stimulate labor
Periodontal Disease and Low Birth Weight
bull Periodontal disease is associated with low birth weight
bull Evidence is not conclusivebull Biochemical mechanism similar cascade
as in preterm labor leading to placental blood flow restriction and necrosis
Periodontal Disease and Preeclampsia
bull Emerging databull Mechanism unclearbull Proposed mechanism
ndash Periodontal infection leads to inflammatory vascular damage
ndash Triggers cell damage in placenta
Periodontitis and Pre-eclampsia
bull Periodontal disease may be associated with pre-eclampsia (Boggess 2003)
bull PGE2 IL-1 and TNF-α from gingival crevicular fluid were higher in women with preeclampsia compared with healthy matched pregnant women (Oettinger-Barak 2003)
Dental Considerations
bull timing of treatment for pregnant patientsbull dental radiation exposurebull use of local anestheticsbull prescription of common antibiotics and
analgesicsbull nitrous oxide gas administration
Treatment Timing
bull First Trimesterndash Spontaneous miscarriages naturally occur
more often in 1st trimesterndash Avoid elective treatment that can be delayedndash Offer anticipatory guidance
bull Second Trimesterndash The optimal time for dental treatmentndash Organogenesis complete fetus not largendash Easier to prevent than treat established disease
bull Third Trimesterndash Late in term very uncomfortable (short visits)ndash Position slightly on left side
Timing of Dental Treatment During Pregnancy - From Little and Fallace
First Trimester
bull Plaque controlbull Oral hygiene instructionbull Scaling polishing curettagebull Avoid elective treatment urgent care
only
Timing of Dental Treatment During Pregnancy - From Little and Fallace
Second Trimester
bull Plaque controlbull Oral hygiene instructionbull Scaling polishing curettagebull Routine dental care
Timing of Dental Treatment During Pregnancy - From Little and Fallace
Third Trimester
bull Plaque controlbull Oral hygiene instructionbull Scaling polishing curettagebull Routine dental care (after middle of third
trimester elective care should be avoided)
Use of Radiation on Pregnant Patientbull Dose given and time of gestation are
importantbull doses lt 5-10 rads (cGy) not teratogenicbull fetus is most susceptible to radiation
between the 2nd and 6th week of gestationbull single dental x-ray exposes patient to 001
millirads of radiation In relative terms this amount is 40 times less than daily dose acquired from cosmic radiation Therefore diagnostic radiation should not be withheld during pregnancy
Radiographs during Pregnancy
bull Take as needed with optimal methods for reducing secondary radiation and exposure time
bull Always use a lead apronbull Exposure to fetus (with apron use) is 00001
centiGray(rad)bull Daily cosmic radiation - 0004 centiGray (rad)
Risks of Dental X-Rays
bull X-ray only if necessary (ie root canal therapy trauma)
bull When x-rays are indicated radiation exposure is extremely low
bull Exposure can be limited byndash Lead apron shielding ndash Modern fast film ndash Avoiding retakes
FDA drug classification for pregnancybull Combines risk statements including
congenital anomalies fetal effects perinatal risks and therapeutic risk-benefit ratio
bull Untreated disease or condition may pose more serious risks to both mother and fetus than any theoretical risks from the medication
bull Category A thru D and X
FDA drug classification for pregnancy
bull A = Controlled Studies in women fail to demonstrate a risk to the fetus in the first trimester and the possibility of fetal harm appears remote
FDA drug classification for pregnancy
bull B = Animal studies show no risk or if risk shown in animals controlled
trials in women showed no risk
FDA drug classification for pregnancy
bull C = Studies in animals with adverse effects and no human studies
OR no animal or human studies but benefits of use may outweigh potential harms
FDA drug classification for pregnancy
bull D = There is evidence of human fetal risk but benefits may outweigh risks
FDA drug classification for pregnancy
bull X = Contraindicated
Common Analgesics
bull paracetamol (B)bull Ibuprofen (BD) bull Oxycodone (BD) bull Hydrocodone and codeine
(CD)
avoid in third trimester
Analgesics
bull Paracetamol is the analgesic of choice for all stages of gestation
bull used to treat mild to moderate pain and fevers
bull short term usage is believed to be safebull avoid chronic and large doses of
paracetamol1048715
Analgesics - continuedbull Aspirin is nonteratogenic but may cause
maternal and fetal hemorrhagebull large and chronic doses during last trimester
may result in premature closure of ductus arteriosus fetal hypertension anemia and low birth weight
bull avoid ibuprofen in 3rd trimester because of possible adverse circulatory effects
bull short term use of codeine seems safebull avoid codeine late in gestation because of
possible fetal respiratory depression and withdrawal symptoms
Analgesics to Use During1st and 2nd Trimester
bull Category B (for best)bull Paracetamol Ibuprofenbull Naproxenbull Category C (use with caution)bull Paracetamol with codeine or
hydrocodonebull Paracetamol with oxycodone
Analgesics to Avoid During theThird Trimesterbull Causes delivery problemsbull Aspirin (C 3D)bull Ibuprofen (B3D)bull Naproxen (B3D)bull Causes neonatal respiratory
depression and opioid withdrawalbull Codeine (C3D)bull Hydrocodone (C3D)bull Oxycodone(C3D)
Sedation in Pregnancy
bull SedativesAnxiolytics (eg Diazepam ) are rated D and can cause oral clefts with prolonged exposure
bull Nitrous oxide should not be used in 1st trimester (If used in 2nd and 3rd do not go below 50 O2)
Common Antibioticsbull To treat oral abscess or cellulitis
ndash Penicillin (B) ndash Amoxicillin (B) ndash Cephalexin (B)ndash Erythromycin base (B) (Not estolate as it
cause cholestatic hepatitis)ndash Clindamycin (B)
Antibioticsbull penicillin V and amoxicillin is preferred drug
for mild to moderate infectionsbull widely used for many years with no ill effectsbull no studies show penicillin to be teratogenicbull amoxicillin extensively used without harming
the fetusbull Drug classes1048715 B penicillin cephalosporins erythromycin clindamycin Azithromycin D Tetracycline
Antibiotics To Use During Pregnancy
bull Penicillin Vbull Amoxicillinbull Erythromycin (base form)bull Cephalexin cephalosporinbull Clindamycinbull Metronidazole
Antibiotics to Avoid duringPregnancy
bull Doxycyclinebull Tetracyclinebull Erythromycin (estolate form)bull Vancomycin
The Problem With Tetracycline
bull Accumulates in bones and chelates calcium
bull Inhibits bone growthbull Discolors teeth
Other Antimicrobial Agentsbull OK to usebull Nystatin (B)bull Chlorhexidine rinse (B)bull Use with cautionbull Clotrimazole (C)bull Ketoconazole (C)bull Fluconazole (C)bull Do not usebull Doxycycline (D)
Local Anesthetic Use inPregnancy
bull Class Bbull Lidocaine (Xylocaine)bull Etidocainebull Prilocaine bull Class Cbull Procainebull Bupivicainebull Mepivicaine
Use of Local Anestheticsbull Lidocaine + vasoconstrictor most common
local anesthetic used in dentistrybull extensively used in pregnancy with no proven ill
effectsbull accidental intravascular injections of lidocaine
pass through the placenta but the concentrations are too low to harm fetus
bull prilocaine might cause methemoglobinemia
Ulcer healing drugsCimetidine bull FDA category B Famotidinebull FDA category BRanitidinebull FDA category Bbull not known to be harmful
Ulcer healing drugsOmeprazolebull FDA category BNot known to be
harmful Esomeprazolebull FDA category BLansoprazolebull FDA category BPantoprazolebull Avoid unless potential benefit
outweighs riskmdashfetotoxic in animals
Ulcer healing drugs
Misoprostolbull First second third trimesters Avoidmdash
potent uterine stimulant (has been used to induce abortion) and may be teratogenic
Ulcer healing drugs
Antacidsbull Almunium hydroxideMagnesium
hydroxidemdashFDA category B Calcium carbonatemdashFDA category C
SimetheconemdashFDA category C
Use of Nitrous Oxide Gas
bull used over 150 years bull safety is being debatedbull SHORT TERM exposure do not cause
birth defects or spontaneous abortionbull CHRONIC exposure may result in fetal
loss and infertilitybull literature suggests that nitrous oxide
should be avoided until more conclusive research is available
bull FDA Drug class not yet assigned
Common Preventives
bull Fluoridendash No increased risk during pregnancy
bull Xylitolndash No studies no harm reported
bull Chlorhexidinendash No increased risk during pregnancy
Are topical agents safe
bull Fluoridebull Toothpaste amp mouthrinse
bull Xylitol chewing gum bull Chlorhexidine (11 alcohol)bull No over the counter mouthrinses with
alcohol (Listerine 20 alcohol)
Pre-natal Fluoride
bull Daily 22 mg tablet of sodium fluoride during 3rd through 9th months
bull decreases caries rate in offspringbull Safe and effective
Glenn FB 1982
Is it safe to use mercury restorations
bull No evidence of harmful effect
bull Benefits outweigh risks
bull Canada Germany and New Zealand have some restrictions
bull Determine the best option
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bull Larimore WL Petrie KA Drug use during pregnacy and lactation Primary Care Clinics in Office Practice 271 35-53 2000
bull Health Canada The Safety of DentalAmalgam Minister Of Supply and Services Canada 1996
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Thank you
- A Review on the principle of Dental Management of the Pregnant patient
- Slide 2
- Questions that a dentist may ask
- Stages of Pregnancy
- Slide 5
- Slide 6
- Physiologic Changes in Pregnancy
- Systemic changes in pregnancy
- FLAT SUPINE POSITIONING
- SUPINE HYPOTENSION SYNDROME (Vena Cava Compression)
- Supine Hypotension Syndrome
- Slide 12
- Supine Hypotension Syndrome
- Prevention of Supine Hypotensive Syndrome
- Treatment of Supine Hypotensive Syndrome
- How should the pregnant woman be positioned
- Slide 17
- Slide 18
- Slide 19
- Slide 20
- Slide 21
- Slide 22
- Slide 23
- Pregnancy Related Oral Health Problems
- Oral Problems in Pregnancy
- Pregnancy Gingivitis Pathophysiology
- Pregnancy Gingivitis
- Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Gum Problems - Pregnancy Granuloma
- Slide 31
- Gum Changes - Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Candidiasis
- Pregnancy Myths
- Other Oral Conditions in Pregnancy
- Changes During Pregnancy that Affect Oral Health
- Saliva changes
- Increased Bacteria
- Slide 40
- Enamel erosion caused by frequent vomiting
- Treatment for Acid Exposure
- Oral Diseases Can Effect Pregnancy
- Periodontal Disease and Preterm Labor
- Periodontal Disease and Low Birth Weight
- Periodontal Disease and Preeclampsia
- Periodontitis and Pre-eclampsia
- Dental Considerations
- Treatment Timing
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Slide 52
- Use of Radiation on Pregnant Patient
- Radiographs during Pregnancy
- Risks of Dental X-Rays
- FDA drug classification for pregnancy
- Slide 57
- FDA drug classification for pregnancy
- Slide 59
- Slide 60
- Slide 61
- Common Analgesics
- Analgesics
- Analgesics - continued
- Analgesics to Use During 1st and 2nd Trimester
- Analgesics to Avoid During the Third Trimester
- Sedation in Pregnancy
- Common Antibiotics
- Antibiotics
- Antibiotics To Use During Pregnancy
- Antibiotics to Avoid during Pregnancy
- The Problem With Tetracycline
- Other Antimicrobial Agents
- Local Anesthetic Use in Pregnancy
- Use of Local Anesthetics
- Ulcer healing drugs
- Slide 77
- Slide 78
- Slide 79
- Use of Nitrous Oxide Gas
- Common Preventives
- Are topical agents safe
- Pre-natal Fluoride
- Is it safe to use mercury restorations
- References
- REFERENCES
- Slide 87
- Slide 88
- Slide 89
- Slide 90
- Slide 91
- Slide 92
- Slide 93
- Slide 94
- Slide 95
- Slide 96
- Slide 97
- Slide 98
- Thank you
-
bull Pregnancy has been considered an impediment to dental treatment However preventive emergency and routine dental procedures are all suitable during various phases of a pregnancy with some treatment modifications and initial planning
Questions that a dentist may askbull Can I take x-raysbull Can I inject local anesthesia with
epinephrinebull What medications can I prescribebull Are topical agents safebull When should I perform necessary
proceduresbull Can I use mercury restorations
Stages of Pregnancybull1st Trimester (1-12 weeks)bullFetal organ formation and differentiationbullMost susceptible to adverse effects of teratogensbullAvoid all elective care but provide care as needed
Stages of Pregnancy
bull2nd Trimester (13-24 weeks)bullFetal growth and maturationbullSafest period to provide dental care
Stages of Pregnancy
bull3rd Trimester (25-40 weeks)bullFetal growth continuesbullFocus of concern is risk to upcoming birth process and safety and comfort of the pregnant woman
Physiologic Changes in Pregnancy
bull Complex hormonal interactions cause profound physiologic changes
bull Increase estrogen by 10 fold and progesterone by 30 folds
bull Increased hormonal secretion and fetal growth causes several systemic as well as physical changes in a pregnant women
Systemic changes in pregnancyCardiovascular system uarr in blood volume by an average of 45bull Anemia due to increased blood volume
(20 of women) darr in pulse by 10-15 beats per minute Systemic murmur occurs in 90 of
pregnancies disappears shortly after delivery
uarrcardiac output Supine hypotension syndrome may occur
FLAT SUPINE POSITIONING
bullNegatively impacts mother and infant
SUPINE HYPOTENSIONSYNDROME (Vena Cava Compression)
bull SUPINE POSITION AFTER 5TH MONTH
bull UTERUS COMPRESSES THE INFERIOR VENA CAVA
bull uarrVOL BLOOD IN THE LErsquoS bull darrRETURN TO THE HEARTbull REDUCED PERFUSION OF
UTERUS bull FETAL HYPOXIA
Supine Hypotension Syndrome
bull Obstruction of inferior vena cava and aorta from pressure of the large fetus
Symptoms Sweating Nausea Weakness Sense of lack of air
Supine Hypotension Syndrome
Other symptomsbull Drop in blood pressurebull Bradycardiabull Possible loss of consciousness
Prevention of Supine HypotensiveSyndrome
bullElevate right hip 10-12 cmbullWeight is taken off the major vessels
Treatment of Supine HypotensiveSyndrome
bullRoll patient onto her left side
How should the pregnant woman be positionedbull Flat position may
cause hypotension and hypoxia
bull Place a small pillow under right hip - left lateral displacement
bull Head above feet
Systemic changes in pregnancy
Diaphragm rises about 4 cm darr residual volume uarr awareness of a desire to breath is
common-may be interpreted as dyspnea Increased estrogen in blood causes
engorgement of the nasal capillaries and rhnitis in pregnant women
Frequent nosebleeds amp predisposition to upper respiratory infection
Respiratory system
Systemic changes in pregnancy
Gastrointestinal system Gastric emptying amp intestinal transit times
are delayed
Heart burn reflux common
Nausea and vomiting common
Systemic changes in pregnancy
For pregnant patient with Hyper-emesis gravidarium ( excessive and uncontrolled vomiting) morning appointments should be avoided
They should be seated in a semi-supine or comfortable position
In case of vomiting the procedure should be stopped immediately amp the patient should be repositioned upright
When vomiting is over rinsing mouth with cold water or mouthwash is recommended
Systemic changes in pregnancybull Urinary System uarr GFR amp renal plasma flow by as much as
50 Nocturia ndashto mobilize the dependent
edema which accumulate during the day uarr Frequency from uarr renal flow plus reduced
bladder capacity from uterine growth It is advisable to ask the patient to void the
bladder just prior to starting the dental procedure
Systemic changes in pregnancyEndocrine Changes uarrEstrogen uarr progesterone uarrhuman
gonadotropin uarr thyroxin steroid and insulin level Estrogen amp progesterone are insulin
antagonists uarr level of these hormones lead to insulin resistance Thus insulin levels are elevated in pregnant in pregnant patient to compensate this resistance
About 45 of women fail to produce sufficient amount of insulin to overcome this antagonist action amp thus develop gestational diabetes
Systemic changes in pregnancy
Hematological changebull uarr red RBC uarrESR darrHbbull uarrWBCbull uarr circulatory catecholamin amp cortisol lead
to leucositosis bull uarr Coagulation factors except factor XI amp
XIII (anticloting factor) bull so pregnancy is a hypercoagulable state amp
uarr risk for thromboembolism
Systemic changes in pregnancy
bull Pregnant women with anti-phospholipid syndrome are at uarr risk for thrombo-embolisim
bull They are placed on subcutaneous low molecular weight heparin (LMWH)
bull These patients must be hospitalized for dental care
Pregnancy RelatedOral Health Problems
bull Pregnancy Gingivitisbull Pregnancy Epulis bull Increased Tooth Mobilitybull Dental Cariesbull Erosionbull Dental Problems in relation to Labor
and Delivery
Oral Problems in Pregnancy
bullPregnancy GingivitisbullMost common oral manifestation (50-100 of women)bullCaused by hormonal and vascular changes of pregnancy
Pregnancy Gingivitis Pathophysiology
bull Elevated circulating estrogen increases capillary permeability
bull Preexisting gingivitis may predispose to pregnancy gingivitis
Pregnancy Gingivitis
bullOccurs commonly in the 2nd to 8th monthsbullTendency to bleed very easilybullTreatment Scaling root-planing currettage OHI
Pregnancy Granuloma
bullOccurs in up to 5 of womenbullMost common in buccal maxillary anterior areasbullUsually starts in an area of gingivitis
Pregnancy Granuloma (continued)
bullRapid growth up to 2 cmbullSingle tumor-like growthbullusually in interdental papillaebullPurplish to bluish in color may be ulcerated- bleeds easily
Gum Problems - Pregnancy Granuloma
Gum Problems - Pregnancy Granuloma
Gum Changes - Pregnancy Granuloma
Pregnancy Granuloma (continued)
Treatment
bull Scaling and root planingbull Excision if it is too large or bleeds too
easilybull May regress spontaneously after
pregnancy
Candidiasis
bullWipes offbullUsually asymptomatic but may burnbullTreatment topical or systemic antifungals
Pregnancy MythsbullldquoA mother loses a tooth for every babyrdquobullNo evidence that aphthous ulcers are any more common in pregnancy
Other Oral Conditions in Pregnancy
bull Dry mouthbull Excessive salivationbull Tooth erosions associated with
severe GERD or hyperemesis
Changes During Pregnancy that Affect Oral Health
bull Hormonal Affects
ndash Increased tooth mobility
ndash Saliva changes
ndash Increased bacteria
ndash Gingival problems
Saliva changesbull Decreased buffers
bull Decreased minerals
bull Decreasing flow first and last trimester
bull Increased flow second trimester
bull More acidic
Increased Bacteriabull Increased acidity
ndash Increase in decay-causing bacteriabull Increased Snacking
ndash Morning sicknesslow blood sugarndash Between-meal snacks
bull Increase in amount and frequency of starchescarbohydrates ndash Crackers are commonly recommendedndash Promotes decay-causing bacteria
Changes During Pregnancy that Affect Oral Healthbull Morning sickness
ndash Difficulty with hygienebull Gingival diseasebull Tooth decay
ndash Vomitingbull Esophogeal Reflux (heartburn)bull Acid exposure
ndash Irritation of the gumsndash Weakening of tooth enamelndash Dental erosion
Enamel erosion caused by frequent vomiting
Treatment for Acid Exposure
bull Do NOT brush immediately after vomiting
bull Rinse ndash Water with baking sodandash Antacidndash Plain water
bull Eat some cheese
Oral Diseases Can Effect Pregnancy
bull Preterm low birth weight (LBW) linked to periodontal disease
bull Thorough calculus (tartar) removal in pregnant women with periodontitis may reduce pre-term births
Periodontal Disease and Preterm LaborbullMaternal periodontal disease is associated with increased risk of preterm laborbullAnaerobic oral gram-negative bacteria cause inflammatory responsebullInflammatory response stimulates prostaglandin and cytokine production to stimulate labor
Periodontal Disease and Low Birth Weight
bull Periodontal disease is associated with low birth weight
bull Evidence is not conclusivebull Biochemical mechanism similar cascade
as in preterm labor leading to placental blood flow restriction and necrosis
Periodontal Disease and Preeclampsia
bull Emerging databull Mechanism unclearbull Proposed mechanism
ndash Periodontal infection leads to inflammatory vascular damage
ndash Triggers cell damage in placenta
Periodontitis and Pre-eclampsia
bull Periodontal disease may be associated with pre-eclampsia (Boggess 2003)
bull PGE2 IL-1 and TNF-α from gingival crevicular fluid were higher in women with preeclampsia compared with healthy matched pregnant women (Oettinger-Barak 2003)
Dental Considerations
bull timing of treatment for pregnant patientsbull dental radiation exposurebull use of local anestheticsbull prescription of common antibiotics and
analgesicsbull nitrous oxide gas administration
Treatment Timing
bull First Trimesterndash Spontaneous miscarriages naturally occur
more often in 1st trimesterndash Avoid elective treatment that can be delayedndash Offer anticipatory guidance
bull Second Trimesterndash The optimal time for dental treatmentndash Organogenesis complete fetus not largendash Easier to prevent than treat established disease
bull Third Trimesterndash Late in term very uncomfortable (short visits)ndash Position slightly on left side
Timing of Dental Treatment During Pregnancy - From Little and Fallace
First Trimester
bull Plaque controlbull Oral hygiene instructionbull Scaling polishing curettagebull Avoid elective treatment urgent care
only
Timing of Dental Treatment During Pregnancy - From Little and Fallace
Second Trimester
bull Plaque controlbull Oral hygiene instructionbull Scaling polishing curettagebull Routine dental care
Timing of Dental Treatment During Pregnancy - From Little and Fallace
Third Trimester
bull Plaque controlbull Oral hygiene instructionbull Scaling polishing curettagebull Routine dental care (after middle of third
trimester elective care should be avoided)
Use of Radiation on Pregnant Patientbull Dose given and time of gestation are
importantbull doses lt 5-10 rads (cGy) not teratogenicbull fetus is most susceptible to radiation
between the 2nd and 6th week of gestationbull single dental x-ray exposes patient to 001
millirads of radiation In relative terms this amount is 40 times less than daily dose acquired from cosmic radiation Therefore diagnostic radiation should not be withheld during pregnancy
Radiographs during Pregnancy
bull Take as needed with optimal methods for reducing secondary radiation and exposure time
bull Always use a lead apronbull Exposure to fetus (with apron use) is 00001
centiGray(rad)bull Daily cosmic radiation - 0004 centiGray (rad)
Risks of Dental X-Rays
bull X-ray only if necessary (ie root canal therapy trauma)
bull When x-rays are indicated radiation exposure is extremely low
bull Exposure can be limited byndash Lead apron shielding ndash Modern fast film ndash Avoiding retakes
FDA drug classification for pregnancybull Combines risk statements including
congenital anomalies fetal effects perinatal risks and therapeutic risk-benefit ratio
bull Untreated disease or condition may pose more serious risks to both mother and fetus than any theoretical risks from the medication
bull Category A thru D and X
FDA drug classification for pregnancy
bull A = Controlled Studies in women fail to demonstrate a risk to the fetus in the first trimester and the possibility of fetal harm appears remote
FDA drug classification for pregnancy
bull B = Animal studies show no risk or if risk shown in animals controlled
trials in women showed no risk
FDA drug classification for pregnancy
bull C = Studies in animals with adverse effects and no human studies
OR no animal or human studies but benefits of use may outweigh potential harms
FDA drug classification for pregnancy
bull D = There is evidence of human fetal risk but benefits may outweigh risks
FDA drug classification for pregnancy
bull X = Contraindicated
Common Analgesics
bull paracetamol (B)bull Ibuprofen (BD) bull Oxycodone (BD) bull Hydrocodone and codeine
(CD)
avoid in third trimester
Analgesics
bull Paracetamol is the analgesic of choice for all stages of gestation
bull used to treat mild to moderate pain and fevers
bull short term usage is believed to be safebull avoid chronic and large doses of
paracetamol1048715
Analgesics - continuedbull Aspirin is nonteratogenic but may cause
maternal and fetal hemorrhagebull large and chronic doses during last trimester
may result in premature closure of ductus arteriosus fetal hypertension anemia and low birth weight
bull avoid ibuprofen in 3rd trimester because of possible adverse circulatory effects
bull short term use of codeine seems safebull avoid codeine late in gestation because of
possible fetal respiratory depression and withdrawal symptoms
Analgesics to Use During1st and 2nd Trimester
bull Category B (for best)bull Paracetamol Ibuprofenbull Naproxenbull Category C (use with caution)bull Paracetamol with codeine or
hydrocodonebull Paracetamol with oxycodone
Analgesics to Avoid During theThird Trimesterbull Causes delivery problemsbull Aspirin (C 3D)bull Ibuprofen (B3D)bull Naproxen (B3D)bull Causes neonatal respiratory
depression and opioid withdrawalbull Codeine (C3D)bull Hydrocodone (C3D)bull Oxycodone(C3D)
Sedation in Pregnancy
bull SedativesAnxiolytics (eg Diazepam ) are rated D and can cause oral clefts with prolonged exposure
bull Nitrous oxide should not be used in 1st trimester (If used in 2nd and 3rd do not go below 50 O2)
Common Antibioticsbull To treat oral abscess or cellulitis
ndash Penicillin (B) ndash Amoxicillin (B) ndash Cephalexin (B)ndash Erythromycin base (B) (Not estolate as it
cause cholestatic hepatitis)ndash Clindamycin (B)
Antibioticsbull penicillin V and amoxicillin is preferred drug
for mild to moderate infectionsbull widely used for many years with no ill effectsbull no studies show penicillin to be teratogenicbull amoxicillin extensively used without harming
the fetusbull Drug classes1048715 B penicillin cephalosporins erythromycin clindamycin Azithromycin D Tetracycline
Antibiotics To Use During Pregnancy
bull Penicillin Vbull Amoxicillinbull Erythromycin (base form)bull Cephalexin cephalosporinbull Clindamycinbull Metronidazole
Antibiotics to Avoid duringPregnancy
bull Doxycyclinebull Tetracyclinebull Erythromycin (estolate form)bull Vancomycin
The Problem With Tetracycline
bull Accumulates in bones and chelates calcium
bull Inhibits bone growthbull Discolors teeth
Other Antimicrobial Agentsbull OK to usebull Nystatin (B)bull Chlorhexidine rinse (B)bull Use with cautionbull Clotrimazole (C)bull Ketoconazole (C)bull Fluconazole (C)bull Do not usebull Doxycycline (D)
Local Anesthetic Use inPregnancy
bull Class Bbull Lidocaine (Xylocaine)bull Etidocainebull Prilocaine bull Class Cbull Procainebull Bupivicainebull Mepivicaine
Use of Local Anestheticsbull Lidocaine + vasoconstrictor most common
local anesthetic used in dentistrybull extensively used in pregnancy with no proven ill
effectsbull accidental intravascular injections of lidocaine
pass through the placenta but the concentrations are too low to harm fetus
bull prilocaine might cause methemoglobinemia
Ulcer healing drugsCimetidine bull FDA category B Famotidinebull FDA category BRanitidinebull FDA category Bbull not known to be harmful
Ulcer healing drugsOmeprazolebull FDA category BNot known to be
harmful Esomeprazolebull FDA category BLansoprazolebull FDA category BPantoprazolebull Avoid unless potential benefit
outweighs riskmdashfetotoxic in animals
Ulcer healing drugs
Misoprostolbull First second third trimesters Avoidmdash
potent uterine stimulant (has been used to induce abortion) and may be teratogenic
Ulcer healing drugs
Antacidsbull Almunium hydroxideMagnesium
hydroxidemdashFDA category B Calcium carbonatemdashFDA category C
SimetheconemdashFDA category C
Use of Nitrous Oxide Gas
bull used over 150 years bull safety is being debatedbull SHORT TERM exposure do not cause
birth defects or spontaneous abortionbull CHRONIC exposure may result in fetal
loss and infertilitybull literature suggests that nitrous oxide
should be avoided until more conclusive research is available
bull FDA Drug class not yet assigned
Common Preventives
bull Fluoridendash No increased risk during pregnancy
bull Xylitolndash No studies no harm reported
bull Chlorhexidinendash No increased risk during pregnancy
Are topical agents safe
bull Fluoridebull Toothpaste amp mouthrinse
bull Xylitol chewing gum bull Chlorhexidine (11 alcohol)bull No over the counter mouthrinses with
alcohol (Listerine 20 alcohol)
Pre-natal Fluoride
bull Daily 22 mg tablet of sodium fluoride during 3rd through 9th months
bull decreases caries rate in offspringbull Safe and effective
Glenn FB 1982
Is it safe to use mercury restorations
bull No evidence of harmful effect
bull Benefits outweigh risks
bull Canada Germany and New Zealand have some restrictions
bull Determine the best option
Referencesbull Wasylko L Matsui D Dykxhoorn SM Rieder MJ Weinberg
S A Review of Common Dental Treatments During Pregnancy J Canadian Dental Association 64434-439 1998
bull Little JW Donald AF Craig SM Rhodus NL Dental Management of the Medically Compromised Patient - 5th edition Mosby Toronto Pp434-442 1997
bull Livingston HM Dellinger TM Holder R Considerations in the management of the pregnant patient Special Care in Dentistry 185 pp183-188 1998
bull Larimore WL Petrie KA Drug use during pregnacy and lactation Primary Care Clinics in Office Practice 271 35-53 2000
bull Health Canada The Safety of DentalAmalgam Minister Of Supply and Services Canada 1996
REFERENCESbull 1 Weiss G Endocrinology of parturition J Clin
Endocrinol Metab 2000854421-5bull 2 Theunissen IM Parer JT Fluid and electrolytes in
pregnancy Clin Obstet Gynecol 1994373-15bull 3 Duvekot JJ Peeters LLH Renal hemodynamics and
volume homeostasis in pregnancy Obstet Gynecol Surv 199449830-9
bull 4 Barron WM Lindheimer MD Medical disorders during pregnancy 2nd ed St Louis Mosby 1995 p 129
bull 5 Thornburg KL Jacobson SL Giraud GD Morton MJ Hemodynamic changes in pregnancy Semin Perinatol 20002411-4
bull 6 Fiese R Herzog S Issues in dental and surgical management of the pregnant patient Oral Surg Oral Med Oral Pathol 198865292-7
bull 7 Martin C Varner MW Physiologic changes in pregnancysurgical implications Clin Obstet Gynecol 199437241-55
bull 8 Clark SL Cotton DB Lee W Bishop C Hill T Southwick J et al Central hemodynamic assessment of normal term pregnancy Am J Obstet Gynecol 19891611439-42
bull 9 Mabie WC Di Sessa TG Crocker LG Sibai BM Arheart KL A longitudinal study of cardiac output in normal human pregnancy Am J Obstet Gynecol 1994170849-56
bull 10 Clapp JF 3rd Capeless E Cardiovascular function before during and after the first and subsequent pregnancies Am J Cardiol 1997801469-73
bull 11 Duvekot JJ Peeters LL Maternal cardiovascular hemodynamic adaptation to pregnancy Obstet Gynecol Surv 199449(Suppl) S1-14
bull 12 Bhagwat AR Engel PJ Heart disease and pregnancy Cardiol Clin 199513163-78
bull 13 Lanni SM Tillinghast J Silver H Hemodynamic changes and baroreflex gain in the supine hypotensive syndrome Am J Obstet Gynecol 20021871636-41
bull 14 Little JW Falace DA Miller CS Rhodus NL Dental management of the medically compromised patient 6th ed St Louis Mosby 2002 p 303
bull 15 Garcia-Rio F Pino JM Gomez L Alvarez-Sala R Villasante C Villamor J Regulation of breathing and perception of dyspnea in healthy pregnant women Chest 1996110446-53
bull 16 McAuliffe F Kametas N Costello J Rafferty GF Greenough A Nicolaides K Respiratory function in singleton and twin pregnancy BJOG 2002109765-9
bull 17 Clapp JF 3rd Seaward BL Sleamaker RH Hiser J Maternal physiologic adaptations to early human pregnancy Am J Obstet Gynecol 19881591456-60
bull 18 OrsquoDay MP Cardio-respiratory physiological adaptation of pregnancy Semin Perinatol 199721268-75
bull 19 Contreras G Gutierrez M Beroiza T Fantin A Oddo H Villarroel L et al Ventilatory drive and respiratory muscle function in pregnancy Am Rev Respir Dis 1991144837-41
bull 20 Turner M Aziz SR Management of the pregnant oral and maxillofac
bull 21 Sifakis S Pharmakides G Anemia in pregnancy Ann N Y Acad Sci 2000900125-36
bull 22 Branch DW Physiologic adaptations of pregnancy Am J Reprod Immunol 199228120-2
bull 23 Burrows RF Kelton JG Incidentally detected thrombocytopenia in healthy mothers and their infants N Engl J Med 1988319 142-5
bull 24 Hanly JG Antiphospholipid syndrome an overview CMAJ 200324(168)1675-82
bull 25 Heilmann L von Tempelhoff GF Pollow K Antiphospholipid syndrome in obstetrics Clin Appl Thromb Hemost 20039 143-50
bull 26 Sherman P Flaxman SM Nausea and vomiting of pregnancy in an evolutionary perspective Am J Obstet Gynecol 2002 185(Suppl)s190-7
bull 27 Koch KL Gastrointestinal factors in nausea and vomiting of pregnancy Am J Obstet Gynecol 2002185(Suppl)s198-203
bull 28 Koch KL Frissora CL Nausea and vomiting during pregnancy Gastroenterol Clin N Am 200332201-34
bull 29 Baron TH Ramirez B Richter JE Gastrointestinal motility disorders during pregnancy Ann Intern Med 1993118 366-75
bull 30 Richter JE Gastroesophageal reflux disease during pregnancy Gastroenterol Clin N Am 200332235-61
bull 31 Marrero JM Goggin PM de Caestecker JS Pearce JM Maxwell JD Determinants of pregnancy heartburn Br J Obstet Gynaecol 199299731-4
bull 32 Hamaoui E Hamaoui M Nutritional assessment and support during pregnancy Gastroenterol Clin N Am 20033259-121
bull 33 King JC Physiology of pregnancy and nutrient metabolism Am J Clin Nutr 200071(suppl)1218s-25s
bull 34 Casanueva E Pfeffer F Fernandez-Gaxiola AC Gutierrez- Valenzuela V Rothenberg SJ Iron and folate status before pregnancy and anemia during pregnancy Ann Nutr Metab 2003 4760-3
bull 35 Chrsquong CL Morgan M Hainsworth I Kingham JG Prospective study of liver dysfunction in Southwest Wales Gut 200251 876-80
bull 36 Rahman TM Wendon J Severe hepatic dysfunction in pregnancy QJM 200295343-57
bull 37 Knox TA Olans LB Liver disease in pregnancy N Engl J Med 1996335569-76
bull 38 Saftlas AF Olson DR Franks AL Atrash H Pokras R Epidemiology of preeclampsia and eclampsia in the United States 1979e1986 Am J Obstet Gynecol 1990163460-5
bull 39 Walker JJ Pre-eclampsia Lancet 20003561260-5
bull 40 Davidson JM Renal disorders in pregnancy Curr Opin Obstet Gynecol 200113109-14
bull 41 Dafnis E Sabatini S The effect of pregnancy on renal function physiology and pathophysiologyAmJMedSci 1992303184-205
bull 42 Davison JM Shiells EA Philips PR Lindheimer MD Serial evaluation of vasopressin release and thirst in human pregnancy Role of human chorionic gonadotrophin in the osmoregulatory changes of gestation J Clin Invest 198881798-806
bull 43 Glinoer D de Nayer P Bourdoux P Lemone M Robyn C van Steirteghem A et al Regulation of maternal thyroid during pregnancy J Clin Endocrinol Metab 199071276-87
bull 44 Wilson SG Retallack RW Kent JC Worth GK Gutteridge DH Serum free 125-dihydroxyvitamin D and the free 125- dihydroxyvitamin D index during a longitudinal study of human pregnancy and lactation Clin Endocrinol 199032613-22
bull 45 Rasmussen N Frolich A Hornnes PJ Hegedus L Serum ionized calcium and intact parathyroid hormone levels during pregnancy and postpartum Br J Obstet Gynaecol 199097857-9
bull 46 Guyton AC Textbook of medical physiology 8th ed Philadelphia W B Saunders 1991 p 915e28
bull 47 Trainer PJ Corticosteroids and pregnancy Semin Reprod Med 200220375-80
bull 48 Soory M Hormonal factors in periodontal disease Dent Update 200027380-3
bull 49 Hugoson A Gingivitis in pregnant women A longitudinal clinical study Odontol Revy 19712265-84
bull 50 Neville BW Damm DD Allen CM Bouquot JE Oral amp Maxillofacial Pathology 3rd ed Philadelphia W B Saunders 2002 p 329-30 447-9
bull 51 Tilakaratne A Soory M Ranasinghe AW Corea SM Ekanayake SL de Silva M Periodontal disease status during pregnancy and 3 months post-partum in rural population of Sri-Lankan women J Clin Periodontol 200027787-92
bull 52 Laine M Tenovuo J Lehtonen OP Ojanatko-Harri A Vilja P Tuohimaa P Pregnancy e related changes in human whole saliva Arch Oral Biol 198833913-7
bull 53 Yuan K Wing LY Lin MT Pathogenetic roles of angiogenic factors in pyogenic granulomas in pregnancy are modulated by female sex hormones J Periodontol 200273701-8
bull 54 Evans RD Briggs PF Tooth-surface loss related to pregnancyinduced vomiting Prim Dent Care 1994124-6
bull 55 Salvolini E Di Giorgio R Curatola A Mazzanti L Fratto G Biochemical modifications of human whole saliva induced by pregnancy Br J Obstet Gynaec 1998105656-60
bull 56 Mauldin JG Newman RB Preterm birth risk assessment Semin Perinatol 200125215-22
bull 57 Heine RP McGregor JA Goodwin TM Artal R Hayashi RH Robertson PA et al Serial salivary estriol to detect an increased risk of preterm birth Obstet Gynecol 200096490-7
bull 58 Kauh YC Zachian TF Melasma Adv Exp Med Biol 1999455 491-9
bull 59 Wong RC Ellis CN Physiologic skin changes in pregnancy J Am Acad Dermatol 198410929-40
bull 60 Errickson CV Matus NR Skin disorders of pregnancy Am Fam Physician 199449605-10
bull 61 Lopez NJ Smith PC Gutierrez J Periodontal therapy may reduce the risk of preterm low birth weight in women with periodontal disease a randomized controlled trial J Periodontol 200273911-24
bull 62 McGaw T Periodontal disease and preterm delivery of lowbirth- weight infants J Can Dent Assoc 200268165-9
bull 63 Richards AG Dental x-ray protection Dent Clin North Am 1968631-41
bull 64 1990 Recommendations of the International Commission on Radiological Protection Ann ICRP 1991211-201
bull 65 Hall EJ Radiation the two-edged sword cancer risks at high and low doses Cancer J 20006343-50
bull 66 Diethelm L Xu H Diagnostic imaging of the lung during pregnancy Clin Obstet Gynecol 19963936-55
bull 67 Brent RL The effects of embryonic and fetal exposure to x-rays microwaves and ultrasound ClinObstetGynecol 198326484-510
bull 68 National Council on Radiation Protection NCRP report no128 1998 Bethesda Md Author
bull 69 Wasylko L Matsui D Dykxhoorn SM Reider MJ Weinberg S A review of common dental treatments during pregnancy implications for patients and dental personnel J Can Dent Assoc 199864434-9
bull 70 Freeman JP Brand JW Radiation doses of commonly used dental radiographic surveys Oral Surg Oral Med Oral Pathol 199477285-9
bull 71 Kircos LTAngin LL Lorton LOrder ofmagnitude dose reduction in intraoral radiography J Am Dent Assoc 1987114344-7
bull 72 Updegrave WJ Simplified and standardized intraoral radiography with reduced tissue irradiation J Am Dent Assoc 197285861-9
bull 73 Wood RE Harris AM van der Merwe EJ Nortje CJ The leaded apron revisited does it reduce gonadal radiation dose in dental radiology Oral Surg Oral Med Oral Pathol 199171642-6
bull 74 An update on radiographic practices information and recommendations ADA Council on Scientific Affairs J Am Dent Assoc 2001132234-8
bull 75 Rayburn WF Recommending medications during pregnancy an evidence based approach Clin Obstet Gynecol 2002451-5
bull 76 Rathmell JP Viscomi C Ashburn MA Management of nonobstetric pain during pregnancy and lactation Anesth Analg 1997851074-87
bull 77 Teratology society public affairs committee FDA classification of drugs for teratogenic risk Teratology 199449446-7
bull 78 Moore PA Selecting drugs for the pregnant dental patient J Am Dent Assoc 19981291281-6
bull 79 Haas DA An update on analgesics for the management of acute postoperative dental pain J Can Dent Assoc 200268476-82
bull 80 Haas DA Pynn BR Sands TD Drug use for the pregnant or lactating patient Gen Dent 20004854-60
bull 81 Committee on Drugs American Academy of Pediatrics The transfer of drugs and other chemicals into human milk Pediatrics 199493137-50
bull 82 Nielsen GL Sorensen HT Larsen H Pedersen L Risk of adverse birth outcome and miscarriage in pregnant users of nonsteroidal anti-inflammatory drugs population based observational study and case-control study BMJ 2001322266-70
bull 83 Janssen N Genta M The effects of immunosuppressive and anti-inflammatory medications on fertility pregnancy and lactation Arch Intern Med 200016610-9
bull 84 Ostensen M Nonsteroidal anti-inflammatory drugs during pregnancy Scand J Rheumatol Suppl 1998107128-32
bull 85 USPDI -Drug information for the health care professional 22nd ed Greenwood Village CO Micromedex 2002 p 152-79
bull 86 Denson DD Coyle DE Thompson GA Santos D Turner PA Myers JA et al Bupivacaine protein binding in the term parturient effects of lactic acidosis Clin Pharmacol Ther 198435702-9
bull 87 Dillon DE Wagner CL Wiest D Newman RB Drug therapy in the nursing mother Obstet Gynecol Clin North Am 199724 675-96
bull 88 Dashe JS Gilstrap LC Antibiotic use in pregnancy Obstet Gynecol Clin North Am 199724617-29
bull 89 American College of Rheumatology Ad hoc Committee on Clinical Guidelines Guidelines for monitoring drug therapy in rheumatoid arthritis Arthritis Rheum 199639723-31
bull 90 Ng PC The fetal and neonatal hypothalamic-pituitary-adrenal axis Arch Dis Child Fetal Neonatal Ed 200082F250-4
bull 91 Crowley P Antenatal corticosteroidsmdashcurrent thinking BJOG 2003110(Suppl 20)77-8
bull 92 ACOG committee opinion antenatal corticosteroid therapy for fetal maturation Obstet Gynecol 200299871-3
bull 93 Ost L Wettrell G Bjorkhem I Rane A Prednisolone excretion in human milk J Pediatr 19851061008-11
bull 94 Rowland AS Baird DD Shore DL Weinberg CR Savitz DA Wilcox AJ Nitrous oxide and spontaneous abortion in female dental assistants Am J Epidemiol 1995141531-8
bull 95 McGlothlin JD Jensen PA Fischbach TJ Hughes RT Jones JH Control of anesthetic gases in dental operatories Scand J Work Environ Health 199218(Suppl 2)103-5
bull ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY Volume 97 Number 6 Suresh and Radfar 681
bull 96 Rosen MA Nitrous oxide for relief of labor pain a systematic review Am J Obstet Gynecol 2002186(Suppl Nature)S110-6
bull 97 Sands TD Pynn BR Management considerations for the pregnant or nursing emergency patient Ont Dent 199875 17-9
bull 98 Daya S Recurrent spontaneous early pregnancy loss and low dose aspirin Minerva Ginecol 200355441-9
bull 99 Sinclair C Handbook of obstetrical emergencies 1st ed Philadelphia WB Saunders 1996 p 29-39 69
bull 100 Tarsitano BF Rollings RE The pregnant dental patient evaluation and management Gen Dent 199341226-34
bull 101 Livingston MH Dlllinger TM Holder R Consideration in the management of the pregnant patient SCD Special Care in Dentistry 199818183-8
Thank you
- A Review on the principle of Dental Management of the Pregnant patient
- Slide 2
- Questions that a dentist may ask
- Stages of Pregnancy
- Slide 5
- Slide 6
- Physiologic Changes in Pregnancy
- Systemic changes in pregnancy
- FLAT SUPINE POSITIONING
- SUPINE HYPOTENSION SYNDROME (Vena Cava Compression)
- Supine Hypotension Syndrome
- Slide 12
- Supine Hypotension Syndrome
- Prevention of Supine Hypotensive Syndrome
- Treatment of Supine Hypotensive Syndrome
- How should the pregnant woman be positioned
- Slide 17
- Slide 18
- Slide 19
- Slide 20
- Slide 21
- Slide 22
- Slide 23
- Pregnancy Related Oral Health Problems
- Oral Problems in Pregnancy
- Pregnancy Gingivitis Pathophysiology
- Pregnancy Gingivitis
- Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Gum Problems - Pregnancy Granuloma
- Slide 31
- Gum Changes - Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Candidiasis
- Pregnancy Myths
- Other Oral Conditions in Pregnancy
- Changes During Pregnancy that Affect Oral Health
- Saliva changes
- Increased Bacteria
- Slide 40
- Enamel erosion caused by frequent vomiting
- Treatment for Acid Exposure
- Oral Diseases Can Effect Pregnancy
- Periodontal Disease and Preterm Labor
- Periodontal Disease and Low Birth Weight
- Periodontal Disease and Preeclampsia
- Periodontitis and Pre-eclampsia
- Dental Considerations
- Treatment Timing
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Slide 52
- Use of Radiation on Pregnant Patient
- Radiographs during Pregnancy
- Risks of Dental X-Rays
- FDA drug classification for pregnancy
- Slide 57
- FDA drug classification for pregnancy
- Slide 59
- Slide 60
- Slide 61
- Common Analgesics
- Analgesics
- Analgesics - continued
- Analgesics to Use During 1st and 2nd Trimester
- Analgesics to Avoid During the Third Trimester
- Sedation in Pregnancy
- Common Antibiotics
- Antibiotics
- Antibiotics To Use During Pregnancy
- Antibiotics to Avoid during Pregnancy
- The Problem With Tetracycline
- Other Antimicrobial Agents
- Local Anesthetic Use in Pregnancy
- Use of Local Anesthetics
- Ulcer healing drugs
- Slide 77
- Slide 78
- Slide 79
- Use of Nitrous Oxide Gas
- Common Preventives
- Are topical agents safe
- Pre-natal Fluoride
- Is it safe to use mercury restorations
- References
- REFERENCES
- Slide 87
- Slide 88
- Slide 89
- Slide 90
- Slide 91
- Slide 92
- Slide 93
- Slide 94
- Slide 95
- Slide 96
- Slide 97
- Slide 98
- Thank you
-
Questions that a dentist may askbull Can I take x-raysbull Can I inject local anesthesia with
epinephrinebull What medications can I prescribebull Are topical agents safebull When should I perform necessary
proceduresbull Can I use mercury restorations
Stages of Pregnancybull1st Trimester (1-12 weeks)bullFetal organ formation and differentiationbullMost susceptible to adverse effects of teratogensbullAvoid all elective care but provide care as needed
Stages of Pregnancy
bull2nd Trimester (13-24 weeks)bullFetal growth and maturationbullSafest period to provide dental care
Stages of Pregnancy
bull3rd Trimester (25-40 weeks)bullFetal growth continuesbullFocus of concern is risk to upcoming birth process and safety and comfort of the pregnant woman
Physiologic Changes in Pregnancy
bull Complex hormonal interactions cause profound physiologic changes
bull Increase estrogen by 10 fold and progesterone by 30 folds
bull Increased hormonal secretion and fetal growth causes several systemic as well as physical changes in a pregnant women
Systemic changes in pregnancyCardiovascular system uarr in blood volume by an average of 45bull Anemia due to increased blood volume
(20 of women) darr in pulse by 10-15 beats per minute Systemic murmur occurs in 90 of
pregnancies disappears shortly after delivery
uarrcardiac output Supine hypotension syndrome may occur
FLAT SUPINE POSITIONING
bullNegatively impacts mother and infant
SUPINE HYPOTENSIONSYNDROME (Vena Cava Compression)
bull SUPINE POSITION AFTER 5TH MONTH
bull UTERUS COMPRESSES THE INFERIOR VENA CAVA
bull uarrVOL BLOOD IN THE LErsquoS bull darrRETURN TO THE HEARTbull REDUCED PERFUSION OF
UTERUS bull FETAL HYPOXIA
Supine Hypotension Syndrome
bull Obstruction of inferior vena cava and aorta from pressure of the large fetus
Symptoms Sweating Nausea Weakness Sense of lack of air
Supine Hypotension Syndrome
Other symptomsbull Drop in blood pressurebull Bradycardiabull Possible loss of consciousness
Prevention of Supine HypotensiveSyndrome
bullElevate right hip 10-12 cmbullWeight is taken off the major vessels
Treatment of Supine HypotensiveSyndrome
bullRoll patient onto her left side
How should the pregnant woman be positionedbull Flat position may
cause hypotension and hypoxia
bull Place a small pillow under right hip - left lateral displacement
bull Head above feet
Systemic changes in pregnancy
Diaphragm rises about 4 cm darr residual volume uarr awareness of a desire to breath is
common-may be interpreted as dyspnea Increased estrogen in blood causes
engorgement of the nasal capillaries and rhnitis in pregnant women
Frequent nosebleeds amp predisposition to upper respiratory infection
Respiratory system
Systemic changes in pregnancy
Gastrointestinal system Gastric emptying amp intestinal transit times
are delayed
Heart burn reflux common
Nausea and vomiting common
Systemic changes in pregnancy
For pregnant patient with Hyper-emesis gravidarium ( excessive and uncontrolled vomiting) morning appointments should be avoided
They should be seated in a semi-supine or comfortable position
In case of vomiting the procedure should be stopped immediately amp the patient should be repositioned upright
When vomiting is over rinsing mouth with cold water or mouthwash is recommended
Systemic changes in pregnancybull Urinary System uarr GFR amp renal plasma flow by as much as
50 Nocturia ndashto mobilize the dependent
edema which accumulate during the day uarr Frequency from uarr renal flow plus reduced
bladder capacity from uterine growth It is advisable to ask the patient to void the
bladder just prior to starting the dental procedure
Systemic changes in pregnancyEndocrine Changes uarrEstrogen uarr progesterone uarrhuman
gonadotropin uarr thyroxin steroid and insulin level Estrogen amp progesterone are insulin
antagonists uarr level of these hormones lead to insulin resistance Thus insulin levels are elevated in pregnant in pregnant patient to compensate this resistance
About 45 of women fail to produce sufficient amount of insulin to overcome this antagonist action amp thus develop gestational diabetes
Systemic changes in pregnancy
Hematological changebull uarr red RBC uarrESR darrHbbull uarrWBCbull uarr circulatory catecholamin amp cortisol lead
to leucositosis bull uarr Coagulation factors except factor XI amp
XIII (anticloting factor) bull so pregnancy is a hypercoagulable state amp
uarr risk for thromboembolism
Systemic changes in pregnancy
bull Pregnant women with anti-phospholipid syndrome are at uarr risk for thrombo-embolisim
bull They are placed on subcutaneous low molecular weight heparin (LMWH)
bull These patients must be hospitalized for dental care
Pregnancy RelatedOral Health Problems
bull Pregnancy Gingivitisbull Pregnancy Epulis bull Increased Tooth Mobilitybull Dental Cariesbull Erosionbull Dental Problems in relation to Labor
and Delivery
Oral Problems in Pregnancy
bullPregnancy GingivitisbullMost common oral manifestation (50-100 of women)bullCaused by hormonal and vascular changes of pregnancy
Pregnancy Gingivitis Pathophysiology
bull Elevated circulating estrogen increases capillary permeability
bull Preexisting gingivitis may predispose to pregnancy gingivitis
Pregnancy Gingivitis
bullOccurs commonly in the 2nd to 8th monthsbullTendency to bleed very easilybullTreatment Scaling root-planing currettage OHI
Pregnancy Granuloma
bullOccurs in up to 5 of womenbullMost common in buccal maxillary anterior areasbullUsually starts in an area of gingivitis
Pregnancy Granuloma (continued)
bullRapid growth up to 2 cmbullSingle tumor-like growthbullusually in interdental papillaebullPurplish to bluish in color may be ulcerated- bleeds easily
Gum Problems - Pregnancy Granuloma
Gum Problems - Pregnancy Granuloma
Gum Changes - Pregnancy Granuloma
Pregnancy Granuloma (continued)
Treatment
bull Scaling and root planingbull Excision if it is too large or bleeds too
easilybull May regress spontaneously after
pregnancy
Candidiasis
bullWipes offbullUsually asymptomatic but may burnbullTreatment topical or systemic antifungals
Pregnancy MythsbullldquoA mother loses a tooth for every babyrdquobullNo evidence that aphthous ulcers are any more common in pregnancy
Other Oral Conditions in Pregnancy
bull Dry mouthbull Excessive salivationbull Tooth erosions associated with
severe GERD or hyperemesis
Changes During Pregnancy that Affect Oral Health
bull Hormonal Affects
ndash Increased tooth mobility
ndash Saliva changes
ndash Increased bacteria
ndash Gingival problems
Saliva changesbull Decreased buffers
bull Decreased minerals
bull Decreasing flow first and last trimester
bull Increased flow second trimester
bull More acidic
Increased Bacteriabull Increased acidity
ndash Increase in decay-causing bacteriabull Increased Snacking
ndash Morning sicknesslow blood sugarndash Between-meal snacks
bull Increase in amount and frequency of starchescarbohydrates ndash Crackers are commonly recommendedndash Promotes decay-causing bacteria
Changes During Pregnancy that Affect Oral Healthbull Morning sickness
ndash Difficulty with hygienebull Gingival diseasebull Tooth decay
ndash Vomitingbull Esophogeal Reflux (heartburn)bull Acid exposure
ndash Irritation of the gumsndash Weakening of tooth enamelndash Dental erosion
Enamel erosion caused by frequent vomiting
Treatment for Acid Exposure
bull Do NOT brush immediately after vomiting
bull Rinse ndash Water with baking sodandash Antacidndash Plain water
bull Eat some cheese
Oral Diseases Can Effect Pregnancy
bull Preterm low birth weight (LBW) linked to periodontal disease
bull Thorough calculus (tartar) removal in pregnant women with periodontitis may reduce pre-term births
Periodontal Disease and Preterm LaborbullMaternal periodontal disease is associated with increased risk of preterm laborbullAnaerobic oral gram-negative bacteria cause inflammatory responsebullInflammatory response stimulates prostaglandin and cytokine production to stimulate labor
Periodontal Disease and Low Birth Weight
bull Periodontal disease is associated with low birth weight
bull Evidence is not conclusivebull Biochemical mechanism similar cascade
as in preterm labor leading to placental blood flow restriction and necrosis
Periodontal Disease and Preeclampsia
bull Emerging databull Mechanism unclearbull Proposed mechanism
ndash Periodontal infection leads to inflammatory vascular damage
ndash Triggers cell damage in placenta
Periodontitis and Pre-eclampsia
bull Periodontal disease may be associated with pre-eclampsia (Boggess 2003)
bull PGE2 IL-1 and TNF-α from gingival crevicular fluid were higher in women with preeclampsia compared with healthy matched pregnant women (Oettinger-Barak 2003)
Dental Considerations
bull timing of treatment for pregnant patientsbull dental radiation exposurebull use of local anestheticsbull prescription of common antibiotics and
analgesicsbull nitrous oxide gas administration
Treatment Timing
bull First Trimesterndash Spontaneous miscarriages naturally occur
more often in 1st trimesterndash Avoid elective treatment that can be delayedndash Offer anticipatory guidance
bull Second Trimesterndash The optimal time for dental treatmentndash Organogenesis complete fetus not largendash Easier to prevent than treat established disease
bull Third Trimesterndash Late in term very uncomfortable (short visits)ndash Position slightly on left side
Timing of Dental Treatment During Pregnancy - From Little and Fallace
First Trimester
bull Plaque controlbull Oral hygiene instructionbull Scaling polishing curettagebull Avoid elective treatment urgent care
only
Timing of Dental Treatment During Pregnancy - From Little and Fallace
Second Trimester
bull Plaque controlbull Oral hygiene instructionbull Scaling polishing curettagebull Routine dental care
Timing of Dental Treatment During Pregnancy - From Little and Fallace
Third Trimester
bull Plaque controlbull Oral hygiene instructionbull Scaling polishing curettagebull Routine dental care (after middle of third
trimester elective care should be avoided)
Use of Radiation on Pregnant Patientbull Dose given and time of gestation are
importantbull doses lt 5-10 rads (cGy) not teratogenicbull fetus is most susceptible to radiation
between the 2nd and 6th week of gestationbull single dental x-ray exposes patient to 001
millirads of radiation In relative terms this amount is 40 times less than daily dose acquired from cosmic radiation Therefore diagnostic radiation should not be withheld during pregnancy
Radiographs during Pregnancy
bull Take as needed with optimal methods for reducing secondary radiation and exposure time
bull Always use a lead apronbull Exposure to fetus (with apron use) is 00001
centiGray(rad)bull Daily cosmic radiation - 0004 centiGray (rad)
Risks of Dental X-Rays
bull X-ray only if necessary (ie root canal therapy trauma)
bull When x-rays are indicated radiation exposure is extremely low
bull Exposure can be limited byndash Lead apron shielding ndash Modern fast film ndash Avoiding retakes
FDA drug classification for pregnancybull Combines risk statements including
congenital anomalies fetal effects perinatal risks and therapeutic risk-benefit ratio
bull Untreated disease or condition may pose more serious risks to both mother and fetus than any theoretical risks from the medication
bull Category A thru D and X
FDA drug classification for pregnancy
bull A = Controlled Studies in women fail to demonstrate a risk to the fetus in the first trimester and the possibility of fetal harm appears remote
FDA drug classification for pregnancy
bull B = Animal studies show no risk or if risk shown in animals controlled
trials in women showed no risk
FDA drug classification for pregnancy
bull C = Studies in animals with adverse effects and no human studies
OR no animal or human studies but benefits of use may outweigh potential harms
FDA drug classification for pregnancy
bull D = There is evidence of human fetal risk but benefits may outweigh risks
FDA drug classification for pregnancy
bull X = Contraindicated
Common Analgesics
bull paracetamol (B)bull Ibuprofen (BD) bull Oxycodone (BD) bull Hydrocodone and codeine
(CD)
avoid in third trimester
Analgesics
bull Paracetamol is the analgesic of choice for all stages of gestation
bull used to treat mild to moderate pain and fevers
bull short term usage is believed to be safebull avoid chronic and large doses of
paracetamol1048715
Analgesics - continuedbull Aspirin is nonteratogenic but may cause
maternal and fetal hemorrhagebull large and chronic doses during last trimester
may result in premature closure of ductus arteriosus fetal hypertension anemia and low birth weight
bull avoid ibuprofen in 3rd trimester because of possible adverse circulatory effects
bull short term use of codeine seems safebull avoid codeine late in gestation because of
possible fetal respiratory depression and withdrawal symptoms
Analgesics to Use During1st and 2nd Trimester
bull Category B (for best)bull Paracetamol Ibuprofenbull Naproxenbull Category C (use with caution)bull Paracetamol with codeine or
hydrocodonebull Paracetamol with oxycodone
Analgesics to Avoid During theThird Trimesterbull Causes delivery problemsbull Aspirin (C 3D)bull Ibuprofen (B3D)bull Naproxen (B3D)bull Causes neonatal respiratory
depression and opioid withdrawalbull Codeine (C3D)bull Hydrocodone (C3D)bull Oxycodone(C3D)
Sedation in Pregnancy
bull SedativesAnxiolytics (eg Diazepam ) are rated D and can cause oral clefts with prolonged exposure
bull Nitrous oxide should not be used in 1st trimester (If used in 2nd and 3rd do not go below 50 O2)
Common Antibioticsbull To treat oral abscess or cellulitis
ndash Penicillin (B) ndash Amoxicillin (B) ndash Cephalexin (B)ndash Erythromycin base (B) (Not estolate as it
cause cholestatic hepatitis)ndash Clindamycin (B)
Antibioticsbull penicillin V and amoxicillin is preferred drug
for mild to moderate infectionsbull widely used for many years with no ill effectsbull no studies show penicillin to be teratogenicbull amoxicillin extensively used without harming
the fetusbull Drug classes1048715 B penicillin cephalosporins erythromycin clindamycin Azithromycin D Tetracycline
Antibiotics To Use During Pregnancy
bull Penicillin Vbull Amoxicillinbull Erythromycin (base form)bull Cephalexin cephalosporinbull Clindamycinbull Metronidazole
Antibiotics to Avoid duringPregnancy
bull Doxycyclinebull Tetracyclinebull Erythromycin (estolate form)bull Vancomycin
The Problem With Tetracycline
bull Accumulates in bones and chelates calcium
bull Inhibits bone growthbull Discolors teeth
Other Antimicrobial Agentsbull OK to usebull Nystatin (B)bull Chlorhexidine rinse (B)bull Use with cautionbull Clotrimazole (C)bull Ketoconazole (C)bull Fluconazole (C)bull Do not usebull Doxycycline (D)
Local Anesthetic Use inPregnancy
bull Class Bbull Lidocaine (Xylocaine)bull Etidocainebull Prilocaine bull Class Cbull Procainebull Bupivicainebull Mepivicaine
Use of Local Anestheticsbull Lidocaine + vasoconstrictor most common
local anesthetic used in dentistrybull extensively used in pregnancy with no proven ill
effectsbull accidental intravascular injections of lidocaine
pass through the placenta but the concentrations are too low to harm fetus
bull prilocaine might cause methemoglobinemia
Ulcer healing drugsCimetidine bull FDA category B Famotidinebull FDA category BRanitidinebull FDA category Bbull not known to be harmful
Ulcer healing drugsOmeprazolebull FDA category BNot known to be
harmful Esomeprazolebull FDA category BLansoprazolebull FDA category BPantoprazolebull Avoid unless potential benefit
outweighs riskmdashfetotoxic in animals
Ulcer healing drugs
Misoprostolbull First second third trimesters Avoidmdash
potent uterine stimulant (has been used to induce abortion) and may be teratogenic
Ulcer healing drugs
Antacidsbull Almunium hydroxideMagnesium
hydroxidemdashFDA category B Calcium carbonatemdashFDA category C
SimetheconemdashFDA category C
Use of Nitrous Oxide Gas
bull used over 150 years bull safety is being debatedbull SHORT TERM exposure do not cause
birth defects or spontaneous abortionbull CHRONIC exposure may result in fetal
loss and infertilitybull literature suggests that nitrous oxide
should be avoided until more conclusive research is available
bull FDA Drug class not yet assigned
Common Preventives
bull Fluoridendash No increased risk during pregnancy
bull Xylitolndash No studies no harm reported
bull Chlorhexidinendash No increased risk during pregnancy
Are topical agents safe
bull Fluoridebull Toothpaste amp mouthrinse
bull Xylitol chewing gum bull Chlorhexidine (11 alcohol)bull No over the counter mouthrinses with
alcohol (Listerine 20 alcohol)
Pre-natal Fluoride
bull Daily 22 mg tablet of sodium fluoride during 3rd through 9th months
bull decreases caries rate in offspringbull Safe and effective
Glenn FB 1982
Is it safe to use mercury restorations
bull No evidence of harmful effect
bull Benefits outweigh risks
bull Canada Germany and New Zealand have some restrictions
bull Determine the best option
Referencesbull Wasylko L Matsui D Dykxhoorn SM Rieder MJ Weinberg
S A Review of Common Dental Treatments During Pregnancy J Canadian Dental Association 64434-439 1998
bull Little JW Donald AF Craig SM Rhodus NL Dental Management of the Medically Compromised Patient - 5th edition Mosby Toronto Pp434-442 1997
bull Livingston HM Dellinger TM Holder R Considerations in the management of the pregnant patient Special Care in Dentistry 185 pp183-188 1998
bull Larimore WL Petrie KA Drug use during pregnacy and lactation Primary Care Clinics in Office Practice 271 35-53 2000
bull Health Canada The Safety of DentalAmalgam Minister Of Supply and Services Canada 1996
REFERENCESbull 1 Weiss G Endocrinology of parturition J Clin
Endocrinol Metab 2000854421-5bull 2 Theunissen IM Parer JT Fluid and electrolytes in
pregnancy Clin Obstet Gynecol 1994373-15bull 3 Duvekot JJ Peeters LLH Renal hemodynamics and
volume homeostasis in pregnancy Obstet Gynecol Surv 199449830-9
bull 4 Barron WM Lindheimer MD Medical disorders during pregnancy 2nd ed St Louis Mosby 1995 p 129
bull 5 Thornburg KL Jacobson SL Giraud GD Morton MJ Hemodynamic changes in pregnancy Semin Perinatol 20002411-4
bull 6 Fiese R Herzog S Issues in dental and surgical management of the pregnant patient Oral Surg Oral Med Oral Pathol 198865292-7
bull 7 Martin C Varner MW Physiologic changes in pregnancysurgical implications Clin Obstet Gynecol 199437241-55
bull 8 Clark SL Cotton DB Lee W Bishop C Hill T Southwick J et al Central hemodynamic assessment of normal term pregnancy Am J Obstet Gynecol 19891611439-42
bull 9 Mabie WC Di Sessa TG Crocker LG Sibai BM Arheart KL A longitudinal study of cardiac output in normal human pregnancy Am J Obstet Gynecol 1994170849-56
bull 10 Clapp JF 3rd Capeless E Cardiovascular function before during and after the first and subsequent pregnancies Am J Cardiol 1997801469-73
bull 11 Duvekot JJ Peeters LL Maternal cardiovascular hemodynamic adaptation to pregnancy Obstet Gynecol Surv 199449(Suppl) S1-14
bull 12 Bhagwat AR Engel PJ Heart disease and pregnancy Cardiol Clin 199513163-78
bull 13 Lanni SM Tillinghast J Silver H Hemodynamic changes and baroreflex gain in the supine hypotensive syndrome Am J Obstet Gynecol 20021871636-41
bull 14 Little JW Falace DA Miller CS Rhodus NL Dental management of the medically compromised patient 6th ed St Louis Mosby 2002 p 303
bull 15 Garcia-Rio F Pino JM Gomez L Alvarez-Sala R Villasante C Villamor J Regulation of breathing and perception of dyspnea in healthy pregnant women Chest 1996110446-53
bull 16 McAuliffe F Kametas N Costello J Rafferty GF Greenough A Nicolaides K Respiratory function in singleton and twin pregnancy BJOG 2002109765-9
bull 17 Clapp JF 3rd Seaward BL Sleamaker RH Hiser J Maternal physiologic adaptations to early human pregnancy Am J Obstet Gynecol 19881591456-60
bull 18 OrsquoDay MP Cardio-respiratory physiological adaptation of pregnancy Semin Perinatol 199721268-75
bull 19 Contreras G Gutierrez M Beroiza T Fantin A Oddo H Villarroel L et al Ventilatory drive and respiratory muscle function in pregnancy Am Rev Respir Dis 1991144837-41
bull 20 Turner M Aziz SR Management of the pregnant oral and maxillofac
bull 21 Sifakis S Pharmakides G Anemia in pregnancy Ann N Y Acad Sci 2000900125-36
bull 22 Branch DW Physiologic adaptations of pregnancy Am J Reprod Immunol 199228120-2
bull 23 Burrows RF Kelton JG Incidentally detected thrombocytopenia in healthy mothers and their infants N Engl J Med 1988319 142-5
bull 24 Hanly JG Antiphospholipid syndrome an overview CMAJ 200324(168)1675-82
bull 25 Heilmann L von Tempelhoff GF Pollow K Antiphospholipid syndrome in obstetrics Clin Appl Thromb Hemost 20039 143-50
bull 26 Sherman P Flaxman SM Nausea and vomiting of pregnancy in an evolutionary perspective Am J Obstet Gynecol 2002 185(Suppl)s190-7
bull 27 Koch KL Gastrointestinal factors in nausea and vomiting of pregnancy Am J Obstet Gynecol 2002185(Suppl)s198-203
bull 28 Koch KL Frissora CL Nausea and vomiting during pregnancy Gastroenterol Clin N Am 200332201-34
bull 29 Baron TH Ramirez B Richter JE Gastrointestinal motility disorders during pregnancy Ann Intern Med 1993118 366-75
bull 30 Richter JE Gastroesophageal reflux disease during pregnancy Gastroenterol Clin N Am 200332235-61
bull 31 Marrero JM Goggin PM de Caestecker JS Pearce JM Maxwell JD Determinants of pregnancy heartburn Br J Obstet Gynaecol 199299731-4
bull 32 Hamaoui E Hamaoui M Nutritional assessment and support during pregnancy Gastroenterol Clin N Am 20033259-121
bull 33 King JC Physiology of pregnancy and nutrient metabolism Am J Clin Nutr 200071(suppl)1218s-25s
bull 34 Casanueva E Pfeffer F Fernandez-Gaxiola AC Gutierrez- Valenzuela V Rothenberg SJ Iron and folate status before pregnancy and anemia during pregnancy Ann Nutr Metab 2003 4760-3
bull 35 Chrsquong CL Morgan M Hainsworth I Kingham JG Prospective study of liver dysfunction in Southwest Wales Gut 200251 876-80
bull 36 Rahman TM Wendon J Severe hepatic dysfunction in pregnancy QJM 200295343-57
bull 37 Knox TA Olans LB Liver disease in pregnancy N Engl J Med 1996335569-76
bull 38 Saftlas AF Olson DR Franks AL Atrash H Pokras R Epidemiology of preeclampsia and eclampsia in the United States 1979e1986 Am J Obstet Gynecol 1990163460-5
bull 39 Walker JJ Pre-eclampsia Lancet 20003561260-5
bull 40 Davidson JM Renal disorders in pregnancy Curr Opin Obstet Gynecol 200113109-14
bull 41 Dafnis E Sabatini S The effect of pregnancy on renal function physiology and pathophysiologyAmJMedSci 1992303184-205
bull 42 Davison JM Shiells EA Philips PR Lindheimer MD Serial evaluation of vasopressin release and thirst in human pregnancy Role of human chorionic gonadotrophin in the osmoregulatory changes of gestation J Clin Invest 198881798-806
bull 43 Glinoer D de Nayer P Bourdoux P Lemone M Robyn C van Steirteghem A et al Regulation of maternal thyroid during pregnancy J Clin Endocrinol Metab 199071276-87
bull 44 Wilson SG Retallack RW Kent JC Worth GK Gutteridge DH Serum free 125-dihydroxyvitamin D and the free 125- dihydroxyvitamin D index during a longitudinal study of human pregnancy and lactation Clin Endocrinol 199032613-22
bull 45 Rasmussen N Frolich A Hornnes PJ Hegedus L Serum ionized calcium and intact parathyroid hormone levels during pregnancy and postpartum Br J Obstet Gynaecol 199097857-9
bull 46 Guyton AC Textbook of medical physiology 8th ed Philadelphia W B Saunders 1991 p 915e28
bull 47 Trainer PJ Corticosteroids and pregnancy Semin Reprod Med 200220375-80
bull 48 Soory M Hormonal factors in periodontal disease Dent Update 200027380-3
bull 49 Hugoson A Gingivitis in pregnant women A longitudinal clinical study Odontol Revy 19712265-84
bull 50 Neville BW Damm DD Allen CM Bouquot JE Oral amp Maxillofacial Pathology 3rd ed Philadelphia W B Saunders 2002 p 329-30 447-9
bull 51 Tilakaratne A Soory M Ranasinghe AW Corea SM Ekanayake SL de Silva M Periodontal disease status during pregnancy and 3 months post-partum in rural population of Sri-Lankan women J Clin Periodontol 200027787-92
bull 52 Laine M Tenovuo J Lehtonen OP Ojanatko-Harri A Vilja P Tuohimaa P Pregnancy e related changes in human whole saliva Arch Oral Biol 198833913-7
bull 53 Yuan K Wing LY Lin MT Pathogenetic roles of angiogenic factors in pyogenic granulomas in pregnancy are modulated by female sex hormones J Periodontol 200273701-8
bull 54 Evans RD Briggs PF Tooth-surface loss related to pregnancyinduced vomiting Prim Dent Care 1994124-6
bull 55 Salvolini E Di Giorgio R Curatola A Mazzanti L Fratto G Biochemical modifications of human whole saliva induced by pregnancy Br J Obstet Gynaec 1998105656-60
bull 56 Mauldin JG Newman RB Preterm birth risk assessment Semin Perinatol 200125215-22
bull 57 Heine RP McGregor JA Goodwin TM Artal R Hayashi RH Robertson PA et al Serial salivary estriol to detect an increased risk of preterm birth Obstet Gynecol 200096490-7
bull 58 Kauh YC Zachian TF Melasma Adv Exp Med Biol 1999455 491-9
bull 59 Wong RC Ellis CN Physiologic skin changes in pregnancy J Am Acad Dermatol 198410929-40
bull 60 Errickson CV Matus NR Skin disorders of pregnancy Am Fam Physician 199449605-10
bull 61 Lopez NJ Smith PC Gutierrez J Periodontal therapy may reduce the risk of preterm low birth weight in women with periodontal disease a randomized controlled trial J Periodontol 200273911-24
bull 62 McGaw T Periodontal disease and preterm delivery of lowbirth- weight infants J Can Dent Assoc 200268165-9
bull 63 Richards AG Dental x-ray protection Dent Clin North Am 1968631-41
bull 64 1990 Recommendations of the International Commission on Radiological Protection Ann ICRP 1991211-201
bull 65 Hall EJ Radiation the two-edged sword cancer risks at high and low doses Cancer J 20006343-50
bull 66 Diethelm L Xu H Diagnostic imaging of the lung during pregnancy Clin Obstet Gynecol 19963936-55
bull 67 Brent RL The effects of embryonic and fetal exposure to x-rays microwaves and ultrasound ClinObstetGynecol 198326484-510
bull 68 National Council on Radiation Protection NCRP report no128 1998 Bethesda Md Author
bull 69 Wasylko L Matsui D Dykxhoorn SM Reider MJ Weinberg S A review of common dental treatments during pregnancy implications for patients and dental personnel J Can Dent Assoc 199864434-9
bull 70 Freeman JP Brand JW Radiation doses of commonly used dental radiographic surveys Oral Surg Oral Med Oral Pathol 199477285-9
bull 71 Kircos LTAngin LL Lorton LOrder ofmagnitude dose reduction in intraoral radiography J Am Dent Assoc 1987114344-7
bull 72 Updegrave WJ Simplified and standardized intraoral radiography with reduced tissue irradiation J Am Dent Assoc 197285861-9
bull 73 Wood RE Harris AM van der Merwe EJ Nortje CJ The leaded apron revisited does it reduce gonadal radiation dose in dental radiology Oral Surg Oral Med Oral Pathol 199171642-6
bull 74 An update on radiographic practices information and recommendations ADA Council on Scientific Affairs J Am Dent Assoc 2001132234-8
bull 75 Rayburn WF Recommending medications during pregnancy an evidence based approach Clin Obstet Gynecol 2002451-5
bull 76 Rathmell JP Viscomi C Ashburn MA Management of nonobstetric pain during pregnancy and lactation Anesth Analg 1997851074-87
bull 77 Teratology society public affairs committee FDA classification of drugs for teratogenic risk Teratology 199449446-7
bull 78 Moore PA Selecting drugs for the pregnant dental patient J Am Dent Assoc 19981291281-6
bull 79 Haas DA An update on analgesics for the management of acute postoperative dental pain J Can Dent Assoc 200268476-82
bull 80 Haas DA Pynn BR Sands TD Drug use for the pregnant or lactating patient Gen Dent 20004854-60
bull 81 Committee on Drugs American Academy of Pediatrics The transfer of drugs and other chemicals into human milk Pediatrics 199493137-50
bull 82 Nielsen GL Sorensen HT Larsen H Pedersen L Risk of adverse birth outcome and miscarriage in pregnant users of nonsteroidal anti-inflammatory drugs population based observational study and case-control study BMJ 2001322266-70
bull 83 Janssen N Genta M The effects of immunosuppressive and anti-inflammatory medications on fertility pregnancy and lactation Arch Intern Med 200016610-9
bull 84 Ostensen M Nonsteroidal anti-inflammatory drugs during pregnancy Scand J Rheumatol Suppl 1998107128-32
bull 85 USPDI -Drug information for the health care professional 22nd ed Greenwood Village CO Micromedex 2002 p 152-79
bull 86 Denson DD Coyle DE Thompson GA Santos D Turner PA Myers JA et al Bupivacaine protein binding in the term parturient effects of lactic acidosis Clin Pharmacol Ther 198435702-9
bull 87 Dillon DE Wagner CL Wiest D Newman RB Drug therapy in the nursing mother Obstet Gynecol Clin North Am 199724 675-96
bull 88 Dashe JS Gilstrap LC Antibiotic use in pregnancy Obstet Gynecol Clin North Am 199724617-29
bull 89 American College of Rheumatology Ad hoc Committee on Clinical Guidelines Guidelines for monitoring drug therapy in rheumatoid arthritis Arthritis Rheum 199639723-31
bull 90 Ng PC The fetal and neonatal hypothalamic-pituitary-adrenal axis Arch Dis Child Fetal Neonatal Ed 200082F250-4
bull 91 Crowley P Antenatal corticosteroidsmdashcurrent thinking BJOG 2003110(Suppl 20)77-8
bull 92 ACOG committee opinion antenatal corticosteroid therapy for fetal maturation Obstet Gynecol 200299871-3
bull 93 Ost L Wettrell G Bjorkhem I Rane A Prednisolone excretion in human milk J Pediatr 19851061008-11
bull 94 Rowland AS Baird DD Shore DL Weinberg CR Savitz DA Wilcox AJ Nitrous oxide and spontaneous abortion in female dental assistants Am J Epidemiol 1995141531-8
bull 95 McGlothlin JD Jensen PA Fischbach TJ Hughes RT Jones JH Control of anesthetic gases in dental operatories Scand J Work Environ Health 199218(Suppl 2)103-5
bull ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY Volume 97 Number 6 Suresh and Radfar 681
bull 96 Rosen MA Nitrous oxide for relief of labor pain a systematic review Am J Obstet Gynecol 2002186(Suppl Nature)S110-6
bull 97 Sands TD Pynn BR Management considerations for the pregnant or nursing emergency patient Ont Dent 199875 17-9
bull 98 Daya S Recurrent spontaneous early pregnancy loss and low dose aspirin Minerva Ginecol 200355441-9
bull 99 Sinclair C Handbook of obstetrical emergencies 1st ed Philadelphia WB Saunders 1996 p 29-39 69
bull 100 Tarsitano BF Rollings RE The pregnant dental patient evaluation and management Gen Dent 199341226-34
bull 101 Livingston MH Dlllinger TM Holder R Consideration in the management of the pregnant patient SCD Special Care in Dentistry 199818183-8
Thank you
- A Review on the principle of Dental Management of the Pregnant patient
- Slide 2
- Questions that a dentist may ask
- Stages of Pregnancy
- Slide 5
- Slide 6
- Physiologic Changes in Pregnancy
- Systemic changes in pregnancy
- FLAT SUPINE POSITIONING
- SUPINE HYPOTENSION SYNDROME (Vena Cava Compression)
- Supine Hypotension Syndrome
- Slide 12
- Supine Hypotension Syndrome
- Prevention of Supine Hypotensive Syndrome
- Treatment of Supine Hypotensive Syndrome
- How should the pregnant woman be positioned
- Slide 17
- Slide 18
- Slide 19
- Slide 20
- Slide 21
- Slide 22
- Slide 23
- Pregnancy Related Oral Health Problems
- Oral Problems in Pregnancy
- Pregnancy Gingivitis Pathophysiology
- Pregnancy Gingivitis
- Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Gum Problems - Pregnancy Granuloma
- Slide 31
- Gum Changes - Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Candidiasis
- Pregnancy Myths
- Other Oral Conditions in Pregnancy
- Changes During Pregnancy that Affect Oral Health
- Saliva changes
- Increased Bacteria
- Slide 40
- Enamel erosion caused by frequent vomiting
- Treatment for Acid Exposure
- Oral Diseases Can Effect Pregnancy
- Periodontal Disease and Preterm Labor
- Periodontal Disease and Low Birth Weight
- Periodontal Disease and Preeclampsia
- Periodontitis and Pre-eclampsia
- Dental Considerations
- Treatment Timing
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Slide 52
- Use of Radiation on Pregnant Patient
- Radiographs during Pregnancy
- Risks of Dental X-Rays
- FDA drug classification for pregnancy
- Slide 57
- FDA drug classification for pregnancy
- Slide 59
- Slide 60
- Slide 61
- Common Analgesics
- Analgesics
- Analgesics - continued
- Analgesics to Use During 1st and 2nd Trimester
- Analgesics to Avoid During the Third Trimester
- Sedation in Pregnancy
- Common Antibiotics
- Antibiotics
- Antibiotics To Use During Pregnancy
- Antibiotics to Avoid during Pregnancy
- The Problem With Tetracycline
- Other Antimicrobial Agents
- Local Anesthetic Use in Pregnancy
- Use of Local Anesthetics
- Ulcer healing drugs
- Slide 77
- Slide 78
- Slide 79
- Use of Nitrous Oxide Gas
- Common Preventives
- Are topical agents safe
- Pre-natal Fluoride
- Is it safe to use mercury restorations
- References
- REFERENCES
- Slide 87
- Slide 88
- Slide 89
- Slide 90
- Slide 91
- Slide 92
- Slide 93
- Slide 94
- Slide 95
- Slide 96
- Slide 97
- Slide 98
- Thank you
-
Stages of Pregnancybull1st Trimester (1-12 weeks)bullFetal organ formation and differentiationbullMost susceptible to adverse effects of teratogensbullAvoid all elective care but provide care as needed
Stages of Pregnancy
bull2nd Trimester (13-24 weeks)bullFetal growth and maturationbullSafest period to provide dental care
Stages of Pregnancy
bull3rd Trimester (25-40 weeks)bullFetal growth continuesbullFocus of concern is risk to upcoming birth process and safety and comfort of the pregnant woman
Physiologic Changes in Pregnancy
bull Complex hormonal interactions cause profound physiologic changes
bull Increase estrogen by 10 fold and progesterone by 30 folds
bull Increased hormonal secretion and fetal growth causes several systemic as well as physical changes in a pregnant women
Systemic changes in pregnancyCardiovascular system uarr in blood volume by an average of 45bull Anemia due to increased blood volume
(20 of women) darr in pulse by 10-15 beats per minute Systemic murmur occurs in 90 of
pregnancies disappears shortly after delivery
uarrcardiac output Supine hypotension syndrome may occur
FLAT SUPINE POSITIONING
bullNegatively impacts mother and infant
SUPINE HYPOTENSIONSYNDROME (Vena Cava Compression)
bull SUPINE POSITION AFTER 5TH MONTH
bull UTERUS COMPRESSES THE INFERIOR VENA CAVA
bull uarrVOL BLOOD IN THE LErsquoS bull darrRETURN TO THE HEARTbull REDUCED PERFUSION OF
UTERUS bull FETAL HYPOXIA
Supine Hypotension Syndrome
bull Obstruction of inferior vena cava and aorta from pressure of the large fetus
Symptoms Sweating Nausea Weakness Sense of lack of air
Supine Hypotension Syndrome
Other symptomsbull Drop in blood pressurebull Bradycardiabull Possible loss of consciousness
Prevention of Supine HypotensiveSyndrome
bullElevate right hip 10-12 cmbullWeight is taken off the major vessels
Treatment of Supine HypotensiveSyndrome
bullRoll patient onto her left side
How should the pregnant woman be positionedbull Flat position may
cause hypotension and hypoxia
bull Place a small pillow under right hip - left lateral displacement
bull Head above feet
Systemic changes in pregnancy
Diaphragm rises about 4 cm darr residual volume uarr awareness of a desire to breath is
common-may be interpreted as dyspnea Increased estrogen in blood causes
engorgement of the nasal capillaries and rhnitis in pregnant women
Frequent nosebleeds amp predisposition to upper respiratory infection
Respiratory system
Systemic changes in pregnancy
Gastrointestinal system Gastric emptying amp intestinal transit times
are delayed
Heart burn reflux common
Nausea and vomiting common
Systemic changes in pregnancy
For pregnant patient with Hyper-emesis gravidarium ( excessive and uncontrolled vomiting) morning appointments should be avoided
They should be seated in a semi-supine or comfortable position
In case of vomiting the procedure should be stopped immediately amp the patient should be repositioned upright
When vomiting is over rinsing mouth with cold water or mouthwash is recommended
Systemic changes in pregnancybull Urinary System uarr GFR amp renal plasma flow by as much as
50 Nocturia ndashto mobilize the dependent
edema which accumulate during the day uarr Frequency from uarr renal flow plus reduced
bladder capacity from uterine growth It is advisable to ask the patient to void the
bladder just prior to starting the dental procedure
Systemic changes in pregnancyEndocrine Changes uarrEstrogen uarr progesterone uarrhuman
gonadotropin uarr thyroxin steroid and insulin level Estrogen amp progesterone are insulin
antagonists uarr level of these hormones lead to insulin resistance Thus insulin levels are elevated in pregnant in pregnant patient to compensate this resistance
About 45 of women fail to produce sufficient amount of insulin to overcome this antagonist action amp thus develop gestational diabetes
Systemic changes in pregnancy
Hematological changebull uarr red RBC uarrESR darrHbbull uarrWBCbull uarr circulatory catecholamin amp cortisol lead
to leucositosis bull uarr Coagulation factors except factor XI amp
XIII (anticloting factor) bull so pregnancy is a hypercoagulable state amp
uarr risk for thromboembolism
Systemic changes in pregnancy
bull Pregnant women with anti-phospholipid syndrome are at uarr risk for thrombo-embolisim
bull They are placed on subcutaneous low molecular weight heparin (LMWH)
bull These patients must be hospitalized for dental care
Pregnancy RelatedOral Health Problems
bull Pregnancy Gingivitisbull Pregnancy Epulis bull Increased Tooth Mobilitybull Dental Cariesbull Erosionbull Dental Problems in relation to Labor
and Delivery
Oral Problems in Pregnancy
bullPregnancy GingivitisbullMost common oral manifestation (50-100 of women)bullCaused by hormonal and vascular changes of pregnancy
Pregnancy Gingivitis Pathophysiology
bull Elevated circulating estrogen increases capillary permeability
bull Preexisting gingivitis may predispose to pregnancy gingivitis
Pregnancy Gingivitis
bullOccurs commonly in the 2nd to 8th monthsbullTendency to bleed very easilybullTreatment Scaling root-planing currettage OHI
Pregnancy Granuloma
bullOccurs in up to 5 of womenbullMost common in buccal maxillary anterior areasbullUsually starts in an area of gingivitis
Pregnancy Granuloma (continued)
bullRapid growth up to 2 cmbullSingle tumor-like growthbullusually in interdental papillaebullPurplish to bluish in color may be ulcerated- bleeds easily
Gum Problems - Pregnancy Granuloma
Gum Problems - Pregnancy Granuloma
Gum Changes - Pregnancy Granuloma
Pregnancy Granuloma (continued)
Treatment
bull Scaling and root planingbull Excision if it is too large or bleeds too
easilybull May regress spontaneously after
pregnancy
Candidiasis
bullWipes offbullUsually asymptomatic but may burnbullTreatment topical or systemic antifungals
Pregnancy MythsbullldquoA mother loses a tooth for every babyrdquobullNo evidence that aphthous ulcers are any more common in pregnancy
Other Oral Conditions in Pregnancy
bull Dry mouthbull Excessive salivationbull Tooth erosions associated with
severe GERD or hyperemesis
Changes During Pregnancy that Affect Oral Health
bull Hormonal Affects
ndash Increased tooth mobility
ndash Saliva changes
ndash Increased bacteria
ndash Gingival problems
Saliva changesbull Decreased buffers
bull Decreased minerals
bull Decreasing flow first and last trimester
bull Increased flow second trimester
bull More acidic
Increased Bacteriabull Increased acidity
ndash Increase in decay-causing bacteriabull Increased Snacking
ndash Morning sicknesslow blood sugarndash Between-meal snacks
bull Increase in amount and frequency of starchescarbohydrates ndash Crackers are commonly recommendedndash Promotes decay-causing bacteria
Changes During Pregnancy that Affect Oral Healthbull Morning sickness
ndash Difficulty with hygienebull Gingival diseasebull Tooth decay
ndash Vomitingbull Esophogeal Reflux (heartburn)bull Acid exposure
ndash Irritation of the gumsndash Weakening of tooth enamelndash Dental erosion
Enamel erosion caused by frequent vomiting
Treatment for Acid Exposure
bull Do NOT brush immediately after vomiting
bull Rinse ndash Water with baking sodandash Antacidndash Plain water
bull Eat some cheese
Oral Diseases Can Effect Pregnancy
bull Preterm low birth weight (LBW) linked to periodontal disease
bull Thorough calculus (tartar) removal in pregnant women with periodontitis may reduce pre-term births
Periodontal Disease and Preterm LaborbullMaternal periodontal disease is associated with increased risk of preterm laborbullAnaerobic oral gram-negative bacteria cause inflammatory responsebullInflammatory response stimulates prostaglandin and cytokine production to stimulate labor
Periodontal Disease and Low Birth Weight
bull Periodontal disease is associated with low birth weight
bull Evidence is not conclusivebull Biochemical mechanism similar cascade
as in preterm labor leading to placental blood flow restriction and necrosis
Periodontal Disease and Preeclampsia
bull Emerging databull Mechanism unclearbull Proposed mechanism
ndash Periodontal infection leads to inflammatory vascular damage
ndash Triggers cell damage in placenta
Periodontitis and Pre-eclampsia
bull Periodontal disease may be associated with pre-eclampsia (Boggess 2003)
bull PGE2 IL-1 and TNF-α from gingival crevicular fluid were higher in women with preeclampsia compared with healthy matched pregnant women (Oettinger-Barak 2003)
Dental Considerations
bull timing of treatment for pregnant patientsbull dental radiation exposurebull use of local anestheticsbull prescription of common antibiotics and
analgesicsbull nitrous oxide gas administration
Treatment Timing
bull First Trimesterndash Spontaneous miscarriages naturally occur
more often in 1st trimesterndash Avoid elective treatment that can be delayedndash Offer anticipatory guidance
bull Second Trimesterndash The optimal time for dental treatmentndash Organogenesis complete fetus not largendash Easier to prevent than treat established disease
bull Third Trimesterndash Late in term very uncomfortable (short visits)ndash Position slightly on left side
Timing of Dental Treatment During Pregnancy - From Little and Fallace
First Trimester
bull Plaque controlbull Oral hygiene instructionbull Scaling polishing curettagebull Avoid elective treatment urgent care
only
Timing of Dental Treatment During Pregnancy - From Little and Fallace
Second Trimester
bull Plaque controlbull Oral hygiene instructionbull Scaling polishing curettagebull Routine dental care
Timing of Dental Treatment During Pregnancy - From Little and Fallace
Third Trimester
bull Plaque controlbull Oral hygiene instructionbull Scaling polishing curettagebull Routine dental care (after middle of third
trimester elective care should be avoided)
Use of Radiation on Pregnant Patientbull Dose given and time of gestation are
importantbull doses lt 5-10 rads (cGy) not teratogenicbull fetus is most susceptible to radiation
between the 2nd and 6th week of gestationbull single dental x-ray exposes patient to 001
millirads of radiation In relative terms this amount is 40 times less than daily dose acquired from cosmic radiation Therefore diagnostic radiation should not be withheld during pregnancy
Radiographs during Pregnancy
bull Take as needed with optimal methods for reducing secondary radiation and exposure time
bull Always use a lead apronbull Exposure to fetus (with apron use) is 00001
centiGray(rad)bull Daily cosmic radiation - 0004 centiGray (rad)
Risks of Dental X-Rays
bull X-ray only if necessary (ie root canal therapy trauma)
bull When x-rays are indicated radiation exposure is extremely low
bull Exposure can be limited byndash Lead apron shielding ndash Modern fast film ndash Avoiding retakes
FDA drug classification for pregnancybull Combines risk statements including
congenital anomalies fetal effects perinatal risks and therapeutic risk-benefit ratio
bull Untreated disease or condition may pose more serious risks to both mother and fetus than any theoretical risks from the medication
bull Category A thru D and X
FDA drug classification for pregnancy
bull A = Controlled Studies in women fail to demonstrate a risk to the fetus in the first trimester and the possibility of fetal harm appears remote
FDA drug classification for pregnancy
bull B = Animal studies show no risk or if risk shown in animals controlled
trials in women showed no risk
FDA drug classification for pregnancy
bull C = Studies in animals with adverse effects and no human studies
OR no animal or human studies but benefits of use may outweigh potential harms
FDA drug classification for pregnancy
bull D = There is evidence of human fetal risk but benefits may outweigh risks
FDA drug classification for pregnancy
bull X = Contraindicated
Common Analgesics
bull paracetamol (B)bull Ibuprofen (BD) bull Oxycodone (BD) bull Hydrocodone and codeine
(CD)
avoid in third trimester
Analgesics
bull Paracetamol is the analgesic of choice for all stages of gestation
bull used to treat mild to moderate pain and fevers
bull short term usage is believed to be safebull avoid chronic and large doses of
paracetamol1048715
Analgesics - continuedbull Aspirin is nonteratogenic but may cause
maternal and fetal hemorrhagebull large and chronic doses during last trimester
may result in premature closure of ductus arteriosus fetal hypertension anemia and low birth weight
bull avoid ibuprofen in 3rd trimester because of possible adverse circulatory effects
bull short term use of codeine seems safebull avoid codeine late in gestation because of
possible fetal respiratory depression and withdrawal symptoms
Analgesics to Use During1st and 2nd Trimester
bull Category B (for best)bull Paracetamol Ibuprofenbull Naproxenbull Category C (use with caution)bull Paracetamol with codeine or
hydrocodonebull Paracetamol with oxycodone
Analgesics to Avoid During theThird Trimesterbull Causes delivery problemsbull Aspirin (C 3D)bull Ibuprofen (B3D)bull Naproxen (B3D)bull Causes neonatal respiratory
depression and opioid withdrawalbull Codeine (C3D)bull Hydrocodone (C3D)bull Oxycodone(C3D)
Sedation in Pregnancy
bull SedativesAnxiolytics (eg Diazepam ) are rated D and can cause oral clefts with prolonged exposure
bull Nitrous oxide should not be used in 1st trimester (If used in 2nd and 3rd do not go below 50 O2)
Common Antibioticsbull To treat oral abscess or cellulitis
ndash Penicillin (B) ndash Amoxicillin (B) ndash Cephalexin (B)ndash Erythromycin base (B) (Not estolate as it
cause cholestatic hepatitis)ndash Clindamycin (B)
Antibioticsbull penicillin V and amoxicillin is preferred drug
for mild to moderate infectionsbull widely used for many years with no ill effectsbull no studies show penicillin to be teratogenicbull amoxicillin extensively used without harming
the fetusbull Drug classes1048715 B penicillin cephalosporins erythromycin clindamycin Azithromycin D Tetracycline
Antibiotics To Use During Pregnancy
bull Penicillin Vbull Amoxicillinbull Erythromycin (base form)bull Cephalexin cephalosporinbull Clindamycinbull Metronidazole
Antibiotics to Avoid duringPregnancy
bull Doxycyclinebull Tetracyclinebull Erythromycin (estolate form)bull Vancomycin
The Problem With Tetracycline
bull Accumulates in bones and chelates calcium
bull Inhibits bone growthbull Discolors teeth
Other Antimicrobial Agentsbull OK to usebull Nystatin (B)bull Chlorhexidine rinse (B)bull Use with cautionbull Clotrimazole (C)bull Ketoconazole (C)bull Fluconazole (C)bull Do not usebull Doxycycline (D)
Local Anesthetic Use inPregnancy
bull Class Bbull Lidocaine (Xylocaine)bull Etidocainebull Prilocaine bull Class Cbull Procainebull Bupivicainebull Mepivicaine
Use of Local Anestheticsbull Lidocaine + vasoconstrictor most common
local anesthetic used in dentistrybull extensively used in pregnancy with no proven ill
effectsbull accidental intravascular injections of lidocaine
pass through the placenta but the concentrations are too low to harm fetus
bull prilocaine might cause methemoglobinemia
Ulcer healing drugsCimetidine bull FDA category B Famotidinebull FDA category BRanitidinebull FDA category Bbull not known to be harmful
Ulcer healing drugsOmeprazolebull FDA category BNot known to be
harmful Esomeprazolebull FDA category BLansoprazolebull FDA category BPantoprazolebull Avoid unless potential benefit
outweighs riskmdashfetotoxic in animals
Ulcer healing drugs
Misoprostolbull First second third trimesters Avoidmdash
potent uterine stimulant (has been used to induce abortion) and may be teratogenic
Ulcer healing drugs
Antacidsbull Almunium hydroxideMagnesium
hydroxidemdashFDA category B Calcium carbonatemdashFDA category C
SimetheconemdashFDA category C
Use of Nitrous Oxide Gas
bull used over 150 years bull safety is being debatedbull SHORT TERM exposure do not cause
birth defects or spontaneous abortionbull CHRONIC exposure may result in fetal
loss and infertilitybull literature suggests that nitrous oxide
should be avoided until more conclusive research is available
bull FDA Drug class not yet assigned
Common Preventives
bull Fluoridendash No increased risk during pregnancy
bull Xylitolndash No studies no harm reported
bull Chlorhexidinendash No increased risk during pregnancy
Are topical agents safe
bull Fluoridebull Toothpaste amp mouthrinse
bull Xylitol chewing gum bull Chlorhexidine (11 alcohol)bull No over the counter mouthrinses with
alcohol (Listerine 20 alcohol)
Pre-natal Fluoride
bull Daily 22 mg tablet of sodium fluoride during 3rd through 9th months
bull decreases caries rate in offspringbull Safe and effective
Glenn FB 1982
Is it safe to use mercury restorations
bull No evidence of harmful effect
bull Benefits outweigh risks
bull Canada Germany and New Zealand have some restrictions
bull Determine the best option
Referencesbull Wasylko L Matsui D Dykxhoorn SM Rieder MJ Weinberg
S A Review of Common Dental Treatments During Pregnancy J Canadian Dental Association 64434-439 1998
bull Little JW Donald AF Craig SM Rhodus NL Dental Management of the Medically Compromised Patient - 5th edition Mosby Toronto Pp434-442 1997
bull Livingston HM Dellinger TM Holder R Considerations in the management of the pregnant patient Special Care in Dentistry 185 pp183-188 1998
bull Larimore WL Petrie KA Drug use during pregnacy and lactation Primary Care Clinics in Office Practice 271 35-53 2000
bull Health Canada The Safety of DentalAmalgam Minister Of Supply and Services Canada 1996
REFERENCESbull 1 Weiss G Endocrinology of parturition J Clin
Endocrinol Metab 2000854421-5bull 2 Theunissen IM Parer JT Fluid and electrolytes in
pregnancy Clin Obstet Gynecol 1994373-15bull 3 Duvekot JJ Peeters LLH Renal hemodynamics and
volume homeostasis in pregnancy Obstet Gynecol Surv 199449830-9
bull 4 Barron WM Lindheimer MD Medical disorders during pregnancy 2nd ed St Louis Mosby 1995 p 129
bull 5 Thornburg KL Jacobson SL Giraud GD Morton MJ Hemodynamic changes in pregnancy Semin Perinatol 20002411-4
bull 6 Fiese R Herzog S Issues in dental and surgical management of the pregnant patient Oral Surg Oral Med Oral Pathol 198865292-7
bull 7 Martin C Varner MW Physiologic changes in pregnancysurgical implications Clin Obstet Gynecol 199437241-55
bull 8 Clark SL Cotton DB Lee W Bishop C Hill T Southwick J et al Central hemodynamic assessment of normal term pregnancy Am J Obstet Gynecol 19891611439-42
bull 9 Mabie WC Di Sessa TG Crocker LG Sibai BM Arheart KL A longitudinal study of cardiac output in normal human pregnancy Am J Obstet Gynecol 1994170849-56
bull 10 Clapp JF 3rd Capeless E Cardiovascular function before during and after the first and subsequent pregnancies Am J Cardiol 1997801469-73
bull 11 Duvekot JJ Peeters LL Maternal cardiovascular hemodynamic adaptation to pregnancy Obstet Gynecol Surv 199449(Suppl) S1-14
bull 12 Bhagwat AR Engel PJ Heart disease and pregnancy Cardiol Clin 199513163-78
bull 13 Lanni SM Tillinghast J Silver H Hemodynamic changes and baroreflex gain in the supine hypotensive syndrome Am J Obstet Gynecol 20021871636-41
bull 14 Little JW Falace DA Miller CS Rhodus NL Dental management of the medically compromised patient 6th ed St Louis Mosby 2002 p 303
bull 15 Garcia-Rio F Pino JM Gomez L Alvarez-Sala R Villasante C Villamor J Regulation of breathing and perception of dyspnea in healthy pregnant women Chest 1996110446-53
bull 16 McAuliffe F Kametas N Costello J Rafferty GF Greenough A Nicolaides K Respiratory function in singleton and twin pregnancy BJOG 2002109765-9
bull 17 Clapp JF 3rd Seaward BL Sleamaker RH Hiser J Maternal physiologic adaptations to early human pregnancy Am J Obstet Gynecol 19881591456-60
bull 18 OrsquoDay MP Cardio-respiratory physiological adaptation of pregnancy Semin Perinatol 199721268-75
bull 19 Contreras G Gutierrez M Beroiza T Fantin A Oddo H Villarroel L et al Ventilatory drive and respiratory muscle function in pregnancy Am Rev Respir Dis 1991144837-41
bull 20 Turner M Aziz SR Management of the pregnant oral and maxillofac
bull 21 Sifakis S Pharmakides G Anemia in pregnancy Ann N Y Acad Sci 2000900125-36
bull 22 Branch DW Physiologic adaptations of pregnancy Am J Reprod Immunol 199228120-2
bull 23 Burrows RF Kelton JG Incidentally detected thrombocytopenia in healthy mothers and their infants N Engl J Med 1988319 142-5
bull 24 Hanly JG Antiphospholipid syndrome an overview CMAJ 200324(168)1675-82
bull 25 Heilmann L von Tempelhoff GF Pollow K Antiphospholipid syndrome in obstetrics Clin Appl Thromb Hemost 20039 143-50
bull 26 Sherman P Flaxman SM Nausea and vomiting of pregnancy in an evolutionary perspective Am J Obstet Gynecol 2002 185(Suppl)s190-7
bull 27 Koch KL Gastrointestinal factors in nausea and vomiting of pregnancy Am J Obstet Gynecol 2002185(Suppl)s198-203
bull 28 Koch KL Frissora CL Nausea and vomiting during pregnancy Gastroenterol Clin N Am 200332201-34
bull 29 Baron TH Ramirez B Richter JE Gastrointestinal motility disorders during pregnancy Ann Intern Med 1993118 366-75
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bull 31 Marrero JM Goggin PM de Caestecker JS Pearce JM Maxwell JD Determinants of pregnancy heartburn Br J Obstet Gynaecol 199299731-4
bull 32 Hamaoui E Hamaoui M Nutritional assessment and support during pregnancy Gastroenterol Clin N Am 20033259-121
bull 33 King JC Physiology of pregnancy and nutrient metabolism Am J Clin Nutr 200071(suppl)1218s-25s
bull 34 Casanueva E Pfeffer F Fernandez-Gaxiola AC Gutierrez- Valenzuela V Rothenberg SJ Iron and folate status before pregnancy and anemia during pregnancy Ann Nutr Metab 2003 4760-3
bull 35 Chrsquong CL Morgan M Hainsworth I Kingham JG Prospective study of liver dysfunction in Southwest Wales Gut 200251 876-80
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bull 39 Walker JJ Pre-eclampsia Lancet 20003561260-5
bull 40 Davidson JM Renal disorders in pregnancy Curr Opin Obstet Gynecol 200113109-14
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bull 43 Glinoer D de Nayer P Bourdoux P Lemone M Robyn C van Steirteghem A et al Regulation of maternal thyroid during pregnancy J Clin Endocrinol Metab 199071276-87
bull 44 Wilson SG Retallack RW Kent JC Worth GK Gutteridge DH Serum free 125-dihydroxyvitamin D and the free 125- dihydroxyvitamin D index during a longitudinal study of human pregnancy and lactation Clin Endocrinol 199032613-22
bull 45 Rasmussen N Frolich A Hornnes PJ Hegedus L Serum ionized calcium and intact parathyroid hormone levels during pregnancy and postpartum Br J Obstet Gynaecol 199097857-9
bull 46 Guyton AC Textbook of medical physiology 8th ed Philadelphia W B Saunders 1991 p 915e28
bull 47 Trainer PJ Corticosteroids and pregnancy Semin Reprod Med 200220375-80
bull 48 Soory M Hormonal factors in periodontal disease Dent Update 200027380-3
bull 49 Hugoson A Gingivitis in pregnant women A longitudinal clinical study Odontol Revy 19712265-84
bull 50 Neville BW Damm DD Allen CM Bouquot JE Oral amp Maxillofacial Pathology 3rd ed Philadelphia W B Saunders 2002 p 329-30 447-9
bull 51 Tilakaratne A Soory M Ranasinghe AW Corea SM Ekanayake SL de Silva M Periodontal disease status during pregnancy and 3 months post-partum in rural population of Sri-Lankan women J Clin Periodontol 200027787-92
bull 52 Laine M Tenovuo J Lehtonen OP Ojanatko-Harri A Vilja P Tuohimaa P Pregnancy e related changes in human whole saliva Arch Oral Biol 198833913-7
bull 53 Yuan K Wing LY Lin MT Pathogenetic roles of angiogenic factors in pyogenic granulomas in pregnancy are modulated by female sex hormones J Periodontol 200273701-8
bull 54 Evans RD Briggs PF Tooth-surface loss related to pregnancyinduced vomiting Prim Dent Care 1994124-6
bull 55 Salvolini E Di Giorgio R Curatola A Mazzanti L Fratto G Biochemical modifications of human whole saliva induced by pregnancy Br J Obstet Gynaec 1998105656-60
bull 56 Mauldin JG Newman RB Preterm birth risk assessment Semin Perinatol 200125215-22
bull 57 Heine RP McGregor JA Goodwin TM Artal R Hayashi RH Robertson PA et al Serial salivary estriol to detect an increased risk of preterm birth Obstet Gynecol 200096490-7
bull 58 Kauh YC Zachian TF Melasma Adv Exp Med Biol 1999455 491-9
bull 59 Wong RC Ellis CN Physiologic skin changes in pregnancy J Am Acad Dermatol 198410929-40
bull 60 Errickson CV Matus NR Skin disorders of pregnancy Am Fam Physician 199449605-10
bull 61 Lopez NJ Smith PC Gutierrez J Periodontal therapy may reduce the risk of preterm low birth weight in women with periodontal disease a randomized controlled trial J Periodontol 200273911-24
bull 62 McGaw T Periodontal disease and preterm delivery of lowbirth- weight infants J Can Dent Assoc 200268165-9
bull 63 Richards AG Dental x-ray protection Dent Clin North Am 1968631-41
bull 64 1990 Recommendations of the International Commission on Radiological Protection Ann ICRP 1991211-201
bull 65 Hall EJ Radiation the two-edged sword cancer risks at high and low doses Cancer J 20006343-50
bull 66 Diethelm L Xu H Diagnostic imaging of the lung during pregnancy Clin Obstet Gynecol 19963936-55
bull 67 Brent RL The effects of embryonic and fetal exposure to x-rays microwaves and ultrasound ClinObstetGynecol 198326484-510
bull 68 National Council on Radiation Protection NCRP report no128 1998 Bethesda Md Author
bull 69 Wasylko L Matsui D Dykxhoorn SM Reider MJ Weinberg S A review of common dental treatments during pregnancy implications for patients and dental personnel J Can Dent Assoc 199864434-9
bull 70 Freeman JP Brand JW Radiation doses of commonly used dental radiographic surveys Oral Surg Oral Med Oral Pathol 199477285-9
bull 71 Kircos LTAngin LL Lorton LOrder ofmagnitude dose reduction in intraoral radiography J Am Dent Assoc 1987114344-7
bull 72 Updegrave WJ Simplified and standardized intraoral radiography with reduced tissue irradiation J Am Dent Assoc 197285861-9
bull 73 Wood RE Harris AM van der Merwe EJ Nortje CJ The leaded apron revisited does it reduce gonadal radiation dose in dental radiology Oral Surg Oral Med Oral Pathol 199171642-6
bull 74 An update on radiographic practices information and recommendations ADA Council on Scientific Affairs J Am Dent Assoc 2001132234-8
bull 75 Rayburn WF Recommending medications during pregnancy an evidence based approach Clin Obstet Gynecol 2002451-5
bull 76 Rathmell JP Viscomi C Ashburn MA Management of nonobstetric pain during pregnancy and lactation Anesth Analg 1997851074-87
bull 77 Teratology society public affairs committee FDA classification of drugs for teratogenic risk Teratology 199449446-7
bull 78 Moore PA Selecting drugs for the pregnant dental patient J Am Dent Assoc 19981291281-6
bull 79 Haas DA An update on analgesics for the management of acute postoperative dental pain J Can Dent Assoc 200268476-82
bull 80 Haas DA Pynn BR Sands TD Drug use for the pregnant or lactating patient Gen Dent 20004854-60
bull 81 Committee on Drugs American Academy of Pediatrics The transfer of drugs and other chemicals into human milk Pediatrics 199493137-50
bull 82 Nielsen GL Sorensen HT Larsen H Pedersen L Risk of adverse birth outcome and miscarriage in pregnant users of nonsteroidal anti-inflammatory drugs population based observational study and case-control study BMJ 2001322266-70
bull 83 Janssen N Genta M The effects of immunosuppressive and anti-inflammatory medications on fertility pregnancy and lactation Arch Intern Med 200016610-9
bull 84 Ostensen M Nonsteroidal anti-inflammatory drugs during pregnancy Scand J Rheumatol Suppl 1998107128-32
bull 85 USPDI -Drug information for the health care professional 22nd ed Greenwood Village CO Micromedex 2002 p 152-79
bull 86 Denson DD Coyle DE Thompson GA Santos D Turner PA Myers JA et al Bupivacaine protein binding in the term parturient effects of lactic acidosis Clin Pharmacol Ther 198435702-9
bull 87 Dillon DE Wagner CL Wiest D Newman RB Drug therapy in the nursing mother Obstet Gynecol Clin North Am 199724 675-96
bull 88 Dashe JS Gilstrap LC Antibiotic use in pregnancy Obstet Gynecol Clin North Am 199724617-29
bull 89 American College of Rheumatology Ad hoc Committee on Clinical Guidelines Guidelines for monitoring drug therapy in rheumatoid arthritis Arthritis Rheum 199639723-31
bull 90 Ng PC The fetal and neonatal hypothalamic-pituitary-adrenal axis Arch Dis Child Fetal Neonatal Ed 200082F250-4
bull 91 Crowley P Antenatal corticosteroidsmdashcurrent thinking BJOG 2003110(Suppl 20)77-8
bull 92 ACOG committee opinion antenatal corticosteroid therapy for fetal maturation Obstet Gynecol 200299871-3
bull 93 Ost L Wettrell G Bjorkhem I Rane A Prednisolone excretion in human milk J Pediatr 19851061008-11
bull 94 Rowland AS Baird DD Shore DL Weinberg CR Savitz DA Wilcox AJ Nitrous oxide and spontaneous abortion in female dental assistants Am J Epidemiol 1995141531-8
bull 95 McGlothlin JD Jensen PA Fischbach TJ Hughes RT Jones JH Control of anesthetic gases in dental operatories Scand J Work Environ Health 199218(Suppl 2)103-5
bull ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY Volume 97 Number 6 Suresh and Radfar 681
bull 96 Rosen MA Nitrous oxide for relief of labor pain a systematic review Am J Obstet Gynecol 2002186(Suppl Nature)S110-6
bull 97 Sands TD Pynn BR Management considerations for the pregnant or nursing emergency patient Ont Dent 199875 17-9
bull 98 Daya S Recurrent spontaneous early pregnancy loss and low dose aspirin Minerva Ginecol 200355441-9
bull 99 Sinclair C Handbook of obstetrical emergencies 1st ed Philadelphia WB Saunders 1996 p 29-39 69
bull 100 Tarsitano BF Rollings RE The pregnant dental patient evaluation and management Gen Dent 199341226-34
bull 101 Livingston MH Dlllinger TM Holder R Consideration in the management of the pregnant patient SCD Special Care in Dentistry 199818183-8
Thank you
- A Review on the principle of Dental Management of the Pregnant patient
- Slide 2
- Questions that a dentist may ask
- Stages of Pregnancy
- Slide 5
- Slide 6
- Physiologic Changes in Pregnancy
- Systemic changes in pregnancy
- FLAT SUPINE POSITIONING
- SUPINE HYPOTENSION SYNDROME (Vena Cava Compression)
- Supine Hypotension Syndrome
- Slide 12
- Supine Hypotension Syndrome
- Prevention of Supine Hypotensive Syndrome
- Treatment of Supine Hypotensive Syndrome
- How should the pregnant woman be positioned
- Slide 17
- Slide 18
- Slide 19
- Slide 20
- Slide 21
- Slide 22
- Slide 23
- Pregnancy Related Oral Health Problems
- Oral Problems in Pregnancy
- Pregnancy Gingivitis Pathophysiology
- Pregnancy Gingivitis
- Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Gum Problems - Pregnancy Granuloma
- Slide 31
- Gum Changes - Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Candidiasis
- Pregnancy Myths
- Other Oral Conditions in Pregnancy
- Changes During Pregnancy that Affect Oral Health
- Saliva changes
- Increased Bacteria
- Slide 40
- Enamel erosion caused by frequent vomiting
- Treatment for Acid Exposure
- Oral Diseases Can Effect Pregnancy
- Periodontal Disease and Preterm Labor
- Periodontal Disease and Low Birth Weight
- Periodontal Disease and Preeclampsia
- Periodontitis and Pre-eclampsia
- Dental Considerations
- Treatment Timing
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Slide 52
- Use of Radiation on Pregnant Patient
- Radiographs during Pregnancy
- Risks of Dental X-Rays
- FDA drug classification for pregnancy
- Slide 57
- FDA drug classification for pregnancy
- Slide 59
- Slide 60
- Slide 61
- Common Analgesics
- Analgesics
- Analgesics - continued
- Analgesics to Use During 1st and 2nd Trimester
- Analgesics to Avoid During the Third Trimester
- Sedation in Pregnancy
- Common Antibiotics
- Antibiotics
- Antibiotics To Use During Pregnancy
- Antibiotics to Avoid during Pregnancy
- The Problem With Tetracycline
- Other Antimicrobial Agents
- Local Anesthetic Use in Pregnancy
- Use of Local Anesthetics
- Ulcer healing drugs
- Slide 77
- Slide 78
- Slide 79
- Use of Nitrous Oxide Gas
- Common Preventives
- Are topical agents safe
- Pre-natal Fluoride
- Is it safe to use mercury restorations
- References
- REFERENCES
- Slide 87
- Slide 88
- Slide 89
- Slide 90
- Slide 91
- Slide 92
- Slide 93
- Slide 94
- Slide 95
- Slide 96
- Slide 97
- Slide 98
- Thank you
-
Stages of Pregnancy
bull2nd Trimester (13-24 weeks)bullFetal growth and maturationbullSafest period to provide dental care
Stages of Pregnancy
bull3rd Trimester (25-40 weeks)bullFetal growth continuesbullFocus of concern is risk to upcoming birth process and safety and comfort of the pregnant woman
Physiologic Changes in Pregnancy
bull Complex hormonal interactions cause profound physiologic changes
bull Increase estrogen by 10 fold and progesterone by 30 folds
bull Increased hormonal secretion and fetal growth causes several systemic as well as physical changes in a pregnant women
Systemic changes in pregnancyCardiovascular system uarr in blood volume by an average of 45bull Anemia due to increased blood volume
(20 of women) darr in pulse by 10-15 beats per minute Systemic murmur occurs in 90 of
pregnancies disappears shortly after delivery
uarrcardiac output Supine hypotension syndrome may occur
FLAT SUPINE POSITIONING
bullNegatively impacts mother and infant
SUPINE HYPOTENSIONSYNDROME (Vena Cava Compression)
bull SUPINE POSITION AFTER 5TH MONTH
bull UTERUS COMPRESSES THE INFERIOR VENA CAVA
bull uarrVOL BLOOD IN THE LErsquoS bull darrRETURN TO THE HEARTbull REDUCED PERFUSION OF
UTERUS bull FETAL HYPOXIA
Supine Hypotension Syndrome
bull Obstruction of inferior vena cava and aorta from pressure of the large fetus
Symptoms Sweating Nausea Weakness Sense of lack of air
Supine Hypotension Syndrome
Other symptomsbull Drop in blood pressurebull Bradycardiabull Possible loss of consciousness
Prevention of Supine HypotensiveSyndrome
bullElevate right hip 10-12 cmbullWeight is taken off the major vessels
Treatment of Supine HypotensiveSyndrome
bullRoll patient onto her left side
How should the pregnant woman be positionedbull Flat position may
cause hypotension and hypoxia
bull Place a small pillow under right hip - left lateral displacement
bull Head above feet
Systemic changes in pregnancy
Diaphragm rises about 4 cm darr residual volume uarr awareness of a desire to breath is
common-may be interpreted as dyspnea Increased estrogen in blood causes
engorgement of the nasal capillaries and rhnitis in pregnant women
Frequent nosebleeds amp predisposition to upper respiratory infection
Respiratory system
Systemic changes in pregnancy
Gastrointestinal system Gastric emptying amp intestinal transit times
are delayed
Heart burn reflux common
Nausea and vomiting common
Systemic changes in pregnancy
For pregnant patient with Hyper-emesis gravidarium ( excessive and uncontrolled vomiting) morning appointments should be avoided
They should be seated in a semi-supine or comfortable position
In case of vomiting the procedure should be stopped immediately amp the patient should be repositioned upright
When vomiting is over rinsing mouth with cold water or mouthwash is recommended
Systemic changes in pregnancybull Urinary System uarr GFR amp renal plasma flow by as much as
50 Nocturia ndashto mobilize the dependent
edema which accumulate during the day uarr Frequency from uarr renal flow plus reduced
bladder capacity from uterine growth It is advisable to ask the patient to void the
bladder just prior to starting the dental procedure
Systemic changes in pregnancyEndocrine Changes uarrEstrogen uarr progesterone uarrhuman
gonadotropin uarr thyroxin steroid and insulin level Estrogen amp progesterone are insulin
antagonists uarr level of these hormones lead to insulin resistance Thus insulin levels are elevated in pregnant in pregnant patient to compensate this resistance
About 45 of women fail to produce sufficient amount of insulin to overcome this antagonist action amp thus develop gestational diabetes
Systemic changes in pregnancy
Hematological changebull uarr red RBC uarrESR darrHbbull uarrWBCbull uarr circulatory catecholamin amp cortisol lead
to leucositosis bull uarr Coagulation factors except factor XI amp
XIII (anticloting factor) bull so pregnancy is a hypercoagulable state amp
uarr risk for thromboembolism
Systemic changes in pregnancy
bull Pregnant women with anti-phospholipid syndrome are at uarr risk for thrombo-embolisim
bull They are placed on subcutaneous low molecular weight heparin (LMWH)
bull These patients must be hospitalized for dental care
Pregnancy RelatedOral Health Problems
bull Pregnancy Gingivitisbull Pregnancy Epulis bull Increased Tooth Mobilitybull Dental Cariesbull Erosionbull Dental Problems in relation to Labor
and Delivery
Oral Problems in Pregnancy
bullPregnancy GingivitisbullMost common oral manifestation (50-100 of women)bullCaused by hormonal and vascular changes of pregnancy
Pregnancy Gingivitis Pathophysiology
bull Elevated circulating estrogen increases capillary permeability
bull Preexisting gingivitis may predispose to pregnancy gingivitis
Pregnancy Gingivitis
bullOccurs commonly in the 2nd to 8th monthsbullTendency to bleed very easilybullTreatment Scaling root-planing currettage OHI
Pregnancy Granuloma
bullOccurs in up to 5 of womenbullMost common in buccal maxillary anterior areasbullUsually starts in an area of gingivitis
Pregnancy Granuloma (continued)
bullRapid growth up to 2 cmbullSingle tumor-like growthbullusually in interdental papillaebullPurplish to bluish in color may be ulcerated- bleeds easily
Gum Problems - Pregnancy Granuloma
Gum Problems - Pregnancy Granuloma
Gum Changes - Pregnancy Granuloma
Pregnancy Granuloma (continued)
Treatment
bull Scaling and root planingbull Excision if it is too large or bleeds too
easilybull May regress spontaneously after
pregnancy
Candidiasis
bullWipes offbullUsually asymptomatic but may burnbullTreatment topical or systemic antifungals
Pregnancy MythsbullldquoA mother loses a tooth for every babyrdquobullNo evidence that aphthous ulcers are any more common in pregnancy
Other Oral Conditions in Pregnancy
bull Dry mouthbull Excessive salivationbull Tooth erosions associated with
severe GERD or hyperemesis
Changes During Pregnancy that Affect Oral Health
bull Hormonal Affects
ndash Increased tooth mobility
ndash Saliva changes
ndash Increased bacteria
ndash Gingival problems
Saliva changesbull Decreased buffers
bull Decreased minerals
bull Decreasing flow first and last trimester
bull Increased flow second trimester
bull More acidic
Increased Bacteriabull Increased acidity
ndash Increase in decay-causing bacteriabull Increased Snacking
ndash Morning sicknesslow blood sugarndash Between-meal snacks
bull Increase in amount and frequency of starchescarbohydrates ndash Crackers are commonly recommendedndash Promotes decay-causing bacteria
Changes During Pregnancy that Affect Oral Healthbull Morning sickness
ndash Difficulty with hygienebull Gingival diseasebull Tooth decay
ndash Vomitingbull Esophogeal Reflux (heartburn)bull Acid exposure
ndash Irritation of the gumsndash Weakening of tooth enamelndash Dental erosion
Enamel erosion caused by frequent vomiting
Treatment for Acid Exposure
bull Do NOT brush immediately after vomiting
bull Rinse ndash Water with baking sodandash Antacidndash Plain water
bull Eat some cheese
Oral Diseases Can Effect Pregnancy
bull Preterm low birth weight (LBW) linked to periodontal disease
bull Thorough calculus (tartar) removal in pregnant women with periodontitis may reduce pre-term births
Periodontal Disease and Preterm LaborbullMaternal periodontal disease is associated with increased risk of preterm laborbullAnaerobic oral gram-negative bacteria cause inflammatory responsebullInflammatory response stimulates prostaglandin and cytokine production to stimulate labor
Periodontal Disease and Low Birth Weight
bull Periodontal disease is associated with low birth weight
bull Evidence is not conclusivebull Biochemical mechanism similar cascade
as in preterm labor leading to placental blood flow restriction and necrosis
Periodontal Disease and Preeclampsia
bull Emerging databull Mechanism unclearbull Proposed mechanism
ndash Periodontal infection leads to inflammatory vascular damage
ndash Triggers cell damage in placenta
Periodontitis and Pre-eclampsia
bull Periodontal disease may be associated with pre-eclampsia (Boggess 2003)
bull PGE2 IL-1 and TNF-α from gingival crevicular fluid were higher in women with preeclampsia compared with healthy matched pregnant women (Oettinger-Barak 2003)
Dental Considerations
bull timing of treatment for pregnant patientsbull dental radiation exposurebull use of local anestheticsbull prescription of common antibiotics and
analgesicsbull nitrous oxide gas administration
Treatment Timing
bull First Trimesterndash Spontaneous miscarriages naturally occur
more often in 1st trimesterndash Avoid elective treatment that can be delayedndash Offer anticipatory guidance
bull Second Trimesterndash The optimal time for dental treatmentndash Organogenesis complete fetus not largendash Easier to prevent than treat established disease
bull Third Trimesterndash Late in term very uncomfortable (short visits)ndash Position slightly on left side
Timing of Dental Treatment During Pregnancy - From Little and Fallace
First Trimester
bull Plaque controlbull Oral hygiene instructionbull Scaling polishing curettagebull Avoid elective treatment urgent care
only
Timing of Dental Treatment During Pregnancy - From Little and Fallace
Second Trimester
bull Plaque controlbull Oral hygiene instructionbull Scaling polishing curettagebull Routine dental care
Timing of Dental Treatment During Pregnancy - From Little and Fallace
Third Trimester
bull Plaque controlbull Oral hygiene instructionbull Scaling polishing curettagebull Routine dental care (after middle of third
trimester elective care should be avoided)
Use of Radiation on Pregnant Patientbull Dose given and time of gestation are
importantbull doses lt 5-10 rads (cGy) not teratogenicbull fetus is most susceptible to radiation
between the 2nd and 6th week of gestationbull single dental x-ray exposes patient to 001
millirads of radiation In relative terms this amount is 40 times less than daily dose acquired from cosmic radiation Therefore diagnostic radiation should not be withheld during pregnancy
Radiographs during Pregnancy
bull Take as needed with optimal methods for reducing secondary radiation and exposure time
bull Always use a lead apronbull Exposure to fetus (with apron use) is 00001
centiGray(rad)bull Daily cosmic radiation - 0004 centiGray (rad)
Risks of Dental X-Rays
bull X-ray only if necessary (ie root canal therapy trauma)
bull When x-rays are indicated radiation exposure is extremely low
bull Exposure can be limited byndash Lead apron shielding ndash Modern fast film ndash Avoiding retakes
FDA drug classification for pregnancybull Combines risk statements including
congenital anomalies fetal effects perinatal risks and therapeutic risk-benefit ratio
bull Untreated disease or condition may pose more serious risks to both mother and fetus than any theoretical risks from the medication
bull Category A thru D and X
FDA drug classification for pregnancy
bull A = Controlled Studies in women fail to demonstrate a risk to the fetus in the first trimester and the possibility of fetal harm appears remote
FDA drug classification for pregnancy
bull B = Animal studies show no risk or if risk shown in animals controlled
trials in women showed no risk
FDA drug classification for pregnancy
bull C = Studies in animals with adverse effects and no human studies
OR no animal or human studies but benefits of use may outweigh potential harms
FDA drug classification for pregnancy
bull D = There is evidence of human fetal risk but benefits may outweigh risks
FDA drug classification for pregnancy
bull X = Contraindicated
Common Analgesics
bull paracetamol (B)bull Ibuprofen (BD) bull Oxycodone (BD) bull Hydrocodone and codeine
(CD)
avoid in third trimester
Analgesics
bull Paracetamol is the analgesic of choice for all stages of gestation
bull used to treat mild to moderate pain and fevers
bull short term usage is believed to be safebull avoid chronic and large doses of
paracetamol1048715
Analgesics - continuedbull Aspirin is nonteratogenic but may cause
maternal and fetal hemorrhagebull large and chronic doses during last trimester
may result in premature closure of ductus arteriosus fetal hypertension anemia and low birth weight
bull avoid ibuprofen in 3rd trimester because of possible adverse circulatory effects
bull short term use of codeine seems safebull avoid codeine late in gestation because of
possible fetal respiratory depression and withdrawal symptoms
Analgesics to Use During1st and 2nd Trimester
bull Category B (for best)bull Paracetamol Ibuprofenbull Naproxenbull Category C (use with caution)bull Paracetamol with codeine or
hydrocodonebull Paracetamol with oxycodone
Analgesics to Avoid During theThird Trimesterbull Causes delivery problemsbull Aspirin (C 3D)bull Ibuprofen (B3D)bull Naproxen (B3D)bull Causes neonatal respiratory
depression and opioid withdrawalbull Codeine (C3D)bull Hydrocodone (C3D)bull Oxycodone(C3D)
Sedation in Pregnancy
bull SedativesAnxiolytics (eg Diazepam ) are rated D and can cause oral clefts with prolonged exposure
bull Nitrous oxide should not be used in 1st trimester (If used in 2nd and 3rd do not go below 50 O2)
Common Antibioticsbull To treat oral abscess or cellulitis
ndash Penicillin (B) ndash Amoxicillin (B) ndash Cephalexin (B)ndash Erythromycin base (B) (Not estolate as it
cause cholestatic hepatitis)ndash Clindamycin (B)
Antibioticsbull penicillin V and amoxicillin is preferred drug
for mild to moderate infectionsbull widely used for many years with no ill effectsbull no studies show penicillin to be teratogenicbull amoxicillin extensively used without harming
the fetusbull Drug classes1048715 B penicillin cephalosporins erythromycin clindamycin Azithromycin D Tetracycline
Antibiotics To Use During Pregnancy
bull Penicillin Vbull Amoxicillinbull Erythromycin (base form)bull Cephalexin cephalosporinbull Clindamycinbull Metronidazole
Antibiotics to Avoid duringPregnancy
bull Doxycyclinebull Tetracyclinebull Erythromycin (estolate form)bull Vancomycin
The Problem With Tetracycline
bull Accumulates in bones and chelates calcium
bull Inhibits bone growthbull Discolors teeth
Other Antimicrobial Agentsbull OK to usebull Nystatin (B)bull Chlorhexidine rinse (B)bull Use with cautionbull Clotrimazole (C)bull Ketoconazole (C)bull Fluconazole (C)bull Do not usebull Doxycycline (D)
Local Anesthetic Use inPregnancy
bull Class Bbull Lidocaine (Xylocaine)bull Etidocainebull Prilocaine bull Class Cbull Procainebull Bupivicainebull Mepivicaine
Use of Local Anestheticsbull Lidocaine + vasoconstrictor most common
local anesthetic used in dentistrybull extensively used in pregnancy with no proven ill
effectsbull accidental intravascular injections of lidocaine
pass through the placenta but the concentrations are too low to harm fetus
bull prilocaine might cause methemoglobinemia
Ulcer healing drugsCimetidine bull FDA category B Famotidinebull FDA category BRanitidinebull FDA category Bbull not known to be harmful
Ulcer healing drugsOmeprazolebull FDA category BNot known to be
harmful Esomeprazolebull FDA category BLansoprazolebull FDA category BPantoprazolebull Avoid unless potential benefit
outweighs riskmdashfetotoxic in animals
Ulcer healing drugs
Misoprostolbull First second third trimesters Avoidmdash
potent uterine stimulant (has been used to induce abortion) and may be teratogenic
Ulcer healing drugs
Antacidsbull Almunium hydroxideMagnesium
hydroxidemdashFDA category B Calcium carbonatemdashFDA category C
SimetheconemdashFDA category C
Use of Nitrous Oxide Gas
bull used over 150 years bull safety is being debatedbull SHORT TERM exposure do not cause
birth defects or spontaneous abortionbull CHRONIC exposure may result in fetal
loss and infertilitybull literature suggests that nitrous oxide
should be avoided until more conclusive research is available
bull FDA Drug class not yet assigned
Common Preventives
bull Fluoridendash No increased risk during pregnancy
bull Xylitolndash No studies no harm reported
bull Chlorhexidinendash No increased risk during pregnancy
Are topical agents safe
bull Fluoridebull Toothpaste amp mouthrinse
bull Xylitol chewing gum bull Chlorhexidine (11 alcohol)bull No over the counter mouthrinses with
alcohol (Listerine 20 alcohol)
Pre-natal Fluoride
bull Daily 22 mg tablet of sodium fluoride during 3rd through 9th months
bull decreases caries rate in offspringbull Safe and effective
Glenn FB 1982
Is it safe to use mercury restorations
bull No evidence of harmful effect
bull Benefits outweigh risks
bull Canada Germany and New Zealand have some restrictions
bull Determine the best option
Referencesbull Wasylko L Matsui D Dykxhoorn SM Rieder MJ Weinberg
S A Review of Common Dental Treatments During Pregnancy J Canadian Dental Association 64434-439 1998
bull Little JW Donald AF Craig SM Rhodus NL Dental Management of the Medically Compromised Patient - 5th edition Mosby Toronto Pp434-442 1997
bull Livingston HM Dellinger TM Holder R Considerations in the management of the pregnant patient Special Care in Dentistry 185 pp183-188 1998
bull Larimore WL Petrie KA Drug use during pregnacy and lactation Primary Care Clinics in Office Practice 271 35-53 2000
bull Health Canada The Safety of DentalAmalgam Minister Of Supply and Services Canada 1996
REFERENCESbull 1 Weiss G Endocrinology of parturition J Clin
Endocrinol Metab 2000854421-5bull 2 Theunissen IM Parer JT Fluid and electrolytes in
pregnancy Clin Obstet Gynecol 1994373-15bull 3 Duvekot JJ Peeters LLH Renal hemodynamics and
volume homeostasis in pregnancy Obstet Gynecol Surv 199449830-9
bull 4 Barron WM Lindheimer MD Medical disorders during pregnancy 2nd ed St Louis Mosby 1995 p 129
bull 5 Thornburg KL Jacobson SL Giraud GD Morton MJ Hemodynamic changes in pregnancy Semin Perinatol 20002411-4
bull 6 Fiese R Herzog S Issues in dental and surgical management of the pregnant patient Oral Surg Oral Med Oral Pathol 198865292-7
bull 7 Martin C Varner MW Physiologic changes in pregnancysurgical implications Clin Obstet Gynecol 199437241-55
bull 8 Clark SL Cotton DB Lee W Bishop C Hill T Southwick J et al Central hemodynamic assessment of normal term pregnancy Am J Obstet Gynecol 19891611439-42
bull 9 Mabie WC Di Sessa TG Crocker LG Sibai BM Arheart KL A longitudinal study of cardiac output in normal human pregnancy Am J Obstet Gynecol 1994170849-56
bull 10 Clapp JF 3rd Capeless E Cardiovascular function before during and after the first and subsequent pregnancies Am J Cardiol 1997801469-73
bull 11 Duvekot JJ Peeters LL Maternal cardiovascular hemodynamic adaptation to pregnancy Obstet Gynecol Surv 199449(Suppl) S1-14
bull 12 Bhagwat AR Engel PJ Heart disease and pregnancy Cardiol Clin 199513163-78
bull 13 Lanni SM Tillinghast J Silver H Hemodynamic changes and baroreflex gain in the supine hypotensive syndrome Am J Obstet Gynecol 20021871636-41
bull 14 Little JW Falace DA Miller CS Rhodus NL Dental management of the medically compromised patient 6th ed St Louis Mosby 2002 p 303
bull 15 Garcia-Rio F Pino JM Gomez L Alvarez-Sala R Villasante C Villamor J Regulation of breathing and perception of dyspnea in healthy pregnant women Chest 1996110446-53
bull 16 McAuliffe F Kametas N Costello J Rafferty GF Greenough A Nicolaides K Respiratory function in singleton and twin pregnancy BJOG 2002109765-9
bull 17 Clapp JF 3rd Seaward BL Sleamaker RH Hiser J Maternal physiologic adaptations to early human pregnancy Am J Obstet Gynecol 19881591456-60
bull 18 OrsquoDay MP Cardio-respiratory physiological adaptation of pregnancy Semin Perinatol 199721268-75
bull 19 Contreras G Gutierrez M Beroiza T Fantin A Oddo H Villarroel L et al Ventilatory drive and respiratory muscle function in pregnancy Am Rev Respir Dis 1991144837-41
bull 20 Turner M Aziz SR Management of the pregnant oral and maxillofac
bull 21 Sifakis S Pharmakides G Anemia in pregnancy Ann N Y Acad Sci 2000900125-36
bull 22 Branch DW Physiologic adaptations of pregnancy Am J Reprod Immunol 199228120-2
bull 23 Burrows RF Kelton JG Incidentally detected thrombocytopenia in healthy mothers and their infants N Engl J Med 1988319 142-5
bull 24 Hanly JG Antiphospholipid syndrome an overview CMAJ 200324(168)1675-82
bull 25 Heilmann L von Tempelhoff GF Pollow K Antiphospholipid syndrome in obstetrics Clin Appl Thromb Hemost 20039 143-50
bull 26 Sherman P Flaxman SM Nausea and vomiting of pregnancy in an evolutionary perspective Am J Obstet Gynecol 2002 185(Suppl)s190-7
bull 27 Koch KL Gastrointestinal factors in nausea and vomiting of pregnancy Am J Obstet Gynecol 2002185(Suppl)s198-203
bull 28 Koch KL Frissora CL Nausea and vomiting during pregnancy Gastroenterol Clin N Am 200332201-34
bull 29 Baron TH Ramirez B Richter JE Gastrointestinal motility disorders during pregnancy Ann Intern Med 1993118 366-75
bull 30 Richter JE Gastroesophageal reflux disease during pregnancy Gastroenterol Clin N Am 200332235-61
bull 31 Marrero JM Goggin PM de Caestecker JS Pearce JM Maxwell JD Determinants of pregnancy heartburn Br J Obstet Gynaecol 199299731-4
bull 32 Hamaoui E Hamaoui M Nutritional assessment and support during pregnancy Gastroenterol Clin N Am 20033259-121
bull 33 King JC Physiology of pregnancy and nutrient metabolism Am J Clin Nutr 200071(suppl)1218s-25s
bull 34 Casanueva E Pfeffer F Fernandez-Gaxiola AC Gutierrez- Valenzuela V Rothenberg SJ Iron and folate status before pregnancy and anemia during pregnancy Ann Nutr Metab 2003 4760-3
bull 35 Chrsquong CL Morgan M Hainsworth I Kingham JG Prospective study of liver dysfunction in Southwest Wales Gut 200251 876-80
bull 36 Rahman TM Wendon J Severe hepatic dysfunction in pregnancy QJM 200295343-57
bull 37 Knox TA Olans LB Liver disease in pregnancy N Engl J Med 1996335569-76
bull 38 Saftlas AF Olson DR Franks AL Atrash H Pokras R Epidemiology of preeclampsia and eclampsia in the United States 1979e1986 Am J Obstet Gynecol 1990163460-5
bull 39 Walker JJ Pre-eclampsia Lancet 20003561260-5
bull 40 Davidson JM Renal disorders in pregnancy Curr Opin Obstet Gynecol 200113109-14
bull 41 Dafnis E Sabatini S The effect of pregnancy on renal function physiology and pathophysiologyAmJMedSci 1992303184-205
bull 42 Davison JM Shiells EA Philips PR Lindheimer MD Serial evaluation of vasopressin release and thirst in human pregnancy Role of human chorionic gonadotrophin in the osmoregulatory changes of gestation J Clin Invest 198881798-806
bull 43 Glinoer D de Nayer P Bourdoux P Lemone M Robyn C van Steirteghem A et al Regulation of maternal thyroid during pregnancy J Clin Endocrinol Metab 199071276-87
bull 44 Wilson SG Retallack RW Kent JC Worth GK Gutteridge DH Serum free 125-dihydroxyvitamin D and the free 125- dihydroxyvitamin D index during a longitudinal study of human pregnancy and lactation Clin Endocrinol 199032613-22
bull 45 Rasmussen N Frolich A Hornnes PJ Hegedus L Serum ionized calcium and intact parathyroid hormone levels during pregnancy and postpartum Br J Obstet Gynaecol 199097857-9
bull 46 Guyton AC Textbook of medical physiology 8th ed Philadelphia W B Saunders 1991 p 915e28
bull 47 Trainer PJ Corticosteroids and pregnancy Semin Reprod Med 200220375-80
bull 48 Soory M Hormonal factors in periodontal disease Dent Update 200027380-3
bull 49 Hugoson A Gingivitis in pregnant women A longitudinal clinical study Odontol Revy 19712265-84
bull 50 Neville BW Damm DD Allen CM Bouquot JE Oral amp Maxillofacial Pathology 3rd ed Philadelphia W B Saunders 2002 p 329-30 447-9
bull 51 Tilakaratne A Soory M Ranasinghe AW Corea SM Ekanayake SL de Silva M Periodontal disease status during pregnancy and 3 months post-partum in rural population of Sri-Lankan women J Clin Periodontol 200027787-92
bull 52 Laine M Tenovuo J Lehtonen OP Ojanatko-Harri A Vilja P Tuohimaa P Pregnancy e related changes in human whole saliva Arch Oral Biol 198833913-7
bull 53 Yuan K Wing LY Lin MT Pathogenetic roles of angiogenic factors in pyogenic granulomas in pregnancy are modulated by female sex hormones J Periodontol 200273701-8
bull 54 Evans RD Briggs PF Tooth-surface loss related to pregnancyinduced vomiting Prim Dent Care 1994124-6
bull 55 Salvolini E Di Giorgio R Curatola A Mazzanti L Fratto G Biochemical modifications of human whole saliva induced by pregnancy Br J Obstet Gynaec 1998105656-60
bull 56 Mauldin JG Newman RB Preterm birth risk assessment Semin Perinatol 200125215-22
bull 57 Heine RP McGregor JA Goodwin TM Artal R Hayashi RH Robertson PA et al Serial salivary estriol to detect an increased risk of preterm birth Obstet Gynecol 200096490-7
bull 58 Kauh YC Zachian TF Melasma Adv Exp Med Biol 1999455 491-9
bull 59 Wong RC Ellis CN Physiologic skin changes in pregnancy J Am Acad Dermatol 198410929-40
bull 60 Errickson CV Matus NR Skin disorders of pregnancy Am Fam Physician 199449605-10
bull 61 Lopez NJ Smith PC Gutierrez J Periodontal therapy may reduce the risk of preterm low birth weight in women with periodontal disease a randomized controlled trial J Periodontol 200273911-24
bull 62 McGaw T Periodontal disease and preterm delivery of lowbirth- weight infants J Can Dent Assoc 200268165-9
bull 63 Richards AG Dental x-ray protection Dent Clin North Am 1968631-41
bull 64 1990 Recommendations of the International Commission on Radiological Protection Ann ICRP 1991211-201
bull 65 Hall EJ Radiation the two-edged sword cancer risks at high and low doses Cancer J 20006343-50
bull 66 Diethelm L Xu H Diagnostic imaging of the lung during pregnancy Clin Obstet Gynecol 19963936-55
bull 67 Brent RL The effects of embryonic and fetal exposure to x-rays microwaves and ultrasound ClinObstetGynecol 198326484-510
bull 68 National Council on Radiation Protection NCRP report no128 1998 Bethesda Md Author
bull 69 Wasylko L Matsui D Dykxhoorn SM Reider MJ Weinberg S A review of common dental treatments during pregnancy implications for patients and dental personnel J Can Dent Assoc 199864434-9
bull 70 Freeman JP Brand JW Radiation doses of commonly used dental radiographic surveys Oral Surg Oral Med Oral Pathol 199477285-9
bull 71 Kircos LTAngin LL Lorton LOrder ofmagnitude dose reduction in intraoral radiography J Am Dent Assoc 1987114344-7
bull 72 Updegrave WJ Simplified and standardized intraoral radiography with reduced tissue irradiation J Am Dent Assoc 197285861-9
bull 73 Wood RE Harris AM van der Merwe EJ Nortje CJ The leaded apron revisited does it reduce gonadal radiation dose in dental radiology Oral Surg Oral Med Oral Pathol 199171642-6
bull 74 An update on radiographic practices information and recommendations ADA Council on Scientific Affairs J Am Dent Assoc 2001132234-8
bull 75 Rayburn WF Recommending medications during pregnancy an evidence based approach Clin Obstet Gynecol 2002451-5
bull 76 Rathmell JP Viscomi C Ashburn MA Management of nonobstetric pain during pregnancy and lactation Anesth Analg 1997851074-87
bull 77 Teratology society public affairs committee FDA classification of drugs for teratogenic risk Teratology 199449446-7
bull 78 Moore PA Selecting drugs for the pregnant dental patient J Am Dent Assoc 19981291281-6
bull 79 Haas DA An update on analgesics for the management of acute postoperative dental pain J Can Dent Assoc 200268476-82
bull 80 Haas DA Pynn BR Sands TD Drug use for the pregnant or lactating patient Gen Dent 20004854-60
bull 81 Committee on Drugs American Academy of Pediatrics The transfer of drugs and other chemicals into human milk Pediatrics 199493137-50
bull 82 Nielsen GL Sorensen HT Larsen H Pedersen L Risk of adverse birth outcome and miscarriage in pregnant users of nonsteroidal anti-inflammatory drugs population based observational study and case-control study BMJ 2001322266-70
bull 83 Janssen N Genta M The effects of immunosuppressive and anti-inflammatory medications on fertility pregnancy and lactation Arch Intern Med 200016610-9
bull 84 Ostensen M Nonsteroidal anti-inflammatory drugs during pregnancy Scand J Rheumatol Suppl 1998107128-32
bull 85 USPDI -Drug information for the health care professional 22nd ed Greenwood Village CO Micromedex 2002 p 152-79
bull 86 Denson DD Coyle DE Thompson GA Santos D Turner PA Myers JA et al Bupivacaine protein binding in the term parturient effects of lactic acidosis Clin Pharmacol Ther 198435702-9
bull 87 Dillon DE Wagner CL Wiest D Newman RB Drug therapy in the nursing mother Obstet Gynecol Clin North Am 199724 675-96
bull 88 Dashe JS Gilstrap LC Antibiotic use in pregnancy Obstet Gynecol Clin North Am 199724617-29
bull 89 American College of Rheumatology Ad hoc Committee on Clinical Guidelines Guidelines for monitoring drug therapy in rheumatoid arthritis Arthritis Rheum 199639723-31
bull 90 Ng PC The fetal and neonatal hypothalamic-pituitary-adrenal axis Arch Dis Child Fetal Neonatal Ed 200082F250-4
bull 91 Crowley P Antenatal corticosteroidsmdashcurrent thinking BJOG 2003110(Suppl 20)77-8
bull 92 ACOG committee opinion antenatal corticosteroid therapy for fetal maturation Obstet Gynecol 200299871-3
bull 93 Ost L Wettrell G Bjorkhem I Rane A Prednisolone excretion in human milk J Pediatr 19851061008-11
bull 94 Rowland AS Baird DD Shore DL Weinberg CR Savitz DA Wilcox AJ Nitrous oxide and spontaneous abortion in female dental assistants Am J Epidemiol 1995141531-8
bull 95 McGlothlin JD Jensen PA Fischbach TJ Hughes RT Jones JH Control of anesthetic gases in dental operatories Scand J Work Environ Health 199218(Suppl 2)103-5
bull ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY Volume 97 Number 6 Suresh and Radfar 681
bull 96 Rosen MA Nitrous oxide for relief of labor pain a systematic review Am J Obstet Gynecol 2002186(Suppl Nature)S110-6
bull 97 Sands TD Pynn BR Management considerations for the pregnant or nursing emergency patient Ont Dent 199875 17-9
bull 98 Daya S Recurrent spontaneous early pregnancy loss and low dose aspirin Minerva Ginecol 200355441-9
bull 99 Sinclair C Handbook of obstetrical emergencies 1st ed Philadelphia WB Saunders 1996 p 29-39 69
bull 100 Tarsitano BF Rollings RE The pregnant dental patient evaluation and management Gen Dent 199341226-34
bull 101 Livingston MH Dlllinger TM Holder R Consideration in the management of the pregnant patient SCD Special Care in Dentistry 199818183-8
Thank you
- A Review on the principle of Dental Management of the Pregnant patient
- Slide 2
- Questions that a dentist may ask
- Stages of Pregnancy
- Slide 5
- Slide 6
- Physiologic Changes in Pregnancy
- Systemic changes in pregnancy
- FLAT SUPINE POSITIONING
- SUPINE HYPOTENSION SYNDROME (Vena Cava Compression)
- Supine Hypotension Syndrome
- Slide 12
- Supine Hypotension Syndrome
- Prevention of Supine Hypotensive Syndrome
- Treatment of Supine Hypotensive Syndrome
- How should the pregnant woman be positioned
- Slide 17
- Slide 18
- Slide 19
- Slide 20
- Slide 21
- Slide 22
- Slide 23
- Pregnancy Related Oral Health Problems
- Oral Problems in Pregnancy
- Pregnancy Gingivitis Pathophysiology
- Pregnancy Gingivitis
- Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Gum Problems - Pregnancy Granuloma
- Slide 31
- Gum Changes - Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Candidiasis
- Pregnancy Myths
- Other Oral Conditions in Pregnancy
- Changes During Pregnancy that Affect Oral Health
- Saliva changes
- Increased Bacteria
- Slide 40
- Enamel erosion caused by frequent vomiting
- Treatment for Acid Exposure
- Oral Diseases Can Effect Pregnancy
- Periodontal Disease and Preterm Labor
- Periodontal Disease and Low Birth Weight
- Periodontal Disease and Preeclampsia
- Periodontitis and Pre-eclampsia
- Dental Considerations
- Treatment Timing
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Slide 52
- Use of Radiation on Pregnant Patient
- Radiographs during Pregnancy
- Risks of Dental X-Rays
- FDA drug classification for pregnancy
- Slide 57
- FDA drug classification for pregnancy
- Slide 59
- Slide 60
- Slide 61
- Common Analgesics
- Analgesics
- Analgesics - continued
- Analgesics to Use During 1st and 2nd Trimester
- Analgesics to Avoid During the Third Trimester
- Sedation in Pregnancy
- Common Antibiotics
- Antibiotics
- Antibiotics To Use During Pregnancy
- Antibiotics to Avoid during Pregnancy
- The Problem With Tetracycline
- Other Antimicrobial Agents
- Local Anesthetic Use in Pregnancy
- Use of Local Anesthetics
- Ulcer healing drugs
- Slide 77
- Slide 78
- Slide 79
- Use of Nitrous Oxide Gas
- Common Preventives
- Are topical agents safe
- Pre-natal Fluoride
- Is it safe to use mercury restorations
- References
- REFERENCES
- Slide 87
- Slide 88
- Slide 89
- Slide 90
- Slide 91
- Slide 92
- Slide 93
- Slide 94
- Slide 95
- Slide 96
- Slide 97
- Slide 98
- Thank you
-
Stages of Pregnancy
bull3rd Trimester (25-40 weeks)bullFetal growth continuesbullFocus of concern is risk to upcoming birth process and safety and comfort of the pregnant woman
Physiologic Changes in Pregnancy
bull Complex hormonal interactions cause profound physiologic changes
bull Increase estrogen by 10 fold and progesterone by 30 folds
bull Increased hormonal secretion and fetal growth causes several systemic as well as physical changes in a pregnant women
Systemic changes in pregnancyCardiovascular system uarr in blood volume by an average of 45bull Anemia due to increased blood volume
(20 of women) darr in pulse by 10-15 beats per minute Systemic murmur occurs in 90 of
pregnancies disappears shortly after delivery
uarrcardiac output Supine hypotension syndrome may occur
FLAT SUPINE POSITIONING
bullNegatively impacts mother and infant
SUPINE HYPOTENSIONSYNDROME (Vena Cava Compression)
bull SUPINE POSITION AFTER 5TH MONTH
bull UTERUS COMPRESSES THE INFERIOR VENA CAVA
bull uarrVOL BLOOD IN THE LErsquoS bull darrRETURN TO THE HEARTbull REDUCED PERFUSION OF
UTERUS bull FETAL HYPOXIA
Supine Hypotension Syndrome
bull Obstruction of inferior vena cava and aorta from pressure of the large fetus
Symptoms Sweating Nausea Weakness Sense of lack of air
Supine Hypotension Syndrome
Other symptomsbull Drop in blood pressurebull Bradycardiabull Possible loss of consciousness
Prevention of Supine HypotensiveSyndrome
bullElevate right hip 10-12 cmbullWeight is taken off the major vessels
Treatment of Supine HypotensiveSyndrome
bullRoll patient onto her left side
How should the pregnant woman be positionedbull Flat position may
cause hypotension and hypoxia
bull Place a small pillow under right hip - left lateral displacement
bull Head above feet
Systemic changes in pregnancy
Diaphragm rises about 4 cm darr residual volume uarr awareness of a desire to breath is
common-may be interpreted as dyspnea Increased estrogen in blood causes
engorgement of the nasal capillaries and rhnitis in pregnant women
Frequent nosebleeds amp predisposition to upper respiratory infection
Respiratory system
Systemic changes in pregnancy
Gastrointestinal system Gastric emptying amp intestinal transit times
are delayed
Heart burn reflux common
Nausea and vomiting common
Systemic changes in pregnancy
For pregnant patient with Hyper-emesis gravidarium ( excessive and uncontrolled vomiting) morning appointments should be avoided
They should be seated in a semi-supine or comfortable position
In case of vomiting the procedure should be stopped immediately amp the patient should be repositioned upright
When vomiting is over rinsing mouth with cold water or mouthwash is recommended
Systemic changes in pregnancybull Urinary System uarr GFR amp renal plasma flow by as much as
50 Nocturia ndashto mobilize the dependent
edema which accumulate during the day uarr Frequency from uarr renal flow plus reduced
bladder capacity from uterine growth It is advisable to ask the patient to void the
bladder just prior to starting the dental procedure
Systemic changes in pregnancyEndocrine Changes uarrEstrogen uarr progesterone uarrhuman
gonadotropin uarr thyroxin steroid and insulin level Estrogen amp progesterone are insulin
antagonists uarr level of these hormones lead to insulin resistance Thus insulin levels are elevated in pregnant in pregnant patient to compensate this resistance
About 45 of women fail to produce sufficient amount of insulin to overcome this antagonist action amp thus develop gestational diabetes
Systemic changes in pregnancy
Hematological changebull uarr red RBC uarrESR darrHbbull uarrWBCbull uarr circulatory catecholamin amp cortisol lead
to leucositosis bull uarr Coagulation factors except factor XI amp
XIII (anticloting factor) bull so pregnancy is a hypercoagulable state amp
uarr risk for thromboembolism
Systemic changes in pregnancy
bull Pregnant women with anti-phospholipid syndrome are at uarr risk for thrombo-embolisim
bull They are placed on subcutaneous low molecular weight heparin (LMWH)
bull These patients must be hospitalized for dental care
Pregnancy RelatedOral Health Problems
bull Pregnancy Gingivitisbull Pregnancy Epulis bull Increased Tooth Mobilitybull Dental Cariesbull Erosionbull Dental Problems in relation to Labor
and Delivery
Oral Problems in Pregnancy
bullPregnancy GingivitisbullMost common oral manifestation (50-100 of women)bullCaused by hormonal and vascular changes of pregnancy
Pregnancy Gingivitis Pathophysiology
bull Elevated circulating estrogen increases capillary permeability
bull Preexisting gingivitis may predispose to pregnancy gingivitis
Pregnancy Gingivitis
bullOccurs commonly in the 2nd to 8th monthsbullTendency to bleed very easilybullTreatment Scaling root-planing currettage OHI
Pregnancy Granuloma
bullOccurs in up to 5 of womenbullMost common in buccal maxillary anterior areasbullUsually starts in an area of gingivitis
Pregnancy Granuloma (continued)
bullRapid growth up to 2 cmbullSingle tumor-like growthbullusually in interdental papillaebullPurplish to bluish in color may be ulcerated- bleeds easily
Gum Problems - Pregnancy Granuloma
Gum Problems - Pregnancy Granuloma
Gum Changes - Pregnancy Granuloma
Pregnancy Granuloma (continued)
Treatment
bull Scaling and root planingbull Excision if it is too large or bleeds too
easilybull May regress spontaneously after
pregnancy
Candidiasis
bullWipes offbullUsually asymptomatic but may burnbullTreatment topical or systemic antifungals
Pregnancy MythsbullldquoA mother loses a tooth for every babyrdquobullNo evidence that aphthous ulcers are any more common in pregnancy
Other Oral Conditions in Pregnancy
bull Dry mouthbull Excessive salivationbull Tooth erosions associated with
severe GERD or hyperemesis
Changes During Pregnancy that Affect Oral Health
bull Hormonal Affects
ndash Increased tooth mobility
ndash Saliva changes
ndash Increased bacteria
ndash Gingival problems
Saliva changesbull Decreased buffers
bull Decreased minerals
bull Decreasing flow first and last trimester
bull Increased flow second trimester
bull More acidic
Increased Bacteriabull Increased acidity
ndash Increase in decay-causing bacteriabull Increased Snacking
ndash Morning sicknesslow blood sugarndash Between-meal snacks
bull Increase in amount and frequency of starchescarbohydrates ndash Crackers are commonly recommendedndash Promotes decay-causing bacteria
Changes During Pregnancy that Affect Oral Healthbull Morning sickness
ndash Difficulty with hygienebull Gingival diseasebull Tooth decay
ndash Vomitingbull Esophogeal Reflux (heartburn)bull Acid exposure
ndash Irritation of the gumsndash Weakening of tooth enamelndash Dental erosion
Enamel erosion caused by frequent vomiting
Treatment for Acid Exposure
bull Do NOT brush immediately after vomiting
bull Rinse ndash Water with baking sodandash Antacidndash Plain water
bull Eat some cheese
Oral Diseases Can Effect Pregnancy
bull Preterm low birth weight (LBW) linked to periodontal disease
bull Thorough calculus (tartar) removal in pregnant women with periodontitis may reduce pre-term births
Periodontal Disease and Preterm LaborbullMaternal periodontal disease is associated with increased risk of preterm laborbullAnaerobic oral gram-negative bacteria cause inflammatory responsebullInflammatory response stimulates prostaglandin and cytokine production to stimulate labor
Periodontal Disease and Low Birth Weight
bull Periodontal disease is associated with low birth weight
bull Evidence is not conclusivebull Biochemical mechanism similar cascade
as in preterm labor leading to placental blood flow restriction and necrosis
Periodontal Disease and Preeclampsia
bull Emerging databull Mechanism unclearbull Proposed mechanism
ndash Periodontal infection leads to inflammatory vascular damage
ndash Triggers cell damage in placenta
Periodontitis and Pre-eclampsia
bull Periodontal disease may be associated with pre-eclampsia (Boggess 2003)
bull PGE2 IL-1 and TNF-α from gingival crevicular fluid were higher in women with preeclampsia compared with healthy matched pregnant women (Oettinger-Barak 2003)
Dental Considerations
bull timing of treatment for pregnant patientsbull dental radiation exposurebull use of local anestheticsbull prescription of common antibiotics and
analgesicsbull nitrous oxide gas administration
Treatment Timing
bull First Trimesterndash Spontaneous miscarriages naturally occur
more often in 1st trimesterndash Avoid elective treatment that can be delayedndash Offer anticipatory guidance
bull Second Trimesterndash The optimal time for dental treatmentndash Organogenesis complete fetus not largendash Easier to prevent than treat established disease
bull Third Trimesterndash Late in term very uncomfortable (short visits)ndash Position slightly on left side
Timing of Dental Treatment During Pregnancy - From Little and Fallace
First Trimester
bull Plaque controlbull Oral hygiene instructionbull Scaling polishing curettagebull Avoid elective treatment urgent care
only
Timing of Dental Treatment During Pregnancy - From Little and Fallace
Second Trimester
bull Plaque controlbull Oral hygiene instructionbull Scaling polishing curettagebull Routine dental care
Timing of Dental Treatment During Pregnancy - From Little and Fallace
Third Trimester
bull Plaque controlbull Oral hygiene instructionbull Scaling polishing curettagebull Routine dental care (after middle of third
trimester elective care should be avoided)
Use of Radiation on Pregnant Patientbull Dose given and time of gestation are
importantbull doses lt 5-10 rads (cGy) not teratogenicbull fetus is most susceptible to radiation
between the 2nd and 6th week of gestationbull single dental x-ray exposes patient to 001
millirads of radiation In relative terms this amount is 40 times less than daily dose acquired from cosmic radiation Therefore diagnostic radiation should not be withheld during pregnancy
Radiographs during Pregnancy
bull Take as needed with optimal methods for reducing secondary radiation and exposure time
bull Always use a lead apronbull Exposure to fetus (with apron use) is 00001
centiGray(rad)bull Daily cosmic radiation - 0004 centiGray (rad)
Risks of Dental X-Rays
bull X-ray only if necessary (ie root canal therapy trauma)
bull When x-rays are indicated radiation exposure is extremely low
bull Exposure can be limited byndash Lead apron shielding ndash Modern fast film ndash Avoiding retakes
FDA drug classification for pregnancybull Combines risk statements including
congenital anomalies fetal effects perinatal risks and therapeutic risk-benefit ratio
bull Untreated disease or condition may pose more serious risks to both mother and fetus than any theoretical risks from the medication
bull Category A thru D and X
FDA drug classification for pregnancy
bull A = Controlled Studies in women fail to demonstrate a risk to the fetus in the first trimester and the possibility of fetal harm appears remote
FDA drug classification for pregnancy
bull B = Animal studies show no risk or if risk shown in animals controlled
trials in women showed no risk
FDA drug classification for pregnancy
bull C = Studies in animals with adverse effects and no human studies
OR no animal or human studies but benefits of use may outweigh potential harms
FDA drug classification for pregnancy
bull D = There is evidence of human fetal risk but benefits may outweigh risks
FDA drug classification for pregnancy
bull X = Contraindicated
Common Analgesics
bull paracetamol (B)bull Ibuprofen (BD) bull Oxycodone (BD) bull Hydrocodone and codeine
(CD)
avoid in third trimester
Analgesics
bull Paracetamol is the analgesic of choice for all stages of gestation
bull used to treat mild to moderate pain and fevers
bull short term usage is believed to be safebull avoid chronic and large doses of
paracetamol1048715
Analgesics - continuedbull Aspirin is nonteratogenic but may cause
maternal and fetal hemorrhagebull large and chronic doses during last trimester
may result in premature closure of ductus arteriosus fetal hypertension anemia and low birth weight
bull avoid ibuprofen in 3rd trimester because of possible adverse circulatory effects
bull short term use of codeine seems safebull avoid codeine late in gestation because of
possible fetal respiratory depression and withdrawal symptoms
Analgesics to Use During1st and 2nd Trimester
bull Category B (for best)bull Paracetamol Ibuprofenbull Naproxenbull Category C (use with caution)bull Paracetamol with codeine or
hydrocodonebull Paracetamol with oxycodone
Analgesics to Avoid During theThird Trimesterbull Causes delivery problemsbull Aspirin (C 3D)bull Ibuprofen (B3D)bull Naproxen (B3D)bull Causes neonatal respiratory
depression and opioid withdrawalbull Codeine (C3D)bull Hydrocodone (C3D)bull Oxycodone(C3D)
Sedation in Pregnancy
bull SedativesAnxiolytics (eg Diazepam ) are rated D and can cause oral clefts with prolonged exposure
bull Nitrous oxide should not be used in 1st trimester (If used in 2nd and 3rd do not go below 50 O2)
Common Antibioticsbull To treat oral abscess or cellulitis
ndash Penicillin (B) ndash Amoxicillin (B) ndash Cephalexin (B)ndash Erythromycin base (B) (Not estolate as it
cause cholestatic hepatitis)ndash Clindamycin (B)
Antibioticsbull penicillin V and amoxicillin is preferred drug
for mild to moderate infectionsbull widely used for many years with no ill effectsbull no studies show penicillin to be teratogenicbull amoxicillin extensively used without harming
the fetusbull Drug classes1048715 B penicillin cephalosporins erythromycin clindamycin Azithromycin D Tetracycline
Antibiotics To Use During Pregnancy
bull Penicillin Vbull Amoxicillinbull Erythromycin (base form)bull Cephalexin cephalosporinbull Clindamycinbull Metronidazole
Antibiotics to Avoid duringPregnancy
bull Doxycyclinebull Tetracyclinebull Erythromycin (estolate form)bull Vancomycin
The Problem With Tetracycline
bull Accumulates in bones and chelates calcium
bull Inhibits bone growthbull Discolors teeth
Other Antimicrobial Agentsbull OK to usebull Nystatin (B)bull Chlorhexidine rinse (B)bull Use with cautionbull Clotrimazole (C)bull Ketoconazole (C)bull Fluconazole (C)bull Do not usebull Doxycycline (D)
Local Anesthetic Use inPregnancy
bull Class Bbull Lidocaine (Xylocaine)bull Etidocainebull Prilocaine bull Class Cbull Procainebull Bupivicainebull Mepivicaine
Use of Local Anestheticsbull Lidocaine + vasoconstrictor most common
local anesthetic used in dentistrybull extensively used in pregnancy with no proven ill
effectsbull accidental intravascular injections of lidocaine
pass through the placenta but the concentrations are too low to harm fetus
bull prilocaine might cause methemoglobinemia
Ulcer healing drugsCimetidine bull FDA category B Famotidinebull FDA category BRanitidinebull FDA category Bbull not known to be harmful
Ulcer healing drugsOmeprazolebull FDA category BNot known to be
harmful Esomeprazolebull FDA category BLansoprazolebull FDA category BPantoprazolebull Avoid unless potential benefit
outweighs riskmdashfetotoxic in animals
Ulcer healing drugs
Misoprostolbull First second third trimesters Avoidmdash
potent uterine stimulant (has been used to induce abortion) and may be teratogenic
Ulcer healing drugs
Antacidsbull Almunium hydroxideMagnesium
hydroxidemdashFDA category B Calcium carbonatemdashFDA category C
SimetheconemdashFDA category C
Use of Nitrous Oxide Gas
bull used over 150 years bull safety is being debatedbull SHORT TERM exposure do not cause
birth defects or spontaneous abortionbull CHRONIC exposure may result in fetal
loss and infertilitybull literature suggests that nitrous oxide
should be avoided until more conclusive research is available
bull FDA Drug class not yet assigned
Common Preventives
bull Fluoridendash No increased risk during pregnancy
bull Xylitolndash No studies no harm reported
bull Chlorhexidinendash No increased risk during pregnancy
Are topical agents safe
bull Fluoridebull Toothpaste amp mouthrinse
bull Xylitol chewing gum bull Chlorhexidine (11 alcohol)bull No over the counter mouthrinses with
alcohol (Listerine 20 alcohol)
Pre-natal Fluoride
bull Daily 22 mg tablet of sodium fluoride during 3rd through 9th months
bull decreases caries rate in offspringbull Safe and effective
Glenn FB 1982
Is it safe to use mercury restorations
bull No evidence of harmful effect
bull Benefits outweigh risks
bull Canada Germany and New Zealand have some restrictions
bull Determine the best option
Referencesbull Wasylko L Matsui D Dykxhoorn SM Rieder MJ Weinberg
S A Review of Common Dental Treatments During Pregnancy J Canadian Dental Association 64434-439 1998
bull Little JW Donald AF Craig SM Rhodus NL Dental Management of the Medically Compromised Patient - 5th edition Mosby Toronto Pp434-442 1997
bull Livingston HM Dellinger TM Holder R Considerations in the management of the pregnant patient Special Care in Dentistry 185 pp183-188 1998
bull Larimore WL Petrie KA Drug use during pregnacy and lactation Primary Care Clinics in Office Practice 271 35-53 2000
bull Health Canada The Safety of DentalAmalgam Minister Of Supply and Services Canada 1996
REFERENCESbull 1 Weiss G Endocrinology of parturition J Clin
Endocrinol Metab 2000854421-5bull 2 Theunissen IM Parer JT Fluid and electrolytes in
pregnancy Clin Obstet Gynecol 1994373-15bull 3 Duvekot JJ Peeters LLH Renal hemodynamics and
volume homeostasis in pregnancy Obstet Gynecol Surv 199449830-9
bull 4 Barron WM Lindheimer MD Medical disorders during pregnancy 2nd ed St Louis Mosby 1995 p 129
bull 5 Thornburg KL Jacobson SL Giraud GD Morton MJ Hemodynamic changes in pregnancy Semin Perinatol 20002411-4
bull 6 Fiese R Herzog S Issues in dental and surgical management of the pregnant patient Oral Surg Oral Med Oral Pathol 198865292-7
bull 7 Martin C Varner MW Physiologic changes in pregnancysurgical implications Clin Obstet Gynecol 199437241-55
bull 8 Clark SL Cotton DB Lee W Bishop C Hill T Southwick J et al Central hemodynamic assessment of normal term pregnancy Am J Obstet Gynecol 19891611439-42
bull 9 Mabie WC Di Sessa TG Crocker LG Sibai BM Arheart KL A longitudinal study of cardiac output in normal human pregnancy Am J Obstet Gynecol 1994170849-56
bull 10 Clapp JF 3rd Capeless E Cardiovascular function before during and after the first and subsequent pregnancies Am J Cardiol 1997801469-73
bull 11 Duvekot JJ Peeters LL Maternal cardiovascular hemodynamic adaptation to pregnancy Obstet Gynecol Surv 199449(Suppl) S1-14
bull 12 Bhagwat AR Engel PJ Heart disease and pregnancy Cardiol Clin 199513163-78
bull 13 Lanni SM Tillinghast J Silver H Hemodynamic changes and baroreflex gain in the supine hypotensive syndrome Am J Obstet Gynecol 20021871636-41
bull 14 Little JW Falace DA Miller CS Rhodus NL Dental management of the medically compromised patient 6th ed St Louis Mosby 2002 p 303
bull 15 Garcia-Rio F Pino JM Gomez L Alvarez-Sala R Villasante C Villamor J Regulation of breathing and perception of dyspnea in healthy pregnant women Chest 1996110446-53
bull 16 McAuliffe F Kametas N Costello J Rafferty GF Greenough A Nicolaides K Respiratory function in singleton and twin pregnancy BJOG 2002109765-9
bull 17 Clapp JF 3rd Seaward BL Sleamaker RH Hiser J Maternal physiologic adaptations to early human pregnancy Am J Obstet Gynecol 19881591456-60
bull 18 OrsquoDay MP Cardio-respiratory physiological adaptation of pregnancy Semin Perinatol 199721268-75
bull 19 Contreras G Gutierrez M Beroiza T Fantin A Oddo H Villarroel L et al Ventilatory drive and respiratory muscle function in pregnancy Am Rev Respir Dis 1991144837-41
bull 20 Turner M Aziz SR Management of the pregnant oral and maxillofac
bull 21 Sifakis S Pharmakides G Anemia in pregnancy Ann N Y Acad Sci 2000900125-36
bull 22 Branch DW Physiologic adaptations of pregnancy Am J Reprod Immunol 199228120-2
bull 23 Burrows RF Kelton JG Incidentally detected thrombocytopenia in healthy mothers and their infants N Engl J Med 1988319 142-5
bull 24 Hanly JG Antiphospholipid syndrome an overview CMAJ 200324(168)1675-82
bull 25 Heilmann L von Tempelhoff GF Pollow K Antiphospholipid syndrome in obstetrics Clin Appl Thromb Hemost 20039 143-50
bull 26 Sherman P Flaxman SM Nausea and vomiting of pregnancy in an evolutionary perspective Am J Obstet Gynecol 2002 185(Suppl)s190-7
bull 27 Koch KL Gastrointestinal factors in nausea and vomiting of pregnancy Am J Obstet Gynecol 2002185(Suppl)s198-203
bull 28 Koch KL Frissora CL Nausea and vomiting during pregnancy Gastroenterol Clin N Am 200332201-34
bull 29 Baron TH Ramirez B Richter JE Gastrointestinal motility disorders during pregnancy Ann Intern Med 1993118 366-75
bull 30 Richter JE Gastroesophageal reflux disease during pregnancy Gastroenterol Clin N Am 200332235-61
bull 31 Marrero JM Goggin PM de Caestecker JS Pearce JM Maxwell JD Determinants of pregnancy heartburn Br J Obstet Gynaecol 199299731-4
bull 32 Hamaoui E Hamaoui M Nutritional assessment and support during pregnancy Gastroenterol Clin N Am 20033259-121
bull 33 King JC Physiology of pregnancy and nutrient metabolism Am J Clin Nutr 200071(suppl)1218s-25s
bull 34 Casanueva E Pfeffer F Fernandez-Gaxiola AC Gutierrez- Valenzuela V Rothenberg SJ Iron and folate status before pregnancy and anemia during pregnancy Ann Nutr Metab 2003 4760-3
bull 35 Chrsquong CL Morgan M Hainsworth I Kingham JG Prospective study of liver dysfunction in Southwest Wales Gut 200251 876-80
bull 36 Rahman TM Wendon J Severe hepatic dysfunction in pregnancy QJM 200295343-57
bull 37 Knox TA Olans LB Liver disease in pregnancy N Engl J Med 1996335569-76
bull 38 Saftlas AF Olson DR Franks AL Atrash H Pokras R Epidemiology of preeclampsia and eclampsia in the United States 1979e1986 Am J Obstet Gynecol 1990163460-5
bull 39 Walker JJ Pre-eclampsia Lancet 20003561260-5
bull 40 Davidson JM Renal disorders in pregnancy Curr Opin Obstet Gynecol 200113109-14
bull 41 Dafnis E Sabatini S The effect of pregnancy on renal function physiology and pathophysiologyAmJMedSci 1992303184-205
bull 42 Davison JM Shiells EA Philips PR Lindheimer MD Serial evaluation of vasopressin release and thirst in human pregnancy Role of human chorionic gonadotrophin in the osmoregulatory changes of gestation J Clin Invest 198881798-806
bull 43 Glinoer D de Nayer P Bourdoux P Lemone M Robyn C van Steirteghem A et al Regulation of maternal thyroid during pregnancy J Clin Endocrinol Metab 199071276-87
bull 44 Wilson SG Retallack RW Kent JC Worth GK Gutteridge DH Serum free 125-dihydroxyvitamin D and the free 125- dihydroxyvitamin D index during a longitudinal study of human pregnancy and lactation Clin Endocrinol 199032613-22
bull 45 Rasmussen N Frolich A Hornnes PJ Hegedus L Serum ionized calcium and intact parathyroid hormone levels during pregnancy and postpartum Br J Obstet Gynaecol 199097857-9
bull 46 Guyton AC Textbook of medical physiology 8th ed Philadelphia W B Saunders 1991 p 915e28
bull 47 Trainer PJ Corticosteroids and pregnancy Semin Reprod Med 200220375-80
bull 48 Soory M Hormonal factors in periodontal disease Dent Update 200027380-3
bull 49 Hugoson A Gingivitis in pregnant women A longitudinal clinical study Odontol Revy 19712265-84
bull 50 Neville BW Damm DD Allen CM Bouquot JE Oral amp Maxillofacial Pathology 3rd ed Philadelphia W B Saunders 2002 p 329-30 447-9
bull 51 Tilakaratne A Soory M Ranasinghe AW Corea SM Ekanayake SL de Silva M Periodontal disease status during pregnancy and 3 months post-partum in rural population of Sri-Lankan women J Clin Periodontol 200027787-92
bull 52 Laine M Tenovuo J Lehtonen OP Ojanatko-Harri A Vilja P Tuohimaa P Pregnancy e related changes in human whole saliva Arch Oral Biol 198833913-7
bull 53 Yuan K Wing LY Lin MT Pathogenetic roles of angiogenic factors in pyogenic granulomas in pregnancy are modulated by female sex hormones J Periodontol 200273701-8
bull 54 Evans RD Briggs PF Tooth-surface loss related to pregnancyinduced vomiting Prim Dent Care 1994124-6
bull 55 Salvolini E Di Giorgio R Curatola A Mazzanti L Fratto G Biochemical modifications of human whole saliva induced by pregnancy Br J Obstet Gynaec 1998105656-60
bull 56 Mauldin JG Newman RB Preterm birth risk assessment Semin Perinatol 200125215-22
bull 57 Heine RP McGregor JA Goodwin TM Artal R Hayashi RH Robertson PA et al Serial salivary estriol to detect an increased risk of preterm birth Obstet Gynecol 200096490-7
bull 58 Kauh YC Zachian TF Melasma Adv Exp Med Biol 1999455 491-9
bull 59 Wong RC Ellis CN Physiologic skin changes in pregnancy J Am Acad Dermatol 198410929-40
bull 60 Errickson CV Matus NR Skin disorders of pregnancy Am Fam Physician 199449605-10
bull 61 Lopez NJ Smith PC Gutierrez J Periodontal therapy may reduce the risk of preterm low birth weight in women with periodontal disease a randomized controlled trial J Periodontol 200273911-24
bull 62 McGaw T Periodontal disease and preterm delivery of lowbirth- weight infants J Can Dent Assoc 200268165-9
bull 63 Richards AG Dental x-ray protection Dent Clin North Am 1968631-41
bull 64 1990 Recommendations of the International Commission on Radiological Protection Ann ICRP 1991211-201
bull 65 Hall EJ Radiation the two-edged sword cancer risks at high and low doses Cancer J 20006343-50
bull 66 Diethelm L Xu H Diagnostic imaging of the lung during pregnancy Clin Obstet Gynecol 19963936-55
bull 67 Brent RL The effects of embryonic and fetal exposure to x-rays microwaves and ultrasound ClinObstetGynecol 198326484-510
bull 68 National Council on Radiation Protection NCRP report no128 1998 Bethesda Md Author
bull 69 Wasylko L Matsui D Dykxhoorn SM Reider MJ Weinberg S A review of common dental treatments during pregnancy implications for patients and dental personnel J Can Dent Assoc 199864434-9
bull 70 Freeman JP Brand JW Radiation doses of commonly used dental radiographic surveys Oral Surg Oral Med Oral Pathol 199477285-9
bull 71 Kircos LTAngin LL Lorton LOrder ofmagnitude dose reduction in intraoral radiography J Am Dent Assoc 1987114344-7
bull 72 Updegrave WJ Simplified and standardized intraoral radiography with reduced tissue irradiation J Am Dent Assoc 197285861-9
bull 73 Wood RE Harris AM van der Merwe EJ Nortje CJ The leaded apron revisited does it reduce gonadal radiation dose in dental radiology Oral Surg Oral Med Oral Pathol 199171642-6
bull 74 An update on radiographic practices information and recommendations ADA Council on Scientific Affairs J Am Dent Assoc 2001132234-8
bull 75 Rayburn WF Recommending medications during pregnancy an evidence based approach Clin Obstet Gynecol 2002451-5
bull 76 Rathmell JP Viscomi C Ashburn MA Management of nonobstetric pain during pregnancy and lactation Anesth Analg 1997851074-87
bull 77 Teratology society public affairs committee FDA classification of drugs for teratogenic risk Teratology 199449446-7
bull 78 Moore PA Selecting drugs for the pregnant dental patient J Am Dent Assoc 19981291281-6
bull 79 Haas DA An update on analgesics for the management of acute postoperative dental pain J Can Dent Assoc 200268476-82
bull 80 Haas DA Pynn BR Sands TD Drug use for the pregnant or lactating patient Gen Dent 20004854-60
bull 81 Committee on Drugs American Academy of Pediatrics The transfer of drugs and other chemicals into human milk Pediatrics 199493137-50
bull 82 Nielsen GL Sorensen HT Larsen H Pedersen L Risk of adverse birth outcome and miscarriage in pregnant users of nonsteroidal anti-inflammatory drugs population based observational study and case-control study BMJ 2001322266-70
bull 83 Janssen N Genta M The effects of immunosuppressive and anti-inflammatory medications on fertility pregnancy and lactation Arch Intern Med 200016610-9
bull 84 Ostensen M Nonsteroidal anti-inflammatory drugs during pregnancy Scand J Rheumatol Suppl 1998107128-32
bull 85 USPDI -Drug information for the health care professional 22nd ed Greenwood Village CO Micromedex 2002 p 152-79
bull 86 Denson DD Coyle DE Thompson GA Santos D Turner PA Myers JA et al Bupivacaine protein binding in the term parturient effects of lactic acidosis Clin Pharmacol Ther 198435702-9
bull 87 Dillon DE Wagner CL Wiest D Newman RB Drug therapy in the nursing mother Obstet Gynecol Clin North Am 199724 675-96
bull 88 Dashe JS Gilstrap LC Antibiotic use in pregnancy Obstet Gynecol Clin North Am 199724617-29
bull 89 American College of Rheumatology Ad hoc Committee on Clinical Guidelines Guidelines for monitoring drug therapy in rheumatoid arthritis Arthritis Rheum 199639723-31
bull 90 Ng PC The fetal and neonatal hypothalamic-pituitary-adrenal axis Arch Dis Child Fetal Neonatal Ed 200082F250-4
bull 91 Crowley P Antenatal corticosteroidsmdashcurrent thinking BJOG 2003110(Suppl 20)77-8
bull 92 ACOG committee opinion antenatal corticosteroid therapy for fetal maturation Obstet Gynecol 200299871-3
bull 93 Ost L Wettrell G Bjorkhem I Rane A Prednisolone excretion in human milk J Pediatr 19851061008-11
bull 94 Rowland AS Baird DD Shore DL Weinberg CR Savitz DA Wilcox AJ Nitrous oxide and spontaneous abortion in female dental assistants Am J Epidemiol 1995141531-8
bull 95 McGlothlin JD Jensen PA Fischbach TJ Hughes RT Jones JH Control of anesthetic gases in dental operatories Scand J Work Environ Health 199218(Suppl 2)103-5
bull ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY Volume 97 Number 6 Suresh and Radfar 681
bull 96 Rosen MA Nitrous oxide for relief of labor pain a systematic review Am J Obstet Gynecol 2002186(Suppl Nature)S110-6
bull 97 Sands TD Pynn BR Management considerations for the pregnant or nursing emergency patient Ont Dent 199875 17-9
bull 98 Daya S Recurrent spontaneous early pregnancy loss and low dose aspirin Minerva Ginecol 200355441-9
bull 99 Sinclair C Handbook of obstetrical emergencies 1st ed Philadelphia WB Saunders 1996 p 29-39 69
bull 100 Tarsitano BF Rollings RE The pregnant dental patient evaluation and management Gen Dent 199341226-34
bull 101 Livingston MH Dlllinger TM Holder R Consideration in the management of the pregnant patient SCD Special Care in Dentistry 199818183-8
Thank you
- A Review on the principle of Dental Management of the Pregnant patient
- Slide 2
- Questions that a dentist may ask
- Stages of Pregnancy
- Slide 5
- Slide 6
- Physiologic Changes in Pregnancy
- Systemic changes in pregnancy
- FLAT SUPINE POSITIONING
- SUPINE HYPOTENSION SYNDROME (Vena Cava Compression)
- Supine Hypotension Syndrome
- Slide 12
- Supine Hypotension Syndrome
- Prevention of Supine Hypotensive Syndrome
- Treatment of Supine Hypotensive Syndrome
- How should the pregnant woman be positioned
- Slide 17
- Slide 18
- Slide 19
- Slide 20
- Slide 21
- Slide 22
- Slide 23
- Pregnancy Related Oral Health Problems
- Oral Problems in Pregnancy
- Pregnancy Gingivitis Pathophysiology
- Pregnancy Gingivitis
- Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Gum Problems - Pregnancy Granuloma
- Slide 31
- Gum Changes - Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Candidiasis
- Pregnancy Myths
- Other Oral Conditions in Pregnancy
- Changes During Pregnancy that Affect Oral Health
- Saliva changes
- Increased Bacteria
- Slide 40
- Enamel erosion caused by frequent vomiting
- Treatment for Acid Exposure
- Oral Diseases Can Effect Pregnancy
- Periodontal Disease and Preterm Labor
- Periodontal Disease and Low Birth Weight
- Periodontal Disease and Preeclampsia
- Periodontitis and Pre-eclampsia
- Dental Considerations
- Treatment Timing
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Slide 52
- Use of Radiation on Pregnant Patient
- Radiographs during Pregnancy
- Risks of Dental X-Rays
- FDA drug classification for pregnancy
- Slide 57
- FDA drug classification for pregnancy
- Slide 59
- Slide 60
- Slide 61
- Common Analgesics
- Analgesics
- Analgesics - continued
- Analgesics to Use During 1st and 2nd Trimester
- Analgesics to Avoid During the Third Trimester
- Sedation in Pregnancy
- Common Antibiotics
- Antibiotics
- Antibiotics To Use During Pregnancy
- Antibiotics to Avoid during Pregnancy
- The Problem With Tetracycline
- Other Antimicrobial Agents
- Local Anesthetic Use in Pregnancy
- Use of Local Anesthetics
- Ulcer healing drugs
- Slide 77
- Slide 78
- Slide 79
- Use of Nitrous Oxide Gas
- Common Preventives
- Are topical agents safe
- Pre-natal Fluoride
- Is it safe to use mercury restorations
- References
- REFERENCES
- Slide 87
- Slide 88
- Slide 89
- Slide 90
- Slide 91
- Slide 92
- Slide 93
- Slide 94
- Slide 95
- Slide 96
- Slide 97
- Slide 98
- Thank you
-
Physiologic Changes in Pregnancy
bull Complex hormonal interactions cause profound physiologic changes
bull Increase estrogen by 10 fold and progesterone by 30 folds
bull Increased hormonal secretion and fetal growth causes several systemic as well as physical changes in a pregnant women
Systemic changes in pregnancyCardiovascular system uarr in blood volume by an average of 45bull Anemia due to increased blood volume
(20 of women) darr in pulse by 10-15 beats per minute Systemic murmur occurs in 90 of
pregnancies disappears shortly after delivery
uarrcardiac output Supine hypotension syndrome may occur
FLAT SUPINE POSITIONING
bullNegatively impacts mother and infant
SUPINE HYPOTENSIONSYNDROME (Vena Cava Compression)
bull SUPINE POSITION AFTER 5TH MONTH
bull UTERUS COMPRESSES THE INFERIOR VENA CAVA
bull uarrVOL BLOOD IN THE LErsquoS bull darrRETURN TO THE HEARTbull REDUCED PERFUSION OF
UTERUS bull FETAL HYPOXIA
Supine Hypotension Syndrome
bull Obstruction of inferior vena cava and aorta from pressure of the large fetus
Symptoms Sweating Nausea Weakness Sense of lack of air
Supine Hypotension Syndrome
Other symptomsbull Drop in blood pressurebull Bradycardiabull Possible loss of consciousness
Prevention of Supine HypotensiveSyndrome
bullElevate right hip 10-12 cmbullWeight is taken off the major vessels
Treatment of Supine HypotensiveSyndrome
bullRoll patient onto her left side
How should the pregnant woman be positionedbull Flat position may
cause hypotension and hypoxia
bull Place a small pillow under right hip - left lateral displacement
bull Head above feet
Systemic changes in pregnancy
Diaphragm rises about 4 cm darr residual volume uarr awareness of a desire to breath is
common-may be interpreted as dyspnea Increased estrogen in blood causes
engorgement of the nasal capillaries and rhnitis in pregnant women
Frequent nosebleeds amp predisposition to upper respiratory infection
Respiratory system
Systemic changes in pregnancy
Gastrointestinal system Gastric emptying amp intestinal transit times
are delayed
Heart burn reflux common
Nausea and vomiting common
Systemic changes in pregnancy
For pregnant patient with Hyper-emesis gravidarium ( excessive and uncontrolled vomiting) morning appointments should be avoided
They should be seated in a semi-supine or comfortable position
In case of vomiting the procedure should be stopped immediately amp the patient should be repositioned upright
When vomiting is over rinsing mouth with cold water or mouthwash is recommended
Systemic changes in pregnancybull Urinary System uarr GFR amp renal plasma flow by as much as
50 Nocturia ndashto mobilize the dependent
edema which accumulate during the day uarr Frequency from uarr renal flow plus reduced
bladder capacity from uterine growth It is advisable to ask the patient to void the
bladder just prior to starting the dental procedure
Systemic changes in pregnancyEndocrine Changes uarrEstrogen uarr progesterone uarrhuman
gonadotropin uarr thyroxin steroid and insulin level Estrogen amp progesterone are insulin
antagonists uarr level of these hormones lead to insulin resistance Thus insulin levels are elevated in pregnant in pregnant patient to compensate this resistance
About 45 of women fail to produce sufficient amount of insulin to overcome this antagonist action amp thus develop gestational diabetes
Systemic changes in pregnancy
Hematological changebull uarr red RBC uarrESR darrHbbull uarrWBCbull uarr circulatory catecholamin amp cortisol lead
to leucositosis bull uarr Coagulation factors except factor XI amp
XIII (anticloting factor) bull so pregnancy is a hypercoagulable state amp
uarr risk for thromboembolism
Systemic changes in pregnancy
bull Pregnant women with anti-phospholipid syndrome are at uarr risk for thrombo-embolisim
bull They are placed on subcutaneous low molecular weight heparin (LMWH)
bull These patients must be hospitalized for dental care
Pregnancy RelatedOral Health Problems
bull Pregnancy Gingivitisbull Pregnancy Epulis bull Increased Tooth Mobilitybull Dental Cariesbull Erosionbull Dental Problems in relation to Labor
and Delivery
Oral Problems in Pregnancy
bullPregnancy GingivitisbullMost common oral manifestation (50-100 of women)bullCaused by hormonal and vascular changes of pregnancy
Pregnancy Gingivitis Pathophysiology
bull Elevated circulating estrogen increases capillary permeability
bull Preexisting gingivitis may predispose to pregnancy gingivitis
Pregnancy Gingivitis
bullOccurs commonly in the 2nd to 8th monthsbullTendency to bleed very easilybullTreatment Scaling root-planing currettage OHI
Pregnancy Granuloma
bullOccurs in up to 5 of womenbullMost common in buccal maxillary anterior areasbullUsually starts in an area of gingivitis
Pregnancy Granuloma (continued)
bullRapid growth up to 2 cmbullSingle tumor-like growthbullusually in interdental papillaebullPurplish to bluish in color may be ulcerated- bleeds easily
Gum Problems - Pregnancy Granuloma
Gum Problems - Pregnancy Granuloma
Gum Changes - Pregnancy Granuloma
Pregnancy Granuloma (continued)
Treatment
bull Scaling and root planingbull Excision if it is too large or bleeds too
easilybull May regress spontaneously after
pregnancy
Candidiasis
bullWipes offbullUsually asymptomatic but may burnbullTreatment topical or systemic antifungals
Pregnancy MythsbullldquoA mother loses a tooth for every babyrdquobullNo evidence that aphthous ulcers are any more common in pregnancy
Other Oral Conditions in Pregnancy
bull Dry mouthbull Excessive salivationbull Tooth erosions associated with
severe GERD or hyperemesis
Changes During Pregnancy that Affect Oral Health
bull Hormonal Affects
ndash Increased tooth mobility
ndash Saliva changes
ndash Increased bacteria
ndash Gingival problems
Saliva changesbull Decreased buffers
bull Decreased minerals
bull Decreasing flow first and last trimester
bull Increased flow second trimester
bull More acidic
Increased Bacteriabull Increased acidity
ndash Increase in decay-causing bacteriabull Increased Snacking
ndash Morning sicknesslow blood sugarndash Between-meal snacks
bull Increase in amount and frequency of starchescarbohydrates ndash Crackers are commonly recommendedndash Promotes decay-causing bacteria
Changes During Pregnancy that Affect Oral Healthbull Morning sickness
ndash Difficulty with hygienebull Gingival diseasebull Tooth decay
ndash Vomitingbull Esophogeal Reflux (heartburn)bull Acid exposure
ndash Irritation of the gumsndash Weakening of tooth enamelndash Dental erosion
Enamel erosion caused by frequent vomiting
Treatment for Acid Exposure
bull Do NOT brush immediately after vomiting
bull Rinse ndash Water with baking sodandash Antacidndash Plain water
bull Eat some cheese
Oral Diseases Can Effect Pregnancy
bull Preterm low birth weight (LBW) linked to periodontal disease
bull Thorough calculus (tartar) removal in pregnant women with periodontitis may reduce pre-term births
Periodontal Disease and Preterm LaborbullMaternal periodontal disease is associated with increased risk of preterm laborbullAnaerobic oral gram-negative bacteria cause inflammatory responsebullInflammatory response stimulates prostaglandin and cytokine production to stimulate labor
Periodontal Disease and Low Birth Weight
bull Periodontal disease is associated with low birth weight
bull Evidence is not conclusivebull Biochemical mechanism similar cascade
as in preterm labor leading to placental blood flow restriction and necrosis
Periodontal Disease and Preeclampsia
bull Emerging databull Mechanism unclearbull Proposed mechanism
ndash Periodontal infection leads to inflammatory vascular damage
ndash Triggers cell damage in placenta
Periodontitis and Pre-eclampsia
bull Periodontal disease may be associated with pre-eclampsia (Boggess 2003)
bull PGE2 IL-1 and TNF-α from gingival crevicular fluid were higher in women with preeclampsia compared with healthy matched pregnant women (Oettinger-Barak 2003)
Dental Considerations
bull timing of treatment for pregnant patientsbull dental radiation exposurebull use of local anestheticsbull prescription of common antibiotics and
analgesicsbull nitrous oxide gas administration
Treatment Timing
bull First Trimesterndash Spontaneous miscarriages naturally occur
more often in 1st trimesterndash Avoid elective treatment that can be delayedndash Offer anticipatory guidance
bull Second Trimesterndash The optimal time for dental treatmentndash Organogenesis complete fetus not largendash Easier to prevent than treat established disease
bull Third Trimesterndash Late in term very uncomfortable (short visits)ndash Position slightly on left side
Timing of Dental Treatment During Pregnancy - From Little and Fallace
First Trimester
bull Plaque controlbull Oral hygiene instructionbull Scaling polishing curettagebull Avoid elective treatment urgent care
only
Timing of Dental Treatment During Pregnancy - From Little and Fallace
Second Trimester
bull Plaque controlbull Oral hygiene instructionbull Scaling polishing curettagebull Routine dental care
Timing of Dental Treatment During Pregnancy - From Little and Fallace
Third Trimester
bull Plaque controlbull Oral hygiene instructionbull Scaling polishing curettagebull Routine dental care (after middle of third
trimester elective care should be avoided)
Use of Radiation on Pregnant Patientbull Dose given and time of gestation are
importantbull doses lt 5-10 rads (cGy) not teratogenicbull fetus is most susceptible to radiation
between the 2nd and 6th week of gestationbull single dental x-ray exposes patient to 001
millirads of radiation In relative terms this amount is 40 times less than daily dose acquired from cosmic radiation Therefore diagnostic radiation should not be withheld during pregnancy
Radiographs during Pregnancy
bull Take as needed with optimal methods for reducing secondary radiation and exposure time
bull Always use a lead apronbull Exposure to fetus (with apron use) is 00001
centiGray(rad)bull Daily cosmic radiation - 0004 centiGray (rad)
Risks of Dental X-Rays
bull X-ray only if necessary (ie root canal therapy trauma)
bull When x-rays are indicated radiation exposure is extremely low
bull Exposure can be limited byndash Lead apron shielding ndash Modern fast film ndash Avoiding retakes
FDA drug classification for pregnancybull Combines risk statements including
congenital anomalies fetal effects perinatal risks and therapeutic risk-benefit ratio
bull Untreated disease or condition may pose more serious risks to both mother and fetus than any theoretical risks from the medication
bull Category A thru D and X
FDA drug classification for pregnancy
bull A = Controlled Studies in women fail to demonstrate a risk to the fetus in the first trimester and the possibility of fetal harm appears remote
FDA drug classification for pregnancy
bull B = Animal studies show no risk or if risk shown in animals controlled
trials in women showed no risk
FDA drug classification for pregnancy
bull C = Studies in animals with adverse effects and no human studies
OR no animal or human studies but benefits of use may outweigh potential harms
FDA drug classification for pregnancy
bull D = There is evidence of human fetal risk but benefits may outweigh risks
FDA drug classification for pregnancy
bull X = Contraindicated
Common Analgesics
bull paracetamol (B)bull Ibuprofen (BD) bull Oxycodone (BD) bull Hydrocodone and codeine
(CD)
avoid in third trimester
Analgesics
bull Paracetamol is the analgesic of choice for all stages of gestation
bull used to treat mild to moderate pain and fevers
bull short term usage is believed to be safebull avoid chronic and large doses of
paracetamol1048715
Analgesics - continuedbull Aspirin is nonteratogenic but may cause
maternal and fetal hemorrhagebull large and chronic doses during last trimester
may result in premature closure of ductus arteriosus fetal hypertension anemia and low birth weight
bull avoid ibuprofen in 3rd trimester because of possible adverse circulatory effects
bull short term use of codeine seems safebull avoid codeine late in gestation because of
possible fetal respiratory depression and withdrawal symptoms
Analgesics to Use During1st and 2nd Trimester
bull Category B (for best)bull Paracetamol Ibuprofenbull Naproxenbull Category C (use with caution)bull Paracetamol with codeine or
hydrocodonebull Paracetamol with oxycodone
Analgesics to Avoid During theThird Trimesterbull Causes delivery problemsbull Aspirin (C 3D)bull Ibuprofen (B3D)bull Naproxen (B3D)bull Causes neonatal respiratory
depression and opioid withdrawalbull Codeine (C3D)bull Hydrocodone (C3D)bull Oxycodone(C3D)
Sedation in Pregnancy
bull SedativesAnxiolytics (eg Diazepam ) are rated D and can cause oral clefts with prolonged exposure
bull Nitrous oxide should not be used in 1st trimester (If used in 2nd and 3rd do not go below 50 O2)
Common Antibioticsbull To treat oral abscess or cellulitis
ndash Penicillin (B) ndash Amoxicillin (B) ndash Cephalexin (B)ndash Erythromycin base (B) (Not estolate as it
cause cholestatic hepatitis)ndash Clindamycin (B)
Antibioticsbull penicillin V and amoxicillin is preferred drug
for mild to moderate infectionsbull widely used for many years with no ill effectsbull no studies show penicillin to be teratogenicbull amoxicillin extensively used without harming
the fetusbull Drug classes1048715 B penicillin cephalosporins erythromycin clindamycin Azithromycin D Tetracycline
Antibiotics To Use During Pregnancy
bull Penicillin Vbull Amoxicillinbull Erythromycin (base form)bull Cephalexin cephalosporinbull Clindamycinbull Metronidazole
Antibiotics to Avoid duringPregnancy
bull Doxycyclinebull Tetracyclinebull Erythromycin (estolate form)bull Vancomycin
The Problem With Tetracycline
bull Accumulates in bones and chelates calcium
bull Inhibits bone growthbull Discolors teeth
Other Antimicrobial Agentsbull OK to usebull Nystatin (B)bull Chlorhexidine rinse (B)bull Use with cautionbull Clotrimazole (C)bull Ketoconazole (C)bull Fluconazole (C)bull Do not usebull Doxycycline (D)
Local Anesthetic Use inPregnancy
bull Class Bbull Lidocaine (Xylocaine)bull Etidocainebull Prilocaine bull Class Cbull Procainebull Bupivicainebull Mepivicaine
Use of Local Anestheticsbull Lidocaine + vasoconstrictor most common
local anesthetic used in dentistrybull extensively used in pregnancy with no proven ill
effectsbull accidental intravascular injections of lidocaine
pass through the placenta but the concentrations are too low to harm fetus
bull prilocaine might cause methemoglobinemia
Ulcer healing drugsCimetidine bull FDA category B Famotidinebull FDA category BRanitidinebull FDA category Bbull not known to be harmful
Ulcer healing drugsOmeprazolebull FDA category BNot known to be
harmful Esomeprazolebull FDA category BLansoprazolebull FDA category BPantoprazolebull Avoid unless potential benefit
outweighs riskmdashfetotoxic in animals
Ulcer healing drugs
Misoprostolbull First second third trimesters Avoidmdash
potent uterine stimulant (has been used to induce abortion) and may be teratogenic
Ulcer healing drugs
Antacidsbull Almunium hydroxideMagnesium
hydroxidemdashFDA category B Calcium carbonatemdashFDA category C
SimetheconemdashFDA category C
Use of Nitrous Oxide Gas
bull used over 150 years bull safety is being debatedbull SHORT TERM exposure do not cause
birth defects or spontaneous abortionbull CHRONIC exposure may result in fetal
loss and infertilitybull literature suggests that nitrous oxide
should be avoided until more conclusive research is available
bull FDA Drug class not yet assigned
Common Preventives
bull Fluoridendash No increased risk during pregnancy
bull Xylitolndash No studies no harm reported
bull Chlorhexidinendash No increased risk during pregnancy
Are topical agents safe
bull Fluoridebull Toothpaste amp mouthrinse
bull Xylitol chewing gum bull Chlorhexidine (11 alcohol)bull No over the counter mouthrinses with
alcohol (Listerine 20 alcohol)
Pre-natal Fluoride
bull Daily 22 mg tablet of sodium fluoride during 3rd through 9th months
bull decreases caries rate in offspringbull Safe and effective
Glenn FB 1982
Is it safe to use mercury restorations
bull No evidence of harmful effect
bull Benefits outweigh risks
bull Canada Germany and New Zealand have some restrictions
bull Determine the best option
Referencesbull Wasylko L Matsui D Dykxhoorn SM Rieder MJ Weinberg
S A Review of Common Dental Treatments During Pregnancy J Canadian Dental Association 64434-439 1998
bull Little JW Donald AF Craig SM Rhodus NL Dental Management of the Medically Compromised Patient - 5th edition Mosby Toronto Pp434-442 1997
bull Livingston HM Dellinger TM Holder R Considerations in the management of the pregnant patient Special Care in Dentistry 185 pp183-188 1998
bull Larimore WL Petrie KA Drug use during pregnacy and lactation Primary Care Clinics in Office Practice 271 35-53 2000
bull Health Canada The Safety of DentalAmalgam Minister Of Supply and Services Canada 1996
REFERENCESbull 1 Weiss G Endocrinology of parturition J Clin
Endocrinol Metab 2000854421-5bull 2 Theunissen IM Parer JT Fluid and electrolytes in
pregnancy Clin Obstet Gynecol 1994373-15bull 3 Duvekot JJ Peeters LLH Renal hemodynamics and
volume homeostasis in pregnancy Obstet Gynecol Surv 199449830-9
bull 4 Barron WM Lindheimer MD Medical disorders during pregnancy 2nd ed St Louis Mosby 1995 p 129
bull 5 Thornburg KL Jacobson SL Giraud GD Morton MJ Hemodynamic changes in pregnancy Semin Perinatol 20002411-4
bull 6 Fiese R Herzog S Issues in dental and surgical management of the pregnant patient Oral Surg Oral Med Oral Pathol 198865292-7
bull 7 Martin C Varner MW Physiologic changes in pregnancysurgical implications Clin Obstet Gynecol 199437241-55
bull 8 Clark SL Cotton DB Lee W Bishop C Hill T Southwick J et al Central hemodynamic assessment of normal term pregnancy Am J Obstet Gynecol 19891611439-42
bull 9 Mabie WC Di Sessa TG Crocker LG Sibai BM Arheart KL A longitudinal study of cardiac output in normal human pregnancy Am J Obstet Gynecol 1994170849-56
bull 10 Clapp JF 3rd Capeless E Cardiovascular function before during and after the first and subsequent pregnancies Am J Cardiol 1997801469-73
bull 11 Duvekot JJ Peeters LL Maternal cardiovascular hemodynamic adaptation to pregnancy Obstet Gynecol Surv 199449(Suppl) S1-14
bull 12 Bhagwat AR Engel PJ Heart disease and pregnancy Cardiol Clin 199513163-78
bull 13 Lanni SM Tillinghast J Silver H Hemodynamic changes and baroreflex gain in the supine hypotensive syndrome Am J Obstet Gynecol 20021871636-41
bull 14 Little JW Falace DA Miller CS Rhodus NL Dental management of the medically compromised patient 6th ed St Louis Mosby 2002 p 303
bull 15 Garcia-Rio F Pino JM Gomez L Alvarez-Sala R Villasante C Villamor J Regulation of breathing and perception of dyspnea in healthy pregnant women Chest 1996110446-53
bull 16 McAuliffe F Kametas N Costello J Rafferty GF Greenough A Nicolaides K Respiratory function in singleton and twin pregnancy BJOG 2002109765-9
bull 17 Clapp JF 3rd Seaward BL Sleamaker RH Hiser J Maternal physiologic adaptations to early human pregnancy Am J Obstet Gynecol 19881591456-60
bull 18 OrsquoDay MP Cardio-respiratory physiological adaptation of pregnancy Semin Perinatol 199721268-75
bull 19 Contreras G Gutierrez M Beroiza T Fantin A Oddo H Villarroel L et al Ventilatory drive and respiratory muscle function in pregnancy Am Rev Respir Dis 1991144837-41
bull 20 Turner M Aziz SR Management of the pregnant oral and maxillofac
bull 21 Sifakis S Pharmakides G Anemia in pregnancy Ann N Y Acad Sci 2000900125-36
bull 22 Branch DW Physiologic adaptations of pregnancy Am J Reprod Immunol 199228120-2
bull 23 Burrows RF Kelton JG Incidentally detected thrombocytopenia in healthy mothers and their infants N Engl J Med 1988319 142-5
bull 24 Hanly JG Antiphospholipid syndrome an overview CMAJ 200324(168)1675-82
bull 25 Heilmann L von Tempelhoff GF Pollow K Antiphospholipid syndrome in obstetrics Clin Appl Thromb Hemost 20039 143-50
bull 26 Sherman P Flaxman SM Nausea and vomiting of pregnancy in an evolutionary perspective Am J Obstet Gynecol 2002 185(Suppl)s190-7
bull 27 Koch KL Gastrointestinal factors in nausea and vomiting of pregnancy Am J Obstet Gynecol 2002185(Suppl)s198-203
bull 28 Koch KL Frissora CL Nausea and vomiting during pregnancy Gastroenterol Clin N Am 200332201-34
bull 29 Baron TH Ramirez B Richter JE Gastrointestinal motility disorders during pregnancy Ann Intern Med 1993118 366-75
bull 30 Richter JE Gastroesophageal reflux disease during pregnancy Gastroenterol Clin N Am 200332235-61
bull 31 Marrero JM Goggin PM de Caestecker JS Pearce JM Maxwell JD Determinants of pregnancy heartburn Br J Obstet Gynaecol 199299731-4
bull 32 Hamaoui E Hamaoui M Nutritional assessment and support during pregnancy Gastroenterol Clin N Am 20033259-121
bull 33 King JC Physiology of pregnancy and nutrient metabolism Am J Clin Nutr 200071(suppl)1218s-25s
bull 34 Casanueva E Pfeffer F Fernandez-Gaxiola AC Gutierrez- Valenzuela V Rothenberg SJ Iron and folate status before pregnancy and anemia during pregnancy Ann Nutr Metab 2003 4760-3
bull 35 Chrsquong CL Morgan M Hainsworth I Kingham JG Prospective study of liver dysfunction in Southwest Wales Gut 200251 876-80
bull 36 Rahman TM Wendon J Severe hepatic dysfunction in pregnancy QJM 200295343-57
bull 37 Knox TA Olans LB Liver disease in pregnancy N Engl J Med 1996335569-76
bull 38 Saftlas AF Olson DR Franks AL Atrash H Pokras R Epidemiology of preeclampsia and eclampsia in the United States 1979e1986 Am J Obstet Gynecol 1990163460-5
bull 39 Walker JJ Pre-eclampsia Lancet 20003561260-5
bull 40 Davidson JM Renal disorders in pregnancy Curr Opin Obstet Gynecol 200113109-14
bull 41 Dafnis E Sabatini S The effect of pregnancy on renal function physiology and pathophysiologyAmJMedSci 1992303184-205
bull 42 Davison JM Shiells EA Philips PR Lindheimer MD Serial evaluation of vasopressin release and thirst in human pregnancy Role of human chorionic gonadotrophin in the osmoregulatory changes of gestation J Clin Invest 198881798-806
bull 43 Glinoer D de Nayer P Bourdoux P Lemone M Robyn C van Steirteghem A et al Regulation of maternal thyroid during pregnancy J Clin Endocrinol Metab 199071276-87
bull 44 Wilson SG Retallack RW Kent JC Worth GK Gutteridge DH Serum free 125-dihydroxyvitamin D and the free 125- dihydroxyvitamin D index during a longitudinal study of human pregnancy and lactation Clin Endocrinol 199032613-22
bull 45 Rasmussen N Frolich A Hornnes PJ Hegedus L Serum ionized calcium and intact parathyroid hormone levels during pregnancy and postpartum Br J Obstet Gynaecol 199097857-9
bull 46 Guyton AC Textbook of medical physiology 8th ed Philadelphia W B Saunders 1991 p 915e28
bull 47 Trainer PJ Corticosteroids and pregnancy Semin Reprod Med 200220375-80
bull 48 Soory M Hormonal factors in periodontal disease Dent Update 200027380-3
bull 49 Hugoson A Gingivitis in pregnant women A longitudinal clinical study Odontol Revy 19712265-84
bull 50 Neville BW Damm DD Allen CM Bouquot JE Oral amp Maxillofacial Pathology 3rd ed Philadelphia W B Saunders 2002 p 329-30 447-9
bull 51 Tilakaratne A Soory M Ranasinghe AW Corea SM Ekanayake SL de Silva M Periodontal disease status during pregnancy and 3 months post-partum in rural population of Sri-Lankan women J Clin Periodontol 200027787-92
bull 52 Laine M Tenovuo J Lehtonen OP Ojanatko-Harri A Vilja P Tuohimaa P Pregnancy e related changes in human whole saliva Arch Oral Biol 198833913-7
bull 53 Yuan K Wing LY Lin MT Pathogenetic roles of angiogenic factors in pyogenic granulomas in pregnancy are modulated by female sex hormones J Periodontol 200273701-8
bull 54 Evans RD Briggs PF Tooth-surface loss related to pregnancyinduced vomiting Prim Dent Care 1994124-6
bull 55 Salvolini E Di Giorgio R Curatola A Mazzanti L Fratto G Biochemical modifications of human whole saliva induced by pregnancy Br J Obstet Gynaec 1998105656-60
bull 56 Mauldin JG Newman RB Preterm birth risk assessment Semin Perinatol 200125215-22
bull 57 Heine RP McGregor JA Goodwin TM Artal R Hayashi RH Robertson PA et al Serial salivary estriol to detect an increased risk of preterm birth Obstet Gynecol 200096490-7
bull 58 Kauh YC Zachian TF Melasma Adv Exp Med Biol 1999455 491-9
bull 59 Wong RC Ellis CN Physiologic skin changes in pregnancy J Am Acad Dermatol 198410929-40
bull 60 Errickson CV Matus NR Skin disorders of pregnancy Am Fam Physician 199449605-10
bull 61 Lopez NJ Smith PC Gutierrez J Periodontal therapy may reduce the risk of preterm low birth weight in women with periodontal disease a randomized controlled trial J Periodontol 200273911-24
bull 62 McGaw T Periodontal disease and preterm delivery of lowbirth- weight infants J Can Dent Assoc 200268165-9
bull 63 Richards AG Dental x-ray protection Dent Clin North Am 1968631-41
bull 64 1990 Recommendations of the International Commission on Radiological Protection Ann ICRP 1991211-201
bull 65 Hall EJ Radiation the two-edged sword cancer risks at high and low doses Cancer J 20006343-50
bull 66 Diethelm L Xu H Diagnostic imaging of the lung during pregnancy Clin Obstet Gynecol 19963936-55
bull 67 Brent RL The effects of embryonic and fetal exposure to x-rays microwaves and ultrasound ClinObstetGynecol 198326484-510
bull 68 National Council on Radiation Protection NCRP report no128 1998 Bethesda Md Author
bull 69 Wasylko L Matsui D Dykxhoorn SM Reider MJ Weinberg S A review of common dental treatments during pregnancy implications for patients and dental personnel J Can Dent Assoc 199864434-9
bull 70 Freeman JP Brand JW Radiation doses of commonly used dental radiographic surveys Oral Surg Oral Med Oral Pathol 199477285-9
bull 71 Kircos LTAngin LL Lorton LOrder ofmagnitude dose reduction in intraoral radiography J Am Dent Assoc 1987114344-7
bull 72 Updegrave WJ Simplified and standardized intraoral radiography with reduced tissue irradiation J Am Dent Assoc 197285861-9
bull 73 Wood RE Harris AM van der Merwe EJ Nortje CJ The leaded apron revisited does it reduce gonadal radiation dose in dental radiology Oral Surg Oral Med Oral Pathol 199171642-6
bull 74 An update on radiographic practices information and recommendations ADA Council on Scientific Affairs J Am Dent Assoc 2001132234-8
bull 75 Rayburn WF Recommending medications during pregnancy an evidence based approach Clin Obstet Gynecol 2002451-5
bull 76 Rathmell JP Viscomi C Ashburn MA Management of nonobstetric pain during pregnancy and lactation Anesth Analg 1997851074-87
bull 77 Teratology society public affairs committee FDA classification of drugs for teratogenic risk Teratology 199449446-7
bull 78 Moore PA Selecting drugs for the pregnant dental patient J Am Dent Assoc 19981291281-6
bull 79 Haas DA An update on analgesics for the management of acute postoperative dental pain J Can Dent Assoc 200268476-82
bull 80 Haas DA Pynn BR Sands TD Drug use for the pregnant or lactating patient Gen Dent 20004854-60
bull 81 Committee on Drugs American Academy of Pediatrics The transfer of drugs and other chemicals into human milk Pediatrics 199493137-50
bull 82 Nielsen GL Sorensen HT Larsen H Pedersen L Risk of adverse birth outcome and miscarriage in pregnant users of nonsteroidal anti-inflammatory drugs population based observational study and case-control study BMJ 2001322266-70
bull 83 Janssen N Genta M The effects of immunosuppressive and anti-inflammatory medications on fertility pregnancy and lactation Arch Intern Med 200016610-9
bull 84 Ostensen M Nonsteroidal anti-inflammatory drugs during pregnancy Scand J Rheumatol Suppl 1998107128-32
bull 85 USPDI -Drug information for the health care professional 22nd ed Greenwood Village CO Micromedex 2002 p 152-79
bull 86 Denson DD Coyle DE Thompson GA Santos D Turner PA Myers JA et al Bupivacaine protein binding in the term parturient effects of lactic acidosis Clin Pharmacol Ther 198435702-9
bull 87 Dillon DE Wagner CL Wiest D Newman RB Drug therapy in the nursing mother Obstet Gynecol Clin North Am 199724 675-96
bull 88 Dashe JS Gilstrap LC Antibiotic use in pregnancy Obstet Gynecol Clin North Am 199724617-29
bull 89 American College of Rheumatology Ad hoc Committee on Clinical Guidelines Guidelines for monitoring drug therapy in rheumatoid arthritis Arthritis Rheum 199639723-31
bull 90 Ng PC The fetal and neonatal hypothalamic-pituitary-adrenal axis Arch Dis Child Fetal Neonatal Ed 200082F250-4
bull 91 Crowley P Antenatal corticosteroidsmdashcurrent thinking BJOG 2003110(Suppl 20)77-8
bull 92 ACOG committee opinion antenatal corticosteroid therapy for fetal maturation Obstet Gynecol 200299871-3
bull 93 Ost L Wettrell G Bjorkhem I Rane A Prednisolone excretion in human milk J Pediatr 19851061008-11
bull 94 Rowland AS Baird DD Shore DL Weinberg CR Savitz DA Wilcox AJ Nitrous oxide and spontaneous abortion in female dental assistants Am J Epidemiol 1995141531-8
bull 95 McGlothlin JD Jensen PA Fischbach TJ Hughes RT Jones JH Control of anesthetic gases in dental operatories Scand J Work Environ Health 199218(Suppl 2)103-5
bull ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY Volume 97 Number 6 Suresh and Radfar 681
bull 96 Rosen MA Nitrous oxide for relief of labor pain a systematic review Am J Obstet Gynecol 2002186(Suppl Nature)S110-6
bull 97 Sands TD Pynn BR Management considerations for the pregnant or nursing emergency patient Ont Dent 199875 17-9
bull 98 Daya S Recurrent spontaneous early pregnancy loss and low dose aspirin Minerva Ginecol 200355441-9
bull 99 Sinclair C Handbook of obstetrical emergencies 1st ed Philadelphia WB Saunders 1996 p 29-39 69
bull 100 Tarsitano BF Rollings RE The pregnant dental patient evaluation and management Gen Dent 199341226-34
bull 101 Livingston MH Dlllinger TM Holder R Consideration in the management of the pregnant patient SCD Special Care in Dentistry 199818183-8
Thank you
- A Review on the principle of Dental Management of the Pregnant patient
- Slide 2
- Questions that a dentist may ask
- Stages of Pregnancy
- Slide 5
- Slide 6
- Physiologic Changes in Pregnancy
- Systemic changes in pregnancy
- FLAT SUPINE POSITIONING
- SUPINE HYPOTENSION SYNDROME (Vena Cava Compression)
- Supine Hypotension Syndrome
- Slide 12
- Supine Hypotension Syndrome
- Prevention of Supine Hypotensive Syndrome
- Treatment of Supine Hypotensive Syndrome
- How should the pregnant woman be positioned
- Slide 17
- Slide 18
- Slide 19
- Slide 20
- Slide 21
- Slide 22
- Slide 23
- Pregnancy Related Oral Health Problems
- Oral Problems in Pregnancy
- Pregnancy Gingivitis Pathophysiology
- Pregnancy Gingivitis
- Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Gum Problems - Pregnancy Granuloma
- Slide 31
- Gum Changes - Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Candidiasis
- Pregnancy Myths
- Other Oral Conditions in Pregnancy
- Changes During Pregnancy that Affect Oral Health
- Saliva changes
- Increased Bacteria
- Slide 40
- Enamel erosion caused by frequent vomiting
- Treatment for Acid Exposure
- Oral Diseases Can Effect Pregnancy
- Periodontal Disease and Preterm Labor
- Periodontal Disease and Low Birth Weight
- Periodontal Disease and Preeclampsia
- Periodontitis and Pre-eclampsia
- Dental Considerations
- Treatment Timing
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Slide 52
- Use of Radiation on Pregnant Patient
- Radiographs during Pregnancy
- Risks of Dental X-Rays
- FDA drug classification for pregnancy
- Slide 57
- FDA drug classification for pregnancy
- Slide 59
- Slide 60
- Slide 61
- Common Analgesics
- Analgesics
- Analgesics - continued
- Analgesics to Use During 1st and 2nd Trimester
- Analgesics to Avoid During the Third Trimester
- Sedation in Pregnancy
- Common Antibiotics
- Antibiotics
- Antibiotics To Use During Pregnancy
- Antibiotics to Avoid during Pregnancy
- The Problem With Tetracycline
- Other Antimicrobial Agents
- Local Anesthetic Use in Pregnancy
- Use of Local Anesthetics
- Ulcer healing drugs
- Slide 77
- Slide 78
- Slide 79
- Use of Nitrous Oxide Gas
- Common Preventives
- Are topical agents safe
- Pre-natal Fluoride
- Is it safe to use mercury restorations
- References
- REFERENCES
- Slide 87
- Slide 88
- Slide 89
- Slide 90
- Slide 91
- Slide 92
- Slide 93
- Slide 94
- Slide 95
- Slide 96
- Slide 97
- Slide 98
- Thank you
-
Systemic changes in pregnancyCardiovascular system uarr in blood volume by an average of 45bull Anemia due to increased blood volume
(20 of women) darr in pulse by 10-15 beats per minute Systemic murmur occurs in 90 of
pregnancies disappears shortly after delivery
uarrcardiac output Supine hypotension syndrome may occur
FLAT SUPINE POSITIONING
bullNegatively impacts mother and infant
SUPINE HYPOTENSIONSYNDROME (Vena Cava Compression)
bull SUPINE POSITION AFTER 5TH MONTH
bull UTERUS COMPRESSES THE INFERIOR VENA CAVA
bull uarrVOL BLOOD IN THE LErsquoS bull darrRETURN TO THE HEARTbull REDUCED PERFUSION OF
UTERUS bull FETAL HYPOXIA
Supine Hypotension Syndrome
bull Obstruction of inferior vena cava and aorta from pressure of the large fetus
Symptoms Sweating Nausea Weakness Sense of lack of air
Supine Hypotension Syndrome
Other symptomsbull Drop in blood pressurebull Bradycardiabull Possible loss of consciousness
Prevention of Supine HypotensiveSyndrome
bullElevate right hip 10-12 cmbullWeight is taken off the major vessels
Treatment of Supine HypotensiveSyndrome
bullRoll patient onto her left side
How should the pregnant woman be positionedbull Flat position may
cause hypotension and hypoxia
bull Place a small pillow under right hip - left lateral displacement
bull Head above feet
Systemic changes in pregnancy
Diaphragm rises about 4 cm darr residual volume uarr awareness of a desire to breath is
common-may be interpreted as dyspnea Increased estrogen in blood causes
engorgement of the nasal capillaries and rhnitis in pregnant women
Frequent nosebleeds amp predisposition to upper respiratory infection
Respiratory system
Systemic changes in pregnancy
Gastrointestinal system Gastric emptying amp intestinal transit times
are delayed
Heart burn reflux common
Nausea and vomiting common
Systemic changes in pregnancy
For pregnant patient with Hyper-emesis gravidarium ( excessive and uncontrolled vomiting) morning appointments should be avoided
They should be seated in a semi-supine or comfortable position
In case of vomiting the procedure should be stopped immediately amp the patient should be repositioned upright
When vomiting is over rinsing mouth with cold water or mouthwash is recommended
Systemic changes in pregnancybull Urinary System uarr GFR amp renal plasma flow by as much as
50 Nocturia ndashto mobilize the dependent
edema which accumulate during the day uarr Frequency from uarr renal flow plus reduced
bladder capacity from uterine growth It is advisable to ask the patient to void the
bladder just prior to starting the dental procedure
Systemic changes in pregnancyEndocrine Changes uarrEstrogen uarr progesterone uarrhuman
gonadotropin uarr thyroxin steroid and insulin level Estrogen amp progesterone are insulin
antagonists uarr level of these hormones lead to insulin resistance Thus insulin levels are elevated in pregnant in pregnant patient to compensate this resistance
About 45 of women fail to produce sufficient amount of insulin to overcome this antagonist action amp thus develop gestational diabetes
Systemic changes in pregnancy
Hematological changebull uarr red RBC uarrESR darrHbbull uarrWBCbull uarr circulatory catecholamin amp cortisol lead
to leucositosis bull uarr Coagulation factors except factor XI amp
XIII (anticloting factor) bull so pregnancy is a hypercoagulable state amp
uarr risk for thromboembolism
Systemic changes in pregnancy
bull Pregnant women with anti-phospholipid syndrome are at uarr risk for thrombo-embolisim
bull They are placed on subcutaneous low molecular weight heparin (LMWH)
bull These patients must be hospitalized for dental care
Pregnancy RelatedOral Health Problems
bull Pregnancy Gingivitisbull Pregnancy Epulis bull Increased Tooth Mobilitybull Dental Cariesbull Erosionbull Dental Problems in relation to Labor
and Delivery
Oral Problems in Pregnancy
bullPregnancy GingivitisbullMost common oral manifestation (50-100 of women)bullCaused by hormonal and vascular changes of pregnancy
Pregnancy Gingivitis Pathophysiology
bull Elevated circulating estrogen increases capillary permeability
bull Preexisting gingivitis may predispose to pregnancy gingivitis
Pregnancy Gingivitis
bullOccurs commonly in the 2nd to 8th monthsbullTendency to bleed very easilybullTreatment Scaling root-planing currettage OHI
Pregnancy Granuloma
bullOccurs in up to 5 of womenbullMost common in buccal maxillary anterior areasbullUsually starts in an area of gingivitis
Pregnancy Granuloma (continued)
bullRapid growth up to 2 cmbullSingle tumor-like growthbullusually in interdental papillaebullPurplish to bluish in color may be ulcerated- bleeds easily
Gum Problems - Pregnancy Granuloma
Gum Problems - Pregnancy Granuloma
Gum Changes - Pregnancy Granuloma
Pregnancy Granuloma (continued)
Treatment
bull Scaling and root planingbull Excision if it is too large or bleeds too
easilybull May regress spontaneously after
pregnancy
Candidiasis
bullWipes offbullUsually asymptomatic but may burnbullTreatment topical or systemic antifungals
Pregnancy MythsbullldquoA mother loses a tooth for every babyrdquobullNo evidence that aphthous ulcers are any more common in pregnancy
Other Oral Conditions in Pregnancy
bull Dry mouthbull Excessive salivationbull Tooth erosions associated with
severe GERD or hyperemesis
Changes During Pregnancy that Affect Oral Health
bull Hormonal Affects
ndash Increased tooth mobility
ndash Saliva changes
ndash Increased bacteria
ndash Gingival problems
Saliva changesbull Decreased buffers
bull Decreased minerals
bull Decreasing flow first and last trimester
bull Increased flow second trimester
bull More acidic
Increased Bacteriabull Increased acidity
ndash Increase in decay-causing bacteriabull Increased Snacking
ndash Morning sicknesslow blood sugarndash Between-meal snacks
bull Increase in amount and frequency of starchescarbohydrates ndash Crackers are commonly recommendedndash Promotes decay-causing bacteria
Changes During Pregnancy that Affect Oral Healthbull Morning sickness
ndash Difficulty with hygienebull Gingival diseasebull Tooth decay
ndash Vomitingbull Esophogeal Reflux (heartburn)bull Acid exposure
ndash Irritation of the gumsndash Weakening of tooth enamelndash Dental erosion
Enamel erosion caused by frequent vomiting
Treatment for Acid Exposure
bull Do NOT brush immediately after vomiting
bull Rinse ndash Water with baking sodandash Antacidndash Plain water
bull Eat some cheese
Oral Diseases Can Effect Pregnancy
bull Preterm low birth weight (LBW) linked to periodontal disease
bull Thorough calculus (tartar) removal in pregnant women with periodontitis may reduce pre-term births
Periodontal Disease and Preterm LaborbullMaternal periodontal disease is associated with increased risk of preterm laborbullAnaerobic oral gram-negative bacteria cause inflammatory responsebullInflammatory response stimulates prostaglandin and cytokine production to stimulate labor
Periodontal Disease and Low Birth Weight
bull Periodontal disease is associated with low birth weight
bull Evidence is not conclusivebull Biochemical mechanism similar cascade
as in preterm labor leading to placental blood flow restriction and necrosis
Periodontal Disease and Preeclampsia
bull Emerging databull Mechanism unclearbull Proposed mechanism
ndash Periodontal infection leads to inflammatory vascular damage
ndash Triggers cell damage in placenta
Periodontitis and Pre-eclampsia
bull Periodontal disease may be associated with pre-eclampsia (Boggess 2003)
bull PGE2 IL-1 and TNF-α from gingival crevicular fluid were higher in women with preeclampsia compared with healthy matched pregnant women (Oettinger-Barak 2003)
Dental Considerations
bull timing of treatment for pregnant patientsbull dental radiation exposurebull use of local anestheticsbull prescription of common antibiotics and
analgesicsbull nitrous oxide gas administration
Treatment Timing
bull First Trimesterndash Spontaneous miscarriages naturally occur
more often in 1st trimesterndash Avoid elective treatment that can be delayedndash Offer anticipatory guidance
bull Second Trimesterndash The optimal time for dental treatmentndash Organogenesis complete fetus not largendash Easier to prevent than treat established disease
bull Third Trimesterndash Late in term very uncomfortable (short visits)ndash Position slightly on left side
Timing of Dental Treatment During Pregnancy - From Little and Fallace
First Trimester
bull Plaque controlbull Oral hygiene instructionbull Scaling polishing curettagebull Avoid elective treatment urgent care
only
Timing of Dental Treatment During Pregnancy - From Little and Fallace
Second Trimester
bull Plaque controlbull Oral hygiene instructionbull Scaling polishing curettagebull Routine dental care
Timing of Dental Treatment During Pregnancy - From Little and Fallace
Third Trimester
bull Plaque controlbull Oral hygiene instructionbull Scaling polishing curettagebull Routine dental care (after middle of third
trimester elective care should be avoided)
Use of Radiation on Pregnant Patientbull Dose given and time of gestation are
importantbull doses lt 5-10 rads (cGy) not teratogenicbull fetus is most susceptible to radiation
between the 2nd and 6th week of gestationbull single dental x-ray exposes patient to 001
millirads of radiation In relative terms this amount is 40 times less than daily dose acquired from cosmic radiation Therefore diagnostic radiation should not be withheld during pregnancy
Radiographs during Pregnancy
bull Take as needed with optimal methods for reducing secondary radiation and exposure time
bull Always use a lead apronbull Exposure to fetus (with apron use) is 00001
centiGray(rad)bull Daily cosmic radiation - 0004 centiGray (rad)
Risks of Dental X-Rays
bull X-ray only if necessary (ie root canal therapy trauma)
bull When x-rays are indicated radiation exposure is extremely low
bull Exposure can be limited byndash Lead apron shielding ndash Modern fast film ndash Avoiding retakes
FDA drug classification for pregnancybull Combines risk statements including
congenital anomalies fetal effects perinatal risks and therapeutic risk-benefit ratio
bull Untreated disease or condition may pose more serious risks to both mother and fetus than any theoretical risks from the medication
bull Category A thru D and X
FDA drug classification for pregnancy
bull A = Controlled Studies in women fail to demonstrate a risk to the fetus in the first trimester and the possibility of fetal harm appears remote
FDA drug classification for pregnancy
bull B = Animal studies show no risk or if risk shown in animals controlled
trials in women showed no risk
FDA drug classification for pregnancy
bull C = Studies in animals with adverse effects and no human studies
OR no animal or human studies but benefits of use may outweigh potential harms
FDA drug classification for pregnancy
bull D = There is evidence of human fetal risk but benefits may outweigh risks
FDA drug classification for pregnancy
bull X = Contraindicated
Common Analgesics
bull paracetamol (B)bull Ibuprofen (BD) bull Oxycodone (BD) bull Hydrocodone and codeine
(CD)
avoid in third trimester
Analgesics
bull Paracetamol is the analgesic of choice for all stages of gestation
bull used to treat mild to moderate pain and fevers
bull short term usage is believed to be safebull avoid chronic and large doses of
paracetamol1048715
Analgesics - continuedbull Aspirin is nonteratogenic but may cause
maternal and fetal hemorrhagebull large and chronic doses during last trimester
may result in premature closure of ductus arteriosus fetal hypertension anemia and low birth weight
bull avoid ibuprofen in 3rd trimester because of possible adverse circulatory effects
bull short term use of codeine seems safebull avoid codeine late in gestation because of
possible fetal respiratory depression and withdrawal symptoms
Analgesics to Use During1st and 2nd Trimester
bull Category B (for best)bull Paracetamol Ibuprofenbull Naproxenbull Category C (use with caution)bull Paracetamol with codeine or
hydrocodonebull Paracetamol with oxycodone
Analgesics to Avoid During theThird Trimesterbull Causes delivery problemsbull Aspirin (C 3D)bull Ibuprofen (B3D)bull Naproxen (B3D)bull Causes neonatal respiratory
depression and opioid withdrawalbull Codeine (C3D)bull Hydrocodone (C3D)bull Oxycodone(C3D)
Sedation in Pregnancy
bull SedativesAnxiolytics (eg Diazepam ) are rated D and can cause oral clefts with prolonged exposure
bull Nitrous oxide should not be used in 1st trimester (If used in 2nd and 3rd do not go below 50 O2)
Common Antibioticsbull To treat oral abscess or cellulitis
ndash Penicillin (B) ndash Amoxicillin (B) ndash Cephalexin (B)ndash Erythromycin base (B) (Not estolate as it
cause cholestatic hepatitis)ndash Clindamycin (B)
Antibioticsbull penicillin V and amoxicillin is preferred drug
for mild to moderate infectionsbull widely used for many years with no ill effectsbull no studies show penicillin to be teratogenicbull amoxicillin extensively used without harming
the fetusbull Drug classes1048715 B penicillin cephalosporins erythromycin clindamycin Azithromycin D Tetracycline
Antibiotics To Use During Pregnancy
bull Penicillin Vbull Amoxicillinbull Erythromycin (base form)bull Cephalexin cephalosporinbull Clindamycinbull Metronidazole
Antibiotics to Avoid duringPregnancy
bull Doxycyclinebull Tetracyclinebull Erythromycin (estolate form)bull Vancomycin
The Problem With Tetracycline
bull Accumulates in bones and chelates calcium
bull Inhibits bone growthbull Discolors teeth
Other Antimicrobial Agentsbull OK to usebull Nystatin (B)bull Chlorhexidine rinse (B)bull Use with cautionbull Clotrimazole (C)bull Ketoconazole (C)bull Fluconazole (C)bull Do not usebull Doxycycline (D)
Local Anesthetic Use inPregnancy
bull Class Bbull Lidocaine (Xylocaine)bull Etidocainebull Prilocaine bull Class Cbull Procainebull Bupivicainebull Mepivicaine
Use of Local Anestheticsbull Lidocaine + vasoconstrictor most common
local anesthetic used in dentistrybull extensively used in pregnancy with no proven ill
effectsbull accidental intravascular injections of lidocaine
pass through the placenta but the concentrations are too low to harm fetus
bull prilocaine might cause methemoglobinemia
Ulcer healing drugsCimetidine bull FDA category B Famotidinebull FDA category BRanitidinebull FDA category Bbull not known to be harmful
Ulcer healing drugsOmeprazolebull FDA category BNot known to be
harmful Esomeprazolebull FDA category BLansoprazolebull FDA category BPantoprazolebull Avoid unless potential benefit
outweighs riskmdashfetotoxic in animals
Ulcer healing drugs
Misoprostolbull First second third trimesters Avoidmdash
potent uterine stimulant (has been used to induce abortion) and may be teratogenic
Ulcer healing drugs
Antacidsbull Almunium hydroxideMagnesium
hydroxidemdashFDA category B Calcium carbonatemdashFDA category C
SimetheconemdashFDA category C
Use of Nitrous Oxide Gas
bull used over 150 years bull safety is being debatedbull SHORT TERM exposure do not cause
birth defects or spontaneous abortionbull CHRONIC exposure may result in fetal
loss and infertilitybull literature suggests that nitrous oxide
should be avoided until more conclusive research is available
bull FDA Drug class not yet assigned
Common Preventives
bull Fluoridendash No increased risk during pregnancy
bull Xylitolndash No studies no harm reported
bull Chlorhexidinendash No increased risk during pregnancy
Are topical agents safe
bull Fluoridebull Toothpaste amp mouthrinse
bull Xylitol chewing gum bull Chlorhexidine (11 alcohol)bull No over the counter mouthrinses with
alcohol (Listerine 20 alcohol)
Pre-natal Fluoride
bull Daily 22 mg tablet of sodium fluoride during 3rd through 9th months
bull decreases caries rate in offspringbull Safe and effective
Glenn FB 1982
Is it safe to use mercury restorations
bull No evidence of harmful effect
bull Benefits outweigh risks
bull Canada Germany and New Zealand have some restrictions
bull Determine the best option
Referencesbull Wasylko L Matsui D Dykxhoorn SM Rieder MJ Weinberg
S A Review of Common Dental Treatments During Pregnancy J Canadian Dental Association 64434-439 1998
bull Little JW Donald AF Craig SM Rhodus NL Dental Management of the Medically Compromised Patient - 5th edition Mosby Toronto Pp434-442 1997
bull Livingston HM Dellinger TM Holder R Considerations in the management of the pregnant patient Special Care in Dentistry 185 pp183-188 1998
bull Larimore WL Petrie KA Drug use during pregnacy and lactation Primary Care Clinics in Office Practice 271 35-53 2000
bull Health Canada The Safety of DentalAmalgam Minister Of Supply and Services Canada 1996
REFERENCESbull 1 Weiss G Endocrinology of parturition J Clin
Endocrinol Metab 2000854421-5bull 2 Theunissen IM Parer JT Fluid and electrolytes in
pregnancy Clin Obstet Gynecol 1994373-15bull 3 Duvekot JJ Peeters LLH Renal hemodynamics and
volume homeostasis in pregnancy Obstet Gynecol Surv 199449830-9
bull 4 Barron WM Lindheimer MD Medical disorders during pregnancy 2nd ed St Louis Mosby 1995 p 129
bull 5 Thornburg KL Jacobson SL Giraud GD Morton MJ Hemodynamic changes in pregnancy Semin Perinatol 20002411-4
bull 6 Fiese R Herzog S Issues in dental and surgical management of the pregnant patient Oral Surg Oral Med Oral Pathol 198865292-7
bull 7 Martin C Varner MW Physiologic changes in pregnancysurgical implications Clin Obstet Gynecol 199437241-55
bull 8 Clark SL Cotton DB Lee W Bishop C Hill T Southwick J et al Central hemodynamic assessment of normal term pregnancy Am J Obstet Gynecol 19891611439-42
bull 9 Mabie WC Di Sessa TG Crocker LG Sibai BM Arheart KL A longitudinal study of cardiac output in normal human pregnancy Am J Obstet Gynecol 1994170849-56
bull 10 Clapp JF 3rd Capeless E Cardiovascular function before during and after the first and subsequent pregnancies Am J Cardiol 1997801469-73
bull 11 Duvekot JJ Peeters LL Maternal cardiovascular hemodynamic adaptation to pregnancy Obstet Gynecol Surv 199449(Suppl) S1-14
bull 12 Bhagwat AR Engel PJ Heart disease and pregnancy Cardiol Clin 199513163-78
bull 13 Lanni SM Tillinghast J Silver H Hemodynamic changes and baroreflex gain in the supine hypotensive syndrome Am J Obstet Gynecol 20021871636-41
bull 14 Little JW Falace DA Miller CS Rhodus NL Dental management of the medically compromised patient 6th ed St Louis Mosby 2002 p 303
bull 15 Garcia-Rio F Pino JM Gomez L Alvarez-Sala R Villasante C Villamor J Regulation of breathing and perception of dyspnea in healthy pregnant women Chest 1996110446-53
bull 16 McAuliffe F Kametas N Costello J Rafferty GF Greenough A Nicolaides K Respiratory function in singleton and twin pregnancy BJOG 2002109765-9
bull 17 Clapp JF 3rd Seaward BL Sleamaker RH Hiser J Maternal physiologic adaptations to early human pregnancy Am J Obstet Gynecol 19881591456-60
bull 18 OrsquoDay MP Cardio-respiratory physiological adaptation of pregnancy Semin Perinatol 199721268-75
bull 19 Contreras G Gutierrez M Beroiza T Fantin A Oddo H Villarroel L et al Ventilatory drive and respiratory muscle function in pregnancy Am Rev Respir Dis 1991144837-41
bull 20 Turner M Aziz SR Management of the pregnant oral and maxillofac
bull 21 Sifakis S Pharmakides G Anemia in pregnancy Ann N Y Acad Sci 2000900125-36
bull 22 Branch DW Physiologic adaptations of pregnancy Am J Reprod Immunol 199228120-2
bull 23 Burrows RF Kelton JG Incidentally detected thrombocytopenia in healthy mothers and their infants N Engl J Med 1988319 142-5
bull 24 Hanly JG Antiphospholipid syndrome an overview CMAJ 200324(168)1675-82
bull 25 Heilmann L von Tempelhoff GF Pollow K Antiphospholipid syndrome in obstetrics Clin Appl Thromb Hemost 20039 143-50
bull 26 Sherman P Flaxman SM Nausea and vomiting of pregnancy in an evolutionary perspective Am J Obstet Gynecol 2002 185(Suppl)s190-7
bull 27 Koch KL Gastrointestinal factors in nausea and vomiting of pregnancy Am J Obstet Gynecol 2002185(Suppl)s198-203
bull 28 Koch KL Frissora CL Nausea and vomiting during pregnancy Gastroenterol Clin N Am 200332201-34
bull 29 Baron TH Ramirez B Richter JE Gastrointestinal motility disorders during pregnancy Ann Intern Med 1993118 366-75
bull 30 Richter JE Gastroesophageal reflux disease during pregnancy Gastroenterol Clin N Am 200332235-61
bull 31 Marrero JM Goggin PM de Caestecker JS Pearce JM Maxwell JD Determinants of pregnancy heartburn Br J Obstet Gynaecol 199299731-4
bull 32 Hamaoui E Hamaoui M Nutritional assessment and support during pregnancy Gastroenterol Clin N Am 20033259-121
bull 33 King JC Physiology of pregnancy and nutrient metabolism Am J Clin Nutr 200071(suppl)1218s-25s
bull 34 Casanueva E Pfeffer F Fernandez-Gaxiola AC Gutierrez- Valenzuela V Rothenberg SJ Iron and folate status before pregnancy and anemia during pregnancy Ann Nutr Metab 2003 4760-3
bull 35 Chrsquong CL Morgan M Hainsworth I Kingham JG Prospective study of liver dysfunction in Southwest Wales Gut 200251 876-80
bull 36 Rahman TM Wendon J Severe hepatic dysfunction in pregnancy QJM 200295343-57
bull 37 Knox TA Olans LB Liver disease in pregnancy N Engl J Med 1996335569-76
bull 38 Saftlas AF Olson DR Franks AL Atrash H Pokras R Epidemiology of preeclampsia and eclampsia in the United States 1979e1986 Am J Obstet Gynecol 1990163460-5
bull 39 Walker JJ Pre-eclampsia Lancet 20003561260-5
bull 40 Davidson JM Renal disorders in pregnancy Curr Opin Obstet Gynecol 200113109-14
bull 41 Dafnis E Sabatini S The effect of pregnancy on renal function physiology and pathophysiologyAmJMedSci 1992303184-205
bull 42 Davison JM Shiells EA Philips PR Lindheimer MD Serial evaluation of vasopressin release and thirst in human pregnancy Role of human chorionic gonadotrophin in the osmoregulatory changes of gestation J Clin Invest 198881798-806
bull 43 Glinoer D de Nayer P Bourdoux P Lemone M Robyn C van Steirteghem A et al Regulation of maternal thyroid during pregnancy J Clin Endocrinol Metab 199071276-87
bull 44 Wilson SG Retallack RW Kent JC Worth GK Gutteridge DH Serum free 125-dihydroxyvitamin D and the free 125- dihydroxyvitamin D index during a longitudinal study of human pregnancy and lactation Clin Endocrinol 199032613-22
bull 45 Rasmussen N Frolich A Hornnes PJ Hegedus L Serum ionized calcium and intact parathyroid hormone levels during pregnancy and postpartum Br J Obstet Gynaecol 199097857-9
bull 46 Guyton AC Textbook of medical physiology 8th ed Philadelphia W B Saunders 1991 p 915e28
bull 47 Trainer PJ Corticosteroids and pregnancy Semin Reprod Med 200220375-80
bull 48 Soory M Hormonal factors in periodontal disease Dent Update 200027380-3
bull 49 Hugoson A Gingivitis in pregnant women A longitudinal clinical study Odontol Revy 19712265-84
bull 50 Neville BW Damm DD Allen CM Bouquot JE Oral amp Maxillofacial Pathology 3rd ed Philadelphia W B Saunders 2002 p 329-30 447-9
bull 51 Tilakaratne A Soory M Ranasinghe AW Corea SM Ekanayake SL de Silva M Periodontal disease status during pregnancy and 3 months post-partum in rural population of Sri-Lankan women J Clin Periodontol 200027787-92
bull 52 Laine M Tenovuo J Lehtonen OP Ojanatko-Harri A Vilja P Tuohimaa P Pregnancy e related changes in human whole saliva Arch Oral Biol 198833913-7
bull 53 Yuan K Wing LY Lin MT Pathogenetic roles of angiogenic factors in pyogenic granulomas in pregnancy are modulated by female sex hormones J Periodontol 200273701-8
bull 54 Evans RD Briggs PF Tooth-surface loss related to pregnancyinduced vomiting Prim Dent Care 1994124-6
bull 55 Salvolini E Di Giorgio R Curatola A Mazzanti L Fratto G Biochemical modifications of human whole saliva induced by pregnancy Br J Obstet Gynaec 1998105656-60
bull 56 Mauldin JG Newman RB Preterm birth risk assessment Semin Perinatol 200125215-22
bull 57 Heine RP McGregor JA Goodwin TM Artal R Hayashi RH Robertson PA et al Serial salivary estriol to detect an increased risk of preterm birth Obstet Gynecol 200096490-7
bull 58 Kauh YC Zachian TF Melasma Adv Exp Med Biol 1999455 491-9
bull 59 Wong RC Ellis CN Physiologic skin changes in pregnancy J Am Acad Dermatol 198410929-40
bull 60 Errickson CV Matus NR Skin disorders of pregnancy Am Fam Physician 199449605-10
bull 61 Lopez NJ Smith PC Gutierrez J Periodontal therapy may reduce the risk of preterm low birth weight in women with periodontal disease a randomized controlled trial J Periodontol 200273911-24
bull 62 McGaw T Periodontal disease and preterm delivery of lowbirth- weight infants J Can Dent Assoc 200268165-9
bull 63 Richards AG Dental x-ray protection Dent Clin North Am 1968631-41
bull 64 1990 Recommendations of the International Commission on Radiological Protection Ann ICRP 1991211-201
bull 65 Hall EJ Radiation the two-edged sword cancer risks at high and low doses Cancer J 20006343-50
bull 66 Diethelm L Xu H Diagnostic imaging of the lung during pregnancy Clin Obstet Gynecol 19963936-55
bull 67 Brent RL The effects of embryonic and fetal exposure to x-rays microwaves and ultrasound ClinObstetGynecol 198326484-510
bull 68 National Council on Radiation Protection NCRP report no128 1998 Bethesda Md Author
bull 69 Wasylko L Matsui D Dykxhoorn SM Reider MJ Weinberg S A review of common dental treatments during pregnancy implications for patients and dental personnel J Can Dent Assoc 199864434-9
bull 70 Freeman JP Brand JW Radiation doses of commonly used dental radiographic surveys Oral Surg Oral Med Oral Pathol 199477285-9
bull 71 Kircos LTAngin LL Lorton LOrder ofmagnitude dose reduction in intraoral radiography J Am Dent Assoc 1987114344-7
bull 72 Updegrave WJ Simplified and standardized intraoral radiography with reduced tissue irradiation J Am Dent Assoc 197285861-9
bull 73 Wood RE Harris AM van der Merwe EJ Nortje CJ The leaded apron revisited does it reduce gonadal radiation dose in dental radiology Oral Surg Oral Med Oral Pathol 199171642-6
bull 74 An update on radiographic practices information and recommendations ADA Council on Scientific Affairs J Am Dent Assoc 2001132234-8
bull 75 Rayburn WF Recommending medications during pregnancy an evidence based approach Clin Obstet Gynecol 2002451-5
bull 76 Rathmell JP Viscomi C Ashburn MA Management of nonobstetric pain during pregnancy and lactation Anesth Analg 1997851074-87
bull 77 Teratology society public affairs committee FDA classification of drugs for teratogenic risk Teratology 199449446-7
bull 78 Moore PA Selecting drugs for the pregnant dental patient J Am Dent Assoc 19981291281-6
bull 79 Haas DA An update on analgesics for the management of acute postoperative dental pain J Can Dent Assoc 200268476-82
bull 80 Haas DA Pynn BR Sands TD Drug use for the pregnant or lactating patient Gen Dent 20004854-60
bull 81 Committee on Drugs American Academy of Pediatrics The transfer of drugs and other chemicals into human milk Pediatrics 199493137-50
bull 82 Nielsen GL Sorensen HT Larsen H Pedersen L Risk of adverse birth outcome and miscarriage in pregnant users of nonsteroidal anti-inflammatory drugs population based observational study and case-control study BMJ 2001322266-70
bull 83 Janssen N Genta M The effects of immunosuppressive and anti-inflammatory medications on fertility pregnancy and lactation Arch Intern Med 200016610-9
bull 84 Ostensen M Nonsteroidal anti-inflammatory drugs during pregnancy Scand J Rheumatol Suppl 1998107128-32
bull 85 USPDI -Drug information for the health care professional 22nd ed Greenwood Village CO Micromedex 2002 p 152-79
bull 86 Denson DD Coyle DE Thompson GA Santos D Turner PA Myers JA et al Bupivacaine protein binding in the term parturient effects of lactic acidosis Clin Pharmacol Ther 198435702-9
bull 87 Dillon DE Wagner CL Wiest D Newman RB Drug therapy in the nursing mother Obstet Gynecol Clin North Am 199724 675-96
bull 88 Dashe JS Gilstrap LC Antibiotic use in pregnancy Obstet Gynecol Clin North Am 199724617-29
bull 89 American College of Rheumatology Ad hoc Committee on Clinical Guidelines Guidelines for monitoring drug therapy in rheumatoid arthritis Arthritis Rheum 199639723-31
bull 90 Ng PC The fetal and neonatal hypothalamic-pituitary-adrenal axis Arch Dis Child Fetal Neonatal Ed 200082F250-4
bull 91 Crowley P Antenatal corticosteroidsmdashcurrent thinking BJOG 2003110(Suppl 20)77-8
bull 92 ACOG committee opinion antenatal corticosteroid therapy for fetal maturation Obstet Gynecol 200299871-3
bull 93 Ost L Wettrell G Bjorkhem I Rane A Prednisolone excretion in human milk J Pediatr 19851061008-11
bull 94 Rowland AS Baird DD Shore DL Weinberg CR Savitz DA Wilcox AJ Nitrous oxide and spontaneous abortion in female dental assistants Am J Epidemiol 1995141531-8
bull 95 McGlothlin JD Jensen PA Fischbach TJ Hughes RT Jones JH Control of anesthetic gases in dental operatories Scand J Work Environ Health 199218(Suppl 2)103-5
bull ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY Volume 97 Number 6 Suresh and Radfar 681
bull 96 Rosen MA Nitrous oxide for relief of labor pain a systematic review Am J Obstet Gynecol 2002186(Suppl Nature)S110-6
bull 97 Sands TD Pynn BR Management considerations for the pregnant or nursing emergency patient Ont Dent 199875 17-9
bull 98 Daya S Recurrent spontaneous early pregnancy loss and low dose aspirin Minerva Ginecol 200355441-9
bull 99 Sinclair C Handbook of obstetrical emergencies 1st ed Philadelphia WB Saunders 1996 p 29-39 69
bull 100 Tarsitano BF Rollings RE The pregnant dental patient evaluation and management Gen Dent 199341226-34
bull 101 Livingston MH Dlllinger TM Holder R Consideration in the management of the pregnant patient SCD Special Care in Dentistry 199818183-8
Thank you
- A Review on the principle of Dental Management of the Pregnant patient
- Slide 2
- Questions that a dentist may ask
- Stages of Pregnancy
- Slide 5
- Slide 6
- Physiologic Changes in Pregnancy
- Systemic changes in pregnancy
- FLAT SUPINE POSITIONING
- SUPINE HYPOTENSION SYNDROME (Vena Cava Compression)
- Supine Hypotension Syndrome
- Slide 12
- Supine Hypotension Syndrome
- Prevention of Supine Hypotensive Syndrome
- Treatment of Supine Hypotensive Syndrome
- How should the pregnant woman be positioned
- Slide 17
- Slide 18
- Slide 19
- Slide 20
- Slide 21
- Slide 22
- Slide 23
- Pregnancy Related Oral Health Problems
- Oral Problems in Pregnancy
- Pregnancy Gingivitis Pathophysiology
- Pregnancy Gingivitis
- Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Gum Problems - Pregnancy Granuloma
- Slide 31
- Gum Changes - Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Candidiasis
- Pregnancy Myths
- Other Oral Conditions in Pregnancy
- Changes During Pregnancy that Affect Oral Health
- Saliva changes
- Increased Bacteria
- Slide 40
- Enamel erosion caused by frequent vomiting
- Treatment for Acid Exposure
- Oral Diseases Can Effect Pregnancy
- Periodontal Disease and Preterm Labor
- Periodontal Disease and Low Birth Weight
- Periodontal Disease and Preeclampsia
- Periodontitis and Pre-eclampsia
- Dental Considerations
- Treatment Timing
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Slide 52
- Use of Radiation on Pregnant Patient
- Radiographs during Pregnancy
- Risks of Dental X-Rays
- FDA drug classification for pregnancy
- Slide 57
- FDA drug classification for pregnancy
- Slide 59
- Slide 60
- Slide 61
- Common Analgesics
- Analgesics
- Analgesics - continued
- Analgesics to Use During 1st and 2nd Trimester
- Analgesics to Avoid During the Third Trimester
- Sedation in Pregnancy
- Common Antibiotics
- Antibiotics
- Antibiotics To Use During Pregnancy
- Antibiotics to Avoid during Pregnancy
- The Problem With Tetracycline
- Other Antimicrobial Agents
- Local Anesthetic Use in Pregnancy
- Use of Local Anesthetics
- Ulcer healing drugs
- Slide 77
- Slide 78
- Slide 79
- Use of Nitrous Oxide Gas
- Common Preventives
- Are topical agents safe
- Pre-natal Fluoride
- Is it safe to use mercury restorations
- References
- REFERENCES
- Slide 87
- Slide 88
- Slide 89
- Slide 90
- Slide 91
- Slide 92
- Slide 93
- Slide 94
- Slide 95
- Slide 96
- Slide 97
- Slide 98
- Thank you
-
FLAT SUPINE POSITIONING
bullNegatively impacts mother and infant
SUPINE HYPOTENSIONSYNDROME (Vena Cava Compression)
bull SUPINE POSITION AFTER 5TH MONTH
bull UTERUS COMPRESSES THE INFERIOR VENA CAVA
bull uarrVOL BLOOD IN THE LErsquoS bull darrRETURN TO THE HEARTbull REDUCED PERFUSION OF
UTERUS bull FETAL HYPOXIA
Supine Hypotension Syndrome
bull Obstruction of inferior vena cava and aorta from pressure of the large fetus
Symptoms Sweating Nausea Weakness Sense of lack of air
Supine Hypotension Syndrome
Other symptomsbull Drop in blood pressurebull Bradycardiabull Possible loss of consciousness
Prevention of Supine HypotensiveSyndrome
bullElevate right hip 10-12 cmbullWeight is taken off the major vessels
Treatment of Supine HypotensiveSyndrome
bullRoll patient onto her left side
How should the pregnant woman be positionedbull Flat position may
cause hypotension and hypoxia
bull Place a small pillow under right hip - left lateral displacement
bull Head above feet
Systemic changes in pregnancy
Diaphragm rises about 4 cm darr residual volume uarr awareness of a desire to breath is
common-may be interpreted as dyspnea Increased estrogen in blood causes
engorgement of the nasal capillaries and rhnitis in pregnant women
Frequent nosebleeds amp predisposition to upper respiratory infection
Respiratory system
Systemic changes in pregnancy
Gastrointestinal system Gastric emptying amp intestinal transit times
are delayed
Heart burn reflux common
Nausea and vomiting common
Systemic changes in pregnancy
For pregnant patient with Hyper-emesis gravidarium ( excessive and uncontrolled vomiting) morning appointments should be avoided
They should be seated in a semi-supine or comfortable position
In case of vomiting the procedure should be stopped immediately amp the patient should be repositioned upright
When vomiting is over rinsing mouth with cold water or mouthwash is recommended
Systemic changes in pregnancybull Urinary System uarr GFR amp renal plasma flow by as much as
50 Nocturia ndashto mobilize the dependent
edema which accumulate during the day uarr Frequency from uarr renal flow plus reduced
bladder capacity from uterine growth It is advisable to ask the patient to void the
bladder just prior to starting the dental procedure
Systemic changes in pregnancyEndocrine Changes uarrEstrogen uarr progesterone uarrhuman
gonadotropin uarr thyroxin steroid and insulin level Estrogen amp progesterone are insulin
antagonists uarr level of these hormones lead to insulin resistance Thus insulin levels are elevated in pregnant in pregnant patient to compensate this resistance
About 45 of women fail to produce sufficient amount of insulin to overcome this antagonist action amp thus develop gestational diabetes
Systemic changes in pregnancy
Hematological changebull uarr red RBC uarrESR darrHbbull uarrWBCbull uarr circulatory catecholamin amp cortisol lead
to leucositosis bull uarr Coagulation factors except factor XI amp
XIII (anticloting factor) bull so pregnancy is a hypercoagulable state amp
uarr risk for thromboembolism
Systemic changes in pregnancy
bull Pregnant women with anti-phospholipid syndrome are at uarr risk for thrombo-embolisim
bull They are placed on subcutaneous low molecular weight heparin (LMWH)
bull These patients must be hospitalized for dental care
Pregnancy RelatedOral Health Problems
bull Pregnancy Gingivitisbull Pregnancy Epulis bull Increased Tooth Mobilitybull Dental Cariesbull Erosionbull Dental Problems in relation to Labor
and Delivery
Oral Problems in Pregnancy
bullPregnancy GingivitisbullMost common oral manifestation (50-100 of women)bullCaused by hormonal and vascular changes of pregnancy
Pregnancy Gingivitis Pathophysiology
bull Elevated circulating estrogen increases capillary permeability
bull Preexisting gingivitis may predispose to pregnancy gingivitis
Pregnancy Gingivitis
bullOccurs commonly in the 2nd to 8th monthsbullTendency to bleed very easilybullTreatment Scaling root-planing currettage OHI
Pregnancy Granuloma
bullOccurs in up to 5 of womenbullMost common in buccal maxillary anterior areasbullUsually starts in an area of gingivitis
Pregnancy Granuloma (continued)
bullRapid growth up to 2 cmbullSingle tumor-like growthbullusually in interdental papillaebullPurplish to bluish in color may be ulcerated- bleeds easily
Gum Problems - Pregnancy Granuloma
Gum Problems - Pregnancy Granuloma
Gum Changes - Pregnancy Granuloma
Pregnancy Granuloma (continued)
Treatment
bull Scaling and root planingbull Excision if it is too large or bleeds too
easilybull May regress spontaneously after
pregnancy
Candidiasis
bullWipes offbullUsually asymptomatic but may burnbullTreatment topical or systemic antifungals
Pregnancy MythsbullldquoA mother loses a tooth for every babyrdquobullNo evidence that aphthous ulcers are any more common in pregnancy
Other Oral Conditions in Pregnancy
bull Dry mouthbull Excessive salivationbull Tooth erosions associated with
severe GERD or hyperemesis
Changes During Pregnancy that Affect Oral Health
bull Hormonal Affects
ndash Increased tooth mobility
ndash Saliva changes
ndash Increased bacteria
ndash Gingival problems
Saliva changesbull Decreased buffers
bull Decreased minerals
bull Decreasing flow first and last trimester
bull Increased flow second trimester
bull More acidic
Increased Bacteriabull Increased acidity
ndash Increase in decay-causing bacteriabull Increased Snacking
ndash Morning sicknesslow blood sugarndash Between-meal snacks
bull Increase in amount and frequency of starchescarbohydrates ndash Crackers are commonly recommendedndash Promotes decay-causing bacteria
Changes During Pregnancy that Affect Oral Healthbull Morning sickness
ndash Difficulty with hygienebull Gingival diseasebull Tooth decay
ndash Vomitingbull Esophogeal Reflux (heartburn)bull Acid exposure
ndash Irritation of the gumsndash Weakening of tooth enamelndash Dental erosion
Enamel erosion caused by frequent vomiting
Treatment for Acid Exposure
bull Do NOT brush immediately after vomiting
bull Rinse ndash Water with baking sodandash Antacidndash Plain water
bull Eat some cheese
Oral Diseases Can Effect Pregnancy
bull Preterm low birth weight (LBW) linked to periodontal disease
bull Thorough calculus (tartar) removal in pregnant women with periodontitis may reduce pre-term births
Periodontal Disease and Preterm LaborbullMaternal periodontal disease is associated with increased risk of preterm laborbullAnaerobic oral gram-negative bacteria cause inflammatory responsebullInflammatory response stimulates prostaglandin and cytokine production to stimulate labor
Periodontal Disease and Low Birth Weight
bull Periodontal disease is associated with low birth weight
bull Evidence is not conclusivebull Biochemical mechanism similar cascade
as in preterm labor leading to placental blood flow restriction and necrosis
Periodontal Disease and Preeclampsia
bull Emerging databull Mechanism unclearbull Proposed mechanism
ndash Periodontal infection leads to inflammatory vascular damage
ndash Triggers cell damage in placenta
Periodontitis and Pre-eclampsia
bull Periodontal disease may be associated with pre-eclampsia (Boggess 2003)
bull PGE2 IL-1 and TNF-α from gingival crevicular fluid were higher in women with preeclampsia compared with healthy matched pregnant women (Oettinger-Barak 2003)
Dental Considerations
bull timing of treatment for pregnant patientsbull dental radiation exposurebull use of local anestheticsbull prescription of common antibiotics and
analgesicsbull nitrous oxide gas administration
Treatment Timing
bull First Trimesterndash Spontaneous miscarriages naturally occur
more often in 1st trimesterndash Avoid elective treatment that can be delayedndash Offer anticipatory guidance
bull Second Trimesterndash The optimal time for dental treatmentndash Organogenesis complete fetus not largendash Easier to prevent than treat established disease
bull Third Trimesterndash Late in term very uncomfortable (short visits)ndash Position slightly on left side
Timing of Dental Treatment During Pregnancy - From Little and Fallace
First Trimester
bull Plaque controlbull Oral hygiene instructionbull Scaling polishing curettagebull Avoid elective treatment urgent care
only
Timing of Dental Treatment During Pregnancy - From Little and Fallace
Second Trimester
bull Plaque controlbull Oral hygiene instructionbull Scaling polishing curettagebull Routine dental care
Timing of Dental Treatment During Pregnancy - From Little and Fallace
Third Trimester
bull Plaque controlbull Oral hygiene instructionbull Scaling polishing curettagebull Routine dental care (after middle of third
trimester elective care should be avoided)
Use of Radiation on Pregnant Patientbull Dose given and time of gestation are
importantbull doses lt 5-10 rads (cGy) not teratogenicbull fetus is most susceptible to radiation
between the 2nd and 6th week of gestationbull single dental x-ray exposes patient to 001
millirads of radiation In relative terms this amount is 40 times less than daily dose acquired from cosmic radiation Therefore diagnostic radiation should not be withheld during pregnancy
Radiographs during Pregnancy
bull Take as needed with optimal methods for reducing secondary radiation and exposure time
bull Always use a lead apronbull Exposure to fetus (with apron use) is 00001
centiGray(rad)bull Daily cosmic radiation - 0004 centiGray (rad)
Risks of Dental X-Rays
bull X-ray only if necessary (ie root canal therapy trauma)
bull When x-rays are indicated radiation exposure is extremely low
bull Exposure can be limited byndash Lead apron shielding ndash Modern fast film ndash Avoiding retakes
FDA drug classification for pregnancybull Combines risk statements including
congenital anomalies fetal effects perinatal risks and therapeutic risk-benefit ratio
bull Untreated disease or condition may pose more serious risks to both mother and fetus than any theoretical risks from the medication
bull Category A thru D and X
FDA drug classification for pregnancy
bull A = Controlled Studies in women fail to demonstrate a risk to the fetus in the first trimester and the possibility of fetal harm appears remote
FDA drug classification for pregnancy
bull B = Animal studies show no risk or if risk shown in animals controlled
trials in women showed no risk
FDA drug classification for pregnancy
bull C = Studies in animals with adverse effects and no human studies
OR no animal or human studies but benefits of use may outweigh potential harms
FDA drug classification for pregnancy
bull D = There is evidence of human fetal risk but benefits may outweigh risks
FDA drug classification for pregnancy
bull X = Contraindicated
Common Analgesics
bull paracetamol (B)bull Ibuprofen (BD) bull Oxycodone (BD) bull Hydrocodone and codeine
(CD)
avoid in third trimester
Analgesics
bull Paracetamol is the analgesic of choice for all stages of gestation
bull used to treat mild to moderate pain and fevers
bull short term usage is believed to be safebull avoid chronic and large doses of
paracetamol1048715
Analgesics - continuedbull Aspirin is nonteratogenic but may cause
maternal and fetal hemorrhagebull large and chronic doses during last trimester
may result in premature closure of ductus arteriosus fetal hypertension anemia and low birth weight
bull avoid ibuprofen in 3rd trimester because of possible adverse circulatory effects
bull short term use of codeine seems safebull avoid codeine late in gestation because of
possible fetal respiratory depression and withdrawal symptoms
Analgesics to Use During1st and 2nd Trimester
bull Category B (for best)bull Paracetamol Ibuprofenbull Naproxenbull Category C (use with caution)bull Paracetamol with codeine or
hydrocodonebull Paracetamol with oxycodone
Analgesics to Avoid During theThird Trimesterbull Causes delivery problemsbull Aspirin (C 3D)bull Ibuprofen (B3D)bull Naproxen (B3D)bull Causes neonatal respiratory
depression and opioid withdrawalbull Codeine (C3D)bull Hydrocodone (C3D)bull Oxycodone(C3D)
Sedation in Pregnancy
bull SedativesAnxiolytics (eg Diazepam ) are rated D and can cause oral clefts with prolonged exposure
bull Nitrous oxide should not be used in 1st trimester (If used in 2nd and 3rd do not go below 50 O2)
Common Antibioticsbull To treat oral abscess or cellulitis
ndash Penicillin (B) ndash Amoxicillin (B) ndash Cephalexin (B)ndash Erythromycin base (B) (Not estolate as it
cause cholestatic hepatitis)ndash Clindamycin (B)
Antibioticsbull penicillin V and amoxicillin is preferred drug
for mild to moderate infectionsbull widely used for many years with no ill effectsbull no studies show penicillin to be teratogenicbull amoxicillin extensively used without harming
the fetusbull Drug classes1048715 B penicillin cephalosporins erythromycin clindamycin Azithromycin D Tetracycline
Antibiotics To Use During Pregnancy
bull Penicillin Vbull Amoxicillinbull Erythromycin (base form)bull Cephalexin cephalosporinbull Clindamycinbull Metronidazole
Antibiotics to Avoid duringPregnancy
bull Doxycyclinebull Tetracyclinebull Erythromycin (estolate form)bull Vancomycin
The Problem With Tetracycline
bull Accumulates in bones and chelates calcium
bull Inhibits bone growthbull Discolors teeth
Other Antimicrobial Agentsbull OK to usebull Nystatin (B)bull Chlorhexidine rinse (B)bull Use with cautionbull Clotrimazole (C)bull Ketoconazole (C)bull Fluconazole (C)bull Do not usebull Doxycycline (D)
Local Anesthetic Use inPregnancy
bull Class Bbull Lidocaine (Xylocaine)bull Etidocainebull Prilocaine bull Class Cbull Procainebull Bupivicainebull Mepivicaine
Use of Local Anestheticsbull Lidocaine + vasoconstrictor most common
local anesthetic used in dentistrybull extensively used in pregnancy with no proven ill
effectsbull accidental intravascular injections of lidocaine
pass through the placenta but the concentrations are too low to harm fetus
bull prilocaine might cause methemoglobinemia
Ulcer healing drugsCimetidine bull FDA category B Famotidinebull FDA category BRanitidinebull FDA category Bbull not known to be harmful
Ulcer healing drugsOmeprazolebull FDA category BNot known to be
harmful Esomeprazolebull FDA category BLansoprazolebull FDA category BPantoprazolebull Avoid unless potential benefit
outweighs riskmdashfetotoxic in animals
Ulcer healing drugs
Misoprostolbull First second third trimesters Avoidmdash
potent uterine stimulant (has been used to induce abortion) and may be teratogenic
Ulcer healing drugs
Antacidsbull Almunium hydroxideMagnesium
hydroxidemdashFDA category B Calcium carbonatemdashFDA category C
SimetheconemdashFDA category C
Use of Nitrous Oxide Gas
bull used over 150 years bull safety is being debatedbull SHORT TERM exposure do not cause
birth defects or spontaneous abortionbull CHRONIC exposure may result in fetal
loss and infertilitybull literature suggests that nitrous oxide
should be avoided until more conclusive research is available
bull FDA Drug class not yet assigned
Common Preventives
bull Fluoridendash No increased risk during pregnancy
bull Xylitolndash No studies no harm reported
bull Chlorhexidinendash No increased risk during pregnancy
Are topical agents safe
bull Fluoridebull Toothpaste amp mouthrinse
bull Xylitol chewing gum bull Chlorhexidine (11 alcohol)bull No over the counter mouthrinses with
alcohol (Listerine 20 alcohol)
Pre-natal Fluoride
bull Daily 22 mg tablet of sodium fluoride during 3rd through 9th months
bull decreases caries rate in offspringbull Safe and effective
Glenn FB 1982
Is it safe to use mercury restorations
bull No evidence of harmful effect
bull Benefits outweigh risks
bull Canada Germany and New Zealand have some restrictions
bull Determine the best option
Referencesbull Wasylko L Matsui D Dykxhoorn SM Rieder MJ Weinberg
S A Review of Common Dental Treatments During Pregnancy J Canadian Dental Association 64434-439 1998
bull Little JW Donald AF Craig SM Rhodus NL Dental Management of the Medically Compromised Patient - 5th edition Mosby Toronto Pp434-442 1997
bull Livingston HM Dellinger TM Holder R Considerations in the management of the pregnant patient Special Care in Dentistry 185 pp183-188 1998
bull Larimore WL Petrie KA Drug use during pregnacy and lactation Primary Care Clinics in Office Practice 271 35-53 2000
bull Health Canada The Safety of DentalAmalgam Minister Of Supply and Services Canada 1996
REFERENCESbull 1 Weiss G Endocrinology of parturition J Clin
Endocrinol Metab 2000854421-5bull 2 Theunissen IM Parer JT Fluid and electrolytes in
pregnancy Clin Obstet Gynecol 1994373-15bull 3 Duvekot JJ Peeters LLH Renal hemodynamics and
volume homeostasis in pregnancy Obstet Gynecol Surv 199449830-9
bull 4 Barron WM Lindheimer MD Medical disorders during pregnancy 2nd ed St Louis Mosby 1995 p 129
bull 5 Thornburg KL Jacobson SL Giraud GD Morton MJ Hemodynamic changes in pregnancy Semin Perinatol 20002411-4
bull 6 Fiese R Herzog S Issues in dental and surgical management of the pregnant patient Oral Surg Oral Med Oral Pathol 198865292-7
bull 7 Martin C Varner MW Physiologic changes in pregnancysurgical implications Clin Obstet Gynecol 199437241-55
bull 8 Clark SL Cotton DB Lee W Bishop C Hill T Southwick J et al Central hemodynamic assessment of normal term pregnancy Am J Obstet Gynecol 19891611439-42
bull 9 Mabie WC Di Sessa TG Crocker LG Sibai BM Arheart KL A longitudinal study of cardiac output in normal human pregnancy Am J Obstet Gynecol 1994170849-56
bull 10 Clapp JF 3rd Capeless E Cardiovascular function before during and after the first and subsequent pregnancies Am J Cardiol 1997801469-73
bull 11 Duvekot JJ Peeters LL Maternal cardiovascular hemodynamic adaptation to pregnancy Obstet Gynecol Surv 199449(Suppl) S1-14
bull 12 Bhagwat AR Engel PJ Heart disease and pregnancy Cardiol Clin 199513163-78
bull 13 Lanni SM Tillinghast J Silver H Hemodynamic changes and baroreflex gain in the supine hypotensive syndrome Am J Obstet Gynecol 20021871636-41
bull 14 Little JW Falace DA Miller CS Rhodus NL Dental management of the medically compromised patient 6th ed St Louis Mosby 2002 p 303
bull 15 Garcia-Rio F Pino JM Gomez L Alvarez-Sala R Villasante C Villamor J Regulation of breathing and perception of dyspnea in healthy pregnant women Chest 1996110446-53
bull 16 McAuliffe F Kametas N Costello J Rafferty GF Greenough A Nicolaides K Respiratory function in singleton and twin pregnancy BJOG 2002109765-9
bull 17 Clapp JF 3rd Seaward BL Sleamaker RH Hiser J Maternal physiologic adaptations to early human pregnancy Am J Obstet Gynecol 19881591456-60
bull 18 OrsquoDay MP Cardio-respiratory physiological adaptation of pregnancy Semin Perinatol 199721268-75
bull 19 Contreras G Gutierrez M Beroiza T Fantin A Oddo H Villarroel L et al Ventilatory drive and respiratory muscle function in pregnancy Am Rev Respir Dis 1991144837-41
bull 20 Turner M Aziz SR Management of the pregnant oral and maxillofac
bull 21 Sifakis S Pharmakides G Anemia in pregnancy Ann N Y Acad Sci 2000900125-36
bull 22 Branch DW Physiologic adaptations of pregnancy Am J Reprod Immunol 199228120-2
bull 23 Burrows RF Kelton JG Incidentally detected thrombocytopenia in healthy mothers and their infants N Engl J Med 1988319 142-5
bull 24 Hanly JG Antiphospholipid syndrome an overview CMAJ 200324(168)1675-82
bull 25 Heilmann L von Tempelhoff GF Pollow K Antiphospholipid syndrome in obstetrics Clin Appl Thromb Hemost 20039 143-50
bull 26 Sherman P Flaxman SM Nausea and vomiting of pregnancy in an evolutionary perspective Am J Obstet Gynecol 2002 185(Suppl)s190-7
bull 27 Koch KL Gastrointestinal factors in nausea and vomiting of pregnancy Am J Obstet Gynecol 2002185(Suppl)s198-203
bull 28 Koch KL Frissora CL Nausea and vomiting during pregnancy Gastroenterol Clin N Am 200332201-34
bull 29 Baron TH Ramirez B Richter JE Gastrointestinal motility disorders during pregnancy Ann Intern Med 1993118 366-75
bull 30 Richter JE Gastroesophageal reflux disease during pregnancy Gastroenterol Clin N Am 200332235-61
bull 31 Marrero JM Goggin PM de Caestecker JS Pearce JM Maxwell JD Determinants of pregnancy heartburn Br J Obstet Gynaecol 199299731-4
bull 32 Hamaoui E Hamaoui M Nutritional assessment and support during pregnancy Gastroenterol Clin N Am 20033259-121
bull 33 King JC Physiology of pregnancy and nutrient metabolism Am J Clin Nutr 200071(suppl)1218s-25s
bull 34 Casanueva E Pfeffer F Fernandez-Gaxiola AC Gutierrez- Valenzuela V Rothenberg SJ Iron and folate status before pregnancy and anemia during pregnancy Ann Nutr Metab 2003 4760-3
bull 35 Chrsquong CL Morgan M Hainsworth I Kingham JG Prospective study of liver dysfunction in Southwest Wales Gut 200251 876-80
bull 36 Rahman TM Wendon J Severe hepatic dysfunction in pregnancy QJM 200295343-57
bull 37 Knox TA Olans LB Liver disease in pregnancy N Engl J Med 1996335569-76
bull 38 Saftlas AF Olson DR Franks AL Atrash H Pokras R Epidemiology of preeclampsia and eclampsia in the United States 1979e1986 Am J Obstet Gynecol 1990163460-5
bull 39 Walker JJ Pre-eclampsia Lancet 20003561260-5
bull 40 Davidson JM Renal disorders in pregnancy Curr Opin Obstet Gynecol 200113109-14
bull 41 Dafnis E Sabatini S The effect of pregnancy on renal function physiology and pathophysiologyAmJMedSci 1992303184-205
bull 42 Davison JM Shiells EA Philips PR Lindheimer MD Serial evaluation of vasopressin release and thirst in human pregnancy Role of human chorionic gonadotrophin in the osmoregulatory changes of gestation J Clin Invest 198881798-806
bull 43 Glinoer D de Nayer P Bourdoux P Lemone M Robyn C van Steirteghem A et al Regulation of maternal thyroid during pregnancy J Clin Endocrinol Metab 199071276-87
bull 44 Wilson SG Retallack RW Kent JC Worth GK Gutteridge DH Serum free 125-dihydroxyvitamin D and the free 125- dihydroxyvitamin D index during a longitudinal study of human pregnancy and lactation Clin Endocrinol 199032613-22
bull 45 Rasmussen N Frolich A Hornnes PJ Hegedus L Serum ionized calcium and intact parathyroid hormone levels during pregnancy and postpartum Br J Obstet Gynaecol 199097857-9
bull 46 Guyton AC Textbook of medical physiology 8th ed Philadelphia W B Saunders 1991 p 915e28
bull 47 Trainer PJ Corticosteroids and pregnancy Semin Reprod Med 200220375-80
bull 48 Soory M Hormonal factors in periodontal disease Dent Update 200027380-3
bull 49 Hugoson A Gingivitis in pregnant women A longitudinal clinical study Odontol Revy 19712265-84
bull 50 Neville BW Damm DD Allen CM Bouquot JE Oral amp Maxillofacial Pathology 3rd ed Philadelphia W B Saunders 2002 p 329-30 447-9
bull 51 Tilakaratne A Soory M Ranasinghe AW Corea SM Ekanayake SL de Silva M Periodontal disease status during pregnancy and 3 months post-partum in rural population of Sri-Lankan women J Clin Periodontol 200027787-92
bull 52 Laine M Tenovuo J Lehtonen OP Ojanatko-Harri A Vilja P Tuohimaa P Pregnancy e related changes in human whole saliva Arch Oral Biol 198833913-7
bull 53 Yuan K Wing LY Lin MT Pathogenetic roles of angiogenic factors in pyogenic granulomas in pregnancy are modulated by female sex hormones J Periodontol 200273701-8
bull 54 Evans RD Briggs PF Tooth-surface loss related to pregnancyinduced vomiting Prim Dent Care 1994124-6
bull 55 Salvolini E Di Giorgio R Curatola A Mazzanti L Fratto G Biochemical modifications of human whole saliva induced by pregnancy Br J Obstet Gynaec 1998105656-60
bull 56 Mauldin JG Newman RB Preterm birth risk assessment Semin Perinatol 200125215-22
bull 57 Heine RP McGregor JA Goodwin TM Artal R Hayashi RH Robertson PA et al Serial salivary estriol to detect an increased risk of preterm birth Obstet Gynecol 200096490-7
bull 58 Kauh YC Zachian TF Melasma Adv Exp Med Biol 1999455 491-9
bull 59 Wong RC Ellis CN Physiologic skin changes in pregnancy J Am Acad Dermatol 198410929-40
bull 60 Errickson CV Matus NR Skin disorders of pregnancy Am Fam Physician 199449605-10
bull 61 Lopez NJ Smith PC Gutierrez J Periodontal therapy may reduce the risk of preterm low birth weight in women with periodontal disease a randomized controlled trial J Periodontol 200273911-24
bull 62 McGaw T Periodontal disease and preterm delivery of lowbirth- weight infants J Can Dent Assoc 200268165-9
bull 63 Richards AG Dental x-ray protection Dent Clin North Am 1968631-41
bull 64 1990 Recommendations of the International Commission on Radiological Protection Ann ICRP 1991211-201
bull 65 Hall EJ Radiation the two-edged sword cancer risks at high and low doses Cancer J 20006343-50
bull 66 Diethelm L Xu H Diagnostic imaging of the lung during pregnancy Clin Obstet Gynecol 19963936-55
bull 67 Brent RL The effects of embryonic and fetal exposure to x-rays microwaves and ultrasound ClinObstetGynecol 198326484-510
bull 68 National Council on Radiation Protection NCRP report no128 1998 Bethesda Md Author
bull 69 Wasylko L Matsui D Dykxhoorn SM Reider MJ Weinberg S A review of common dental treatments during pregnancy implications for patients and dental personnel J Can Dent Assoc 199864434-9
bull 70 Freeman JP Brand JW Radiation doses of commonly used dental radiographic surveys Oral Surg Oral Med Oral Pathol 199477285-9
bull 71 Kircos LTAngin LL Lorton LOrder ofmagnitude dose reduction in intraoral radiography J Am Dent Assoc 1987114344-7
bull 72 Updegrave WJ Simplified and standardized intraoral radiography with reduced tissue irradiation J Am Dent Assoc 197285861-9
bull 73 Wood RE Harris AM van der Merwe EJ Nortje CJ The leaded apron revisited does it reduce gonadal radiation dose in dental radiology Oral Surg Oral Med Oral Pathol 199171642-6
bull 74 An update on radiographic practices information and recommendations ADA Council on Scientific Affairs J Am Dent Assoc 2001132234-8
bull 75 Rayburn WF Recommending medications during pregnancy an evidence based approach Clin Obstet Gynecol 2002451-5
bull 76 Rathmell JP Viscomi C Ashburn MA Management of nonobstetric pain during pregnancy and lactation Anesth Analg 1997851074-87
bull 77 Teratology society public affairs committee FDA classification of drugs for teratogenic risk Teratology 199449446-7
bull 78 Moore PA Selecting drugs for the pregnant dental patient J Am Dent Assoc 19981291281-6
bull 79 Haas DA An update on analgesics for the management of acute postoperative dental pain J Can Dent Assoc 200268476-82
bull 80 Haas DA Pynn BR Sands TD Drug use for the pregnant or lactating patient Gen Dent 20004854-60
bull 81 Committee on Drugs American Academy of Pediatrics The transfer of drugs and other chemicals into human milk Pediatrics 199493137-50
bull 82 Nielsen GL Sorensen HT Larsen H Pedersen L Risk of adverse birth outcome and miscarriage in pregnant users of nonsteroidal anti-inflammatory drugs population based observational study and case-control study BMJ 2001322266-70
bull 83 Janssen N Genta M The effects of immunosuppressive and anti-inflammatory medications on fertility pregnancy and lactation Arch Intern Med 200016610-9
bull 84 Ostensen M Nonsteroidal anti-inflammatory drugs during pregnancy Scand J Rheumatol Suppl 1998107128-32
bull 85 USPDI -Drug information for the health care professional 22nd ed Greenwood Village CO Micromedex 2002 p 152-79
bull 86 Denson DD Coyle DE Thompson GA Santos D Turner PA Myers JA et al Bupivacaine protein binding in the term parturient effects of lactic acidosis Clin Pharmacol Ther 198435702-9
bull 87 Dillon DE Wagner CL Wiest D Newman RB Drug therapy in the nursing mother Obstet Gynecol Clin North Am 199724 675-96
bull 88 Dashe JS Gilstrap LC Antibiotic use in pregnancy Obstet Gynecol Clin North Am 199724617-29
bull 89 American College of Rheumatology Ad hoc Committee on Clinical Guidelines Guidelines for monitoring drug therapy in rheumatoid arthritis Arthritis Rheum 199639723-31
bull 90 Ng PC The fetal and neonatal hypothalamic-pituitary-adrenal axis Arch Dis Child Fetal Neonatal Ed 200082F250-4
bull 91 Crowley P Antenatal corticosteroidsmdashcurrent thinking BJOG 2003110(Suppl 20)77-8
bull 92 ACOG committee opinion antenatal corticosteroid therapy for fetal maturation Obstet Gynecol 200299871-3
bull 93 Ost L Wettrell G Bjorkhem I Rane A Prednisolone excretion in human milk J Pediatr 19851061008-11
bull 94 Rowland AS Baird DD Shore DL Weinberg CR Savitz DA Wilcox AJ Nitrous oxide and spontaneous abortion in female dental assistants Am J Epidemiol 1995141531-8
bull 95 McGlothlin JD Jensen PA Fischbach TJ Hughes RT Jones JH Control of anesthetic gases in dental operatories Scand J Work Environ Health 199218(Suppl 2)103-5
bull ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY Volume 97 Number 6 Suresh and Radfar 681
bull 96 Rosen MA Nitrous oxide for relief of labor pain a systematic review Am J Obstet Gynecol 2002186(Suppl Nature)S110-6
bull 97 Sands TD Pynn BR Management considerations for the pregnant or nursing emergency patient Ont Dent 199875 17-9
bull 98 Daya S Recurrent spontaneous early pregnancy loss and low dose aspirin Minerva Ginecol 200355441-9
bull 99 Sinclair C Handbook of obstetrical emergencies 1st ed Philadelphia WB Saunders 1996 p 29-39 69
bull 100 Tarsitano BF Rollings RE The pregnant dental patient evaluation and management Gen Dent 199341226-34
bull 101 Livingston MH Dlllinger TM Holder R Consideration in the management of the pregnant patient SCD Special Care in Dentistry 199818183-8
Thank you
- A Review on the principle of Dental Management of the Pregnant patient
- Slide 2
- Questions that a dentist may ask
- Stages of Pregnancy
- Slide 5
- Slide 6
- Physiologic Changes in Pregnancy
- Systemic changes in pregnancy
- FLAT SUPINE POSITIONING
- SUPINE HYPOTENSION SYNDROME (Vena Cava Compression)
- Supine Hypotension Syndrome
- Slide 12
- Supine Hypotension Syndrome
- Prevention of Supine Hypotensive Syndrome
- Treatment of Supine Hypotensive Syndrome
- How should the pregnant woman be positioned
- Slide 17
- Slide 18
- Slide 19
- Slide 20
- Slide 21
- Slide 22
- Slide 23
- Pregnancy Related Oral Health Problems
- Oral Problems in Pregnancy
- Pregnancy Gingivitis Pathophysiology
- Pregnancy Gingivitis
- Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Gum Problems - Pregnancy Granuloma
- Slide 31
- Gum Changes - Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Candidiasis
- Pregnancy Myths
- Other Oral Conditions in Pregnancy
- Changes During Pregnancy that Affect Oral Health
- Saliva changes
- Increased Bacteria
- Slide 40
- Enamel erosion caused by frequent vomiting
- Treatment for Acid Exposure
- Oral Diseases Can Effect Pregnancy
- Periodontal Disease and Preterm Labor
- Periodontal Disease and Low Birth Weight
- Periodontal Disease and Preeclampsia
- Periodontitis and Pre-eclampsia
- Dental Considerations
- Treatment Timing
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Slide 52
- Use of Radiation on Pregnant Patient
- Radiographs during Pregnancy
- Risks of Dental X-Rays
- FDA drug classification for pregnancy
- Slide 57
- FDA drug classification for pregnancy
- Slide 59
- Slide 60
- Slide 61
- Common Analgesics
- Analgesics
- Analgesics - continued
- Analgesics to Use During 1st and 2nd Trimester
- Analgesics to Avoid During the Third Trimester
- Sedation in Pregnancy
- Common Antibiotics
- Antibiotics
- Antibiotics To Use During Pregnancy
- Antibiotics to Avoid during Pregnancy
- The Problem With Tetracycline
- Other Antimicrobial Agents
- Local Anesthetic Use in Pregnancy
- Use of Local Anesthetics
- Ulcer healing drugs
- Slide 77
- Slide 78
- Slide 79
- Use of Nitrous Oxide Gas
- Common Preventives
- Are topical agents safe
- Pre-natal Fluoride
- Is it safe to use mercury restorations
- References
- REFERENCES
- Slide 87
- Slide 88
- Slide 89
- Slide 90
- Slide 91
- Slide 92
- Slide 93
- Slide 94
- Slide 95
- Slide 96
- Slide 97
- Slide 98
- Thank you
-
SUPINE HYPOTENSIONSYNDROME (Vena Cava Compression)
bull SUPINE POSITION AFTER 5TH MONTH
bull UTERUS COMPRESSES THE INFERIOR VENA CAVA
bull uarrVOL BLOOD IN THE LErsquoS bull darrRETURN TO THE HEARTbull REDUCED PERFUSION OF
UTERUS bull FETAL HYPOXIA
Supine Hypotension Syndrome
bull Obstruction of inferior vena cava and aorta from pressure of the large fetus
Symptoms Sweating Nausea Weakness Sense of lack of air
Supine Hypotension Syndrome
Other symptomsbull Drop in blood pressurebull Bradycardiabull Possible loss of consciousness
Prevention of Supine HypotensiveSyndrome
bullElevate right hip 10-12 cmbullWeight is taken off the major vessels
Treatment of Supine HypotensiveSyndrome
bullRoll patient onto her left side
How should the pregnant woman be positionedbull Flat position may
cause hypotension and hypoxia
bull Place a small pillow under right hip - left lateral displacement
bull Head above feet
Systemic changes in pregnancy
Diaphragm rises about 4 cm darr residual volume uarr awareness of a desire to breath is
common-may be interpreted as dyspnea Increased estrogen in blood causes
engorgement of the nasal capillaries and rhnitis in pregnant women
Frequent nosebleeds amp predisposition to upper respiratory infection
Respiratory system
Systemic changes in pregnancy
Gastrointestinal system Gastric emptying amp intestinal transit times
are delayed
Heart burn reflux common
Nausea and vomiting common
Systemic changes in pregnancy
For pregnant patient with Hyper-emesis gravidarium ( excessive and uncontrolled vomiting) morning appointments should be avoided
They should be seated in a semi-supine or comfortable position
In case of vomiting the procedure should be stopped immediately amp the patient should be repositioned upright
When vomiting is over rinsing mouth with cold water or mouthwash is recommended
Systemic changes in pregnancybull Urinary System uarr GFR amp renal plasma flow by as much as
50 Nocturia ndashto mobilize the dependent
edema which accumulate during the day uarr Frequency from uarr renal flow plus reduced
bladder capacity from uterine growth It is advisable to ask the patient to void the
bladder just prior to starting the dental procedure
Systemic changes in pregnancyEndocrine Changes uarrEstrogen uarr progesterone uarrhuman
gonadotropin uarr thyroxin steroid and insulin level Estrogen amp progesterone are insulin
antagonists uarr level of these hormones lead to insulin resistance Thus insulin levels are elevated in pregnant in pregnant patient to compensate this resistance
About 45 of women fail to produce sufficient amount of insulin to overcome this antagonist action amp thus develop gestational diabetes
Systemic changes in pregnancy
Hematological changebull uarr red RBC uarrESR darrHbbull uarrWBCbull uarr circulatory catecholamin amp cortisol lead
to leucositosis bull uarr Coagulation factors except factor XI amp
XIII (anticloting factor) bull so pregnancy is a hypercoagulable state amp
uarr risk for thromboembolism
Systemic changes in pregnancy
bull Pregnant women with anti-phospholipid syndrome are at uarr risk for thrombo-embolisim
bull They are placed on subcutaneous low molecular weight heparin (LMWH)
bull These patients must be hospitalized for dental care
Pregnancy RelatedOral Health Problems
bull Pregnancy Gingivitisbull Pregnancy Epulis bull Increased Tooth Mobilitybull Dental Cariesbull Erosionbull Dental Problems in relation to Labor
and Delivery
Oral Problems in Pregnancy
bullPregnancy GingivitisbullMost common oral manifestation (50-100 of women)bullCaused by hormonal and vascular changes of pregnancy
Pregnancy Gingivitis Pathophysiology
bull Elevated circulating estrogen increases capillary permeability
bull Preexisting gingivitis may predispose to pregnancy gingivitis
Pregnancy Gingivitis
bullOccurs commonly in the 2nd to 8th monthsbullTendency to bleed very easilybullTreatment Scaling root-planing currettage OHI
Pregnancy Granuloma
bullOccurs in up to 5 of womenbullMost common in buccal maxillary anterior areasbullUsually starts in an area of gingivitis
Pregnancy Granuloma (continued)
bullRapid growth up to 2 cmbullSingle tumor-like growthbullusually in interdental papillaebullPurplish to bluish in color may be ulcerated- bleeds easily
Gum Problems - Pregnancy Granuloma
Gum Problems - Pregnancy Granuloma
Gum Changes - Pregnancy Granuloma
Pregnancy Granuloma (continued)
Treatment
bull Scaling and root planingbull Excision if it is too large or bleeds too
easilybull May regress spontaneously after
pregnancy
Candidiasis
bullWipes offbullUsually asymptomatic but may burnbullTreatment topical or systemic antifungals
Pregnancy MythsbullldquoA mother loses a tooth for every babyrdquobullNo evidence that aphthous ulcers are any more common in pregnancy
Other Oral Conditions in Pregnancy
bull Dry mouthbull Excessive salivationbull Tooth erosions associated with
severe GERD or hyperemesis
Changes During Pregnancy that Affect Oral Health
bull Hormonal Affects
ndash Increased tooth mobility
ndash Saliva changes
ndash Increased bacteria
ndash Gingival problems
Saliva changesbull Decreased buffers
bull Decreased minerals
bull Decreasing flow first and last trimester
bull Increased flow second trimester
bull More acidic
Increased Bacteriabull Increased acidity
ndash Increase in decay-causing bacteriabull Increased Snacking
ndash Morning sicknesslow blood sugarndash Between-meal snacks
bull Increase in amount and frequency of starchescarbohydrates ndash Crackers are commonly recommendedndash Promotes decay-causing bacteria
Changes During Pregnancy that Affect Oral Healthbull Morning sickness
ndash Difficulty with hygienebull Gingival diseasebull Tooth decay
ndash Vomitingbull Esophogeal Reflux (heartburn)bull Acid exposure
ndash Irritation of the gumsndash Weakening of tooth enamelndash Dental erosion
Enamel erosion caused by frequent vomiting
Treatment for Acid Exposure
bull Do NOT brush immediately after vomiting
bull Rinse ndash Water with baking sodandash Antacidndash Plain water
bull Eat some cheese
Oral Diseases Can Effect Pregnancy
bull Preterm low birth weight (LBW) linked to periodontal disease
bull Thorough calculus (tartar) removal in pregnant women with periodontitis may reduce pre-term births
Periodontal Disease and Preterm LaborbullMaternal periodontal disease is associated with increased risk of preterm laborbullAnaerobic oral gram-negative bacteria cause inflammatory responsebullInflammatory response stimulates prostaglandin and cytokine production to stimulate labor
Periodontal Disease and Low Birth Weight
bull Periodontal disease is associated with low birth weight
bull Evidence is not conclusivebull Biochemical mechanism similar cascade
as in preterm labor leading to placental blood flow restriction and necrosis
Periodontal Disease and Preeclampsia
bull Emerging databull Mechanism unclearbull Proposed mechanism
ndash Periodontal infection leads to inflammatory vascular damage
ndash Triggers cell damage in placenta
Periodontitis and Pre-eclampsia
bull Periodontal disease may be associated with pre-eclampsia (Boggess 2003)
bull PGE2 IL-1 and TNF-α from gingival crevicular fluid were higher in women with preeclampsia compared with healthy matched pregnant women (Oettinger-Barak 2003)
Dental Considerations
bull timing of treatment for pregnant patientsbull dental radiation exposurebull use of local anestheticsbull prescription of common antibiotics and
analgesicsbull nitrous oxide gas administration
Treatment Timing
bull First Trimesterndash Spontaneous miscarriages naturally occur
more often in 1st trimesterndash Avoid elective treatment that can be delayedndash Offer anticipatory guidance
bull Second Trimesterndash The optimal time for dental treatmentndash Organogenesis complete fetus not largendash Easier to prevent than treat established disease
bull Third Trimesterndash Late in term very uncomfortable (short visits)ndash Position slightly on left side
Timing of Dental Treatment During Pregnancy - From Little and Fallace
First Trimester
bull Plaque controlbull Oral hygiene instructionbull Scaling polishing curettagebull Avoid elective treatment urgent care
only
Timing of Dental Treatment During Pregnancy - From Little and Fallace
Second Trimester
bull Plaque controlbull Oral hygiene instructionbull Scaling polishing curettagebull Routine dental care
Timing of Dental Treatment During Pregnancy - From Little and Fallace
Third Trimester
bull Plaque controlbull Oral hygiene instructionbull Scaling polishing curettagebull Routine dental care (after middle of third
trimester elective care should be avoided)
Use of Radiation on Pregnant Patientbull Dose given and time of gestation are
importantbull doses lt 5-10 rads (cGy) not teratogenicbull fetus is most susceptible to radiation
between the 2nd and 6th week of gestationbull single dental x-ray exposes patient to 001
millirads of radiation In relative terms this amount is 40 times less than daily dose acquired from cosmic radiation Therefore diagnostic radiation should not be withheld during pregnancy
Radiographs during Pregnancy
bull Take as needed with optimal methods for reducing secondary radiation and exposure time
bull Always use a lead apronbull Exposure to fetus (with apron use) is 00001
centiGray(rad)bull Daily cosmic radiation - 0004 centiGray (rad)
Risks of Dental X-Rays
bull X-ray only if necessary (ie root canal therapy trauma)
bull When x-rays are indicated radiation exposure is extremely low
bull Exposure can be limited byndash Lead apron shielding ndash Modern fast film ndash Avoiding retakes
FDA drug classification for pregnancybull Combines risk statements including
congenital anomalies fetal effects perinatal risks and therapeutic risk-benefit ratio
bull Untreated disease or condition may pose more serious risks to both mother and fetus than any theoretical risks from the medication
bull Category A thru D and X
FDA drug classification for pregnancy
bull A = Controlled Studies in women fail to demonstrate a risk to the fetus in the first trimester and the possibility of fetal harm appears remote
FDA drug classification for pregnancy
bull B = Animal studies show no risk or if risk shown in animals controlled
trials in women showed no risk
FDA drug classification for pregnancy
bull C = Studies in animals with adverse effects and no human studies
OR no animal or human studies but benefits of use may outweigh potential harms
FDA drug classification for pregnancy
bull D = There is evidence of human fetal risk but benefits may outweigh risks
FDA drug classification for pregnancy
bull X = Contraindicated
Common Analgesics
bull paracetamol (B)bull Ibuprofen (BD) bull Oxycodone (BD) bull Hydrocodone and codeine
(CD)
avoid in third trimester
Analgesics
bull Paracetamol is the analgesic of choice for all stages of gestation
bull used to treat mild to moderate pain and fevers
bull short term usage is believed to be safebull avoid chronic and large doses of
paracetamol1048715
Analgesics - continuedbull Aspirin is nonteratogenic but may cause
maternal and fetal hemorrhagebull large and chronic doses during last trimester
may result in premature closure of ductus arteriosus fetal hypertension anemia and low birth weight
bull avoid ibuprofen in 3rd trimester because of possible adverse circulatory effects
bull short term use of codeine seems safebull avoid codeine late in gestation because of
possible fetal respiratory depression and withdrawal symptoms
Analgesics to Use During1st and 2nd Trimester
bull Category B (for best)bull Paracetamol Ibuprofenbull Naproxenbull Category C (use with caution)bull Paracetamol with codeine or
hydrocodonebull Paracetamol with oxycodone
Analgesics to Avoid During theThird Trimesterbull Causes delivery problemsbull Aspirin (C 3D)bull Ibuprofen (B3D)bull Naproxen (B3D)bull Causes neonatal respiratory
depression and opioid withdrawalbull Codeine (C3D)bull Hydrocodone (C3D)bull Oxycodone(C3D)
Sedation in Pregnancy
bull SedativesAnxiolytics (eg Diazepam ) are rated D and can cause oral clefts with prolonged exposure
bull Nitrous oxide should not be used in 1st trimester (If used in 2nd and 3rd do not go below 50 O2)
Common Antibioticsbull To treat oral abscess or cellulitis
ndash Penicillin (B) ndash Amoxicillin (B) ndash Cephalexin (B)ndash Erythromycin base (B) (Not estolate as it
cause cholestatic hepatitis)ndash Clindamycin (B)
Antibioticsbull penicillin V and amoxicillin is preferred drug
for mild to moderate infectionsbull widely used for many years with no ill effectsbull no studies show penicillin to be teratogenicbull amoxicillin extensively used without harming
the fetusbull Drug classes1048715 B penicillin cephalosporins erythromycin clindamycin Azithromycin D Tetracycline
Antibiotics To Use During Pregnancy
bull Penicillin Vbull Amoxicillinbull Erythromycin (base form)bull Cephalexin cephalosporinbull Clindamycinbull Metronidazole
Antibiotics to Avoid duringPregnancy
bull Doxycyclinebull Tetracyclinebull Erythromycin (estolate form)bull Vancomycin
The Problem With Tetracycline
bull Accumulates in bones and chelates calcium
bull Inhibits bone growthbull Discolors teeth
Other Antimicrobial Agentsbull OK to usebull Nystatin (B)bull Chlorhexidine rinse (B)bull Use with cautionbull Clotrimazole (C)bull Ketoconazole (C)bull Fluconazole (C)bull Do not usebull Doxycycline (D)
Local Anesthetic Use inPregnancy
bull Class Bbull Lidocaine (Xylocaine)bull Etidocainebull Prilocaine bull Class Cbull Procainebull Bupivicainebull Mepivicaine
Use of Local Anestheticsbull Lidocaine + vasoconstrictor most common
local anesthetic used in dentistrybull extensively used in pregnancy with no proven ill
effectsbull accidental intravascular injections of lidocaine
pass through the placenta but the concentrations are too low to harm fetus
bull prilocaine might cause methemoglobinemia
Ulcer healing drugsCimetidine bull FDA category B Famotidinebull FDA category BRanitidinebull FDA category Bbull not known to be harmful
Ulcer healing drugsOmeprazolebull FDA category BNot known to be
harmful Esomeprazolebull FDA category BLansoprazolebull FDA category BPantoprazolebull Avoid unless potential benefit
outweighs riskmdashfetotoxic in animals
Ulcer healing drugs
Misoprostolbull First second third trimesters Avoidmdash
potent uterine stimulant (has been used to induce abortion) and may be teratogenic
Ulcer healing drugs
Antacidsbull Almunium hydroxideMagnesium
hydroxidemdashFDA category B Calcium carbonatemdashFDA category C
SimetheconemdashFDA category C
Use of Nitrous Oxide Gas
bull used over 150 years bull safety is being debatedbull SHORT TERM exposure do not cause
birth defects or spontaneous abortionbull CHRONIC exposure may result in fetal
loss and infertilitybull literature suggests that nitrous oxide
should be avoided until more conclusive research is available
bull FDA Drug class not yet assigned
Common Preventives
bull Fluoridendash No increased risk during pregnancy
bull Xylitolndash No studies no harm reported
bull Chlorhexidinendash No increased risk during pregnancy
Are topical agents safe
bull Fluoridebull Toothpaste amp mouthrinse
bull Xylitol chewing gum bull Chlorhexidine (11 alcohol)bull No over the counter mouthrinses with
alcohol (Listerine 20 alcohol)
Pre-natal Fluoride
bull Daily 22 mg tablet of sodium fluoride during 3rd through 9th months
bull decreases caries rate in offspringbull Safe and effective
Glenn FB 1982
Is it safe to use mercury restorations
bull No evidence of harmful effect
bull Benefits outweigh risks
bull Canada Germany and New Zealand have some restrictions
bull Determine the best option
Referencesbull Wasylko L Matsui D Dykxhoorn SM Rieder MJ Weinberg
S A Review of Common Dental Treatments During Pregnancy J Canadian Dental Association 64434-439 1998
bull Little JW Donald AF Craig SM Rhodus NL Dental Management of the Medically Compromised Patient - 5th edition Mosby Toronto Pp434-442 1997
bull Livingston HM Dellinger TM Holder R Considerations in the management of the pregnant patient Special Care in Dentistry 185 pp183-188 1998
bull Larimore WL Petrie KA Drug use during pregnacy and lactation Primary Care Clinics in Office Practice 271 35-53 2000
bull Health Canada The Safety of DentalAmalgam Minister Of Supply and Services Canada 1996
REFERENCESbull 1 Weiss G Endocrinology of parturition J Clin
Endocrinol Metab 2000854421-5bull 2 Theunissen IM Parer JT Fluid and electrolytes in
pregnancy Clin Obstet Gynecol 1994373-15bull 3 Duvekot JJ Peeters LLH Renal hemodynamics and
volume homeostasis in pregnancy Obstet Gynecol Surv 199449830-9
bull 4 Barron WM Lindheimer MD Medical disorders during pregnancy 2nd ed St Louis Mosby 1995 p 129
bull 5 Thornburg KL Jacobson SL Giraud GD Morton MJ Hemodynamic changes in pregnancy Semin Perinatol 20002411-4
bull 6 Fiese R Herzog S Issues in dental and surgical management of the pregnant patient Oral Surg Oral Med Oral Pathol 198865292-7
bull 7 Martin C Varner MW Physiologic changes in pregnancysurgical implications Clin Obstet Gynecol 199437241-55
bull 8 Clark SL Cotton DB Lee W Bishop C Hill T Southwick J et al Central hemodynamic assessment of normal term pregnancy Am J Obstet Gynecol 19891611439-42
bull 9 Mabie WC Di Sessa TG Crocker LG Sibai BM Arheart KL A longitudinal study of cardiac output in normal human pregnancy Am J Obstet Gynecol 1994170849-56
bull 10 Clapp JF 3rd Capeless E Cardiovascular function before during and after the first and subsequent pregnancies Am J Cardiol 1997801469-73
bull 11 Duvekot JJ Peeters LL Maternal cardiovascular hemodynamic adaptation to pregnancy Obstet Gynecol Surv 199449(Suppl) S1-14
bull 12 Bhagwat AR Engel PJ Heart disease and pregnancy Cardiol Clin 199513163-78
bull 13 Lanni SM Tillinghast J Silver H Hemodynamic changes and baroreflex gain in the supine hypotensive syndrome Am J Obstet Gynecol 20021871636-41
bull 14 Little JW Falace DA Miller CS Rhodus NL Dental management of the medically compromised patient 6th ed St Louis Mosby 2002 p 303
bull 15 Garcia-Rio F Pino JM Gomez L Alvarez-Sala R Villasante C Villamor J Regulation of breathing and perception of dyspnea in healthy pregnant women Chest 1996110446-53
bull 16 McAuliffe F Kametas N Costello J Rafferty GF Greenough A Nicolaides K Respiratory function in singleton and twin pregnancy BJOG 2002109765-9
bull 17 Clapp JF 3rd Seaward BL Sleamaker RH Hiser J Maternal physiologic adaptations to early human pregnancy Am J Obstet Gynecol 19881591456-60
bull 18 OrsquoDay MP Cardio-respiratory physiological adaptation of pregnancy Semin Perinatol 199721268-75
bull 19 Contreras G Gutierrez M Beroiza T Fantin A Oddo H Villarroel L et al Ventilatory drive and respiratory muscle function in pregnancy Am Rev Respir Dis 1991144837-41
bull 20 Turner M Aziz SR Management of the pregnant oral and maxillofac
bull 21 Sifakis S Pharmakides G Anemia in pregnancy Ann N Y Acad Sci 2000900125-36
bull 22 Branch DW Physiologic adaptations of pregnancy Am J Reprod Immunol 199228120-2
bull 23 Burrows RF Kelton JG Incidentally detected thrombocytopenia in healthy mothers and their infants N Engl J Med 1988319 142-5
bull 24 Hanly JG Antiphospholipid syndrome an overview CMAJ 200324(168)1675-82
bull 25 Heilmann L von Tempelhoff GF Pollow K Antiphospholipid syndrome in obstetrics Clin Appl Thromb Hemost 20039 143-50
bull 26 Sherman P Flaxman SM Nausea and vomiting of pregnancy in an evolutionary perspective Am J Obstet Gynecol 2002 185(Suppl)s190-7
bull 27 Koch KL Gastrointestinal factors in nausea and vomiting of pregnancy Am J Obstet Gynecol 2002185(Suppl)s198-203
bull 28 Koch KL Frissora CL Nausea and vomiting during pregnancy Gastroenterol Clin N Am 200332201-34
bull 29 Baron TH Ramirez B Richter JE Gastrointestinal motility disorders during pregnancy Ann Intern Med 1993118 366-75
bull 30 Richter JE Gastroesophageal reflux disease during pregnancy Gastroenterol Clin N Am 200332235-61
bull 31 Marrero JM Goggin PM de Caestecker JS Pearce JM Maxwell JD Determinants of pregnancy heartburn Br J Obstet Gynaecol 199299731-4
bull 32 Hamaoui E Hamaoui M Nutritional assessment and support during pregnancy Gastroenterol Clin N Am 20033259-121
bull 33 King JC Physiology of pregnancy and nutrient metabolism Am J Clin Nutr 200071(suppl)1218s-25s
bull 34 Casanueva E Pfeffer F Fernandez-Gaxiola AC Gutierrez- Valenzuela V Rothenberg SJ Iron and folate status before pregnancy and anemia during pregnancy Ann Nutr Metab 2003 4760-3
bull 35 Chrsquong CL Morgan M Hainsworth I Kingham JG Prospective study of liver dysfunction in Southwest Wales Gut 200251 876-80
bull 36 Rahman TM Wendon J Severe hepatic dysfunction in pregnancy QJM 200295343-57
bull 37 Knox TA Olans LB Liver disease in pregnancy N Engl J Med 1996335569-76
bull 38 Saftlas AF Olson DR Franks AL Atrash H Pokras R Epidemiology of preeclampsia and eclampsia in the United States 1979e1986 Am J Obstet Gynecol 1990163460-5
bull 39 Walker JJ Pre-eclampsia Lancet 20003561260-5
bull 40 Davidson JM Renal disorders in pregnancy Curr Opin Obstet Gynecol 200113109-14
bull 41 Dafnis E Sabatini S The effect of pregnancy on renal function physiology and pathophysiologyAmJMedSci 1992303184-205
bull 42 Davison JM Shiells EA Philips PR Lindheimer MD Serial evaluation of vasopressin release and thirst in human pregnancy Role of human chorionic gonadotrophin in the osmoregulatory changes of gestation J Clin Invest 198881798-806
bull 43 Glinoer D de Nayer P Bourdoux P Lemone M Robyn C van Steirteghem A et al Regulation of maternal thyroid during pregnancy J Clin Endocrinol Metab 199071276-87
bull 44 Wilson SG Retallack RW Kent JC Worth GK Gutteridge DH Serum free 125-dihydroxyvitamin D and the free 125- dihydroxyvitamin D index during a longitudinal study of human pregnancy and lactation Clin Endocrinol 199032613-22
bull 45 Rasmussen N Frolich A Hornnes PJ Hegedus L Serum ionized calcium and intact parathyroid hormone levels during pregnancy and postpartum Br J Obstet Gynaecol 199097857-9
bull 46 Guyton AC Textbook of medical physiology 8th ed Philadelphia W B Saunders 1991 p 915e28
bull 47 Trainer PJ Corticosteroids and pregnancy Semin Reprod Med 200220375-80
bull 48 Soory M Hormonal factors in periodontal disease Dent Update 200027380-3
bull 49 Hugoson A Gingivitis in pregnant women A longitudinal clinical study Odontol Revy 19712265-84
bull 50 Neville BW Damm DD Allen CM Bouquot JE Oral amp Maxillofacial Pathology 3rd ed Philadelphia W B Saunders 2002 p 329-30 447-9
bull 51 Tilakaratne A Soory M Ranasinghe AW Corea SM Ekanayake SL de Silva M Periodontal disease status during pregnancy and 3 months post-partum in rural population of Sri-Lankan women J Clin Periodontol 200027787-92
bull 52 Laine M Tenovuo J Lehtonen OP Ojanatko-Harri A Vilja P Tuohimaa P Pregnancy e related changes in human whole saliva Arch Oral Biol 198833913-7
bull 53 Yuan K Wing LY Lin MT Pathogenetic roles of angiogenic factors in pyogenic granulomas in pregnancy are modulated by female sex hormones J Periodontol 200273701-8
bull 54 Evans RD Briggs PF Tooth-surface loss related to pregnancyinduced vomiting Prim Dent Care 1994124-6
bull 55 Salvolini E Di Giorgio R Curatola A Mazzanti L Fratto G Biochemical modifications of human whole saliva induced by pregnancy Br J Obstet Gynaec 1998105656-60
bull 56 Mauldin JG Newman RB Preterm birth risk assessment Semin Perinatol 200125215-22
bull 57 Heine RP McGregor JA Goodwin TM Artal R Hayashi RH Robertson PA et al Serial salivary estriol to detect an increased risk of preterm birth Obstet Gynecol 200096490-7
bull 58 Kauh YC Zachian TF Melasma Adv Exp Med Biol 1999455 491-9
bull 59 Wong RC Ellis CN Physiologic skin changes in pregnancy J Am Acad Dermatol 198410929-40
bull 60 Errickson CV Matus NR Skin disorders of pregnancy Am Fam Physician 199449605-10
bull 61 Lopez NJ Smith PC Gutierrez J Periodontal therapy may reduce the risk of preterm low birth weight in women with periodontal disease a randomized controlled trial J Periodontol 200273911-24
bull 62 McGaw T Periodontal disease and preterm delivery of lowbirth- weight infants J Can Dent Assoc 200268165-9
bull 63 Richards AG Dental x-ray protection Dent Clin North Am 1968631-41
bull 64 1990 Recommendations of the International Commission on Radiological Protection Ann ICRP 1991211-201
bull 65 Hall EJ Radiation the two-edged sword cancer risks at high and low doses Cancer J 20006343-50
bull 66 Diethelm L Xu H Diagnostic imaging of the lung during pregnancy Clin Obstet Gynecol 19963936-55
bull 67 Brent RL The effects of embryonic and fetal exposure to x-rays microwaves and ultrasound ClinObstetGynecol 198326484-510
bull 68 National Council on Radiation Protection NCRP report no128 1998 Bethesda Md Author
bull 69 Wasylko L Matsui D Dykxhoorn SM Reider MJ Weinberg S A review of common dental treatments during pregnancy implications for patients and dental personnel J Can Dent Assoc 199864434-9
bull 70 Freeman JP Brand JW Radiation doses of commonly used dental radiographic surveys Oral Surg Oral Med Oral Pathol 199477285-9
bull 71 Kircos LTAngin LL Lorton LOrder ofmagnitude dose reduction in intraoral radiography J Am Dent Assoc 1987114344-7
bull 72 Updegrave WJ Simplified and standardized intraoral radiography with reduced tissue irradiation J Am Dent Assoc 197285861-9
bull 73 Wood RE Harris AM van der Merwe EJ Nortje CJ The leaded apron revisited does it reduce gonadal radiation dose in dental radiology Oral Surg Oral Med Oral Pathol 199171642-6
bull 74 An update on radiographic practices information and recommendations ADA Council on Scientific Affairs J Am Dent Assoc 2001132234-8
bull 75 Rayburn WF Recommending medications during pregnancy an evidence based approach Clin Obstet Gynecol 2002451-5
bull 76 Rathmell JP Viscomi C Ashburn MA Management of nonobstetric pain during pregnancy and lactation Anesth Analg 1997851074-87
bull 77 Teratology society public affairs committee FDA classification of drugs for teratogenic risk Teratology 199449446-7
bull 78 Moore PA Selecting drugs for the pregnant dental patient J Am Dent Assoc 19981291281-6
bull 79 Haas DA An update on analgesics for the management of acute postoperative dental pain J Can Dent Assoc 200268476-82
bull 80 Haas DA Pynn BR Sands TD Drug use for the pregnant or lactating patient Gen Dent 20004854-60
bull 81 Committee on Drugs American Academy of Pediatrics The transfer of drugs and other chemicals into human milk Pediatrics 199493137-50
bull 82 Nielsen GL Sorensen HT Larsen H Pedersen L Risk of adverse birth outcome and miscarriage in pregnant users of nonsteroidal anti-inflammatory drugs population based observational study and case-control study BMJ 2001322266-70
bull 83 Janssen N Genta M The effects of immunosuppressive and anti-inflammatory medications on fertility pregnancy and lactation Arch Intern Med 200016610-9
bull 84 Ostensen M Nonsteroidal anti-inflammatory drugs during pregnancy Scand J Rheumatol Suppl 1998107128-32
bull 85 USPDI -Drug information for the health care professional 22nd ed Greenwood Village CO Micromedex 2002 p 152-79
bull 86 Denson DD Coyle DE Thompson GA Santos D Turner PA Myers JA et al Bupivacaine protein binding in the term parturient effects of lactic acidosis Clin Pharmacol Ther 198435702-9
bull 87 Dillon DE Wagner CL Wiest D Newman RB Drug therapy in the nursing mother Obstet Gynecol Clin North Am 199724 675-96
bull 88 Dashe JS Gilstrap LC Antibiotic use in pregnancy Obstet Gynecol Clin North Am 199724617-29
bull 89 American College of Rheumatology Ad hoc Committee on Clinical Guidelines Guidelines for monitoring drug therapy in rheumatoid arthritis Arthritis Rheum 199639723-31
bull 90 Ng PC The fetal and neonatal hypothalamic-pituitary-adrenal axis Arch Dis Child Fetal Neonatal Ed 200082F250-4
bull 91 Crowley P Antenatal corticosteroidsmdashcurrent thinking BJOG 2003110(Suppl 20)77-8
bull 92 ACOG committee opinion antenatal corticosteroid therapy for fetal maturation Obstet Gynecol 200299871-3
bull 93 Ost L Wettrell G Bjorkhem I Rane A Prednisolone excretion in human milk J Pediatr 19851061008-11
bull 94 Rowland AS Baird DD Shore DL Weinberg CR Savitz DA Wilcox AJ Nitrous oxide and spontaneous abortion in female dental assistants Am J Epidemiol 1995141531-8
bull 95 McGlothlin JD Jensen PA Fischbach TJ Hughes RT Jones JH Control of anesthetic gases in dental operatories Scand J Work Environ Health 199218(Suppl 2)103-5
bull ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY Volume 97 Number 6 Suresh and Radfar 681
bull 96 Rosen MA Nitrous oxide for relief of labor pain a systematic review Am J Obstet Gynecol 2002186(Suppl Nature)S110-6
bull 97 Sands TD Pynn BR Management considerations for the pregnant or nursing emergency patient Ont Dent 199875 17-9
bull 98 Daya S Recurrent spontaneous early pregnancy loss and low dose aspirin Minerva Ginecol 200355441-9
bull 99 Sinclair C Handbook of obstetrical emergencies 1st ed Philadelphia WB Saunders 1996 p 29-39 69
bull 100 Tarsitano BF Rollings RE The pregnant dental patient evaluation and management Gen Dent 199341226-34
bull 101 Livingston MH Dlllinger TM Holder R Consideration in the management of the pregnant patient SCD Special Care in Dentistry 199818183-8
Thank you
- A Review on the principle of Dental Management of the Pregnant patient
- Slide 2
- Questions that a dentist may ask
- Stages of Pregnancy
- Slide 5
- Slide 6
- Physiologic Changes in Pregnancy
- Systemic changes in pregnancy
- FLAT SUPINE POSITIONING
- SUPINE HYPOTENSION SYNDROME (Vena Cava Compression)
- Supine Hypotension Syndrome
- Slide 12
- Supine Hypotension Syndrome
- Prevention of Supine Hypotensive Syndrome
- Treatment of Supine Hypotensive Syndrome
- How should the pregnant woman be positioned
- Slide 17
- Slide 18
- Slide 19
- Slide 20
- Slide 21
- Slide 22
- Slide 23
- Pregnancy Related Oral Health Problems
- Oral Problems in Pregnancy
- Pregnancy Gingivitis Pathophysiology
- Pregnancy Gingivitis
- Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Gum Problems - Pregnancy Granuloma
- Slide 31
- Gum Changes - Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Candidiasis
- Pregnancy Myths
- Other Oral Conditions in Pregnancy
- Changes During Pregnancy that Affect Oral Health
- Saliva changes
- Increased Bacteria
- Slide 40
- Enamel erosion caused by frequent vomiting
- Treatment for Acid Exposure
- Oral Diseases Can Effect Pregnancy
- Periodontal Disease and Preterm Labor
- Periodontal Disease and Low Birth Weight
- Periodontal Disease and Preeclampsia
- Periodontitis and Pre-eclampsia
- Dental Considerations
- Treatment Timing
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Slide 52
- Use of Radiation on Pregnant Patient
- Radiographs during Pregnancy
- Risks of Dental X-Rays
- FDA drug classification for pregnancy
- Slide 57
- FDA drug classification for pregnancy
- Slide 59
- Slide 60
- Slide 61
- Common Analgesics
- Analgesics
- Analgesics - continued
- Analgesics to Use During 1st and 2nd Trimester
- Analgesics to Avoid During the Third Trimester
- Sedation in Pregnancy
- Common Antibiotics
- Antibiotics
- Antibiotics To Use During Pregnancy
- Antibiotics to Avoid during Pregnancy
- The Problem With Tetracycline
- Other Antimicrobial Agents
- Local Anesthetic Use in Pregnancy
- Use of Local Anesthetics
- Ulcer healing drugs
- Slide 77
- Slide 78
- Slide 79
- Use of Nitrous Oxide Gas
- Common Preventives
- Are topical agents safe
- Pre-natal Fluoride
- Is it safe to use mercury restorations
- References
- REFERENCES
- Slide 87
- Slide 88
- Slide 89
- Slide 90
- Slide 91
- Slide 92
- Slide 93
- Slide 94
- Slide 95
- Slide 96
- Slide 97
- Slide 98
- Thank you
-
Supine Hypotension Syndrome
bull Obstruction of inferior vena cava and aorta from pressure of the large fetus
Symptoms Sweating Nausea Weakness Sense of lack of air
Supine Hypotension Syndrome
Other symptomsbull Drop in blood pressurebull Bradycardiabull Possible loss of consciousness
Prevention of Supine HypotensiveSyndrome
bullElevate right hip 10-12 cmbullWeight is taken off the major vessels
Treatment of Supine HypotensiveSyndrome
bullRoll patient onto her left side
How should the pregnant woman be positionedbull Flat position may
cause hypotension and hypoxia
bull Place a small pillow under right hip - left lateral displacement
bull Head above feet
Systemic changes in pregnancy
Diaphragm rises about 4 cm darr residual volume uarr awareness of a desire to breath is
common-may be interpreted as dyspnea Increased estrogen in blood causes
engorgement of the nasal capillaries and rhnitis in pregnant women
Frequent nosebleeds amp predisposition to upper respiratory infection
Respiratory system
Systemic changes in pregnancy
Gastrointestinal system Gastric emptying amp intestinal transit times
are delayed
Heart burn reflux common
Nausea and vomiting common
Systemic changes in pregnancy
For pregnant patient with Hyper-emesis gravidarium ( excessive and uncontrolled vomiting) morning appointments should be avoided
They should be seated in a semi-supine or comfortable position
In case of vomiting the procedure should be stopped immediately amp the patient should be repositioned upright
When vomiting is over rinsing mouth with cold water or mouthwash is recommended
Systemic changes in pregnancybull Urinary System uarr GFR amp renal plasma flow by as much as
50 Nocturia ndashto mobilize the dependent
edema which accumulate during the day uarr Frequency from uarr renal flow plus reduced
bladder capacity from uterine growth It is advisable to ask the patient to void the
bladder just prior to starting the dental procedure
Systemic changes in pregnancyEndocrine Changes uarrEstrogen uarr progesterone uarrhuman
gonadotropin uarr thyroxin steroid and insulin level Estrogen amp progesterone are insulin
antagonists uarr level of these hormones lead to insulin resistance Thus insulin levels are elevated in pregnant in pregnant patient to compensate this resistance
About 45 of women fail to produce sufficient amount of insulin to overcome this antagonist action amp thus develop gestational diabetes
Systemic changes in pregnancy
Hematological changebull uarr red RBC uarrESR darrHbbull uarrWBCbull uarr circulatory catecholamin amp cortisol lead
to leucositosis bull uarr Coagulation factors except factor XI amp
XIII (anticloting factor) bull so pregnancy is a hypercoagulable state amp
uarr risk for thromboembolism
Systemic changes in pregnancy
bull Pregnant women with anti-phospholipid syndrome are at uarr risk for thrombo-embolisim
bull They are placed on subcutaneous low molecular weight heparin (LMWH)
bull These patients must be hospitalized for dental care
Pregnancy RelatedOral Health Problems
bull Pregnancy Gingivitisbull Pregnancy Epulis bull Increased Tooth Mobilitybull Dental Cariesbull Erosionbull Dental Problems in relation to Labor
and Delivery
Oral Problems in Pregnancy
bullPregnancy GingivitisbullMost common oral manifestation (50-100 of women)bullCaused by hormonal and vascular changes of pregnancy
Pregnancy Gingivitis Pathophysiology
bull Elevated circulating estrogen increases capillary permeability
bull Preexisting gingivitis may predispose to pregnancy gingivitis
Pregnancy Gingivitis
bullOccurs commonly in the 2nd to 8th monthsbullTendency to bleed very easilybullTreatment Scaling root-planing currettage OHI
Pregnancy Granuloma
bullOccurs in up to 5 of womenbullMost common in buccal maxillary anterior areasbullUsually starts in an area of gingivitis
Pregnancy Granuloma (continued)
bullRapid growth up to 2 cmbullSingle tumor-like growthbullusually in interdental papillaebullPurplish to bluish in color may be ulcerated- bleeds easily
Gum Problems - Pregnancy Granuloma
Gum Problems - Pregnancy Granuloma
Gum Changes - Pregnancy Granuloma
Pregnancy Granuloma (continued)
Treatment
bull Scaling and root planingbull Excision if it is too large or bleeds too
easilybull May regress spontaneously after
pregnancy
Candidiasis
bullWipes offbullUsually asymptomatic but may burnbullTreatment topical or systemic antifungals
Pregnancy MythsbullldquoA mother loses a tooth for every babyrdquobullNo evidence that aphthous ulcers are any more common in pregnancy
Other Oral Conditions in Pregnancy
bull Dry mouthbull Excessive salivationbull Tooth erosions associated with
severe GERD or hyperemesis
Changes During Pregnancy that Affect Oral Health
bull Hormonal Affects
ndash Increased tooth mobility
ndash Saliva changes
ndash Increased bacteria
ndash Gingival problems
Saliva changesbull Decreased buffers
bull Decreased minerals
bull Decreasing flow first and last trimester
bull Increased flow second trimester
bull More acidic
Increased Bacteriabull Increased acidity
ndash Increase in decay-causing bacteriabull Increased Snacking
ndash Morning sicknesslow blood sugarndash Between-meal snacks
bull Increase in amount and frequency of starchescarbohydrates ndash Crackers are commonly recommendedndash Promotes decay-causing bacteria
Changes During Pregnancy that Affect Oral Healthbull Morning sickness
ndash Difficulty with hygienebull Gingival diseasebull Tooth decay
ndash Vomitingbull Esophogeal Reflux (heartburn)bull Acid exposure
ndash Irritation of the gumsndash Weakening of tooth enamelndash Dental erosion
Enamel erosion caused by frequent vomiting
Treatment for Acid Exposure
bull Do NOT brush immediately after vomiting
bull Rinse ndash Water with baking sodandash Antacidndash Plain water
bull Eat some cheese
Oral Diseases Can Effect Pregnancy
bull Preterm low birth weight (LBW) linked to periodontal disease
bull Thorough calculus (tartar) removal in pregnant women with periodontitis may reduce pre-term births
Periodontal Disease and Preterm LaborbullMaternal periodontal disease is associated with increased risk of preterm laborbullAnaerobic oral gram-negative bacteria cause inflammatory responsebullInflammatory response stimulates prostaglandin and cytokine production to stimulate labor
Periodontal Disease and Low Birth Weight
bull Periodontal disease is associated with low birth weight
bull Evidence is not conclusivebull Biochemical mechanism similar cascade
as in preterm labor leading to placental blood flow restriction and necrosis
Periodontal Disease and Preeclampsia
bull Emerging databull Mechanism unclearbull Proposed mechanism
ndash Periodontal infection leads to inflammatory vascular damage
ndash Triggers cell damage in placenta
Periodontitis and Pre-eclampsia
bull Periodontal disease may be associated with pre-eclampsia (Boggess 2003)
bull PGE2 IL-1 and TNF-α from gingival crevicular fluid were higher in women with preeclampsia compared with healthy matched pregnant women (Oettinger-Barak 2003)
Dental Considerations
bull timing of treatment for pregnant patientsbull dental radiation exposurebull use of local anestheticsbull prescription of common antibiotics and
analgesicsbull nitrous oxide gas administration
Treatment Timing
bull First Trimesterndash Spontaneous miscarriages naturally occur
more often in 1st trimesterndash Avoid elective treatment that can be delayedndash Offer anticipatory guidance
bull Second Trimesterndash The optimal time for dental treatmentndash Organogenesis complete fetus not largendash Easier to prevent than treat established disease
bull Third Trimesterndash Late in term very uncomfortable (short visits)ndash Position slightly on left side
Timing of Dental Treatment During Pregnancy - From Little and Fallace
First Trimester
bull Plaque controlbull Oral hygiene instructionbull Scaling polishing curettagebull Avoid elective treatment urgent care
only
Timing of Dental Treatment During Pregnancy - From Little and Fallace
Second Trimester
bull Plaque controlbull Oral hygiene instructionbull Scaling polishing curettagebull Routine dental care
Timing of Dental Treatment During Pregnancy - From Little and Fallace
Third Trimester
bull Plaque controlbull Oral hygiene instructionbull Scaling polishing curettagebull Routine dental care (after middle of third
trimester elective care should be avoided)
Use of Radiation on Pregnant Patientbull Dose given and time of gestation are
importantbull doses lt 5-10 rads (cGy) not teratogenicbull fetus is most susceptible to radiation
between the 2nd and 6th week of gestationbull single dental x-ray exposes patient to 001
millirads of radiation In relative terms this amount is 40 times less than daily dose acquired from cosmic radiation Therefore diagnostic radiation should not be withheld during pregnancy
Radiographs during Pregnancy
bull Take as needed with optimal methods for reducing secondary radiation and exposure time
bull Always use a lead apronbull Exposure to fetus (with apron use) is 00001
centiGray(rad)bull Daily cosmic radiation - 0004 centiGray (rad)
Risks of Dental X-Rays
bull X-ray only if necessary (ie root canal therapy trauma)
bull When x-rays are indicated radiation exposure is extremely low
bull Exposure can be limited byndash Lead apron shielding ndash Modern fast film ndash Avoiding retakes
FDA drug classification for pregnancybull Combines risk statements including
congenital anomalies fetal effects perinatal risks and therapeutic risk-benefit ratio
bull Untreated disease or condition may pose more serious risks to both mother and fetus than any theoretical risks from the medication
bull Category A thru D and X
FDA drug classification for pregnancy
bull A = Controlled Studies in women fail to demonstrate a risk to the fetus in the first trimester and the possibility of fetal harm appears remote
FDA drug classification for pregnancy
bull B = Animal studies show no risk or if risk shown in animals controlled
trials in women showed no risk
FDA drug classification for pregnancy
bull C = Studies in animals with adverse effects and no human studies
OR no animal or human studies but benefits of use may outweigh potential harms
FDA drug classification for pregnancy
bull D = There is evidence of human fetal risk but benefits may outweigh risks
FDA drug classification for pregnancy
bull X = Contraindicated
Common Analgesics
bull paracetamol (B)bull Ibuprofen (BD) bull Oxycodone (BD) bull Hydrocodone and codeine
(CD)
avoid in third trimester
Analgesics
bull Paracetamol is the analgesic of choice for all stages of gestation
bull used to treat mild to moderate pain and fevers
bull short term usage is believed to be safebull avoid chronic and large doses of
paracetamol1048715
Analgesics - continuedbull Aspirin is nonteratogenic but may cause
maternal and fetal hemorrhagebull large and chronic doses during last trimester
may result in premature closure of ductus arteriosus fetal hypertension anemia and low birth weight
bull avoid ibuprofen in 3rd trimester because of possible adverse circulatory effects
bull short term use of codeine seems safebull avoid codeine late in gestation because of
possible fetal respiratory depression and withdrawal symptoms
Analgesics to Use During1st and 2nd Trimester
bull Category B (for best)bull Paracetamol Ibuprofenbull Naproxenbull Category C (use with caution)bull Paracetamol with codeine or
hydrocodonebull Paracetamol with oxycodone
Analgesics to Avoid During theThird Trimesterbull Causes delivery problemsbull Aspirin (C 3D)bull Ibuprofen (B3D)bull Naproxen (B3D)bull Causes neonatal respiratory
depression and opioid withdrawalbull Codeine (C3D)bull Hydrocodone (C3D)bull Oxycodone(C3D)
Sedation in Pregnancy
bull SedativesAnxiolytics (eg Diazepam ) are rated D and can cause oral clefts with prolonged exposure
bull Nitrous oxide should not be used in 1st trimester (If used in 2nd and 3rd do not go below 50 O2)
Common Antibioticsbull To treat oral abscess or cellulitis
ndash Penicillin (B) ndash Amoxicillin (B) ndash Cephalexin (B)ndash Erythromycin base (B) (Not estolate as it
cause cholestatic hepatitis)ndash Clindamycin (B)
Antibioticsbull penicillin V and amoxicillin is preferred drug
for mild to moderate infectionsbull widely used for many years with no ill effectsbull no studies show penicillin to be teratogenicbull amoxicillin extensively used without harming
the fetusbull Drug classes1048715 B penicillin cephalosporins erythromycin clindamycin Azithromycin D Tetracycline
Antibiotics To Use During Pregnancy
bull Penicillin Vbull Amoxicillinbull Erythromycin (base form)bull Cephalexin cephalosporinbull Clindamycinbull Metronidazole
Antibiotics to Avoid duringPregnancy
bull Doxycyclinebull Tetracyclinebull Erythromycin (estolate form)bull Vancomycin
The Problem With Tetracycline
bull Accumulates in bones and chelates calcium
bull Inhibits bone growthbull Discolors teeth
Other Antimicrobial Agentsbull OK to usebull Nystatin (B)bull Chlorhexidine rinse (B)bull Use with cautionbull Clotrimazole (C)bull Ketoconazole (C)bull Fluconazole (C)bull Do not usebull Doxycycline (D)
Local Anesthetic Use inPregnancy
bull Class Bbull Lidocaine (Xylocaine)bull Etidocainebull Prilocaine bull Class Cbull Procainebull Bupivicainebull Mepivicaine
Use of Local Anestheticsbull Lidocaine + vasoconstrictor most common
local anesthetic used in dentistrybull extensively used in pregnancy with no proven ill
effectsbull accidental intravascular injections of lidocaine
pass through the placenta but the concentrations are too low to harm fetus
bull prilocaine might cause methemoglobinemia
Ulcer healing drugsCimetidine bull FDA category B Famotidinebull FDA category BRanitidinebull FDA category Bbull not known to be harmful
Ulcer healing drugsOmeprazolebull FDA category BNot known to be
harmful Esomeprazolebull FDA category BLansoprazolebull FDA category BPantoprazolebull Avoid unless potential benefit
outweighs riskmdashfetotoxic in animals
Ulcer healing drugs
Misoprostolbull First second third trimesters Avoidmdash
potent uterine stimulant (has been used to induce abortion) and may be teratogenic
Ulcer healing drugs
Antacidsbull Almunium hydroxideMagnesium
hydroxidemdashFDA category B Calcium carbonatemdashFDA category C
SimetheconemdashFDA category C
Use of Nitrous Oxide Gas
bull used over 150 years bull safety is being debatedbull SHORT TERM exposure do not cause
birth defects or spontaneous abortionbull CHRONIC exposure may result in fetal
loss and infertilitybull literature suggests that nitrous oxide
should be avoided until more conclusive research is available
bull FDA Drug class not yet assigned
Common Preventives
bull Fluoridendash No increased risk during pregnancy
bull Xylitolndash No studies no harm reported
bull Chlorhexidinendash No increased risk during pregnancy
Are topical agents safe
bull Fluoridebull Toothpaste amp mouthrinse
bull Xylitol chewing gum bull Chlorhexidine (11 alcohol)bull No over the counter mouthrinses with
alcohol (Listerine 20 alcohol)
Pre-natal Fluoride
bull Daily 22 mg tablet of sodium fluoride during 3rd through 9th months
bull decreases caries rate in offspringbull Safe and effective
Glenn FB 1982
Is it safe to use mercury restorations
bull No evidence of harmful effect
bull Benefits outweigh risks
bull Canada Germany and New Zealand have some restrictions
bull Determine the best option
Referencesbull Wasylko L Matsui D Dykxhoorn SM Rieder MJ Weinberg
S A Review of Common Dental Treatments During Pregnancy J Canadian Dental Association 64434-439 1998
bull Little JW Donald AF Craig SM Rhodus NL Dental Management of the Medically Compromised Patient - 5th edition Mosby Toronto Pp434-442 1997
bull Livingston HM Dellinger TM Holder R Considerations in the management of the pregnant patient Special Care in Dentistry 185 pp183-188 1998
bull Larimore WL Petrie KA Drug use during pregnacy and lactation Primary Care Clinics in Office Practice 271 35-53 2000
bull Health Canada The Safety of DentalAmalgam Minister Of Supply and Services Canada 1996
REFERENCESbull 1 Weiss G Endocrinology of parturition J Clin
Endocrinol Metab 2000854421-5bull 2 Theunissen IM Parer JT Fluid and electrolytes in
pregnancy Clin Obstet Gynecol 1994373-15bull 3 Duvekot JJ Peeters LLH Renal hemodynamics and
volume homeostasis in pregnancy Obstet Gynecol Surv 199449830-9
bull 4 Barron WM Lindheimer MD Medical disorders during pregnancy 2nd ed St Louis Mosby 1995 p 129
bull 5 Thornburg KL Jacobson SL Giraud GD Morton MJ Hemodynamic changes in pregnancy Semin Perinatol 20002411-4
bull 6 Fiese R Herzog S Issues in dental and surgical management of the pregnant patient Oral Surg Oral Med Oral Pathol 198865292-7
bull 7 Martin C Varner MW Physiologic changes in pregnancysurgical implications Clin Obstet Gynecol 199437241-55
bull 8 Clark SL Cotton DB Lee W Bishop C Hill T Southwick J et al Central hemodynamic assessment of normal term pregnancy Am J Obstet Gynecol 19891611439-42
bull 9 Mabie WC Di Sessa TG Crocker LG Sibai BM Arheart KL A longitudinal study of cardiac output in normal human pregnancy Am J Obstet Gynecol 1994170849-56
bull 10 Clapp JF 3rd Capeless E Cardiovascular function before during and after the first and subsequent pregnancies Am J Cardiol 1997801469-73
bull 11 Duvekot JJ Peeters LL Maternal cardiovascular hemodynamic adaptation to pregnancy Obstet Gynecol Surv 199449(Suppl) S1-14
bull 12 Bhagwat AR Engel PJ Heart disease and pregnancy Cardiol Clin 199513163-78
bull 13 Lanni SM Tillinghast J Silver H Hemodynamic changes and baroreflex gain in the supine hypotensive syndrome Am J Obstet Gynecol 20021871636-41
bull 14 Little JW Falace DA Miller CS Rhodus NL Dental management of the medically compromised patient 6th ed St Louis Mosby 2002 p 303
bull 15 Garcia-Rio F Pino JM Gomez L Alvarez-Sala R Villasante C Villamor J Regulation of breathing and perception of dyspnea in healthy pregnant women Chest 1996110446-53
bull 16 McAuliffe F Kametas N Costello J Rafferty GF Greenough A Nicolaides K Respiratory function in singleton and twin pregnancy BJOG 2002109765-9
bull 17 Clapp JF 3rd Seaward BL Sleamaker RH Hiser J Maternal physiologic adaptations to early human pregnancy Am J Obstet Gynecol 19881591456-60
bull 18 OrsquoDay MP Cardio-respiratory physiological adaptation of pregnancy Semin Perinatol 199721268-75
bull 19 Contreras G Gutierrez M Beroiza T Fantin A Oddo H Villarroel L et al Ventilatory drive and respiratory muscle function in pregnancy Am Rev Respir Dis 1991144837-41
bull 20 Turner M Aziz SR Management of the pregnant oral and maxillofac
bull 21 Sifakis S Pharmakides G Anemia in pregnancy Ann N Y Acad Sci 2000900125-36
bull 22 Branch DW Physiologic adaptations of pregnancy Am J Reprod Immunol 199228120-2
bull 23 Burrows RF Kelton JG Incidentally detected thrombocytopenia in healthy mothers and their infants N Engl J Med 1988319 142-5
bull 24 Hanly JG Antiphospholipid syndrome an overview CMAJ 200324(168)1675-82
bull 25 Heilmann L von Tempelhoff GF Pollow K Antiphospholipid syndrome in obstetrics Clin Appl Thromb Hemost 20039 143-50
bull 26 Sherman P Flaxman SM Nausea and vomiting of pregnancy in an evolutionary perspective Am J Obstet Gynecol 2002 185(Suppl)s190-7
bull 27 Koch KL Gastrointestinal factors in nausea and vomiting of pregnancy Am J Obstet Gynecol 2002185(Suppl)s198-203
bull 28 Koch KL Frissora CL Nausea and vomiting during pregnancy Gastroenterol Clin N Am 200332201-34
bull 29 Baron TH Ramirez B Richter JE Gastrointestinal motility disorders during pregnancy Ann Intern Med 1993118 366-75
bull 30 Richter JE Gastroesophageal reflux disease during pregnancy Gastroenterol Clin N Am 200332235-61
bull 31 Marrero JM Goggin PM de Caestecker JS Pearce JM Maxwell JD Determinants of pregnancy heartburn Br J Obstet Gynaecol 199299731-4
bull 32 Hamaoui E Hamaoui M Nutritional assessment and support during pregnancy Gastroenterol Clin N Am 20033259-121
bull 33 King JC Physiology of pregnancy and nutrient metabolism Am J Clin Nutr 200071(suppl)1218s-25s
bull 34 Casanueva E Pfeffer F Fernandez-Gaxiola AC Gutierrez- Valenzuela V Rothenberg SJ Iron and folate status before pregnancy and anemia during pregnancy Ann Nutr Metab 2003 4760-3
bull 35 Chrsquong CL Morgan M Hainsworth I Kingham JG Prospective study of liver dysfunction in Southwest Wales Gut 200251 876-80
bull 36 Rahman TM Wendon J Severe hepatic dysfunction in pregnancy QJM 200295343-57
bull 37 Knox TA Olans LB Liver disease in pregnancy N Engl J Med 1996335569-76
bull 38 Saftlas AF Olson DR Franks AL Atrash H Pokras R Epidemiology of preeclampsia and eclampsia in the United States 1979e1986 Am J Obstet Gynecol 1990163460-5
bull 39 Walker JJ Pre-eclampsia Lancet 20003561260-5
bull 40 Davidson JM Renal disorders in pregnancy Curr Opin Obstet Gynecol 200113109-14
bull 41 Dafnis E Sabatini S The effect of pregnancy on renal function physiology and pathophysiologyAmJMedSci 1992303184-205
bull 42 Davison JM Shiells EA Philips PR Lindheimer MD Serial evaluation of vasopressin release and thirst in human pregnancy Role of human chorionic gonadotrophin in the osmoregulatory changes of gestation J Clin Invest 198881798-806
bull 43 Glinoer D de Nayer P Bourdoux P Lemone M Robyn C van Steirteghem A et al Regulation of maternal thyroid during pregnancy J Clin Endocrinol Metab 199071276-87
bull 44 Wilson SG Retallack RW Kent JC Worth GK Gutteridge DH Serum free 125-dihydroxyvitamin D and the free 125- dihydroxyvitamin D index during a longitudinal study of human pregnancy and lactation Clin Endocrinol 199032613-22
bull 45 Rasmussen N Frolich A Hornnes PJ Hegedus L Serum ionized calcium and intact parathyroid hormone levels during pregnancy and postpartum Br J Obstet Gynaecol 199097857-9
bull 46 Guyton AC Textbook of medical physiology 8th ed Philadelphia W B Saunders 1991 p 915e28
bull 47 Trainer PJ Corticosteroids and pregnancy Semin Reprod Med 200220375-80
bull 48 Soory M Hormonal factors in periodontal disease Dent Update 200027380-3
bull 49 Hugoson A Gingivitis in pregnant women A longitudinal clinical study Odontol Revy 19712265-84
bull 50 Neville BW Damm DD Allen CM Bouquot JE Oral amp Maxillofacial Pathology 3rd ed Philadelphia W B Saunders 2002 p 329-30 447-9
bull 51 Tilakaratne A Soory M Ranasinghe AW Corea SM Ekanayake SL de Silva M Periodontal disease status during pregnancy and 3 months post-partum in rural population of Sri-Lankan women J Clin Periodontol 200027787-92
bull 52 Laine M Tenovuo J Lehtonen OP Ojanatko-Harri A Vilja P Tuohimaa P Pregnancy e related changes in human whole saliva Arch Oral Biol 198833913-7
bull 53 Yuan K Wing LY Lin MT Pathogenetic roles of angiogenic factors in pyogenic granulomas in pregnancy are modulated by female sex hormones J Periodontol 200273701-8
bull 54 Evans RD Briggs PF Tooth-surface loss related to pregnancyinduced vomiting Prim Dent Care 1994124-6
bull 55 Salvolini E Di Giorgio R Curatola A Mazzanti L Fratto G Biochemical modifications of human whole saliva induced by pregnancy Br J Obstet Gynaec 1998105656-60
bull 56 Mauldin JG Newman RB Preterm birth risk assessment Semin Perinatol 200125215-22
bull 57 Heine RP McGregor JA Goodwin TM Artal R Hayashi RH Robertson PA et al Serial salivary estriol to detect an increased risk of preterm birth Obstet Gynecol 200096490-7
bull 58 Kauh YC Zachian TF Melasma Adv Exp Med Biol 1999455 491-9
bull 59 Wong RC Ellis CN Physiologic skin changes in pregnancy J Am Acad Dermatol 198410929-40
bull 60 Errickson CV Matus NR Skin disorders of pregnancy Am Fam Physician 199449605-10
bull 61 Lopez NJ Smith PC Gutierrez J Periodontal therapy may reduce the risk of preterm low birth weight in women with periodontal disease a randomized controlled trial J Periodontol 200273911-24
bull 62 McGaw T Periodontal disease and preterm delivery of lowbirth- weight infants J Can Dent Assoc 200268165-9
bull 63 Richards AG Dental x-ray protection Dent Clin North Am 1968631-41
bull 64 1990 Recommendations of the International Commission on Radiological Protection Ann ICRP 1991211-201
bull 65 Hall EJ Radiation the two-edged sword cancer risks at high and low doses Cancer J 20006343-50
bull 66 Diethelm L Xu H Diagnostic imaging of the lung during pregnancy Clin Obstet Gynecol 19963936-55
bull 67 Brent RL The effects of embryonic and fetal exposure to x-rays microwaves and ultrasound ClinObstetGynecol 198326484-510
bull 68 National Council on Radiation Protection NCRP report no128 1998 Bethesda Md Author
bull 69 Wasylko L Matsui D Dykxhoorn SM Reider MJ Weinberg S A review of common dental treatments during pregnancy implications for patients and dental personnel J Can Dent Assoc 199864434-9
bull 70 Freeman JP Brand JW Radiation doses of commonly used dental radiographic surveys Oral Surg Oral Med Oral Pathol 199477285-9
bull 71 Kircos LTAngin LL Lorton LOrder ofmagnitude dose reduction in intraoral radiography J Am Dent Assoc 1987114344-7
bull 72 Updegrave WJ Simplified and standardized intraoral radiography with reduced tissue irradiation J Am Dent Assoc 197285861-9
bull 73 Wood RE Harris AM van der Merwe EJ Nortje CJ The leaded apron revisited does it reduce gonadal radiation dose in dental radiology Oral Surg Oral Med Oral Pathol 199171642-6
bull 74 An update on radiographic practices information and recommendations ADA Council on Scientific Affairs J Am Dent Assoc 2001132234-8
bull 75 Rayburn WF Recommending medications during pregnancy an evidence based approach Clin Obstet Gynecol 2002451-5
bull 76 Rathmell JP Viscomi C Ashburn MA Management of nonobstetric pain during pregnancy and lactation Anesth Analg 1997851074-87
bull 77 Teratology society public affairs committee FDA classification of drugs for teratogenic risk Teratology 199449446-7
bull 78 Moore PA Selecting drugs for the pregnant dental patient J Am Dent Assoc 19981291281-6
bull 79 Haas DA An update on analgesics for the management of acute postoperative dental pain J Can Dent Assoc 200268476-82
bull 80 Haas DA Pynn BR Sands TD Drug use for the pregnant or lactating patient Gen Dent 20004854-60
bull 81 Committee on Drugs American Academy of Pediatrics The transfer of drugs and other chemicals into human milk Pediatrics 199493137-50
bull 82 Nielsen GL Sorensen HT Larsen H Pedersen L Risk of adverse birth outcome and miscarriage in pregnant users of nonsteroidal anti-inflammatory drugs population based observational study and case-control study BMJ 2001322266-70
bull 83 Janssen N Genta M The effects of immunosuppressive and anti-inflammatory medications on fertility pregnancy and lactation Arch Intern Med 200016610-9
bull 84 Ostensen M Nonsteroidal anti-inflammatory drugs during pregnancy Scand J Rheumatol Suppl 1998107128-32
bull 85 USPDI -Drug information for the health care professional 22nd ed Greenwood Village CO Micromedex 2002 p 152-79
bull 86 Denson DD Coyle DE Thompson GA Santos D Turner PA Myers JA et al Bupivacaine protein binding in the term parturient effects of lactic acidosis Clin Pharmacol Ther 198435702-9
bull 87 Dillon DE Wagner CL Wiest D Newman RB Drug therapy in the nursing mother Obstet Gynecol Clin North Am 199724 675-96
bull 88 Dashe JS Gilstrap LC Antibiotic use in pregnancy Obstet Gynecol Clin North Am 199724617-29
bull 89 American College of Rheumatology Ad hoc Committee on Clinical Guidelines Guidelines for monitoring drug therapy in rheumatoid arthritis Arthritis Rheum 199639723-31
bull 90 Ng PC The fetal and neonatal hypothalamic-pituitary-adrenal axis Arch Dis Child Fetal Neonatal Ed 200082F250-4
bull 91 Crowley P Antenatal corticosteroidsmdashcurrent thinking BJOG 2003110(Suppl 20)77-8
bull 92 ACOG committee opinion antenatal corticosteroid therapy for fetal maturation Obstet Gynecol 200299871-3
bull 93 Ost L Wettrell G Bjorkhem I Rane A Prednisolone excretion in human milk J Pediatr 19851061008-11
bull 94 Rowland AS Baird DD Shore DL Weinberg CR Savitz DA Wilcox AJ Nitrous oxide and spontaneous abortion in female dental assistants Am J Epidemiol 1995141531-8
bull 95 McGlothlin JD Jensen PA Fischbach TJ Hughes RT Jones JH Control of anesthetic gases in dental operatories Scand J Work Environ Health 199218(Suppl 2)103-5
bull ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY Volume 97 Number 6 Suresh and Radfar 681
bull 96 Rosen MA Nitrous oxide for relief of labor pain a systematic review Am J Obstet Gynecol 2002186(Suppl Nature)S110-6
bull 97 Sands TD Pynn BR Management considerations for the pregnant or nursing emergency patient Ont Dent 199875 17-9
bull 98 Daya S Recurrent spontaneous early pregnancy loss and low dose aspirin Minerva Ginecol 200355441-9
bull 99 Sinclair C Handbook of obstetrical emergencies 1st ed Philadelphia WB Saunders 1996 p 29-39 69
bull 100 Tarsitano BF Rollings RE The pregnant dental patient evaluation and management Gen Dent 199341226-34
bull 101 Livingston MH Dlllinger TM Holder R Consideration in the management of the pregnant patient SCD Special Care in Dentistry 199818183-8
Thank you
- A Review on the principle of Dental Management of the Pregnant patient
- Slide 2
- Questions that a dentist may ask
- Stages of Pregnancy
- Slide 5
- Slide 6
- Physiologic Changes in Pregnancy
- Systemic changes in pregnancy
- FLAT SUPINE POSITIONING
- SUPINE HYPOTENSION SYNDROME (Vena Cava Compression)
- Supine Hypotension Syndrome
- Slide 12
- Supine Hypotension Syndrome
- Prevention of Supine Hypotensive Syndrome
- Treatment of Supine Hypotensive Syndrome
- How should the pregnant woman be positioned
- Slide 17
- Slide 18
- Slide 19
- Slide 20
- Slide 21
- Slide 22
- Slide 23
- Pregnancy Related Oral Health Problems
- Oral Problems in Pregnancy
- Pregnancy Gingivitis Pathophysiology
- Pregnancy Gingivitis
- Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Gum Problems - Pregnancy Granuloma
- Slide 31
- Gum Changes - Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Candidiasis
- Pregnancy Myths
- Other Oral Conditions in Pregnancy
- Changes During Pregnancy that Affect Oral Health
- Saliva changes
- Increased Bacteria
- Slide 40
- Enamel erosion caused by frequent vomiting
- Treatment for Acid Exposure
- Oral Diseases Can Effect Pregnancy
- Periodontal Disease and Preterm Labor
- Periodontal Disease and Low Birth Weight
- Periodontal Disease and Preeclampsia
- Periodontitis and Pre-eclampsia
- Dental Considerations
- Treatment Timing
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Slide 52
- Use of Radiation on Pregnant Patient
- Radiographs during Pregnancy
- Risks of Dental X-Rays
- FDA drug classification for pregnancy
- Slide 57
- FDA drug classification for pregnancy
- Slide 59
- Slide 60
- Slide 61
- Common Analgesics
- Analgesics
- Analgesics - continued
- Analgesics to Use During 1st and 2nd Trimester
- Analgesics to Avoid During the Third Trimester
- Sedation in Pregnancy
- Common Antibiotics
- Antibiotics
- Antibiotics To Use During Pregnancy
- Antibiotics to Avoid during Pregnancy
- The Problem With Tetracycline
- Other Antimicrobial Agents
- Local Anesthetic Use in Pregnancy
- Use of Local Anesthetics
- Ulcer healing drugs
- Slide 77
- Slide 78
- Slide 79
- Use of Nitrous Oxide Gas
- Common Preventives
- Are topical agents safe
- Pre-natal Fluoride
- Is it safe to use mercury restorations
- References
- REFERENCES
- Slide 87
- Slide 88
- Slide 89
- Slide 90
- Slide 91
- Slide 92
- Slide 93
- Slide 94
- Slide 95
- Slide 96
- Slide 97
- Slide 98
- Thank you
-
Supine Hypotension Syndrome
Other symptomsbull Drop in blood pressurebull Bradycardiabull Possible loss of consciousness
Prevention of Supine HypotensiveSyndrome
bullElevate right hip 10-12 cmbullWeight is taken off the major vessels
Treatment of Supine HypotensiveSyndrome
bullRoll patient onto her left side
How should the pregnant woman be positionedbull Flat position may
cause hypotension and hypoxia
bull Place a small pillow under right hip - left lateral displacement
bull Head above feet
Systemic changes in pregnancy
Diaphragm rises about 4 cm darr residual volume uarr awareness of a desire to breath is
common-may be interpreted as dyspnea Increased estrogen in blood causes
engorgement of the nasal capillaries and rhnitis in pregnant women
Frequent nosebleeds amp predisposition to upper respiratory infection
Respiratory system
Systemic changes in pregnancy
Gastrointestinal system Gastric emptying amp intestinal transit times
are delayed
Heart burn reflux common
Nausea and vomiting common
Systemic changes in pregnancy
For pregnant patient with Hyper-emesis gravidarium ( excessive and uncontrolled vomiting) morning appointments should be avoided
They should be seated in a semi-supine or comfortable position
In case of vomiting the procedure should be stopped immediately amp the patient should be repositioned upright
When vomiting is over rinsing mouth with cold water or mouthwash is recommended
Systemic changes in pregnancybull Urinary System uarr GFR amp renal plasma flow by as much as
50 Nocturia ndashto mobilize the dependent
edema which accumulate during the day uarr Frequency from uarr renal flow plus reduced
bladder capacity from uterine growth It is advisable to ask the patient to void the
bladder just prior to starting the dental procedure
Systemic changes in pregnancyEndocrine Changes uarrEstrogen uarr progesterone uarrhuman
gonadotropin uarr thyroxin steroid and insulin level Estrogen amp progesterone are insulin
antagonists uarr level of these hormones lead to insulin resistance Thus insulin levels are elevated in pregnant in pregnant patient to compensate this resistance
About 45 of women fail to produce sufficient amount of insulin to overcome this antagonist action amp thus develop gestational diabetes
Systemic changes in pregnancy
Hematological changebull uarr red RBC uarrESR darrHbbull uarrWBCbull uarr circulatory catecholamin amp cortisol lead
to leucositosis bull uarr Coagulation factors except factor XI amp
XIII (anticloting factor) bull so pregnancy is a hypercoagulable state amp
uarr risk for thromboembolism
Systemic changes in pregnancy
bull Pregnant women with anti-phospholipid syndrome are at uarr risk for thrombo-embolisim
bull They are placed on subcutaneous low molecular weight heparin (LMWH)
bull These patients must be hospitalized for dental care
Pregnancy RelatedOral Health Problems
bull Pregnancy Gingivitisbull Pregnancy Epulis bull Increased Tooth Mobilitybull Dental Cariesbull Erosionbull Dental Problems in relation to Labor
and Delivery
Oral Problems in Pregnancy
bullPregnancy GingivitisbullMost common oral manifestation (50-100 of women)bullCaused by hormonal and vascular changes of pregnancy
Pregnancy Gingivitis Pathophysiology
bull Elevated circulating estrogen increases capillary permeability
bull Preexisting gingivitis may predispose to pregnancy gingivitis
Pregnancy Gingivitis
bullOccurs commonly in the 2nd to 8th monthsbullTendency to bleed very easilybullTreatment Scaling root-planing currettage OHI
Pregnancy Granuloma
bullOccurs in up to 5 of womenbullMost common in buccal maxillary anterior areasbullUsually starts in an area of gingivitis
Pregnancy Granuloma (continued)
bullRapid growth up to 2 cmbullSingle tumor-like growthbullusually in interdental papillaebullPurplish to bluish in color may be ulcerated- bleeds easily
Gum Problems - Pregnancy Granuloma
Gum Problems - Pregnancy Granuloma
Gum Changes - Pregnancy Granuloma
Pregnancy Granuloma (continued)
Treatment
bull Scaling and root planingbull Excision if it is too large or bleeds too
easilybull May regress spontaneously after
pregnancy
Candidiasis
bullWipes offbullUsually asymptomatic but may burnbullTreatment topical or systemic antifungals
Pregnancy MythsbullldquoA mother loses a tooth for every babyrdquobullNo evidence that aphthous ulcers are any more common in pregnancy
Other Oral Conditions in Pregnancy
bull Dry mouthbull Excessive salivationbull Tooth erosions associated with
severe GERD or hyperemesis
Changes During Pregnancy that Affect Oral Health
bull Hormonal Affects
ndash Increased tooth mobility
ndash Saliva changes
ndash Increased bacteria
ndash Gingival problems
Saliva changesbull Decreased buffers
bull Decreased minerals
bull Decreasing flow first and last trimester
bull Increased flow second trimester
bull More acidic
Increased Bacteriabull Increased acidity
ndash Increase in decay-causing bacteriabull Increased Snacking
ndash Morning sicknesslow blood sugarndash Between-meal snacks
bull Increase in amount and frequency of starchescarbohydrates ndash Crackers are commonly recommendedndash Promotes decay-causing bacteria
Changes During Pregnancy that Affect Oral Healthbull Morning sickness
ndash Difficulty with hygienebull Gingival diseasebull Tooth decay
ndash Vomitingbull Esophogeal Reflux (heartburn)bull Acid exposure
ndash Irritation of the gumsndash Weakening of tooth enamelndash Dental erosion
Enamel erosion caused by frequent vomiting
Treatment for Acid Exposure
bull Do NOT brush immediately after vomiting
bull Rinse ndash Water with baking sodandash Antacidndash Plain water
bull Eat some cheese
Oral Diseases Can Effect Pregnancy
bull Preterm low birth weight (LBW) linked to periodontal disease
bull Thorough calculus (tartar) removal in pregnant women with periodontitis may reduce pre-term births
Periodontal Disease and Preterm LaborbullMaternal periodontal disease is associated with increased risk of preterm laborbullAnaerobic oral gram-negative bacteria cause inflammatory responsebullInflammatory response stimulates prostaglandin and cytokine production to stimulate labor
Periodontal Disease and Low Birth Weight
bull Periodontal disease is associated with low birth weight
bull Evidence is not conclusivebull Biochemical mechanism similar cascade
as in preterm labor leading to placental blood flow restriction and necrosis
Periodontal Disease and Preeclampsia
bull Emerging databull Mechanism unclearbull Proposed mechanism
ndash Periodontal infection leads to inflammatory vascular damage
ndash Triggers cell damage in placenta
Periodontitis and Pre-eclampsia
bull Periodontal disease may be associated with pre-eclampsia (Boggess 2003)
bull PGE2 IL-1 and TNF-α from gingival crevicular fluid were higher in women with preeclampsia compared with healthy matched pregnant women (Oettinger-Barak 2003)
Dental Considerations
bull timing of treatment for pregnant patientsbull dental radiation exposurebull use of local anestheticsbull prescription of common antibiotics and
analgesicsbull nitrous oxide gas administration
Treatment Timing
bull First Trimesterndash Spontaneous miscarriages naturally occur
more often in 1st trimesterndash Avoid elective treatment that can be delayedndash Offer anticipatory guidance
bull Second Trimesterndash The optimal time for dental treatmentndash Organogenesis complete fetus not largendash Easier to prevent than treat established disease
bull Third Trimesterndash Late in term very uncomfortable (short visits)ndash Position slightly on left side
Timing of Dental Treatment During Pregnancy - From Little and Fallace
First Trimester
bull Plaque controlbull Oral hygiene instructionbull Scaling polishing curettagebull Avoid elective treatment urgent care
only
Timing of Dental Treatment During Pregnancy - From Little and Fallace
Second Trimester
bull Plaque controlbull Oral hygiene instructionbull Scaling polishing curettagebull Routine dental care
Timing of Dental Treatment During Pregnancy - From Little and Fallace
Third Trimester
bull Plaque controlbull Oral hygiene instructionbull Scaling polishing curettagebull Routine dental care (after middle of third
trimester elective care should be avoided)
Use of Radiation on Pregnant Patientbull Dose given and time of gestation are
importantbull doses lt 5-10 rads (cGy) not teratogenicbull fetus is most susceptible to radiation
between the 2nd and 6th week of gestationbull single dental x-ray exposes patient to 001
millirads of radiation In relative terms this amount is 40 times less than daily dose acquired from cosmic radiation Therefore diagnostic radiation should not be withheld during pregnancy
Radiographs during Pregnancy
bull Take as needed with optimal methods for reducing secondary radiation and exposure time
bull Always use a lead apronbull Exposure to fetus (with apron use) is 00001
centiGray(rad)bull Daily cosmic radiation - 0004 centiGray (rad)
Risks of Dental X-Rays
bull X-ray only if necessary (ie root canal therapy trauma)
bull When x-rays are indicated radiation exposure is extremely low
bull Exposure can be limited byndash Lead apron shielding ndash Modern fast film ndash Avoiding retakes
FDA drug classification for pregnancybull Combines risk statements including
congenital anomalies fetal effects perinatal risks and therapeutic risk-benefit ratio
bull Untreated disease or condition may pose more serious risks to both mother and fetus than any theoretical risks from the medication
bull Category A thru D and X
FDA drug classification for pregnancy
bull A = Controlled Studies in women fail to demonstrate a risk to the fetus in the first trimester and the possibility of fetal harm appears remote
FDA drug classification for pregnancy
bull B = Animal studies show no risk or if risk shown in animals controlled
trials in women showed no risk
FDA drug classification for pregnancy
bull C = Studies in animals with adverse effects and no human studies
OR no animal or human studies but benefits of use may outweigh potential harms
FDA drug classification for pregnancy
bull D = There is evidence of human fetal risk but benefits may outweigh risks
FDA drug classification for pregnancy
bull X = Contraindicated
Common Analgesics
bull paracetamol (B)bull Ibuprofen (BD) bull Oxycodone (BD) bull Hydrocodone and codeine
(CD)
avoid in third trimester
Analgesics
bull Paracetamol is the analgesic of choice for all stages of gestation
bull used to treat mild to moderate pain and fevers
bull short term usage is believed to be safebull avoid chronic and large doses of
paracetamol1048715
Analgesics - continuedbull Aspirin is nonteratogenic but may cause
maternal and fetal hemorrhagebull large and chronic doses during last trimester
may result in premature closure of ductus arteriosus fetal hypertension anemia and low birth weight
bull avoid ibuprofen in 3rd trimester because of possible adverse circulatory effects
bull short term use of codeine seems safebull avoid codeine late in gestation because of
possible fetal respiratory depression and withdrawal symptoms
Analgesics to Use During1st and 2nd Trimester
bull Category B (for best)bull Paracetamol Ibuprofenbull Naproxenbull Category C (use with caution)bull Paracetamol with codeine or
hydrocodonebull Paracetamol with oxycodone
Analgesics to Avoid During theThird Trimesterbull Causes delivery problemsbull Aspirin (C 3D)bull Ibuprofen (B3D)bull Naproxen (B3D)bull Causes neonatal respiratory
depression and opioid withdrawalbull Codeine (C3D)bull Hydrocodone (C3D)bull Oxycodone(C3D)
Sedation in Pregnancy
bull SedativesAnxiolytics (eg Diazepam ) are rated D and can cause oral clefts with prolonged exposure
bull Nitrous oxide should not be used in 1st trimester (If used in 2nd and 3rd do not go below 50 O2)
Common Antibioticsbull To treat oral abscess or cellulitis
ndash Penicillin (B) ndash Amoxicillin (B) ndash Cephalexin (B)ndash Erythromycin base (B) (Not estolate as it
cause cholestatic hepatitis)ndash Clindamycin (B)
Antibioticsbull penicillin V and amoxicillin is preferred drug
for mild to moderate infectionsbull widely used for many years with no ill effectsbull no studies show penicillin to be teratogenicbull amoxicillin extensively used without harming
the fetusbull Drug classes1048715 B penicillin cephalosporins erythromycin clindamycin Azithromycin D Tetracycline
Antibiotics To Use During Pregnancy
bull Penicillin Vbull Amoxicillinbull Erythromycin (base form)bull Cephalexin cephalosporinbull Clindamycinbull Metronidazole
Antibiotics to Avoid duringPregnancy
bull Doxycyclinebull Tetracyclinebull Erythromycin (estolate form)bull Vancomycin
The Problem With Tetracycline
bull Accumulates in bones and chelates calcium
bull Inhibits bone growthbull Discolors teeth
Other Antimicrobial Agentsbull OK to usebull Nystatin (B)bull Chlorhexidine rinse (B)bull Use with cautionbull Clotrimazole (C)bull Ketoconazole (C)bull Fluconazole (C)bull Do not usebull Doxycycline (D)
Local Anesthetic Use inPregnancy
bull Class Bbull Lidocaine (Xylocaine)bull Etidocainebull Prilocaine bull Class Cbull Procainebull Bupivicainebull Mepivicaine
Use of Local Anestheticsbull Lidocaine + vasoconstrictor most common
local anesthetic used in dentistrybull extensively used in pregnancy with no proven ill
effectsbull accidental intravascular injections of lidocaine
pass through the placenta but the concentrations are too low to harm fetus
bull prilocaine might cause methemoglobinemia
Ulcer healing drugsCimetidine bull FDA category B Famotidinebull FDA category BRanitidinebull FDA category Bbull not known to be harmful
Ulcer healing drugsOmeprazolebull FDA category BNot known to be
harmful Esomeprazolebull FDA category BLansoprazolebull FDA category BPantoprazolebull Avoid unless potential benefit
outweighs riskmdashfetotoxic in animals
Ulcer healing drugs
Misoprostolbull First second third trimesters Avoidmdash
potent uterine stimulant (has been used to induce abortion) and may be teratogenic
Ulcer healing drugs
Antacidsbull Almunium hydroxideMagnesium
hydroxidemdashFDA category B Calcium carbonatemdashFDA category C
SimetheconemdashFDA category C
Use of Nitrous Oxide Gas
bull used over 150 years bull safety is being debatedbull SHORT TERM exposure do not cause
birth defects or spontaneous abortionbull CHRONIC exposure may result in fetal
loss and infertilitybull literature suggests that nitrous oxide
should be avoided until more conclusive research is available
bull FDA Drug class not yet assigned
Common Preventives
bull Fluoridendash No increased risk during pregnancy
bull Xylitolndash No studies no harm reported
bull Chlorhexidinendash No increased risk during pregnancy
Are topical agents safe
bull Fluoridebull Toothpaste amp mouthrinse
bull Xylitol chewing gum bull Chlorhexidine (11 alcohol)bull No over the counter mouthrinses with
alcohol (Listerine 20 alcohol)
Pre-natal Fluoride
bull Daily 22 mg tablet of sodium fluoride during 3rd through 9th months
bull decreases caries rate in offspringbull Safe and effective
Glenn FB 1982
Is it safe to use mercury restorations
bull No evidence of harmful effect
bull Benefits outweigh risks
bull Canada Germany and New Zealand have some restrictions
bull Determine the best option
Referencesbull Wasylko L Matsui D Dykxhoorn SM Rieder MJ Weinberg
S A Review of Common Dental Treatments During Pregnancy J Canadian Dental Association 64434-439 1998
bull Little JW Donald AF Craig SM Rhodus NL Dental Management of the Medically Compromised Patient - 5th edition Mosby Toronto Pp434-442 1997
bull Livingston HM Dellinger TM Holder R Considerations in the management of the pregnant patient Special Care in Dentistry 185 pp183-188 1998
bull Larimore WL Petrie KA Drug use during pregnacy and lactation Primary Care Clinics in Office Practice 271 35-53 2000
bull Health Canada The Safety of DentalAmalgam Minister Of Supply and Services Canada 1996
REFERENCESbull 1 Weiss G Endocrinology of parturition J Clin
Endocrinol Metab 2000854421-5bull 2 Theunissen IM Parer JT Fluid and electrolytes in
pregnancy Clin Obstet Gynecol 1994373-15bull 3 Duvekot JJ Peeters LLH Renal hemodynamics and
volume homeostasis in pregnancy Obstet Gynecol Surv 199449830-9
bull 4 Barron WM Lindheimer MD Medical disorders during pregnancy 2nd ed St Louis Mosby 1995 p 129
bull 5 Thornburg KL Jacobson SL Giraud GD Morton MJ Hemodynamic changes in pregnancy Semin Perinatol 20002411-4
bull 6 Fiese R Herzog S Issues in dental and surgical management of the pregnant patient Oral Surg Oral Med Oral Pathol 198865292-7
bull 7 Martin C Varner MW Physiologic changes in pregnancysurgical implications Clin Obstet Gynecol 199437241-55
bull 8 Clark SL Cotton DB Lee W Bishop C Hill T Southwick J et al Central hemodynamic assessment of normal term pregnancy Am J Obstet Gynecol 19891611439-42
bull 9 Mabie WC Di Sessa TG Crocker LG Sibai BM Arheart KL A longitudinal study of cardiac output in normal human pregnancy Am J Obstet Gynecol 1994170849-56
bull 10 Clapp JF 3rd Capeless E Cardiovascular function before during and after the first and subsequent pregnancies Am J Cardiol 1997801469-73
bull 11 Duvekot JJ Peeters LL Maternal cardiovascular hemodynamic adaptation to pregnancy Obstet Gynecol Surv 199449(Suppl) S1-14
bull 12 Bhagwat AR Engel PJ Heart disease and pregnancy Cardiol Clin 199513163-78
bull 13 Lanni SM Tillinghast J Silver H Hemodynamic changes and baroreflex gain in the supine hypotensive syndrome Am J Obstet Gynecol 20021871636-41
bull 14 Little JW Falace DA Miller CS Rhodus NL Dental management of the medically compromised patient 6th ed St Louis Mosby 2002 p 303
bull 15 Garcia-Rio F Pino JM Gomez L Alvarez-Sala R Villasante C Villamor J Regulation of breathing and perception of dyspnea in healthy pregnant women Chest 1996110446-53
bull 16 McAuliffe F Kametas N Costello J Rafferty GF Greenough A Nicolaides K Respiratory function in singleton and twin pregnancy BJOG 2002109765-9
bull 17 Clapp JF 3rd Seaward BL Sleamaker RH Hiser J Maternal physiologic adaptations to early human pregnancy Am J Obstet Gynecol 19881591456-60
bull 18 OrsquoDay MP Cardio-respiratory physiological adaptation of pregnancy Semin Perinatol 199721268-75
bull 19 Contreras G Gutierrez M Beroiza T Fantin A Oddo H Villarroel L et al Ventilatory drive and respiratory muscle function in pregnancy Am Rev Respir Dis 1991144837-41
bull 20 Turner M Aziz SR Management of the pregnant oral and maxillofac
bull 21 Sifakis S Pharmakides G Anemia in pregnancy Ann N Y Acad Sci 2000900125-36
bull 22 Branch DW Physiologic adaptations of pregnancy Am J Reprod Immunol 199228120-2
bull 23 Burrows RF Kelton JG Incidentally detected thrombocytopenia in healthy mothers and their infants N Engl J Med 1988319 142-5
bull 24 Hanly JG Antiphospholipid syndrome an overview CMAJ 200324(168)1675-82
bull 25 Heilmann L von Tempelhoff GF Pollow K Antiphospholipid syndrome in obstetrics Clin Appl Thromb Hemost 20039 143-50
bull 26 Sherman P Flaxman SM Nausea and vomiting of pregnancy in an evolutionary perspective Am J Obstet Gynecol 2002 185(Suppl)s190-7
bull 27 Koch KL Gastrointestinal factors in nausea and vomiting of pregnancy Am J Obstet Gynecol 2002185(Suppl)s198-203
bull 28 Koch KL Frissora CL Nausea and vomiting during pregnancy Gastroenterol Clin N Am 200332201-34
bull 29 Baron TH Ramirez B Richter JE Gastrointestinal motility disorders during pregnancy Ann Intern Med 1993118 366-75
bull 30 Richter JE Gastroesophageal reflux disease during pregnancy Gastroenterol Clin N Am 200332235-61
bull 31 Marrero JM Goggin PM de Caestecker JS Pearce JM Maxwell JD Determinants of pregnancy heartburn Br J Obstet Gynaecol 199299731-4
bull 32 Hamaoui E Hamaoui M Nutritional assessment and support during pregnancy Gastroenterol Clin N Am 20033259-121
bull 33 King JC Physiology of pregnancy and nutrient metabolism Am J Clin Nutr 200071(suppl)1218s-25s
bull 34 Casanueva E Pfeffer F Fernandez-Gaxiola AC Gutierrez- Valenzuela V Rothenberg SJ Iron and folate status before pregnancy and anemia during pregnancy Ann Nutr Metab 2003 4760-3
bull 35 Chrsquong CL Morgan M Hainsworth I Kingham JG Prospective study of liver dysfunction in Southwest Wales Gut 200251 876-80
bull 36 Rahman TM Wendon J Severe hepatic dysfunction in pregnancy QJM 200295343-57
bull 37 Knox TA Olans LB Liver disease in pregnancy N Engl J Med 1996335569-76
bull 38 Saftlas AF Olson DR Franks AL Atrash H Pokras R Epidemiology of preeclampsia and eclampsia in the United States 1979e1986 Am J Obstet Gynecol 1990163460-5
bull 39 Walker JJ Pre-eclampsia Lancet 20003561260-5
bull 40 Davidson JM Renal disorders in pregnancy Curr Opin Obstet Gynecol 200113109-14
bull 41 Dafnis E Sabatini S The effect of pregnancy on renal function physiology and pathophysiologyAmJMedSci 1992303184-205
bull 42 Davison JM Shiells EA Philips PR Lindheimer MD Serial evaluation of vasopressin release and thirst in human pregnancy Role of human chorionic gonadotrophin in the osmoregulatory changes of gestation J Clin Invest 198881798-806
bull 43 Glinoer D de Nayer P Bourdoux P Lemone M Robyn C van Steirteghem A et al Regulation of maternal thyroid during pregnancy J Clin Endocrinol Metab 199071276-87
bull 44 Wilson SG Retallack RW Kent JC Worth GK Gutteridge DH Serum free 125-dihydroxyvitamin D and the free 125- dihydroxyvitamin D index during a longitudinal study of human pregnancy and lactation Clin Endocrinol 199032613-22
bull 45 Rasmussen N Frolich A Hornnes PJ Hegedus L Serum ionized calcium and intact parathyroid hormone levels during pregnancy and postpartum Br J Obstet Gynaecol 199097857-9
bull 46 Guyton AC Textbook of medical physiology 8th ed Philadelphia W B Saunders 1991 p 915e28
bull 47 Trainer PJ Corticosteroids and pregnancy Semin Reprod Med 200220375-80
bull 48 Soory M Hormonal factors in periodontal disease Dent Update 200027380-3
bull 49 Hugoson A Gingivitis in pregnant women A longitudinal clinical study Odontol Revy 19712265-84
bull 50 Neville BW Damm DD Allen CM Bouquot JE Oral amp Maxillofacial Pathology 3rd ed Philadelphia W B Saunders 2002 p 329-30 447-9
bull 51 Tilakaratne A Soory M Ranasinghe AW Corea SM Ekanayake SL de Silva M Periodontal disease status during pregnancy and 3 months post-partum in rural population of Sri-Lankan women J Clin Periodontol 200027787-92
bull 52 Laine M Tenovuo J Lehtonen OP Ojanatko-Harri A Vilja P Tuohimaa P Pregnancy e related changes in human whole saliva Arch Oral Biol 198833913-7
bull 53 Yuan K Wing LY Lin MT Pathogenetic roles of angiogenic factors in pyogenic granulomas in pregnancy are modulated by female sex hormones J Periodontol 200273701-8
bull 54 Evans RD Briggs PF Tooth-surface loss related to pregnancyinduced vomiting Prim Dent Care 1994124-6
bull 55 Salvolini E Di Giorgio R Curatola A Mazzanti L Fratto G Biochemical modifications of human whole saliva induced by pregnancy Br J Obstet Gynaec 1998105656-60
bull 56 Mauldin JG Newman RB Preterm birth risk assessment Semin Perinatol 200125215-22
bull 57 Heine RP McGregor JA Goodwin TM Artal R Hayashi RH Robertson PA et al Serial salivary estriol to detect an increased risk of preterm birth Obstet Gynecol 200096490-7
bull 58 Kauh YC Zachian TF Melasma Adv Exp Med Biol 1999455 491-9
bull 59 Wong RC Ellis CN Physiologic skin changes in pregnancy J Am Acad Dermatol 198410929-40
bull 60 Errickson CV Matus NR Skin disorders of pregnancy Am Fam Physician 199449605-10
bull 61 Lopez NJ Smith PC Gutierrez J Periodontal therapy may reduce the risk of preterm low birth weight in women with periodontal disease a randomized controlled trial J Periodontol 200273911-24
bull 62 McGaw T Periodontal disease and preterm delivery of lowbirth- weight infants J Can Dent Assoc 200268165-9
bull 63 Richards AG Dental x-ray protection Dent Clin North Am 1968631-41
bull 64 1990 Recommendations of the International Commission on Radiological Protection Ann ICRP 1991211-201
bull 65 Hall EJ Radiation the two-edged sword cancer risks at high and low doses Cancer J 20006343-50
bull 66 Diethelm L Xu H Diagnostic imaging of the lung during pregnancy Clin Obstet Gynecol 19963936-55
bull 67 Brent RL The effects of embryonic and fetal exposure to x-rays microwaves and ultrasound ClinObstetGynecol 198326484-510
bull 68 National Council on Radiation Protection NCRP report no128 1998 Bethesda Md Author
bull 69 Wasylko L Matsui D Dykxhoorn SM Reider MJ Weinberg S A review of common dental treatments during pregnancy implications for patients and dental personnel J Can Dent Assoc 199864434-9
bull 70 Freeman JP Brand JW Radiation doses of commonly used dental radiographic surveys Oral Surg Oral Med Oral Pathol 199477285-9
bull 71 Kircos LTAngin LL Lorton LOrder ofmagnitude dose reduction in intraoral radiography J Am Dent Assoc 1987114344-7
bull 72 Updegrave WJ Simplified and standardized intraoral radiography with reduced tissue irradiation J Am Dent Assoc 197285861-9
bull 73 Wood RE Harris AM van der Merwe EJ Nortje CJ The leaded apron revisited does it reduce gonadal radiation dose in dental radiology Oral Surg Oral Med Oral Pathol 199171642-6
bull 74 An update on radiographic practices information and recommendations ADA Council on Scientific Affairs J Am Dent Assoc 2001132234-8
bull 75 Rayburn WF Recommending medications during pregnancy an evidence based approach Clin Obstet Gynecol 2002451-5
bull 76 Rathmell JP Viscomi C Ashburn MA Management of nonobstetric pain during pregnancy and lactation Anesth Analg 1997851074-87
bull 77 Teratology society public affairs committee FDA classification of drugs for teratogenic risk Teratology 199449446-7
bull 78 Moore PA Selecting drugs for the pregnant dental patient J Am Dent Assoc 19981291281-6
bull 79 Haas DA An update on analgesics for the management of acute postoperative dental pain J Can Dent Assoc 200268476-82
bull 80 Haas DA Pynn BR Sands TD Drug use for the pregnant or lactating patient Gen Dent 20004854-60
bull 81 Committee on Drugs American Academy of Pediatrics The transfer of drugs and other chemicals into human milk Pediatrics 199493137-50
bull 82 Nielsen GL Sorensen HT Larsen H Pedersen L Risk of adverse birth outcome and miscarriage in pregnant users of nonsteroidal anti-inflammatory drugs population based observational study and case-control study BMJ 2001322266-70
bull 83 Janssen N Genta M The effects of immunosuppressive and anti-inflammatory medications on fertility pregnancy and lactation Arch Intern Med 200016610-9
bull 84 Ostensen M Nonsteroidal anti-inflammatory drugs during pregnancy Scand J Rheumatol Suppl 1998107128-32
bull 85 USPDI -Drug information for the health care professional 22nd ed Greenwood Village CO Micromedex 2002 p 152-79
bull 86 Denson DD Coyle DE Thompson GA Santos D Turner PA Myers JA et al Bupivacaine protein binding in the term parturient effects of lactic acidosis Clin Pharmacol Ther 198435702-9
bull 87 Dillon DE Wagner CL Wiest D Newman RB Drug therapy in the nursing mother Obstet Gynecol Clin North Am 199724 675-96
bull 88 Dashe JS Gilstrap LC Antibiotic use in pregnancy Obstet Gynecol Clin North Am 199724617-29
bull 89 American College of Rheumatology Ad hoc Committee on Clinical Guidelines Guidelines for monitoring drug therapy in rheumatoid arthritis Arthritis Rheum 199639723-31
bull 90 Ng PC The fetal and neonatal hypothalamic-pituitary-adrenal axis Arch Dis Child Fetal Neonatal Ed 200082F250-4
bull 91 Crowley P Antenatal corticosteroidsmdashcurrent thinking BJOG 2003110(Suppl 20)77-8
bull 92 ACOG committee opinion antenatal corticosteroid therapy for fetal maturation Obstet Gynecol 200299871-3
bull 93 Ost L Wettrell G Bjorkhem I Rane A Prednisolone excretion in human milk J Pediatr 19851061008-11
bull 94 Rowland AS Baird DD Shore DL Weinberg CR Savitz DA Wilcox AJ Nitrous oxide and spontaneous abortion in female dental assistants Am J Epidemiol 1995141531-8
bull 95 McGlothlin JD Jensen PA Fischbach TJ Hughes RT Jones JH Control of anesthetic gases in dental operatories Scand J Work Environ Health 199218(Suppl 2)103-5
bull ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY Volume 97 Number 6 Suresh and Radfar 681
bull 96 Rosen MA Nitrous oxide for relief of labor pain a systematic review Am J Obstet Gynecol 2002186(Suppl Nature)S110-6
bull 97 Sands TD Pynn BR Management considerations for the pregnant or nursing emergency patient Ont Dent 199875 17-9
bull 98 Daya S Recurrent spontaneous early pregnancy loss and low dose aspirin Minerva Ginecol 200355441-9
bull 99 Sinclair C Handbook of obstetrical emergencies 1st ed Philadelphia WB Saunders 1996 p 29-39 69
bull 100 Tarsitano BF Rollings RE The pregnant dental patient evaluation and management Gen Dent 199341226-34
bull 101 Livingston MH Dlllinger TM Holder R Consideration in the management of the pregnant patient SCD Special Care in Dentistry 199818183-8
Thank you
- A Review on the principle of Dental Management of the Pregnant patient
- Slide 2
- Questions that a dentist may ask
- Stages of Pregnancy
- Slide 5
- Slide 6
- Physiologic Changes in Pregnancy
- Systemic changes in pregnancy
- FLAT SUPINE POSITIONING
- SUPINE HYPOTENSION SYNDROME (Vena Cava Compression)
- Supine Hypotension Syndrome
- Slide 12
- Supine Hypotension Syndrome
- Prevention of Supine Hypotensive Syndrome
- Treatment of Supine Hypotensive Syndrome
- How should the pregnant woman be positioned
- Slide 17
- Slide 18
- Slide 19
- Slide 20
- Slide 21
- Slide 22
- Slide 23
- Pregnancy Related Oral Health Problems
- Oral Problems in Pregnancy
- Pregnancy Gingivitis Pathophysiology
- Pregnancy Gingivitis
- Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Gum Problems - Pregnancy Granuloma
- Slide 31
- Gum Changes - Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Candidiasis
- Pregnancy Myths
- Other Oral Conditions in Pregnancy
- Changes During Pregnancy that Affect Oral Health
- Saliva changes
- Increased Bacteria
- Slide 40
- Enamel erosion caused by frequent vomiting
- Treatment for Acid Exposure
- Oral Diseases Can Effect Pregnancy
- Periodontal Disease and Preterm Labor
- Periodontal Disease and Low Birth Weight
- Periodontal Disease and Preeclampsia
- Periodontitis and Pre-eclampsia
- Dental Considerations
- Treatment Timing
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Slide 52
- Use of Radiation on Pregnant Patient
- Radiographs during Pregnancy
- Risks of Dental X-Rays
- FDA drug classification for pregnancy
- Slide 57
- FDA drug classification for pregnancy
- Slide 59
- Slide 60
- Slide 61
- Common Analgesics
- Analgesics
- Analgesics - continued
- Analgesics to Use During 1st and 2nd Trimester
- Analgesics to Avoid During the Third Trimester
- Sedation in Pregnancy
- Common Antibiotics
- Antibiotics
- Antibiotics To Use During Pregnancy
- Antibiotics to Avoid during Pregnancy
- The Problem With Tetracycline
- Other Antimicrobial Agents
- Local Anesthetic Use in Pregnancy
- Use of Local Anesthetics
- Ulcer healing drugs
- Slide 77
- Slide 78
- Slide 79
- Use of Nitrous Oxide Gas
- Common Preventives
- Are topical agents safe
- Pre-natal Fluoride
- Is it safe to use mercury restorations
- References
- REFERENCES
- Slide 87
- Slide 88
- Slide 89
- Slide 90
- Slide 91
- Slide 92
- Slide 93
- Slide 94
- Slide 95
- Slide 96
- Slide 97
- Slide 98
- Thank you
-
Prevention of Supine HypotensiveSyndrome
bullElevate right hip 10-12 cmbullWeight is taken off the major vessels
Treatment of Supine HypotensiveSyndrome
bullRoll patient onto her left side
How should the pregnant woman be positionedbull Flat position may
cause hypotension and hypoxia
bull Place a small pillow under right hip - left lateral displacement
bull Head above feet
Systemic changes in pregnancy
Diaphragm rises about 4 cm darr residual volume uarr awareness of a desire to breath is
common-may be interpreted as dyspnea Increased estrogen in blood causes
engorgement of the nasal capillaries and rhnitis in pregnant women
Frequent nosebleeds amp predisposition to upper respiratory infection
Respiratory system
Systemic changes in pregnancy
Gastrointestinal system Gastric emptying amp intestinal transit times
are delayed
Heart burn reflux common
Nausea and vomiting common
Systemic changes in pregnancy
For pregnant patient with Hyper-emesis gravidarium ( excessive and uncontrolled vomiting) morning appointments should be avoided
They should be seated in a semi-supine or comfortable position
In case of vomiting the procedure should be stopped immediately amp the patient should be repositioned upright
When vomiting is over rinsing mouth with cold water or mouthwash is recommended
Systemic changes in pregnancybull Urinary System uarr GFR amp renal plasma flow by as much as
50 Nocturia ndashto mobilize the dependent
edema which accumulate during the day uarr Frequency from uarr renal flow plus reduced
bladder capacity from uterine growth It is advisable to ask the patient to void the
bladder just prior to starting the dental procedure
Systemic changes in pregnancyEndocrine Changes uarrEstrogen uarr progesterone uarrhuman
gonadotropin uarr thyroxin steroid and insulin level Estrogen amp progesterone are insulin
antagonists uarr level of these hormones lead to insulin resistance Thus insulin levels are elevated in pregnant in pregnant patient to compensate this resistance
About 45 of women fail to produce sufficient amount of insulin to overcome this antagonist action amp thus develop gestational diabetes
Systemic changes in pregnancy
Hematological changebull uarr red RBC uarrESR darrHbbull uarrWBCbull uarr circulatory catecholamin amp cortisol lead
to leucositosis bull uarr Coagulation factors except factor XI amp
XIII (anticloting factor) bull so pregnancy is a hypercoagulable state amp
uarr risk for thromboembolism
Systemic changes in pregnancy
bull Pregnant women with anti-phospholipid syndrome are at uarr risk for thrombo-embolisim
bull They are placed on subcutaneous low molecular weight heparin (LMWH)
bull These patients must be hospitalized for dental care
Pregnancy RelatedOral Health Problems
bull Pregnancy Gingivitisbull Pregnancy Epulis bull Increased Tooth Mobilitybull Dental Cariesbull Erosionbull Dental Problems in relation to Labor
and Delivery
Oral Problems in Pregnancy
bullPregnancy GingivitisbullMost common oral manifestation (50-100 of women)bullCaused by hormonal and vascular changes of pregnancy
Pregnancy Gingivitis Pathophysiology
bull Elevated circulating estrogen increases capillary permeability
bull Preexisting gingivitis may predispose to pregnancy gingivitis
Pregnancy Gingivitis
bullOccurs commonly in the 2nd to 8th monthsbullTendency to bleed very easilybullTreatment Scaling root-planing currettage OHI
Pregnancy Granuloma
bullOccurs in up to 5 of womenbullMost common in buccal maxillary anterior areasbullUsually starts in an area of gingivitis
Pregnancy Granuloma (continued)
bullRapid growth up to 2 cmbullSingle tumor-like growthbullusually in interdental papillaebullPurplish to bluish in color may be ulcerated- bleeds easily
Gum Problems - Pregnancy Granuloma
Gum Problems - Pregnancy Granuloma
Gum Changes - Pregnancy Granuloma
Pregnancy Granuloma (continued)
Treatment
bull Scaling and root planingbull Excision if it is too large or bleeds too
easilybull May regress spontaneously after
pregnancy
Candidiasis
bullWipes offbullUsually asymptomatic but may burnbullTreatment topical or systemic antifungals
Pregnancy MythsbullldquoA mother loses a tooth for every babyrdquobullNo evidence that aphthous ulcers are any more common in pregnancy
Other Oral Conditions in Pregnancy
bull Dry mouthbull Excessive salivationbull Tooth erosions associated with
severe GERD or hyperemesis
Changes During Pregnancy that Affect Oral Health
bull Hormonal Affects
ndash Increased tooth mobility
ndash Saliva changes
ndash Increased bacteria
ndash Gingival problems
Saliva changesbull Decreased buffers
bull Decreased minerals
bull Decreasing flow first and last trimester
bull Increased flow second trimester
bull More acidic
Increased Bacteriabull Increased acidity
ndash Increase in decay-causing bacteriabull Increased Snacking
ndash Morning sicknesslow blood sugarndash Between-meal snacks
bull Increase in amount and frequency of starchescarbohydrates ndash Crackers are commonly recommendedndash Promotes decay-causing bacteria
Changes During Pregnancy that Affect Oral Healthbull Morning sickness
ndash Difficulty with hygienebull Gingival diseasebull Tooth decay
ndash Vomitingbull Esophogeal Reflux (heartburn)bull Acid exposure
ndash Irritation of the gumsndash Weakening of tooth enamelndash Dental erosion
Enamel erosion caused by frequent vomiting
Treatment for Acid Exposure
bull Do NOT brush immediately after vomiting
bull Rinse ndash Water with baking sodandash Antacidndash Plain water
bull Eat some cheese
Oral Diseases Can Effect Pregnancy
bull Preterm low birth weight (LBW) linked to periodontal disease
bull Thorough calculus (tartar) removal in pregnant women with periodontitis may reduce pre-term births
Periodontal Disease and Preterm LaborbullMaternal periodontal disease is associated with increased risk of preterm laborbullAnaerobic oral gram-negative bacteria cause inflammatory responsebullInflammatory response stimulates prostaglandin and cytokine production to stimulate labor
Periodontal Disease and Low Birth Weight
bull Periodontal disease is associated with low birth weight
bull Evidence is not conclusivebull Biochemical mechanism similar cascade
as in preterm labor leading to placental blood flow restriction and necrosis
Periodontal Disease and Preeclampsia
bull Emerging databull Mechanism unclearbull Proposed mechanism
ndash Periodontal infection leads to inflammatory vascular damage
ndash Triggers cell damage in placenta
Periodontitis and Pre-eclampsia
bull Periodontal disease may be associated with pre-eclampsia (Boggess 2003)
bull PGE2 IL-1 and TNF-α from gingival crevicular fluid were higher in women with preeclampsia compared with healthy matched pregnant women (Oettinger-Barak 2003)
Dental Considerations
bull timing of treatment for pregnant patientsbull dental radiation exposurebull use of local anestheticsbull prescription of common antibiotics and
analgesicsbull nitrous oxide gas administration
Treatment Timing
bull First Trimesterndash Spontaneous miscarriages naturally occur
more often in 1st trimesterndash Avoid elective treatment that can be delayedndash Offer anticipatory guidance
bull Second Trimesterndash The optimal time for dental treatmentndash Organogenesis complete fetus not largendash Easier to prevent than treat established disease
bull Third Trimesterndash Late in term very uncomfortable (short visits)ndash Position slightly on left side
Timing of Dental Treatment During Pregnancy - From Little and Fallace
First Trimester
bull Plaque controlbull Oral hygiene instructionbull Scaling polishing curettagebull Avoid elective treatment urgent care
only
Timing of Dental Treatment During Pregnancy - From Little and Fallace
Second Trimester
bull Plaque controlbull Oral hygiene instructionbull Scaling polishing curettagebull Routine dental care
Timing of Dental Treatment During Pregnancy - From Little and Fallace
Third Trimester
bull Plaque controlbull Oral hygiene instructionbull Scaling polishing curettagebull Routine dental care (after middle of third
trimester elective care should be avoided)
Use of Radiation on Pregnant Patientbull Dose given and time of gestation are
importantbull doses lt 5-10 rads (cGy) not teratogenicbull fetus is most susceptible to radiation
between the 2nd and 6th week of gestationbull single dental x-ray exposes patient to 001
millirads of radiation In relative terms this amount is 40 times less than daily dose acquired from cosmic radiation Therefore diagnostic radiation should not be withheld during pregnancy
Radiographs during Pregnancy
bull Take as needed with optimal methods for reducing secondary radiation and exposure time
bull Always use a lead apronbull Exposure to fetus (with apron use) is 00001
centiGray(rad)bull Daily cosmic radiation - 0004 centiGray (rad)
Risks of Dental X-Rays
bull X-ray only if necessary (ie root canal therapy trauma)
bull When x-rays are indicated radiation exposure is extremely low
bull Exposure can be limited byndash Lead apron shielding ndash Modern fast film ndash Avoiding retakes
FDA drug classification for pregnancybull Combines risk statements including
congenital anomalies fetal effects perinatal risks and therapeutic risk-benefit ratio
bull Untreated disease or condition may pose more serious risks to both mother and fetus than any theoretical risks from the medication
bull Category A thru D and X
FDA drug classification for pregnancy
bull A = Controlled Studies in women fail to demonstrate a risk to the fetus in the first trimester and the possibility of fetal harm appears remote
FDA drug classification for pregnancy
bull B = Animal studies show no risk or if risk shown in animals controlled
trials in women showed no risk
FDA drug classification for pregnancy
bull C = Studies in animals with adverse effects and no human studies
OR no animal or human studies but benefits of use may outweigh potential harms
FDA drug classification for pregnancy
bull D = There is evidence of human fetal risk but benefits may outweigh risks
FDA drug classification for pregnancy
bull X = Contraindicated
Common Analgesics
bull paracetamol (B)bull Ibuprofen (BD) bull Oxycodone (BD) bull Hydrocodone and codeine
(CD)
avoid in third trimester
Analgesics
bull Paracetamol is the analgesic of choice for all stages of gestation
bull used to treat mild to moderate pain and fevers
bull short term usage is believed to be safebull avoid chronic and large doses of
paracetamol1048715
Analgesics - continuedbull Aspirin is nonteratogenic but may cause
maternal and fetal hemorrhagebull large and chronic doses during last trimester
may result in premature closure of ductus arteriosus fetal hypertension anemia and low birth weight
bull avoid ibuprofen in 3rd trimester because of possible adverse circulatory effects
bull short term use of codeine seems safebull avoid codeine late in gestation because of
possible fetal respiratory depression and withdrawal symptoms
Analgesics to Use During1st and 2nd Trimester
bull Category B (for best)bull Paracetamol Ibuprofenbull Naproxenbull Category C (use with caution)bull Paracetamol with codeine or
hydrocodonebull Paracetamol with oxycodone
Analgesics to Avoid During theThird Trimesterbull Causes delivery problemsbull Aspirin (C 3D)bull Ibuprofen (B3D)bull Naproxen (B3D)bull Causes neonatal respiratory
depression and opioid withdrawalbull Codeine (C3D)bull Hydrocodone (C3D)bull Oxycodone(C3D)
Sedation in Pregnancy
bull SedativesAnxiolytics (eg Diazepam ) are rated D and can cause oral clefts with prolonged exposure
bull Nitrous oxide should not be used in 1st trimester (If used in 2nd and 3rd do not go below 50 O2)
Common Antibioticsbull To treat oral abscess or cellulitis
ndash Penicillin (B) ndash Amoxicillin (B) ndash Cephalexin (B)ndash Erythromycin base (B) (Not estolate as it
cause cholestatic hepatitis)ndash Clindamycin (B)
Antibioticsbull penicillin V and amoxicillin is preferred drug
for mild to moderate infectionsbull widely used for many years with no ill effectsbull no studies show penicillin to be teratogenicbull amoxicillin extensively used without harming
the fetusbull Drug classes1048715 B penicillin cephalosporins erythromycin clindamycin Azithromycin D Tetracycline
Antibiotics To Use During Pregnancy
bull Penicillin Vbull Amoxicillinbull Erythromycin (base form)bull Cephalexin cephalosporinbull Clindamycinbull Metronidazole
Antibiotics to Avoid duringPregnancy
bull Doxycyclinebull Tetracyclinebull Erythromycin (estolate form)bull Vancomycin
The Problem With Tetracycline
bull Accumulates in bones and chelates calcium
bull Inhibits bone growthbull Discolors teeth
Other Antimicrobial Agentsbull OK to usebull Nystatin (B)bull Chlorhexidine rinse (B)bull Use with cautionbull Clotrimazole (C)bull Ketoconazole (C)bull Fluconazole (C)bull Do not usebull Doxycycline (D)
Local Anesthetic Use inPregnancy
bull Class Bbull Lidocaine (Xylocaine)bull Etidocainebull Prilocaine bull Class Cbull Procainebull Bupivicainebull Mepivicaine
Use of Local Anestheticsbull Lidocaine + vasoconstrictor most common
local anesthetic used in dentistrybull extensively used in pregnancy with no proven ill
effectsbull accidental intravascular injections of lidocaine
pass through the placenta but the concentrations are too low to harm fetus
bull prilocaine might cause methemoglobinemia
Ulcer healing drugsCimetidine bull FDA category B Famotidinebull FDA category BRanitidinebull FDA category Bbull not known to be harmful
Ulcer healing drugsOmeprazolebull FDA category BNot known to be
harmful Esomeprazolebull FDA category BLansoprazolebull FDA category BPantoprazolebull Avoid unless potential benefit
outweighs riskmdashfetotoxic in animals
Ulcer healing drugs
Misoprostolbull First second third trimesters Avoidmdash
potent uterine stimulant (has been used to induce abortion) and may be teratogenic
Ulcer healing drugs
Antacidsbull Almunium hydroxideMagnesium
hydroxidemdashFDA category B Calcium carbonatemdashFDA category C
SimetheconemdashFDA category C
Use of Nitrous Oxide Gas
bull used over 150 years bull safety is being debatedbull SHORT TERM exposure do not cause
birth defects or spontaneous abortionbull CHRONIC exposure may result in fetal
loss and infertilitybull literature suggests that nitrous oxide
should be avoided until more conclusive research is available
bull FDA Drug class not yet assigned
Common Preventives
bull Fluoridendash No increased risk during pregnancy
bull Xylitolndash No studies no harm reported
bull Chlorhexidinendash No increased risk during pregnancy
Are topical agents safe
bull Fluoridebull Toothpaste amp mouthrinse
bull Xylitol chewing gum bull Chlorhexidine (11 alcohol)bull No over the counter mouthrinses with
alcohol (Listerine 20 alcohol)
Pre-natal Fluoride
bull Daily 22 mg tablet of sodium fluoride during 3rd through 9th months
bull decreases caries rate in offspringbull Safe and effective
Glenn FB 1982
Is it safe to use mercury restorations
bull No evidence of harmful effect
bull Benefits outweigh risks
bull Canada Germany and New Zealand have some restrictions
bull Determine the best option
Referencesbull Wasylko L Matsui D Dykxhoorn SM Rieder MJ Weinberg
S A Review of Common Dental Treatments During Pregnancy J Canadian Dental Association 64434-439 1998
bull Little JW Donald AF Craig SM Rhodus NL Dental Management of the Medically Compromised Patient - 5th edition Mosby Toronto Pp434-442 1997
bull Livingston HM Dellinger TM Holder R Considerations in the management of the pregnant patient Special Care in Dentistry 185 pp183-188 1998
bull Larimore WL Petrie KA Drug use during pregnacy and lactation Primary Care Clinics in Office Practice 271 35-53 2000
bull Health Canada The Safety of DentalAmalgam Minister Of Supply and Services Canada 1996
REFERENCESbull 1 Weiss G Endocrinology of parturition J Clin
Endocrinol Metab 2000854421-5bull 2 Theunissen IM Parer JT Fluid and electrolytes in
pregnancy Clin Obstet Gynecol 1994373-15bull 3 Duvekot JJ Peeters LLH Renal hemodynamics and
volume homeostasis in pregnancy Obstet Gynecol Surv 199449830-9
bull 4 Barron WM Lindheimer MD Medical disorders during pregnancy 2nd ed St Louis Mosby 1995 p 129
bull 5 Thornburg KL Jacobson SL Giraud GD Morton MJ Hemodynamic changes in pregnancy Semin Perinatol 20002411-4
bull 6 Fiese R Herzog S Issues in dental and surgical management of the pregnant patient Oral Surg Oral Med Oral Pathol 198865292-7
bull 7 Martin C Varner MW Physiologic changes in pregnancysurgical implications Clin Obstet Gynecol 199437241-55
bull 8 Clark SL Cotton DB Lee W Bishop C Hill T Southwick J et al Central hemodynamic assessment of normal term pregnancy Am J Obstet Gynecol 19891611439-42
bull 9 Mabie WC Di Sessa TG Crocker LG Sibai BM Arheart KL A longitudinal study of cardiac output in normal human pregnancy Am J Obstet Gynecol 1994170849-56
bull 10 Clapp JF 3rd Capeless E Cardiovascular function before during and after the first and subsequent pregnancies Am J Cardiol 1997801469-73
bull 11 Duvekot JJ Peeters LL Maternal cardiovascular hemodynamic adaptation to pregnancy Obstet Gynecol Surv 199449(Suppl) S1-14
bull 12 Bhagwat AR Engel PJ Heart disease and pregnancy Cardiol Clin 199513163-78
bull 13 Lanni SM Tillinghast J Silver H Hemodynamic changes and baroreflex gain in the supine hypotensive syndrome Am J Obstet Gynecol 20021871636-41
bull 14 Little JW Falace DA Miller CS Rhodus NL Dental management of the medically compromised patient 6th ed St Louis Mosby 2002 p 303
bull 15 Garcia-Rio F Pino JM Gomez L Alvarez-Sala R Villasante C Villamor J Regulation of breathing and perception of dyspnea in healthy pregnant women Chest 1996110446-53
bull 16 McAuliffe F Kametas N Costello J Rafferty GF Greenough A Nicolaides K Respiratory function in singleton and twin pregnancy BJOG 2002109765-9
bull 17 Clapp JF 3rd Seaward BL Sleamaker RH Hiser J Maternal physiologic adaptations to early human pregnancy Am J Obstet Gynecol 19881591456-60
bull 18 OrsquoDay MP Cardio-respiratory physiological adaptation of pregnancy Semin Perinatol 199721268-75
bull 19 Contreras G Gutierrez M Beroiza T Fantin A Oddo H Villarroel L et al Ventilatory drive and respiratory muscle function in pregnancy Am Rev Respir Dis 1991144837-41
bull 20 Turner M Aziz SR Management of the pregnant oral and maxillofac
bull 21 Sifakis S Pharmakides G Anemia in pregnancy Ann N Y Acad Sci 2000900125-36
bull 22 Branch DW Physiologic adaptations of pregnancy Am J Reprod Immunol 199228120-2
bull 23 Burrows RF Kelton JG Incidentally detected thrombocytopenia in healthy mothers and their infants N Engl J Med 1988319 142-5
bull 24 Hanly JG Antiphospholipid syndrome an overview CMAJ 200324(168)1675-82
bull 25 Heilmann L von Tempelhoff GF Pollow K Antiphospholipid syndrome in obstetrics Clin Appl Thromb Hemost 20039 143-50
bull 26 Sherman P Flaxman SM Nausea and vomiting of pregnancy in an evolutionary perspective Am J Obstet Gynecol 2002 185(Suppl)s190-7
bull 27 Koch KL Gastrointestinal factors in nausea and vomiting of pregnancy Am J Obstet Gynecol 2002185(Suppl)s198-203
bull 28 Koch KL Frissora CL Nausea and vomiting during pregnancy Gastroenterol Clin N Am 200332201-34
bull 29 Baron TH Ramirez B Richter JE Gastrointestinal motility disorders during pregnancy Ann Intern Med 1993118 366-75
bull 30 Richter JE Gastroesophageal reflux disease during pregnancy Gastroenterol Clin N Am 200332235-61
bull 31 Marrero JM Goggin PM de Caestecker JS Pearce JM Maxwell JD Determinants of pregnancy heartburn Br J Obstet Gynaecol 199299731-4
bull 32 Hamaoui E Hamaoui M Nutritional assessment and support during pregnancy Gastroenterol Clin N Am 20033259-121
bull 33 King JC Physiology of pregnancy and nutrient metabolism Am J Clin Nutr 200071(suppl)1218s-25s
bull 34 Casanueva E Pfeffer F Fernandez-Gaxiola AC Gutierrez- Valenzuela V Rothenberg SJ Iron and folate status before pregnancy and anemia during pregnancy Ann Nutr Metab 2003 4760-3
bull 35 Chrsquong CL Morgan M Hainsworth I Kingham JG Prospective study of liver dysfunction in Southwest Wales Gut 200251 876-80
bull 36 Rahman TM Wendon J Severe hepatic dysfunction in pregnancy QJM 200295343-57
bull 37 Knox TA Olans LB Liver disease in pregnancy N Engl J Med 1996335569-76
bull 38 Saftlas AF Olson DR Franks AL Atrash H Pokras R Epidemiology of preeclampsia and eclampsia in the United States 1979e1986 Am J Obstet Gynecol 1990163460-5
bull 39 Walker JJ Pre-eclampsia Lancet 20003561260-5
bull 40 Davidson JM Renal disorders in pregnancy Curr Opin Obstet Gynecol 200113109-14
bull 41 Dafnis E Sabatini S The effect of pregnancy on renal function physiology and pathophysiologyAmJMedSci 1992303184-205
bull 42 Davison JM Shiells EA Philips PR Lindheimer MD Serial evaluation of vasopressin release and thirst in human pregnancy Role of human chorionic gonadotrophin in the osmoregulatory changes of gestation J Clin Invest 198881798-806
bull 43 Glinoer D de Nayer P Bourdoux P Lemone M Robyn C van Steirteghem A et al Regulation of maternal thyroid during pregnancy J Clin Endocrinol Metab 199071276-87
bull 44 Wilson SG Retallack RW Kent JC Worth GK Gutteridge DH Serum free 125-dihydroxyvitamin D and the free 125- dihydroxyvitamin D index during a longitudinal study of human pregnancy and lactation Clin Endocrinol 199032613-22
bull 45 Rasmussen N Frolich A Hornnes PJ Hegedus L Serum ionized calcium and intact parathyroid hormone levels during pregnancy and postpartum Br J Obstet Gynaecol 199097857-9
bull 46 Guyton AC Textbook of medical physiology 8th ed Philadelphia W B Saunders 1991 p 915e28
bull 47 Trainer PJ Corticosteroids and pregnancy Semin Reprod Med 200220375-80
bull 48 Soory M Hormonal factors in periodontal disease Dent Update 200027380-3
bull 49 Hugoson A Gingivitis in pregnant women A longitudinal clinical study Odontol Revy 19712265-84
bull 50 Neville BW Damm DD Allen CM Bouquot JE Oral amp Maxillofacial Pathology 3rd ed Philadelphia W B Saunders 2002 p 329-30 447-9
bull 51 Tilakaratne A Soory M Ranasinghe AW Corea SM Ekanayake SL de Silva M Periodontal disease status during pregnancy and 3 months post-partum in rural population of Sri-Lankan women J Clin Periodontol 200027787-92
bull 52 Laine M Tenovuo J Lehtonen OP Ojanatko-Harri A Vilja P Tuohimaa P Pregnancy e related changes in human whole saliva Arch Oral Biol 198833913-7
bull 53 Yuan K Wing LY Lin MT Pathogenetic roles of angiogenic factors in pyogenic granulomas in pregnancy are modulated by female sex hormones J Periodontol 200273701-8
bull 54 Evans RD Briggs PF Tooth-surface loss related to pregnancyinduced vomiting Prim Dent Care 1994124-6
bull 55 Salvolini E Di Giorgio R Curatola A Mazzanti L Fratto G Biochemical modifications of human whole saliva induced by pregnancy Br J Obstet Gynaec 1998105656-60
bull 56 Mauldin JG Newman RB Preterm birth risk assessment Semin Perinatol 200125215-22
bull 57 Heine RP McGregor JA Goodwin TM Artal R Hayashi RH Robertson PA et al Serial salivary estriol to detect an increased risk of preterm birth Obstet Gynecol 200096490-7
bull 58 Kauh YC Zachian TF Melasma Adv Exp Med Biol 1999455 491-9
bull 59 Wong RC Ellis CN Physiologic skin changes in pregnancy J Am Acad Dermatol 198410929-40
bull 60 Errickson CV Matus NR Skin disorders of pregnancy Am Fam Physician 199449605-10
bull 61 Lopez NJ Smith PC Gutierrez J Periodontal therapy may reduce the risk of preterm low birth weight in women with periodontal disease a randomized controlled trial J Periodontol 200273911-24
bull 62 McGaw T Periodontal disease and preterm delivery of lowbirth- weight infants J Can Dent Assoc 200268165-9
bull 63 Richards AG Dental x-ray protection Dent Clin North Am 1968631-41
bull 64 1990 Recommendations of the International Commission on Radiological Protection Ann ICRP 1991211-201
bull 65 Hall EJ Radiation the two-edged sword cancer risks at high and low doses Cancer J 20006343-50
bull 66 Diethelm L Xu H Diagnostic imaging of the lung during pregnancy Clin Obstet Gynecol 19963936-55
bull 67 Brent RL The effects of embryonic and fetal exposure to x-rays microwaves and ultrasound ClinObstetGynecol 198326484-510
bull 68 National Council on Radiation Protection NCRP report no128 1998 Bethesda Md Author
bull 69 Wasylko L Matsui D Dykxhoorn SM Reider MJ Weinberg S A review of common dental treatments during pregnancy implications for patients and dental personnel J Can Dent Assoc 199864434-9
bull 70 Freeman JP Brand JW Radiation doses of commonly used dental radiographic surveys Oral Surg Oral Med Oral Pathol 199477285-9
bull 71 Kircos LTAngin LL Lorton LOrder ofmagnitude dose reduction in intraoral radiography J Am Dent Assoc 1987114344-7
bull 72 Updegrave WJ Simplified and standardized intraoral radiography with reduced tissue irradiation J Am Dent Assoc 197285861-9
bull 73 Wood RE Harris AM van der Merwe EJ Nortje CJ The leaded apron revisited does it reduce gonadal radiation dose in dental radiology Oral Surg Oral Med Oral Pathol 199171642-6
bull 74 An update on radiographic practices information and recommendations ADA Council on Scientific Affairs J Am Dent Assoc 2001132234-8
bull 75 Rayburn WF Recommending medications during pregnancy an evidence based approach Clin Obstet Gynecol 2002451-5
bull 76 Rathmell JP Viscomi C Ashburn MA Management of nonobstetric pain during pregnancy and lactation Anesth Analg 1997851074-87
bull 77 Teratology society public affairs committee FDA classification of drugs for teratogenic risk Teratology 199449446-7
bull 78 Moore PA Selecting drugs for the pregnant dental patient J Am Dent Assoc 19981291281-6
bull 79 Haas DA An update on analgesics for the management of acute postoperative dental pain J Can Dent Assoc 200268476-82
bull 80 Haas DA Pynn BR Sands TD Drug use for the pregnant or lactating patient Gen Dent 20004854-60
bull 81 Committee on Drugs American Academy of Pediatrics The transfer of drugs and other chemicals into human milk Pediatrics 199493137-50
bull 82 Nielsen GL Sorensen HT Larsen H Pedersen L Risk of adverse birth outcome and miscarriage in pregnant users of nonsteroidal anti-inflammatory drugs population based observational study and case-control study BMJ 2001322266-70
bull 83 Janssen N Genta M The effects of immunosuppressive and anti-inflammatory medications on fertility pregnancy and lactation Arch Intern Med 200016610-9
bull 84 Ostensen M Nonsteroidal anti-inflammatory drugs during pregnancy Scand J Rheumatol Suppl 1998107128-32
bull 85 USPDI -Drug information for the health care professional 22nd ed Greenwood Village CO Micromedex 2002 p 152-79
bull 86 Denson DD Coyle DE Thompson GA Santos D Turner PA Myers JA et al Bupivacaine protein binding in the term parturient effects of lactic acidosis Clin Pharmacol Ther 198435702-9
bull 87 Dillon DE Wagner CL Wiest D Newman RB Drug therapy in the nursing mother Obstet Gynecol Clin North Am 199724 675-96
bull 88 Dashe JS Gilstrap LC Antibiotic use in pregnancy Obstet Gynecol Clin North Am 199724617-29
bull 89 American College of Rheumatology Ad hoc Committee on Clinical Guidelines Guidelines for monitoring drug therapy in rheumatoid arthritis Arthritis Rheum 199639723-31
bull 90 Ng PC The fetal and neonatal hypothalamic-pituitary-adrenal axis Arch Dis Child Fetal Neonatal Ed 200082F250-4
bull 91 Crowley P Antenatal corticosteroidsmdashcurrent thinking BJOG 2003110(Suppl 20)77-8
bull 92 ACOG committee opinion antenatal corticosteroid therapy for fetal maturation Obstet Gynecol 200299871-3
bull 93 Ost L Wettrell G Bjorkhem I Rane A Prednisolone excretion in human milk J Pediatr 19851061008-11
bull 94 Rowland AS Baird DD Shore DL Weinberg CR Savitz DA Wilcox AJ Nitrous oxide and spontaneous abortion in female dental assistants Am J Epidemiol 1995141531-8
bull 95 McGlothlin JD Jensen PA Fischbach TJ Hughes RT Jones JH Control of anesthetic gases in dental operatories Scand J Work Environ Health 199218(Suppl 2)103-5
bull ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY Volume 97 Number 6 Suresh and Radfar 681
bull 96 Rosen MA Nitrous oxide for relief of labor pain a systematic review Am J Obstet Gynecol 2002186(Suppl Nature)S110-6
bull 97 Sands TD Pynn BR Management considerations for the pregnant or nursing emergency patient Ont Dent 199875 17-9
bull 98 Daya S Recurrent spontaneous early pregnancy loss and low dose aspirin Minerva Ginecol 200355441-9
bull 99 Sinclair C Handbook of obstetrical emergencies 1st ed Philadelphia WB Saunders 1996 p 29-39 69
bull 100 Tarsitano BF Rollings RE The pregnant dental patient evaluation and management Gen Dent 199341226-34
bull 101 Livingston MH Dlllinger TM Holder R Consideration in the management of the pregnant patient SCD Special Care in Dentistry 199818183-8
Thank you
- A Review on the principle of Dental Management of the Pregnant patient
- Slide 2
- Questions that a dentist may ask
- Stages of Pregnancy
- Slide 5
- Slide 6
- Physiologic Changes in Pregnancy
- Systemic changes in pregnancy
- FLAT SUPINE POSITIONING
- SUPINE HYPOTENSION SYNDROME (Vena Cava Compression)
- Supine Hypotension Syndrome
- Slide 12
- Supine Hypotension Syndrome
- Prevention of Supine Hypotensive Syndrome
- Treatment of Supine Hypotensive Syndrome
- How should the pregnant woman be positioned
- Slide 17
- Slide 18
- Slide 19
- Slide 20
- Slide 21
- Slide 22
- Slide 23
- Pregnancy Related Oral Health Problems
- Oral Problems in Pregnancy
- Pregnancy Gingivitis Pathophysiology
- Pregnancy Gingivitis
- Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Gum Problems - Pregnancy Granuloma
- Slide 31
- Gum Changes - Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Candidiasis
- Pregnancy Myths
- Other Oral Conditions in Pregnancy
- Changes During Pregnancy that Affect Oral Health
- Saliva changes
- Increased Bacteria
- Slide 40
- Enamel erosion caused by frequent vomiting
- Treatment for Acid Exposure
- Oral Diseases Can Effect Pregnancy
- Periodontal Disease and Preterm Labor
- Periodontal Disease and Low Birth Weight
- Periodontal Disease and Preeclampsia
- Periodontitis and Pre-eclampsia
- Dental Considerations
- Treatment Timing
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Slide 52
- Use of Radiation on Pregnant Patient
- Radiographs during Pregnancy
- Risks of Dental X-Rays
- FDA drug classification for pregnancy
- Slide 57
- FDA drug classification for pregnancy
- Slide 59
- Slide 60
- Slide 61
- Common Analgesics
- Analgesics
- Analgesics - continued
- Analgesics to Use During 1st and 2nd Trimester
- Analgesics to Avoid During the Third Trimester
- Sedation in Pregnancy
- Common Antibiotics
- Antibiotics
- Antibiotics To Use During Pregnancy
- Antibiotics to Avoid during Pregnancy
- The Problem With Tetracycline
- Other Antimicrobial Agents
- Local Anesthetic Use in Pregnancy
- Use of Local Anesthetics
- Ulcer healing drugs
- Slide 77
- Slide 78
- Slide 79
- Use of Nitrous Oxide Gas
- Common Preventives
- Are topical agents safe
- Pre-natal Fluoride
- Is it safe to use mercury restorations
- References
- REFERENCES
- Slide 87
- Slide 88
- Slide 89
- Slide 90
- Slide 91
- Slide 92
- Slide 93
- Slide 94
- Slide 95
- Slide 96
- Slide 97
- Slide 98
- Thank you
-
Treatment of Supine HypotensiveSyndrome
bullRoll patient onto her left side
How should the pregnant woman be positionedbull Flat position may
cause hypotension and hypoxia
bull Place a small pillow under right hip - left lateral displacement
bull Head above feet
Systemic changes in pregnancy
Diaphragm rises about 4 cm darr residual volume uarr awareness of a desire to breath is
common-may be interpreted as dyspnea Increased estrogen in blood causes
engorgement of the nasal capillaries and rhnitis in pregnant women
Frequent nosebleeds amp predisposition to upper respiratory infection
Respiratory system
Systemic changes in pregnancy
Gastrointestinal system Gastric emptying amp intestinal transit times
are delayed
Heart burn reflux common
Nausea and vomiting common
Systemic changes in pregnancy
For pregnant patient with Hyper-emesis gravidarium ( excessive and uncontrolled vomiting) morning appointments should be avoided
They should be seated in a semi-supine or comfortable position
In case of vomiting the procedure should be stopped immediately amp the patient should be repositioned upright
When vomiting is over rinsing mouth with cold water or mouthwash is recommended
Systemic changes in pregnancybull Urinary System uarr GFR amp renal plasma flow by as much as
50 Nocturia ndashto mobilize the dependent
edema which accumulate during the day uarr Frequency from uarr renal flow plus reduced
bladder capacity from uterine growth It is advisable to ask the patient to void the
bladder just prior to starting the dental procedure
Systemic changes in pregnancyEndocrine Changes uarrEstrogen uarr progesterone uarrhuman
gonadotropin uarr thyroxin steroid and insulin level Estrogen amp progesterone are insulin
antagonists uarr level of these hormones lead to insulin resistance Thus insulin levels are elevated in pregnant in pregnant patient to compensate this resistance
About 45 of women fail to produce sufficient amount of insulin to overcome this antagonist action amp thus develop gestational diabetes
Systemic changes in pregnancy
Hematological changebull uarr red RBC uarrESR darrHbbull uarrWBCbull uarr circulatory catecholamin amp cortisol lead
to leucositosis bull uarr Coagulation factors except factor XI amp
XIII (anticloting factor) bull so pregnancy is a hypercoagulable state amp
uarr risk for thromboembolism
Systemic changes in pregnancy
bull Pregnant women with anti-phospholipid syndrome are at uarr risk for thrombo-embolisim
bull They are placed on subcutaneous low molecular weight heparin (LMWH)
bull These patients must be hospitalized for dental care
Pregnancy RelatedOral Health Problems
bull Pregnancy Gingivitisbull Pregnancy Epulis bull Increased Tooth Mobilitybull Dental Cariesbull Erosionbull Dental Problems in relation to Labor
and Delivery
Oral Problems in Pregnancy
bullPregnancy GingivitisbullMost common oral manifestation (50-100 of women)bullCaused by hormonal and vascular changes of pregnancy
Pregnancy Gingivitis Pathophysiology
bull Elevated circulating estrogen increases capillary permeability
bull Preexisting gingivitis may predispose to pregnancy gingivitis
Pregnancy Gingivitis
bullOccurs commonly in the 2nd to 8th monthsbullTendency to bleed very easilybullTreatment Scaling root-planing currettage OHI
Pregnancy Granuloma
bullOccurs in up to 5 of womenbullMost common in buccal maxillary anterior areasbullUsually starts in an area of gingivitis
Pregnancy Granuloma (continued)
bullRapid growth up to 2 cmbullSingle tumor-like growthbullusually in interdental papillaebullPurplish to bluish in color may be ulcerated- bleeds easily
Gum Problems - Pregnancy Granuloma
Gum Problems - Pregnancy Granuloma
Gum Changes - Pregnancy Granuloma
Pregnancy Granuloma (continued)
Treatment
bull Scaling and root planingbull Excision if it is too large or bleeds too
easilybull May regress spontaneously after
pregnancy
Candidiasis
bullWipes offbullUsually asymptomatic but may burnbullTreatment topical or systemic antifungals
Pregnancy MythsbullldquoA mother loses a tooth for every babyrdquobullNo evidence that aphthous ulcers are any more common in pregnancy
Other Oral Conditions in Pregnancy
bull Dry mouthbull Excessive salivationbull Tooth erosions associated with
severe GERD or hyperemesis
Changes During Pregnancy that Affect Oral Health
bull Hormonal Affects
ndash Increased tooth mobility
ndash Saliva changes
ndash Increased bacteria
ndash Gingival problems
Saliva changesbull Decreased buffers
bull Decreased minerals
bull Decreasing flow first and last trimester
bull Increased flow second trimester
bull More acidic
Increased Bacteriabull Increased acidity
ndash Increase in decay-causing bacteriabull Increased Snacking
ndash Morning sicknesslow blood sugarndash Between-meal snacks
bull Increase in amount and frequency of starchescarbohydrates ndash Crackers are commonly recommendedndash Promotes decay-causing bacteria
Changes During Pregnancy that Affect Oral Healthbull Morning sickness
ndash Difficulty with hygienebull Gingival diseasebull Tooth decay
ndash Vomitingbull Esophogeal Reflux (heartburn)bull Acid exposure
ndash Irritation of the gumsndash Weakening of tooth enamelndash Dental erosion
Enamel erosion caused by frequent vomiting
Treatment for Acid Exposure
bull Do NOT brush immediately after vomiting
bull Rinse ndash Water with baking sodandash Antacidndash Plain water
bull Eat some cheese
Oral Diseases Can Effect Pregnancy
bull Preterm low birth weight (LBW) linked to periodontal disease
bull Thorough calculus (tartar) removal in pregnant women with periodontitis may reduce pre-term births
Periodontal Disease and Preterm LaborbullMaternal periodontal disease is associated with increased risk of preterm laborbullAnaerobic oral gram-negative bacteria cause inflammatory responsebullInflammatory response stimulates prostaglandin and cytokine production to stimulate labor
Periodontal Disease and Low Birth Weight
bull Periodontal disease is associated with low birth weight
bull Evidence is not conclusivebull Biochemical mechanism similar cascade
as in preterm labor leading to placental blood flow restriction and necrosis
Periodontal Disease and Preeclampsia
bull Emerging databull Mechanism unclearbull Proposed mechanism
ndash Periodontal infection leads to inflammatory vascular damage
ndash Triggers cell damage in placenta
Periodontitis and Pre-eclampsia
bull Periodontal disease may be associated with pre-eclampsia (Boggess 2003)
bull PGE2 IL-1 and TNF-α from gingival crevicular fluid were higher in women with preeclampsia compared with healthy matched pregnant women (Oettinger-Barak 2003)
Dental Considerations
bull timing of treatment for pregnant patientsbull dental radiation exposurebull use of local anestheticsbull prescription of common antibiotics and
analgesicsbull nitrous oxide gas administration
Treatment Timing
bull First Trimesterndash Spontaneous miscarriages naturally occur
more often in 1st trimesterndash Avoid elective treatment that can be delayedndash Offer anticipatory guidance
bull Second Trimesterndash The optimal time for dental treatmentndash Organogenesis complete fetus not largendash Easier to prevent than treat established disease
bull Third Trimesterndash Late in term very uncomfortable (short visits)ndash Position slightly on left side
Timing of Dental Treatment During Pregnancy - From Little and Fallace
First Trimester
bull Plaque controlbull Oral hygiene instructionbull Scaling polishing curettagebull Avoid elective treatment urgent care
only
Timing of Dental Treatment During Pregnancy - From Little and Fallace
Second Trimester
bull Plaque controlbull Oral hygiene instructionbull Scaling polishing curettagebull Routine dental care
Timing of Dental Treatment During Pregnancy - From Little and Fallace
Third Trimester
bull Plaque controlbull Oral hygiene instructionbull Scaling polishing curettagebull Routine dental care (after middle of third
trimester elective care should be avoided)
Use of Radiation on Pregnant Patientbull Dose given and time of gestation are
importantbull doses lt 5-10 rads (cGy) not teratogenicbull fetus is most susceptible to radiation
between the 2nd and 6th week of gestationbull single dental x-ray exposes patient to 001
millirads of radiation In relative terms this amount is 40 times less than daily dose acquired from cosmic radiation Therefore diagnostic radiation should not be withheld during pregnancy
Radiographs during Pregnancy
bull Take as needed with optimal methods for reducing secondary radiation and exposure time
bull Always use a lead apronbull Exposure to fetus (with apron use) is 00001
centiGray(rad)bull Daily cosmic radiation - 0004 centiGray (rad)
Risks of Dental X-Rays
bull X-ray only if necessary (ie root canal therapy trauma)
bull When x-rays are indicated radiation exposure is extremely low
bull Exposure can be limited byndash Lead apron shielding ndash Modern fast film ndash Avoiding retakes
FDA drug classification for pregnancybull Combines risk statements including
congenital anomalies fetal effects perinatal risks and therapeutic risk-benefit ratio
bull Untreated disease or condition may pose more serious risks to both mother and fetus than any theoretical risks from the medication
bull Category A thru D and X
FDA drug classification for pregnancy
bull A = Controlled Studies in women fail to demonstrate a risk to the fetus in the first trimester and the possibility of fetal harm appears remote
FDA drug classification for pregnancy
bull B = Animal studies show no risk or if risk shown in animals controlled
trials in women showed no risk
FDA drug classification for pregnancy
bull C = Studies in animals with adverse effects and no human studies
OR no animal or human studies but benefits of use may outweigh potential harms
FDA drug classification for pregnancy
bull D = There is evidence of human fetal risk but benefits may outweigh risks
FDA drug classification for pregnancy
bull X = Contraindicated
Common Analgesics
bull paracetamol (B)bull Ibuprofen (BD) bull Oxycodone (BD) bull Hydrocodone and codeine
(CD)
avoid in third trimester
Analgesics
bull Paracetamol is the analgesic of choice for all stages of gestation
bull used to treat mild to moderate pain and fevers
bull short term usage is believed to be safebull avoid chronic and large doses of
paracetamol1048715
Analgesics - continuedbull Aspirin is nonteratogenic but may cause
maternal and fetal hemorrhagebull large and chronic doses during last trimester
may result in premature closure of ductus arteriosus fetal hypertension anemia and low birth weight
bull avoid ibuprofen in 3rd trimester because of possible adverse circulatory effects
bull short term use of codeine seems safebull avoid codeine late in gestation because of
possible fetal respiratory depression and withdrawal symptoms
Analgesics to Use During1st and 2nd Trimester
bull Category B (for best)bull Paracetamol Ibuprofenbull Naproxenbull Category C (use with caution)bull Paracetamol with codeine or
hydrocodonebull Paracetamol with oxycodone
Analgesics to Avoid During theThird Trimesterbull Causes delivery problemsbull Aspirin (C 3D)bull Ibuprofen (B3D)bull Naproxen (B3D)bull Causes neonatal respiratory
depression and opioid withdrawalbull Codeine (C3D)bull Hydrocodone (C3D)bull Oxycodone(C3D)
Sedation in Pregnancy
bull SedativesAnxiolytics (eg Diazepam ) are rated D and can cause oral clefts with prolonged exposure
bull Nitrous oxide should not be used in 1st trimester (If used in 2nd and 3rd do not go below 50 O2)
Common Antibioticsbull To treat oral abscess or cellulitis
ndash Penicillin (B) ndash Amoxicillin (B) ndash Cephalexin (B)ndash Erythromycin base (B) (Not estolate as it
cause cholestatic hepatitis)ndash Clindamycin (B)
Antibioticsbull penicillin V and amoxicillin is preferred drug
for mild to moderate infectionsbull widely used for many years with no ill effectsbull no studies show penicillin to be teratogenicbull amoxicillin extensively used without harming
the fetusbull Drug classes1048715 B penicillin cephalosporins erythromycin clindamycin Azithromycin D Tetracycline
Antibiotics To Use During Pregnancy
bull Penicillin Vbull Amoxicillinbull Erythromycin (base form)bull Cephalexin cephalosporinbull Clindamycinbull Metronidazole
Antibiotics to Avoid duringPregnancy
bull Doxycyclinebull Tetracyclinebull Erythromycin (estolate form)bull Vancomycin
The Problem With Tetracycline
bull Accumulates in bones and chelates calcium
bull Inhibits bone growthbull Discolors teeth
Other Antimicrobial Agentsbull OK to usebull Nystatin (B)bull Chlorhexidine rinse (B)bull Use with cautionbull Clotrimazole (C)bull Ketoconazole (C)bull Fluconazole (C)bull Do not usebull Doxycycline (D)
Local Anesthetic Use inPregnancy
bull Class Bbull Lidocaine (Xylocaine)bull Etidocainebull Prilocaine bull Class Cbull Procainebull Bupivicainebull Mepivicaine
Use of Local Anestheticsbull Lidocaine + vasoconstrictor most common
local anesthetic used in dentistrybull extensively used in pregnancy with no proven ill
effectsbull accidental intravascular injections of lidocaine
pass through the placenta but the concentrations are too low to harm fetus
bull prilocaine might cause methemoglobinemia
Ulcer healing drugsCimetidine bull FDA category B Famotidinebull FDA category BRanitidinebull FDA category Bbull not known to be harmful
Ulcer healing drugsOmeprazolebull FDA category BNot known to be
harmful Esomeprazolebull FDA category BLansoprazolebull FDA category BPantoprazolebull Avoid unless potential benefit
outweighs riskmdashfetotoxic in animals
Ulcer healing drugs
Misoprostolbull First second third trimesters Avoidmdash
potent uterine stimulant (has been used to induce abortion) and may be teratogenic
Ulcer healing drugs
Antacidsbull Almunium hydroxideMagnesium
hydroxidemdashFDA category B Calcium carbonatemdashFDA category C
SimetheconemdashFDA category C
Use of Nitrous Oxide Gas
bull used over 150 years bull safety is being debatedbull SHORT TERM exposure do not cause
birth defects or spontaneous abortionbull CHRONIC exposure may result in fetal
loss and infertilitybull literature suggests that nitrous oxide
should be avoided until more conclusive research is available
bull FDA Drug class not yet assigned
Common Preventives
bull Fluoridendash No increased risk during pregnancy
bull Xylitolndash No studies no harm reported
bull Chlorhexidinendash No increased risk during pregnancy
Are topical agents safe
bull Fluoridebull Toothpaste amp mouthrinse
bull Xylitol chewing gum bull Chlorhexidine (11 alcohol)bull No over the counter mouthrinses with
alcohol (Listerine 20 alcohol)
Pre-natal Fluoride
bull Daily 22 mg tablet of sodium fluoride during 3rd through 9th months
bull decreases caries rate in offspringbull Safe and effective
Glenn FB 1982
Is it safe to use mercury restorations
bull No evidence of harmful effect
bull Benefits outweigh risks
bull Canada Germany and New Zealand have some restrictions
bull Determine the best option
Referencesbull Wasylko L Matsui D Dykxhoorn SM Rieder MJ Weinberg
S A Review of Common Dental Treatments During Pregnancy J Canadian Dental Association 64434-439 1998
bull Little JW Donald AF Craig SM Rhodus NL Dental Management of the Medically Compromised Patient - 5th edition Mosby Toronto Pp434-442 1997
bull Livingston HM Dellinger TM Holder R Considerations in the management of the pregnant patient Special Care in Dentistry 185 pp183-188 1998
bull Larimore WL Petrie KA Drug use during pregnacy and lactation Primary Care Clinics in Office Practice 271 35-53 2000
bull Health Canada The Safety of DentalAmalgam Minister Of Supply and Services Canada 1996
REFERENCESbull 1 Weiss G Endocrinology of parturition J Clin
Endocrinol Metab 2000854421-5bull 2 Theunissen IM Parer JT Fluid and electrolytes in
pregnancy Clin Obstet Gynecol 1994373-15bull 3 Duvekot JJ Peeters LLH Renal hemodynamics and
volume homeostasis in pregnancy Obstet Gynecol Surv 199449830-9
bull 4 Barron WM Lindheimer MD Medical disorders during pregnancy 2nd ed St Louis Mosby 1995 p 129
bull 5 Thornburg KL Jacobson SL Giraud GD Morton MJ Hemodynamic changes in pregnancy Semin Perinatol 20002411-4
bull 6 Fiese R Herzog S Issues in dental and surgical management of the pregnant patient Oral Surg Oral Med Oral Pathol 198865292-7
bull 7 Martin C Varner MW Physiologic changes in pregnancysurgical implications Clin Obstet Gynecol 199437241-55
bull 8 Clark SL Cotton DB Lee W Bishop C Hill T Southwick J et al Central hemodynamic assessment of normal term pregnancy Am J Obstet Gynecol 19891611439-42
bull 9 Mabie WC Di Sessa TG Crocker LG Sibai BM Arheart KL A longitudinal study of cardiac output in normal human pregnancy Am J Obstet Gynecol 1994170849-56
bull 10 Clapp JF 3rd Capeless E Cardiovascular function before during and after the first and subsequent pregnancies Am J Cardiol 1997801469-73
bull 11 Duvekot JJ Peeters LL Maternal cardiovascular hemodynamic adaptation to pregnancy Obstet Gynecol Surv 199449(Suppl) S1-14
bull 12 Bhagwat AR Engel PJ Heart disease and pregnancy Cardiol Clin 199513163-78
bull 13 Lanni SM Tillinghast J Silver H Hemodynamic changes and baroreflex gain in the supine hypotensive syndrome Am J Obstet Gynecol 20021871636-41
bull 14 Little JW Falace DA Miller CS Rhodus NL Dental management of the medically compromised patient 6th ed St Louis Mosby 2002 p 303
bull 15 Garcia-Rio F Pino JM Gomez L Alvarez-Sala R Villasante C Villamor J Regulation of breathing and perception of dyspnea in healthy pregnant women Chest 1996110446-53
bull 16 McAuliffe F Kametas N Costello J Rafferty GF Greenough A Nicolaides K Respiratory function in singleton and twin pregnancy BJOG 2002109765-9
bull 17 Clapp JF 3rd Seaward BL Sleamaker RH Hiser J Maternal physiologic adaptations to early human pregnancy Am J Obstet Gynecol 19881591456-60
bull 18 OrsquoDay MP Cardio-respiratory physiological adaptation of pregnancy Semin Perinatol 199721268-75
bull 19 Contreras G Gutierrez M Beroiza T Fantin A Oddo H Villarroel L et al Ventilatory drive and respiratory muscle function in pregnancy Am Rev Respir Dis 1991144837-41
bull 20 Turner M Aziz SR Management of the pregnant oral and maxillofac
bull 21 Sifakis S Pharmakides G Anemia in pregnancy Ann N Y Acad Sci 2000900125-36
bull 22 Branch DW Physiologic adaptations of pregnancy Am J Reprod Immunol 199228120-2
bull 23 Burrows RF Kelton JG Incidentally detected thrombocytopenia in healthy mothers and their infants N Engl J Med 1988319 142-5
bull 24 Hanly JG Antiphospholipid syndrome an overview CMAJ 200324(168)1675-82
bull 25 Heilmann L von Tempelhoff GF Pollow K Antiphospholipid syndrome in obstetrics Clin Appl Thromb Hemost 20039 143-50
bull 26 Sherman P Flaxman SM Nausea and vomiting of pregnancy in an evolutionary perspective Am J Obstet Gynecol 2002 185(Suppl)s190-7
bull 27 Koch KL Gastrointestinal factors in nausea and vomiting of pregnancy Am J Obstet Gynecol 2002185(Suppl)s198-203
bull 28 Koch KL Frissora CL Nausea and vomiting during pregnancy Gastroenterol Clin N Am 200332201-34
bull 29 Baron TH Ramirez B Richter JE Gastrointestinal motility disorders during pregnancy Ann Intern Med 1993118 366-75
bull 30 Richter JE Gastroesophageal reflux disease during pregnancy Gastroenterol Clin N Am 200332235-61
bull 31 Marrero JM Goggin PM de Caestecker JS Pearce JM Maxwell JD Determinants of pregnancy heartburn Br J Obstet Gynaecol 199299731-4
bull 32 Hamaoui E Hamaoui M Nutritional assessment and support during pregnancy Gastroenterol Clin N Am 20033259-121
bull 33 King JC Physiology of pregnancy and nutrient metabolism Am J Clin Nutr 200071(suppl)1218s-25s
bull 34 Casanueva E Pfeffer F Fernandez-Gaxiola AC Gutierrez- Valenzuela V Rothenberg SJ Iron and folate status before pregnancy and anemia during pregnancy Ann Nutr Metab 2003 4760-3
bull 35 Chrsquong CL Morgan M Hainsworth I Kingham JG Prospective study of liver dysfunction in Southwest Wales Gut 200251 876-80
bull 36 Rahman TM Wendon J Severe hepatic dysfunction in pregnancy QJM 200295343-57
bull 37 Knox TA Olans LB Liver disease in pregnancy N Engl J Med 1996335569-76
bull 38 Saftlas AF Olson DR Franks AL Atrash H Pokras R Epidemiology of preeclampsia and eclampsia in the United States 1979e1986 Am J Obstet Gynecol 1990163460-5
bull 39 Walker JJ Pre-eclampsia Lancet 20003561260-5
bull 40 Davidson JM Renal disorders in pregnancy Curr Opin Obstet Gynecol 200113109-14
bull 41 Dafnis E Sabatini S The effect of pregnancy on renal function physiology and pathophysiologyAmJMedSci 1992303184-205
bull 42 Davison JM Shiells EA Philips PR Lindheimer MD Serial evaluation of vasopressin release and thirst in human pregnancy Role of human chorionic gonadotrophin in the osmoregulatory changes of gestation J Clin Invest 198881798-806
bull 43 Glinoer D de Nayer P Bourdoux P Lemone M Robyn C van Steirteghem A et al Regulation of maternal thyroid during pregnancy J Clin Endocrinol Metab 199071276-87
bull 44 Wilson SG Retallack RW Kent JC Worth GK Gutteridge DH Serum free 125-dihydroxyvitamin D and the free 125- dihydroxyvitamin D index during a longitudinal study of human pregnancy and lactation Clin Endocrinol 199032613-22
bull 45 Rasmussen N Frolich A Hornnes PJ Hegedus L Serum ionized calcium and intact parathyroid hormone levels during pregnancy and postpartum Br J Obstet Gynaecol 199097857-9
bull 46 Guyton AC Textbook of medical physiology 8th ed Philadelphia W B Saunders 1991 p 915e28
bull 47 Trainer PJ Corticosteroids and pregnancy Semin Reprod Med 200220375-80
bull 48 Soory M Hormonal factors in periodontal disease Dent Update 200027380-3
bull 49 Hugoson A Gingivitis in pregnant women A longitudinal clinical study Odontol Revy 19712265-84
bull 50 Neville BW Damm DD Allen CM Bouquot JE Oral amp Maxillofacial Pathology 3rd ed Philadelphia W B Saunders 2002 p 329-30 447-9
bull 51 Tilakaratne A Soory M Ranasinghe AW Corea SM Ekanayake SL de Silva M Periodontal disease status during pregnancy and 3 months post-partum in rural population of Sri-Lankan women J Clin Periodontol 200027787-92
bull 52 Laine M Tenovuo J Lehtonen OP Ojanatko-Harri A Vilja P Tuohimaa P Pregnancy e related changes in human whole saliva Arch Oral Biol 198833913-7
bull 53 Yuan K Wing LY Lin MT Pathogenetic roles of angiogenic factors in pyogenic granulomas in pregnancy are modulated by female sex hormones J Periodontol 200273701-8
bull 54 Evans RD Briggs PF Tooth-surface loss related to pregnancyinduced vomiting Prim Dent Care 1994124-6
bull 55 Salvolini E Di Giorgio R Curatola A Mazzanti L Fratto G Biochemical modifications of human whole saliva induced by pregnancy Br J Obstet Gynaec 1998105656-60
bull 56 Mauldin JG Newman RB Preterm birth risk assessment Semin Perinatol 200125215-22
bull 57 Heine RP McGregor JA Goodwin TM Artal R Hayashi RH Robertson PA et al Serial salivary estriol to detect an increased risk of preterm birth Obstet Gynecol 200096490-7
bull 58 Kauh YC Zachian TF Melasma Adv Exp Med Biol 1999455 491-9
bull 59 Wong RC Ellis CN Physiologic skin changes in pregnancy J Am Acad Dermatol 198410929-40
bull 60 Errickson CV Matus NR Skin disorders of pregnancy Am Fam Physician 199449605-10
bull 61 Lopez NJ Smith PC Gutierrez J Periodontal therapy may reduce the risk of preterm low birth weight in women with periodontal disease a randomized controlled trial J Periodontol 200273911-24
bull 62 McGaw T Periodontal disease and preterm delivery of lowbirth- weight infants J Can Dent Assoc 200268165-9
bull 63 Richards AG Dental x-ray protection Dent Clin North Am 1968631-41
bull 64 1990 Recommendations of the International Commission on Radiological Protection Ann ICRP 1991211-201
bull 65 Hall EJ Radiation the two-edged sword cancer risks at high and low doses Cancer J 20006343-50
bull 66 Diethelm L Xu H Diagnostic imaging of the lung during pregnancy Clin Obstet Gynecol 19963936-55
bull 67 Brent RL The effects of embryonic and fetal exposure to x-rays microwaves and ultrasound ClinObstetGynecol 198326484-510
bull 68 National Council on Radiation Protection NCRP report no128 1998 Bethesda Md Author
bull 69 Wasylko L Matsui D Dykxhoorn SM Reider MJ Weinberg S A review of common dental treatments during pregnancy implications for patients and dental personnel J Can Dent Assoc 199864434-9
bull 70 Freeman JP Brand JW Radiation doses of commonly used dental radiographic surveys Oral Surg Oral Med Oral Pathol 199477285-9
bull 71 Kircos LTAngin LL Lorton LOrder ofmagnitude dose reduction in intraoral radiography J Am Dent Assoc 1987114344-7
bull 72 Updegrave WJ Simplified and standardized intraoral radiography with reduced tissue irradiation J Am Dent Assoc 197285861-9
bull 73 Wood RE Harris AM van der Merwe EJ Nortje CJ The leaded apron revisited does it reduce gonadal radiation dose in dental radiology Oral Surg Oral Med Oral Pathol 199171642-6
bull 74 An update on radiographic practices information and recommendations ADA Council on Scientific Affairs J Am Dent Assoc 2001132234-8
bull 75 Rayburn WF Recommending medications during pregnancy an evidence based approach Clin Obstet Gynecol 2002451-5
bull 76 Rathmell JP Viscomi C Ashburn MA Management of nonobstetric pain during pregnancy and lactation Anesth Analg 1997851074-87
bull 77 Teratology society public affairs committee FDA classification of drugs for teratogenic risk Teratology 199449446-7
bull 78 Moore PA Selecting drugs for the pregnant dental patient J Am Dent Assoc 19981291281-6
bull 79 Haas DA An update on analgesics for the management of acute postoperative dental pain J Can Dent Assoc 200268476-82
bull 80 Haas DA Pynn BR Sands TD Drug use for the pregnant or lactating patient Gen Dent 20004854-60
bull 81 Committee on Drugs American Academy of Pediatrics The transfer of drugs and other chemicals into human milk Pediatrics 199493137-50
bull 82 Nielsen GL Sorensen HT Larsen H Pedersen L Risk of adverse birth outcome and miscarriage in pregnant users of nonsteroidal anti-inflammatory drugs population based observational study and case-control study BMJ 2001322266-70
bull 83 Janssen N Genta M The effects of immunosuppressive and anti-inflammatory medications on fertility pregnancy and lactation Arch Intern Med 200016610-9
bull 84 Ostensen M Nonsteroidal anti-inflammatory drugs during pregnancy Scand J Rheumatol Suppl 1998107128-32
bull 85 USPDI -Drug information for the health care professional 22nd ed Greenwood Village CO Micromedex 2002 p 152-79
bull 86 Denson DD Coyle DE Thompson GA Santos D Turner PA Myers JA et al Bupivacaine protein binding in the term parturient effects of lactic acidosis Clin Pharmacol Ther 198435702-9
bull 87 Dillon DE Wagner CL Wiest D Newman RB Drug therapy in the nursing mother Obstet Gynecol Clin North Am 199724 675-96
bull 88 Dashe JS Gilstrap LC Antibiotic use in pregnancy Obstet Gynecol Clin North Am 199724617-29
bull 89 American College of Rheumatology Ad hoc Committee on Clinical Guidelines Guidelines for monitoring drug therapy in rheumatoid arthritis Arthritis Rheum 199639723-31
bull 90 Ng PC The fetal and neonatal hypothalamic-pituitary-adrenal axis Arch Dis Child Fetal Neonatal Ed 200082F250-4
bull 91 Crowley P Antenatal corticosteroidsmdashcurrent thinking BJOG 2003110(Suppl 20)77-8
bull 92 ACOG committee opinion antenatal corticosteroid therapy for fetal maturation Obstet Gynecol 200299871-3
bull 93 Ost L Wettrell G Bjorkhem I Rane A Prednisolone excretion in human milk J Pediatr 19851061008-11
bull 94 Rowland AS Baird DD Shore DL Weinberg CR Savitz DA Wilcox AJ Nitrous oxide and spontaneous abortion in female dental assistants Am J Epidemiol 1995141531-8
bull 95 McGlothlin JD Jensen PA Fischbach TJ Hughes RT Jones JH Control of anesthetic gases in dental operatories Scand J Work Environ Health 199218(Suppl 2)103-5
bull ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY Volume 97 Number 6 Suresh and Radfar 681
bull 96 Rosen MA Nitrous oxide for relief of labor pain a systematic review Am J Obstet Gynecol 2002186(Suppl Nature)S110-6
bull 97 Sands TD Pynn BR Management considerations for the pregnant or nursing emergency patient Ont Dent 199875 17-9
bull 98 Daya S Recurrent spontaneous early pregnancy loss and low dose aspirin Minerva Ginecol 200355441-9
bull 99 Sinclair C Handbook of obstetrical emergencies 1st ed Philadelphia WB Saunders 1996 p 29-39 69
bull 100 Tarsitano BF Rollings RE The pregnant dental patient evaluation and management Gen Dent 199341226-34
bull 101 Livingston MH Dlllinger TM Holder R Consideration in the management of the pregnant patient SCD Special Care in Dentistry 199818183-8
Thank you
- A Review on the principle of Dental Management of the Pregnant patient
- Slide 2
- Questions that a dentist may ask
- Stages of Pregnancy
- Slide 5
- Slide 6
- Physiologic Changes in Pregnancy
- Systemic changes in pregnancy
- FLAT SUPINE POSITIONING
- SUPINE HYPOTENSION SYNDROME (Vena Cava Compression)
- Supine Hypotension Syndrome
- Slide 12
- Supine Hypotension Syndrome
- Prevention of Supine Hypotensive Syndrome
- Treatment of Supine Hypotensive Syndrome
- How should the pregnant woman be positioned
- Slide 17
- Slide 18
- Slide 19
- Slide 20
- Slide 21
- Slide 22
- Slide 23
- Pregnancy Related Oral Health Problems
- Oral Problems in Pregnancy
- Pregnancy Gingivitis Pathophysiology
- Pregnancy Gingivitis
- Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Gum Problems - Pregnancy Granuloma
- Slide 31
- Gum Changes - Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Candidiasis
- Pregnancy Myths
- Other Oral Conditions in Pregnancy
- Changes During Pregnancy that Affect Oral Health
- Saliva changes
- Increased Bacteria
- Slide 40
- Enamel erosion caused by frequent vomiting
- Treatment for Acid Exposure
- Oral Diseases Can Effect Pregnancy
- Periodontal Disease and Preterm Labor
- Periodontal Disease and Low Birth Weight
- Periodontal Disease and Preeclampsia
- Periodontitis and Pre-eclampsia
- Dental Considerations
- Treatment Timing
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Slide 52
- Use of Radiation on Pregnant Patient
- Radiographs during Pregnancy
- Risks of Dental X-Rays
- FDA drug classification for pregnancy
- Slide 57
- FDA drug classification for pregnancy
- Slide 59
- Slide 60
- Slide 61
- Common Analgesics
- Analgesics
- Analgesics - continued
- Analgesics to Use During 1st and 2nd Trimester
- Analgesics to Avoid During the Third Trimester
- Sedation in Pregnancy
- Common Antibiotics
- Antibiotics
- Antibiotics To Use During Pregnancy
- Antibiotics to Avoid during Pregnancy
- The Problem With Tetracycline
- Other Antimicrobial Agents
- Local Anesthetic Use in Pregnancy
- Use of Local Anesthetics
- Ulcer healing drugs
- Slide 77
- Slide 78
- Slide 79
- Use of Nitrous Oxide Gas
- Common Preventives
- Are topical agents safe
- Pre-natal Fluoride
- Is it safe to use mercury restorations
- References
- REFERENCES
- Slide 87
- Slide 88
- Slide 89
- Slide 90
- Slide 91
- Slide 92
- Slide 93
- Slide 94
- Slide 95
- Slide 96
- Slide 97
- Slide 98
- Thank you
-
How should the pregnant woman be positionedbull Flat position may
cause hypotension and hypoxia
bull Place a small pillow under right hip - left lateral displacement
bull Head above feet
Systemic changes in pregnancy
Diaphragm rises about 4 cm darr residual volume uarr awareness of a desire to breath is
common-may be interpreted as dyspnea Increased estrogen in blood causes
engorgement of the nasal capillaries and rhnitis in pregnant women
Frequent nosebleeds amp predisposition to upper respiratory infection
Respiratory system
Systemic changes in pregnancy
Gastrointestinal system Gastric emptying amp intestinal transit times
are delayed
Heart burn reflux common
Nausea and vomiting common
Systemic changes in pregnancy
For pregnant patient with Hyper-emesis gravidarium ( excessive and uncontrolled vomiting) morning appointments should be avoided
They should be seated in a semi-supine or comfortable position
In case of vomiting the procedure should be stopped immediately amp the patient should be repositioned upright
When vomiting is over rinsing mouth with cold water or mouthwash is recommended
Systemic changes in pregnancybull Urinary System uarr GFR amp renal plasma flow by as much as
50 Nocturia ndashto mobilize the dependent
edema which accumulate during the day uarr Frequency from uarr renal flow plus reduced
bladder capacity from uterine growth It is advisable to ask the patient to void the
bladder just prior to starting the dental procedure
Systemic changes in pregnancyEndocrine Changes uarrEstrogen uarr progesterone uarrhuman
gonadotropin uarr thyroxin steroid and insulin level Estrogen amp progesterone are insulin
antagonists uarr level of these hormones lead to insulin resistance Thus insulin levels are elevated in pregnant in pregnant patient to compensate this resistance
About 45 of women fail to produce sufficient amount of insulin to overcome this antagonist action amp thus develop gestational diabetes
Systemic changes in pregnancy
Hematological changebull uarr red RBC uarrESR darrHbbull uarrWBCbull uarr circulatory catecholamin amp cortisol lead
to leucositosis bull uarr Coagulation factors except factor XI amp
XIII (anticloting factor) bull so pregnancy is a hypercoagulable state amp
uarr risk for thromboembolism
Systemic changes in pregnancy
bull Pregnant women with anti-phospholipid syndrome are at uarr risk for thrombo-embolisim
bull They are placed on subcutaneous low molecular weight heparin (LMWH)
bull These patients must be hospitalized for dental care
Pregnancy RelatedOral Health Problems
bull Pregnancy Gingivitisbull Pregnancy Epulis bull Increased Tooth Mobilitybull Dental Cariesbull Erosionbull Dental Problems in relation to Labor
and Delivery
Oral Problems in Pregnancy
bullPregnancy GingivitisbullMost common oral manifestation (50-100 of women)bullCaused by hormonal and vascular changes of pregnancy
Pregnancy Gingivitis Pathophysiology
bull Elevated circulating estrogen increases capillary permeability
bull Preexisting gingivitis may predispose to pregnancy gingivitis
Pregnancy Gingivitis
bullOccurs commonly in the 2nd to 8th monthsbullTendency to bleed very easilybullTreatment Scaling root-planing currettage OHI
Pregnancy Granuloma
bullOccurs in up to 5 of womenbullMost common in buccal maxillary anterior areasbullUsually starts in an area of gingivitis
Pregnancy Granuloma (continued)
bullRapid growth up to 2 cmbullSingle tumor-like growthbullusually in interdental papillaebullPurplish to bluish in color may be ulcerated- bleeds easily
Gum Problems - Pregnancy Granuloma
Gum Problems - Pregnancy Granuloma
Gum Changes - Pregnancy Granuloma
Pregnancy Granuloma (continued)
Treatment
bull Scaling and root planingbull Excision if it is too large or bleeds too
easilybull May regress spontaneously after
pregnancy
Candidiasis
bullWipes offbullUsually asymptomatic but may burnbullTreatment topical or systemic antifungals
Pregnancy MythsbullldquoA mother loses a tooth for every babyrdquobullNo evidence that aphthous ulcers are any more common in pregnancy
Other Oral Conditions in Pregnancy
bull Dry mouthbull Excessive salivationbull Tooth erosions associated with
severe GERD or hyperemesis
Changes During Pregnancy that Affect Oral Health
bull Hormonal Affects
ndash Increased tooth mobility
ndash Saliva changes
ndash Increased bacteria
ndash Gingival problems
Saliva changesbull Decreased buffers
bull Decreased minerals
bull Decreasing flow first and last trimester
bull Increased flow second trimester
bull More acidic
Increased Bacteriabull Increased acidity
ndash Increase in decay-causing bacteriabull Increased Snacking
ndash Morning sicknesslow blood sugarndash Between-meal snacks
bull Increase in amount and frequency of starchescarbohydrates ndash Crackers are commonly recommendedndash Promotes decay-causing bacteria
Changes During Pregnancy that Affect Oral Healthbull Morning sickness
ndash Difficulty with hygienebull Gingival diseasebull Tooth decay
ndash Vomitingbull Esophogeal Reflux (heartburn)bull Acid exposure
ndash Irritation of the gumsndash Weakening of tooth enamelndash Dental erosion
Enamel erosion caused by frequent vomiting
Treatment for Acid Exposure
bull Do NOT brush immediately after vomiting
bull Rinse ndash Water with baking sodandash Antacidndash Plain water
bull Eat some cheese
Oral Diseases Can Effect Pregnancy
bull Preterm low birth weight (LBW) linked to periodontal disease
bull Thorough calculus (tartar) removal in pregnant women with periodontitis may reduce pre-term births
Periodontal Disease and Preterm LaborbullMaternal periodontal disease is associated with increased risk of preterm laborbullAnaerobic oral gram-negative bacteria cause inflammatory responsebullInflammatory response stimulates prostaglandin and cytokine production to stimulate labor
Periodontal Disease and Low Birth Weight
bull Periodontal disease is associated with low birth weight
bull Evidence is not conclusivebull Biochemical mechanism similar cascade
as in preterm labor leading to placental blood flow restriction and necrosis
Periodontal Disease and Preeclampsia
bull Emerging databull Mechanism unclearbull Proposed mechanism
ndash Periodontal infection leads to inflammatory vascular damage
ndash Triggers cell damage in placenta
Periodontitis and Pre-eclampsia
bull Periodontal disease may be associated with pre-eclampsia (Boggess 2003)
bull PGE2 IL-1 and TNF-α from gingival crevicular fluid were higher in women with preeclampsia compared with healthy matched pregnant women (Oettinger-Barak 2003)
Dental Considerations
bull timing of treatment for pregnant patientsbull dental radiation exposurebull use of local anestheticsbull prescription of common antibiotics and
analgesicsbull nitrous oxide gas administration
Treatment Timing
bull First Trimesterndash Spontaneous miscarriages naturally occur
more often in 1st trimesterndash Avoid elective treatment that can be delayedndash Offer anticipatory guidance
bull Second Trimesterndash The optimal time for dental treatmentndash Organogenesis complete fetus not largendash Easier to prevent than treat established disease
bull Third Trimesterndash Late in term very uncomfortable (short visits)ndash Position slightly on left side
Timing of Dental Treatment During Pregnancy - From Little and Fallace
First Trimester
bull Plaque controlbull Oral hygiene instructionbull Scaling polishing curettagebull Avoid elective treatment urgent care
only
Timing of Dental Treatment During Pregnancy - From Little and Fallace
Second Trimester
bull Plaque controlbull Oral hygiene instructionbull Scaling polishing curettagebull Routine dental care
Timing of Dental Treatment During Pregnancy - From Little and Fallace
Third Trimester
bull Plaque controlbull Oral hygiene instructionbull Scaling polishing curettagebull Routine dental care (after middle of third
trimester elective care should be avoided)
Use of Radiation on Pregnant Patientbull Dose given and time of gestation are
importantbull doses lt 5-10 rads (cGy) not teratogenicbull fetus is most susceptible to radiation
between the 2nd and 6th week of gestationbull single dental x-ray exposes patient to 001
millirads of radiation In relative terms this amount is 40 times less than daily dose acquired from cosmic radiation Therefore diagnostic radiation should not be withheld during pregnancy
Radiographs during Pregnancy
bull Take as needed with optimal methods for reducing secondary radiation and exposure time
bull Always use a lead apronbull Exposure to fetus (with apron use) is 00001
centiGray(rad)bull Daily cosmic radiation - 0004 centiGray (rad)
Risks of Dental X-Rays
bull X-ray only if necessary (ie root canal therapy trauma)
bull When x-rays are indicated radiation exposure is extremely low
bull Exposure can be limited byndash Lead apron shielding ndash Modern fast film ndash Avoiding retakes
FDA drug classification for pregnancybull Combines risk statements including
congenital anomalies fetal effects perinatal risks and therapeutic risk-benefit ratio
bull Untreated disease or condition may pose more serious risks to both mother and fetus than any theoretical risks from the medication
bull Category A thru D and X
FDA drug classification for pregnancy
bull A = Controlled Studies in women fail to demonstrate a risk to the fetus in the first trimester and the possibility of fetal harm appears remote
FDA drug classification for pregnancy
bull B = Animal studies show no risk or if risk shown in animals controlled
trials in women showed no risk
FDA drug classification for pregnancy
bull C = Studies in animals with adverse effects and no human studies
OR no animal or human studies but benefits of use may outweigh potential harms
FDA drug classification for pregnancy
bull D = There is evidence of human fetal risk but benefits may outweigh risks
FDA drug classification for pregnancy
bull X = Contraindicated
Common Analgesics
bull paracetamol (B)bull Ibuprofen (BD) bull Oxycodone (BD) bull Hydrocodone and codeine
(CD)
avoid in third trimester
Analgesics
bull Paracetamol is the analgesic of choice for all stages of gestation
bull used to treat mild to moderate pain and fevers
bull short term usage is believed to be safebull avoid chronic and large doses of
paracetamol1048715
Analgesics - continuedbull Aspirin is nonteratogenic but may cause
maternal and fetal hemorrhagebull large and chronic doses during last trimester
may result in premature closure of ductus arteriosus fetal hypertension anemia and low birth weight
bull avoid ibuprofen in 3rd trimester because of possible adverse circulatory effects
bull short term use of codeine seems safebull avoid codeine late in gestation because of
possible fetal respiratory depression and withdrawal symptoms
Analgesics to Use During1st and 2nd Trimester
bull Category B (for best)bull Paracetamol Ibuprofenbull Naproxenbull Category C (use with caution)bull Paracetamol with codeine or
hydrocodonebull Paracetamol with oxycodone
Analgesics to Avoid During theThird Trimesterbull Causes delivery problemsbull Aspirin (C 3D)bull Ibuprofen (B3D)bull Naproxen (B3D)bull Causes neonatal respiratory
depression and opioid withdrawalbull Codeine (C3D)bull Hydrocodone (C3D)bull Oxycodone(C3D)
Sedation in Pregnancy
bull SedativesAnxiolytics (eg Diazepam ) are rated D and can cause oral clefts with prolonged exposure
bull Nitrous oxide should not be used in 1st trimester (If used in 2nd and 3rd do not go below 50 O2)
Common Antibioticsbull To treat oral abscess or cellulitis
ndash Penicillin (B) ndash Amoxicillin (B) ndash Cephalexin (B)ndash Erythromycin base (B) (Not estolate as it
cause cholestatic hepatitis)ndash Clindamycin (B)
Antibioticsbull penicillin V and amoxicillin is preferred drug
for mild to moderate infectionsbull widely used for many years with no ill effectsbull no studies show penicillin to be teratogenicbull amoxicillin extensively used without harming
the fetusbull Drug classes1048715 B penicillin cephalosporins erythromycin clindamycin Azithromycin D Tetracycline
Antibiotics To Use During Pregnancy
bull Penicillin Vbull Amoxicillinbull Erythromycin (base form)bull Cephalexin cephalosporinbull Clindamycinbull Metronidazole
Antibiotics to Avoid duringPregnancy
bull Doxycyclinebull Tetracyclinebull Erythromycin (estolate form)bull Vancomycin
The Problem With Tetracycline
bull Accumulates in bones and chelates calcium
bull Inhibits bone growthbull Discolors teeth
Other Antimicrobial Agentsbull OK to usebull Nystatin (B)bull Chlorhexidine rinse (B)bull Use with cautionbull Clotrimazole (C)bull Ketoconazole (C)bull Fluconazole (C)bull Do not usebull Doxycycline (D)
Local Anesthetic Use inPregnancy
bull Class Bbull Lidocaine (Xylocaine)bull Etidocainebull Prilocaine bull Class Cbull Procainebull Bupivicainebull Mepivicaine
Use of Local Anestheticsbull Lidocaine + vasoconstrictor most common
local anesthetic used in dentistrybull extensively used in pregnancy with no proven ill
effectsbull accidental intravascular injections of lidocaine
pass through the placenta but the concentrations are too low to harm fetus
bull prilocaine might cause methemoglobinemia
Ulcer healing drugsCimetidine bull FDA category B Famotidinebull FDA category BRanitidinebull FDA category Bbull not known to be harmful
Ulcer healing drugsOmeprazolebull FDA category BNot known to be
harmful Esomeprazolebull FDA category BLansoprazolebull FDA category BPantoprazolebull Avoid unless potential benefit
outweighs riskmdashfetotoxic in animals
Ulcer healing drugs
Misoprostolbull First second third trimesters Avoidmdash
potent uterine stimulant (has been used to induce abortion) and may be teratogenic
Ulcer healing drugs
Antacidsbull Almunium hydroxideMagnesium
hydroxidemdashFDA category B Calcium carbonatemdashFDA category C
SimetheconemdashFDA category C
Use of Nitrous Oxide Gas
bull used over 150 years bull safety is being debatedbull SHORT TERM exposure do not cause
birth defects or spontaneous abortionbull CHRONIC exposure may result in fetal
loss and infertilitybull literature suggests that nitrous oxide
should be avoided until more conclusive research is available
bull FDA Drug class not yet assigned
Common Preventives
bull Fluoridendash No increased risk during pregnancy
bull Xylitolndash No studies no harm reported
bull Chlorhexidinendash No increased risk during pregnancy
Are topical agents safe
bull Fluoridebull Toothpaste amp mouthrinse
bull Xylitol chewing gum bull Chlorhexidine (11 alcohol)bull No over the counter mouthrinses with
alcohol (Listerine 20 alcohol)
Pre-natal Fluoride
bull Daily 22 mg tablet of sodium fluoride during 3rd through 9th months
bull decreases caries rate in offspringbull Safe and effective
Glenn FB 1982
Is it safe to use mercury restorations
bull No evidence of harmful effect
bull Benefits outweigh risks
bull Canada Germany and New Zealand have some restrictions
bull Determine the best option
Referencesbull Wasylko L Matsui D Dykxhoorn SM Rieder MJ Weinberg
S A Review of Common Dental Treatments During Pregnancy J Canadian Dental Association 64434-439 1998
bull Little JW Donald AF Craig SM Rhodus NL Dental Management of the Medically Compromised Patient - 5th edition Mosby Toronto Pp434-442 1997
bull Livingston HM Dellinger TM Holder R Considerations in the management of the pregnant patient Special Care in Dentistry 185 pp183-188 1998
bull Larimore WL Petrie KA Drug use during pregnacy and lactation Primary Care Clinics in Office Practice 271 35-53 2000
bull Health Canada The Safety of DentalAmalgam Minister Of Supply and Services Canada 1996
REFERENCESbull 1 Weiss G Endocrinology of parturition J Clin
Endocrinol Metab 2000854421-5bull 2 Theunissen IM Parer JT Fluid and electrolytes in
pregnancy Clin Obstet Gynecol 1994373-15bull 3 Duvekot JJ Peeters LLH Renal hemodynamics and
volume homeostasis in pregnancy Obstet Gynecol Surv 199449830-9
bull 4 Barron WM Lindheimer MD Medical disorders during pregnancy 2nd ed St Louis Mosby 1995 p 129
bull 5 Thornburg KL Jacobson SL Giraud GD Morton MJ Hemodynamic changes in pregnancy Semin Perinatol 20002411-4
bull 6 Fiese R Herzog S Issues in dental and surgical management of the pregnant patient Oral Surg Oral Med Oral Pathol 198865292-7
bull 7 Martin C Varner MW Physiologic changes in pregnancysurgical implications Clin Obstet Gynecol 199437241-55
bull 8 Clark SL Cotton DB Lee W Bishop C Hill T Southwick J et al Central hemodynamic assessment of normal term pregnancy Am J Obstet Gynecol 19891611439-42
bull 9 Mabie WC Di Sessa TG Crocker LG Sibai BM Arheart KL A longitudinal study of cardiac output in normal human pregnancy Am J Obstet Gynecol 1994170849-56
bull 10 Clapp JF 3rd Capeless E Cardiovascular function before during and after the first and subsequent pregnancies Am J Cardiol 1997801469-73
bull 11 Duvekot JJ Peeters LL Maternal cardiovascular hemodynamic adaptation to pregnancy Obstet Gynecol Surv 199449(Suppl) S1-14
bull 12 Bhagwat AR Engel PJ Heart disease and pregnancy Cardiol Clin 199513163-78
bull 13 Lanni SM Tillinghast J Silver H Hemodynamic changes and baroreflex gain in the supine hypotensive syndrome Am J Obstet Gynecol 20021871636-41
bull 14 Little JW Falace DA Miller CS Rhodus NL Dental management of the medically compromised patient 6th ed St Louis Mosby 2002 p 303
bull 15 Garcia-Rio F Pino JM Gomez L Alvarez-Sala R Villasante C Villamor J Regulation of breathing and perception of dyspnea in healthy pregnant women Chest 1996110446-53
bull 16 McAuliffe F Kametas N Costello J Rafferty GF Greenough A Nicolaides K Respiratory function in singleton and twin pregnancy BJOG 2002109765-9
bull 17 Clapp JF 3rd Seaward BL Sleamaker RH Hiser J Maternal physiologic adaptations to early human pregnancy Am J Obstet Gynecol 19881591456-60
bull 18 OrsquoDay MP Cardio-respiratory physiological adaptation of pregnancy Semin Perinatol 199721268-75
bull 19 Contreras G Gutierrez M Beroiza T Fantin A Oddo H Villarroel L et al Ventilatory drive and respiratory muscle function in pregnancy Am Rev Respir Dis 1991144837-41
bull 20 Turner M Aziz SR Management of the pregnant oral and maxillofac
bull 21 Sifakis S Pharmakides G Anemia in pregnancy Ann N Y Acad Sci 2000900125-36
bull 22 Branch DW Physiologic adaptations of pregnancy Am J Reprod Immunol 199228120-2
bull 23 Burrows RF Kelton JG Incidentally detected thrombocytopenia in healthy mothers and their infants N Engl J Med 1988319 142-5
bull 24 Hanly JG Antiphospholipid syndrome an overview CMAJ 200324(168)1675-82
bull 25 Heilmann L von Tempelhoff GF Pollow K Antiphospholipid syndrome in obstetrics Clin Appl Thromb Hemost 20039 143-50
bull 26 Sherman P Flaxman SM Nausea and vomiting of pregnancy in an evolutionary perspective Am J Obstet Gynecol 2002 185(Suppl)s190-7
bull 27 Koch KL Gastrointestinal factors in nausea and vomiting of pregnancy Am J Obstet Gynecol 2002185(Suppl)s198-203
bull 28 Koch KL Frissora CL Nausea and vomiting during pregnancy Gastroenterol Clin N Am 200332201-34
bull 29 Baron TH Ramirez B Richter JE Gastrointestinal motility disorders during pregnancy Ann Intern Med 1993118 366-75
bull 30 Richter JE Gastroesophageal reflux disease during pregnancy Gastroenterol Clin N Am 200332235-61
bull 31 Marrero JM Goggin PM de Caestecker JS Pearce JM Maxwell JD Determinants of pregnancy heartburn Br J Obstet Gynaecol 199299731-4
bull 32 Hamaoui E Hamaoui M Nutritional assessment and support during pregnancy Gastroenterol Clin N Am 20033259-121
bull 33 King JC Physiology of pregnancy and nutrient metabolism Am J Clin Nutr 200071(suppl)1218s-25s
bull 34 Casanueva E Pfeffer F Fernandez-Gaxiola AC Gutierrez- Valenzuela V Rothenberg SJ Iron and folate status before pregnancy and anemia during pregnancy Ann Nutr Metab 2003 4760-3
bull 35 Chrsquong CL Morgan M Hainsworth I Kingham JG Prospective study of liver dysfunction in Southwest Wales Gut 200251 876-80
bull 36 Rahman TM Wendon J Severe hepatic dysfunction in pregnancy QJM 200295343-57
bull 37 Knox TA Olans LB Liver disease in pregnancy N Engl J Med 1996335569-76
bull 38 Saftlas AF Olson DR Franks AL Atrash H Pokras R Epidemiology of preeclampsia and eclampsia in the United States 1979e1986 Am J Obstet Gynecol 1990163460-5
bull 39 Walker JJ Pre-eclampsia Lancet 20003561260-5
bull 40 Davidson JM Renal disorders in pregnancy Curr Opin Obstet Gynecol 200113109-14
bull 41 Dafnis E Sabatini S The effect of pregnancy on renal function physiology and pathophysiologyAmJMedSci 1992303184-205
bull 42 Davison JM Shiells EA Philips PR Lindheimer MD Serial evaluation of vasopressin release and thirst in human pregnancy Role of human chorionic gonadotrophin in the osmoregulatory changes of gestation J Clin Invest 198881798-806
bull 43 Glinoer D de Nayer P Bourdoux P Lemone M Robyn C van Steirteghem A et al Regulation of maternal thyroid during pregnancy J Clin Endocrinol Metab 199071276-87
bull 44 Wilson SG Retallack RW Kent JC Worth GK Gutteridge DH Serum free 125-dihydroxyvitamin D and the free 125- dihydroxyvitamin D index during a longitudinal study of human pregnancy and lactation Clin Endocrinol 199032613-22
bull 45 Rasmussen N Frolich A Hornnes PJ Hegedus L Serum ionized calcium and intact parathyroid hormone levels during pregnancy and postpartum Br J Obstet Gynaecol 199097857-9
bull 46 Guyton AC Textbook of medical physiology 8th ed Philadelphia W B Saunders 1991 p 915e28
bull 47 Trainer PJ Corticosteroids and pregnancy Semin Reprod Med 200220375-80
bull 48 Soory M Hormonal factors in periodontal disease Dent Update 200027380-3
bull 49 Hugoson A Gingivitis in pregnant women A longitudinal clinical study Odontol Revy 19712265-84
bull 50 Neville BW Damm DD Allen CM Bouquot JE Oral amp Maxillofacial Pathology 3rd ed Philadelphia W B Saunders 2002 p 329-30 447-9
bull 51 Tilakaratne A Soory M Ranasinghe AW Corea SM Ekanayake SL de Silva M Periodontal disease status during pregnancy and 3 months post-partum in rural population of Sri-Lankan women J Clin Periodontol 200027787-92
bull 52 Laine M Tenovuo J Lehtonen OP Ojanatko-Harri A Vilja P Tuohimaa P Pregnancy e related changes in human whole saliva Arch Oral Biol 198833913-7
bull 53 Yuan K Wing LY Lin MT Pathogenetic roles of angiogenic factors in pyogenic granulomas in pregnancy are modulated by female sex hormones J Periodontol 200273701-8
bull 54 Evans RD Briggs PF Tooth-surface loss related to pregnancyinduced vomiting Prim Dent Care 1994124-6
bull 55 Salvolini E Di Giorgio R Curatola A Mazzanti L Fratto G Biochemical modifications of human whole saliva induced by pregnancy Br J Obstet Gynaec 1998105656-60
bull 56 Mauldin JG Newman RB Preterm birth risk assessment Semin Perinatol 200125215-22
bull 57 Heine RP McGregor JA Goodwin TM Artal R Hayashi RH Robertson PA et al Serial salivary estriol to detect an increased risk of preterm birth Obstet Gynecol 200096490-7
bull 58 Kauh YC Zachian TF Melasma Adv Exp Med Biol 1999455 491-9
bull 59 Wong RC Ellis CN Physiologic skin changes in pregnancy J Am Acad Dermatol 198410929-40
bull 60 Errickson CV Matus NR Skin disorders of pregnancy Am Fam Physician 199449605-10
bull 61 Lopez NJ Smith PC Gutierrez J Periodontal therapy may reduce the risk of preterm low birth weight in women with periodontal disease a randomized controlled trial J Periodontol 200273911-24
bull 62 McGaw T Periodontal disease and preterm delivery of lowbirth- weight infants J Can Dent Assoc 200268165-9
bull 63 Richards AG Dental x-ray protection Dent Clin North Am 1968631-41
bull 64 1990 Recommendations of the International Commission on Radiological Protection Ann ICRP 1991211-201
bull 65 Hall EJ Radiation the two-edged sword cancer risks at high and low doses Cancer J 20006343-50
bull 66 Diethelm L Xu H Diagnostic imaging of the lung during pregnancy Clin Obstet Gynecol 19963936-55
bull 67 Brent RL The effects of embryonic and fetal exposure to x-rays microwaves and ultrasound ClinObstetGynecol 198326484-510
bull 68 National Council on Radiation Protection NCRP report no128 1998 Bethesda Md Author
bull 69 Wasylko L Matsui D Dykxhoorn SM Reider MJ Weinberg S A review of common dental treatments during pregnancy implications for patients and dental personnel J Can Dent Assoc 199864434-9
bull 70 Freeman JP Brand JW Radiation doses of commonly used dental radiographic surveys Oral Surg Oral Med Oral Pathol 199477285-9
bull 71 Kircos LTAngin LL Lorton LOrder ofmagnitude dose reduction in intraoral radiography J Am Dent Assoc 1987114344-7
bull 72 Updegrave WJ Simplified and standardized intraoral radiography with reduced tissue irradiation J Am Dent Assoc 197285861-9
bull 73 Wood RE Harris AM van der Merwe EJ Nortje CJ The leaded apron revisited does it reduce gonadal radiation dose in dental radiology Oral Surg Oral Med Oral Pathol 199171642-6
bull 74 An update on radiographic practices information and recommendations ADA Council on Scientific Affairs J Am Dent Assoc 2001132234-8
bull 75 Rayburn WF Recommending medications during pregnancy an evidence based approach Clin Obstet Gynecol 2002451-5
bull 76 Rathmell JP Viscomi C Ashburn MA Management of nonobstetric pain during pregnancy and lactation Anesth Analg 1997851074-87
bull 77 Teratology society public affairs committee FDA classification of drugs for teratogenic risk Teratology 199449446-7
bull 78 Moore PA Selecting drugs for the pregnant dental patient J Am Dent Assoc 19981291281-6
bull 79 Haas DA An update on analgesics for the management of acute postoperative dental pain J Can Dent Assoc 200268476-82
bull 80 Haas DA Pynn BR Sands TD Drug use for the pregnant or lactating patient Gen Dent 20004854-60
bull 81 Committee on Drugs American Academy of Pediatrics The transfer of drugs and other chemicals into human milk Pediatrics 199493137-50
bull 82 Nielsen GL Sorensen HT Larsen H Pedersen L Risk of adverse birth outcome and miscarriage in pregnant users of nonsteroidal anti-inflammatory drugs population based observational study and case-control study BMJ 2001322266-70
bull 83 Janssen N Genta M The effects of immunosuppressive and anti-inflammatory medications on fertility pregnancy and lactation Arch Intern Med 200016610-9
bull 84 Ostensen M Nonsteroidal anti-inflammatory drugs during pregnancy Scand J Rheumatol Suppl 1998107128-32
bull 85 USPDI -Drug information for the health care professional 22nd ed Greenwood Village CO Micromedex 2002 p 152-79
bull 86 Denson DD Coyle DE Thompson GA Santos D Turner PA Myers JA et al Bupivacaine protein binding in the term parturient effects of lactic acidosis Clin Pharmacol Ther 198435702-9
bull 87 Dillon DE Wagner CL Wiest D Newman RB Drug therapy in the nursing mother Obstet Gynecol Clin North Am 199724 675-96
bull 88 Dashe JS Gilstrap LC Antibiotic use in pregnancy Obstet Gynecol Clin North Am 199724617-29
bull 89 American College of Rheumatology Ad hoc Committee on Clinical Guidelines Guidelines for monitoring drug therapy in rheumatoid arthritis Arthritis Rheum 199639723-31
bull 90 Ng PC The fetal and neonatal hypothalamic-pituitary-adrenal axis Arch Dis Child Fetal Neonatal Ed 200082F250-4
bull 91 Crowley P Antenatal corticosteroidsmdashcurrent thinking BJOG 2003110(Suppl 20)77-8
bull 92 ACOG committee opinion antenatal corticosteroid therapy for fetal maturation Obstet Gynecol 200299871-3
bull 93 Ost L Wettrell G Bjorkhem I Rane A Prednisolone excretion in human milk J Pediatr 19851061008-11
bull 94 Rowland AS Baird DD Shore DL Weinberg CR Savitz DA Wilcox AJ Nitrous oxide and spontaneous abortion in female dental assistants Am J Epidemiol 1995141531-8
bull 95 McGlothlin JD Jensen PA Fischbach TJ Hughes RT Jones JH Control of anesthetic gases in dental operatories Scand J Work Environ Health 199218(Suppl 2)103-5
bull ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY Volume 97 Number 6 Suresh and Radfar 681
bull 96 Rosen MA Nitrous oxide for relief of labor pain a systematic review Am J Obstet Gynecol 2002186(Suppl Nature)S110-6
bull 97 Sands TD Pynn BR Management considerations for the pregnant or nursing emergency patient Ont Dent 199875 17-9
bull 98 Daya S Recurrent spontaneous early pregnancy loss and low dose aspirin Minerva Ginecol 200355441-9
bull 99 Sinclair C Handbook of obstetrical emergencies 1st ed Philadelphia WB Saunders 1996 p 29-39 69
bull 100 Tarsitano BF Rollings RE The pregnant dental patient evaluation and management Gen Dent 199341226-34
bull 101 Livingston MH Dlllinger TM Holder R Consideration in the management of the pregnant patient SCD Special Care in Dentistry 199818183-8
Thank you
- A Review on the principle of Dental Management of the Pregnant patient
- Slide 2
- Questions that a dentist may ask
- Stages of Pregnancy
- Slide 5
- Slide 6
- Physiologic Changes in Pregnancy
- Systemic changes in pregnancy
- FLAT SUPINE POSITIONING
- SUPINE HYPOTENSION SYNDROME (Vena Cava Compression)
- Supine Hypotension Syndrome
- Slide 12
- Supine Hypotension Syndrome
- Prevention of Supine Hypotensive Syndrome
- Treatment of Supine Hypotensive Syndrome
- How should the pregnant woman be positioned
- Slide 17
- Slide 18
- Slide 19
- Slide 20
- Slide 21
- Slide 22
- Slide 23
- Pregnancy Related Oral Health Problems
- Oral Problems in Pregnancy
- Pregnancy Gingivitis Pathophysiology
- Pregnancy Gingivitis
- Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Gum Problems - Pregnancy Granuloma
- Slide 31
- Gum Changes - Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Candidiasis
- Pregnancy Myths
- Other Oral Conditions in Pregnancy
- Changes During Pregnancy that Affect Oral Health
- Saliva changes
- Increased Bacteria
- Slide 40
- Enamel erosion caused by frequent vomiting
- Treatment for Acid Exposure
- Oral Diseases Can Effect Pregnancy
- Periodontal Disease and Preterm Labor
- Periodontal Disease and Low Birth Weight
- Periodontal Disease and Preeclampsia
- Periodontitis and Pre-eclampsia
- Dental Considerations
- Treatment Timing
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Slide 52
- Use of Radiation on Pregnant Patient
- Radiographs during Pregnancy
- Risks of Dental X-Rays
- FDA drug classification for pregnancy
- Slide 57
- FDA drug classification for pregnancy
- Slide 59
- Slide 60
- Slide 61
- Common Analgesics
- Analgesics
- Analgesics - continued
- Analgesics to Use During 1st and 2nd Trimester
- Analgesics to Avoid During the Third Trimester
- Sedation in Pregnancy
- Common Antibiotics
- Antibiotics
- Antibiotics To Use During Pregnancy
- Antibiotics to Avoid during Pregnancy
- The Problem With Tetracycline
- Other Antimicrobial Agents
- Local Anesthetic Use in Pregnancy
- Use of Local Anesthetics
- Ulcer healing drugs
- Slide 77
- Slide 78
- Slide 79
- Use of Nitrous Oxide Gas
- Common Preventives
- Are topical agents safe
- Pre-natal Fluoride
- Is it safe to use mercury restorations
- References
- REFERENCES
- Slide 87
- Slide 88
- Slide 89
- Slide 90
- Slide 91
- Slide 92
- Slide 93
- Slide 94
- Slide 95
- Slide 96
- Slide 97
- Slide 98
- Thank you
-
Systemic changes in pregnancy
Diaphragm rises about 4 cm darr residual volume uarr awareness of a desire to breath is
common-may be interpreted as dyspnea Increased estrogen in blood causes
engorgement of the nasal capillaries and rhnitis in pregnant women
Frequent nosebleeds amp predisposition to upper respiratory infection
Respiratory system
Systemic changes in pregnancy
Gastrointestinal system Gastric emptying amp intestinal transit times
are delayed
Heart burn reflux common
Nausea and vomiting common
Systemic changes in pregnancy
For pregnant patient with Hyper-emesis gravidarium ( excessive and uncontrolled vomiting) morning appointments should be avoided
They should be seated in a semi-supine or comfortable position
In case of vomiting the procedure should be stopped immediately amp the patient should be repositioned upright
When vomiting is over rinsing mouth with cold water or mouthwash is recommended
Systemic changes in pregnancybull Urinary System uarr GFR amp renal plasma flow by as much as
50 Nocturia ndashto mobilize the dependent
edema which accumulate during the day uarr Frequency from uarr renal flow plus reduced
bladder capacity from uterine growth It is advisable to ask the patient to void the
bladder just prior to starting the dental procedure
Systemic changes in pregnancyEndocrine Changes uarrEstrogen uarr progesterone uarrhuman
gonadotropin uarr thyroxin steroid and insulin level Estrogen amp progesterone are insulin
antagonists uarr level of these hormones lead to insulin resistance Thus insulin levels are elevated in pregnant in pregnant patient to compensate this resistance
About 45 of women fail to produce sufficient amount of insulin to overcome this antagonist action amp thus develop gestational diabetes
Systemic changes in pregnancy
Hematological changebull uarr red RBC uarrESR darrHbbull uarrWBCbull uarr circulatory catecholamin amp cortisol lead
to leucositosis bull uarr Coagulation factors except factor XI amp
XIII (anticloting factor) bull so pregnancy is a hypercoagulable state amp
uarr risk for thromboembolism
Systemic changes in pregnancy
bull Pregnant women with anti-phospholipid syndrome are at uarr risk for thrombo-embolisim
bull They are placed on subcutaneous low molecular weight heparin (LMWH)
bull These patients must be hospitalized for dental care
Pregnancy RelatedOral Health Problems
bull Pregnancy Gingivitisbull Pregnancy Epulis bull Increased Tooth Mobilitybull Dental Cariesbull Erosionbull Dental Problems in relation to Labor
and Delivery
Oral Problems in Pregnancy
bullPregnancy GingivitisbullMost common oral manifestation (50-100 of women)bullCaused by hormonal and vascular changes of pregnancy
Pregnancy Gingivitis Pathophysiology
bull Elevated circulating estrogen increases capillary permeability
bull Preexisting gingivitis may predispose to pregnancy gingivitis
Pregnancy Gingivitis
bullOccurs commonly in the 2nd to 8th monthsbullTendency to bleed very easilybullTreatment Scaling root-planing currettage OHI
Pregnancy Granuloma
bullOccurs in up to 5 of womenbullMost common in buccal maxillary anterior areasbullUsually starts in an area of gingivitis
Pregnancy Granuloma (continued)
bullRapid growth up to 2 cmbullSingle tumor-like growthbullusually in interdental papillaebullPurplish to bluish in color may be ulcerated- bleeds easily
Gum Problems - Pregnancy Granuloma
Gum Problems - Pregnancy Granuloma
Gum Changes - Pregnancy Granuloma
Pregnancy Granuloma (continued)
Treatment
bull Scaling and root planingbull Excision if it is too large or bleeds too
easilybull May regress spontaneously after
pregnancy
Candidiasis
bullWipes offbullUsually asymptomatic but may burnbullTreatment topical or systemic antifungals
Pregnancy MythsbullldquoA mother loses a tooth for every babyrdquobullNo evidence that aphthous ulcers are any more common in pregnancy
Other Oral Conditions in Pregnancy
bull Dry mouthbull Excessive salivationbull Tooth erosions associated with
severe GERD or hyperemesis
Changes During Pregnancy that Affect Oral Health
bull Hormonal Affects
ndash Increased tooth mobility
ndash Saliva changes
ndash Increased bacteria
ndash Gingival problems
Saliva changesbull Decreased buffers
bull Decreased minerals
bull Decreasing flow first and last trimester
bull Increased flow second trimester
bull More acidic
Increased Bacteriabull Increased acidity
ndash Increase in decay-causing bacteriabull Increased Snacking
ndash Morning sicknesslow blood sugarndash Between-meal snacks
bull Increase in amount and frequency of starchescarbohydrates ndash Crackers are commonly recommendedndash Promotes decay-causing bacteria
Changes During Pregnancy that Affect Oral Healthbull Morning sickness
ndash Difficulty with hygienebull Gingival diseasebull Tooth decay
ndash Vomitingbull Esophogeal Reflux (heartburn)bull Acid exposure
ndash Irritation of the gumsndash Weakening of tooth enamelndash Dental erosion
Enamel erosion caused by frequent vomiting
Treatment for Acid Exposure
bull Do NOT brush immediately after vomiting
bull Rinse ndash Water with baking sodandash Antacidndash Plain water
bull Eat some cheese
Oral Diseases Can Effect Pregnancy
bull Preterm low birth weight (LBW) linked to periodontal disease
bull Thorough calculus (tartar) removal in pregnant women with periodontitis may reduce pre-term births
Periodontal Disease and Preterm LaborbullMaternal periodontal disease is associated with increased risk of preterm laborbullAnaerobic oral gram-negative bacteria cause inflammatory responsebullInflammatory response stimulates prostaglandin and cytokine production to stimulate labor
Periodontal Disease and Low Birth Weight
bull Periodontal disease is associated with low birth weight
bull Evidence is not conclusivebull Biochemical mechanism similar cascade
as in preterm labor leading to placental blood flow restriction and necrosis
Periodontal Disease and Preeclampsia
bull Emerging databull Mechanism unclearbull Proposed mechanism
ndash Periodontal infection leads to inflammatory vascular damage
ndash Triggers cell damage in placenta
Periodontitis and Pre-eclampsia
bull Periodontal disease may be associated with pre-eclampsia (Boggess 2003)
bull PGE2 IL-1 and TNF-α from gingival crevicular fluid were higher in women with preeclampsia compared with healthy matched pregnant women (Oettinger-Barak 2003)
Dental Considerations
bull timing of treatment for pregnant patientsbull dental radiation exposurebull use of local anestheticsbull prescription of common antibiotics and
analgesicsbull nitrous oxide gas administration
Treatment Timing
bull First Trimesterndash Spontaneous miscarriages naturally occur
more often in 1st trimesterndash Avoid elective treatment that can be delayedndash Offer anticipatory guidance
bull Second Trimesterndash The optimal time for dental treatmentndash Organogenesis complete fetus not largendash Easier to prevent than treat established disease
bull Third Trimesterndash Late in term very uncomfortable (short visits)ndash Position slightly on left side
Timing of Dental Treatment During Pregnancy - From Little and Fallace
First Trimester
bull Plaque controlbull Oral hygiene instructionbull Scaling polishing curettagebull Avoid elective treatment urgent care
only
Timing of Dental Treatment During Pregnancy - From Little and Fallace
Second Trimester
bull Plaque controlbull Oral hygiene instructionbull Scaling polishing curettagebull Routine dental care
Timing of Dental Treatment During Pregnancy - From Little and Fallace
Third Trimester
bull Plaque controlbull Oral hygiene instructionbull Scaling polishing curettagebull Routine dental care (after middle of third
trimester elective care should be avoided)
Use of Radiation on Pregnant Patientbull Dose given and time of gestation are
importantbull doses lt 5-10 rads (cGy) not teratogenicbull fetus is most susceptible to radiation
between the 2nd and 6th week of gestationbull single dental x-ray exposes patient to 001
millirads of radiation In relative terms this amount is 40 times less than daily dose acquired from cosmic radiation Therefore diagnostic radiation should not be withheld during pregnancy
Radiographs during Pregnancy
bull Take as needed with optimal methods for reducing secondary radiation and exposure time
bull Always use a lead apronbull Exposure to fetus (with apron use) is 00001
centiGray(rad)bull Daily cosmic radiation - 0004 centiGray (rad)
Risks of Dental X-Rays
bull X-ray only if necessary (ie root canal therapy trauma)
bull When x-rays are indicated radiation exposure is extremely low
bull Exposure can be limited byndash Lead apron shielding ndash Modern fast film ndash Avoiding retakes
FDA drug classification for pregnancybull Combines risk statements including
congenital anomalies fetal effects perinatal risks and therapeutic risk-benefit ratio
bull Untreated disease or condition may pose more serious risks to both mother and fetus than any theoretical risks from the medication
bull Category A thru D and X
FDA drug classification for pregnancy
bull A = Controlled Studies in women fail to demonstrate a risk to the fetus in the first trimester and the possibility of fetal harm appears remote
FDA drug classification for pregnancy
bull B = Animal studies show no risk or if risk shown in animals controlled
trials in women showed no risk
FDA drug classification for pregnancy
bull C = Studies in animals with adverse effects and no human studies
OR no animal or human studies but benefits of use may outweigh potential harms
FDA drug classification for pregnancy
bull D = There is evidence of human fetal risk but benefits may outweigh risks
FDA drug classification for pregnancy
bull X = Contraindicated
Common Analgesics
bull paracetamol (B)bull Ibuprofen (BD) bull Oxycodone (BD) bull Hydrocodone and codeine
(CD)
avoid in third trimester
Analgesics
bull Paracetamol is the analgesic of choice for all stages of gestation
bull used to treat mild to moderate pain and fevers
bull short term usage is believed to be safebull avoid chronic and large doses of
paracetamol1048715
Analgesics - continuedbull Aspirin is nonteratogenic but may cause
maternal and fetal hemorrhagebull large and chronic doses during last trimester
may result in premature closure of ductus arteriosus fetal hypertension anemia and low birth weight
bull avoid ibuprofen in 3rd trimester because of possible adverse circulatory effects
bull short term use of codeine seems safebull avoid codeine late in gestation because of
possible fetal respiratory depression and withdrawal symptoms
Analgesics to Use During1st and 2nd Trimester
bull Category B (for best)bull Paracetamol Ibuprofenbull Naproxenbull Category C (use with caution)bull Paracetamol with codeine or
hydrocodonebull Paracetamol with oxycodone
Analgesics to Avoid During theThird Trimesterbull Causes delivery problemsbull Aspirin (C 3D)bull Ibuprofen (B3D)bull Naproxen (B3D)bull Causes neonatal respiratory
depression and opioid withdrawalbull Codeine (C3D)bull Hydrocodone (C3D)bull Oxycodone(C3D)
Sedation in Pregnancy
bull SedativesAnxiolytics (eg Diazepam ) are rated D and can cause oral clefts with prolonged exposure
bull Nitrous oxide should not be used in 1st trimester (If used in 2nd and 3rd do not go below 50 O2)
Common Antibioticsbull To treat oral abscess or cellulitis
ndash Penicillin (B) ndash Amoxicillin (B) ndash Cephalexin (B)ndash Erythromycin base (B) (Not estolate as it
cause cholestatic hepatitis)ndash Clindamycin (B)
Antibioticsbull penicillin V and amoxicillin is preferred drug
for mild to moderate infectionsbull widely used for many years with no ill effectsbull no studies show penicillin to be teratogenicbull amoxicillin extensively used without harming
the fetusbull Drug classes1048715 B penicillin cephalosporins erythromycin clindamycin Azithromycin D Tetracycline
Antibiotics To Use During Pregnancy
bull Penicillin Vbull Amoxicillinbull Erythromycin (base form)bull Cephalexin cephalosporinbull Clindamycinbull Metronidazole
Antibiotics to Avoid duringPregnancy
bull Doxycyclinebull Tetracyclinebull Erythromycin (estolate form)bull Vancomycin
The Problem With Tetracycline
bull Accumulates in bones and chelates calcium
bull Inhibits bone growthbull Discolors teeth
Other Antimicrobial Agentsbull OK to usebull Nystatin (B)bull Chlorhexidine rinse (B)bull Use with cautionbull Clotrimazole (C)bull Ketoconazole (C)bull Fluconazole (C)bull Do not usebull Doxycycline (D)
Local Anesthetic Use inPregnancy
bull Class Bbull Lidocaine (Xylocaine)bull Etidocainebull Prilocaine bull Class Cbull Procainebull Bupivicainebull Mepivicaine
Use of Local Anestheticsbull Lidocaine + vasoconstrictor most common
local anesthetic used in dentistrybull extensively used in pregnancy with no proven ill
effectsbull accidental intravascular injections of lidocaine
pass through the placenta but the concentrations are too low to harm fetus
bull prilocaine might cause methemoglobinemia
Ulcer healing drugsCimetidine bull FDA category B Famotidinebull FDA category BRanitidinebull FDA category Bbull not known to be harmful
Ulcer healing drugsOmeprazolebull FDA category BNot known to be
harmful Esomeprazolebull FDA category BLansoprazolebull FDA category BPantoprazolebull Avoid unless potential benefit
outweighs riskmdashfetotoxic in animals
Ulcer healing drugs
Misoprostolbull First second third trimesters Avoidmdash
potent uterine stimulant (has been used to induce abortion) and may be teratogenic
Ulcer healing drugs
Antacidsbull Almunium hydroxideMagnesium
hydroxidemdashFDA category B Calcium carbonatemdashFDA category C
SimetheconemdashFDA category C
Use of Nitrous Oxide Gas
bull used over 150 years bull safety is being debatedbull SHORT TERM exposure do not cause
birth defects or spontaneous abortionbull CHRONIC exposure may result in fetal
loss and infertilitybull literature suggests that nitrous oxide
should be avoided until more conclusive research is available
bull FDA Drug class not yet assigned
Common Preventives
bull Fluoridendash No increased risk during pregnancy
bull Xylitolndash No studies no harm reported
bull Chlorhexidinendash No increased risk during pregnancy
Are topical agents safe
bull Fluoridebull Toothpaste amp mouthrinse
bull Xylitol chewing gum bull Chlorhexidine (11 alcohol)bull No over the counter mouthrinses with
alcohol (Listerine 20 alcohol)
Pre-natal Fluoride
bull Daily 22 mg tablet of sodium fluoride during 3rd through 9th months
bull decreases caries rate in offspringbull Safe and effective
Glenn FB 1982
Is it safe to use mercury restorations
bull No evidence of harmful effect
bull Benefits outweigh risks
bull Canada Germany and New Zealand have some restrictions
bull Determine the best option
Referencesbull Wasylko L Matsui D Dykxhoorn SM Rieder MJ Weinberg
S A Review of Common Dental Treatments During Pregnancy J Canadian Dental Association 64434-439 1998
bull Little JW Donald AF Craig SM Rhodus NL Dental Management of the Medically Compromised Patient - 5th edition Mosby Toronto Pp434-442 1997
bull Livingston HM Dellinger TM Holder R Considerations in the management of the pregnant patient Special Care in Dentistry 185 pp183-188 1998
bull Larimore WL Petrie KA Drug use during pregnacy and lactation Primary Care Clinics in Office Practice 271 35-53 2000
bull Health Canada The Safety of DentalAmalgam Minister Of Supply and Services Canada 1996
REFERENCESbull 1 Weiss G Endocrinology of parturition J Clin
Endocrinol Metab 2000854421-5bull 2 Theunissen IM Parer JT Fluid and electrolytes in
pregnancy Clin Obstet Gynecol 1994373-15bull 3 Duvekot JJ Peeters LLH Renal hemodynamics and
volume homeostasis in pregnancy Obstet Gynecol Surv 199449830-9
bull 4 Barron WM Lindheimer MD Medical disorders during pregnancy 2nd ed St Louis Mosby 1995 p 129
bull 5 Thornburg KL Jacobson SL Giraud GD Morton MJ Hemodynamic changes in pregnancy Semin Perinatol 20002411-4
bull 6 Fiese R Herzog S Issues in dental and surgical management of the pregnant patient Oral Surg Oral Med Oral Pathol 198865292-7
bull 7 Martin C Varner MW Physiologic changes in pregnancysurgical implications Clin Obstet Gynecol 199437241-55
bull 8 Clark SL Cotton DB Lee W Bishop C Hill T Southwick J et al Central hemodynamic assessment of normal term pregnancy Am J Obstet Gynecol 19891611439-42
bull 9 Mabie WC Di Sessa TG Crocker LG Sibai BM Arheart KL A longitudinal study of cardiac output in normal human pregnancy Am J Obstet Gynecol 1994170849-56
bull 10 Clapp JF 3rd Capeless E Cardiovascular function before during and after the first and subsequent pregnancies Am J Cardiol 1997801469-73
bull 11 Duvekot JJ Peeters LL Maternal cardiovascular hemodynamic adaptation to pregnancy Obstet Gynecol Surv 199449(Suppl) S1-14
bull 12 Bhagwat AR Engel PJ Heart disease and pregnancy Cardiol Clin 199513163-78
bull 13 Lanni SM Tillinghast J Silver H Hemodynamic changes and baroreflex gain in the supine hypotensive syndrome Am J Obstet Gynecol 20021871636-41
bull 14 Little JW Falace DA Miller CS Rhodus NL Dental management of the medically compromised patient 6th ed St Louis Mosby 2002 p 303
bull 15 Garcia-Rio F Pino JM Gomez L Alvarez-Sala R Villasante C Villamor J Regulation of breathing and perception of dyspnea in healthy pregnant women Chest 1996110446-53
bull 16 McAuliffe F Kametas N Costello J Rafferty GF Greenough A Nicolaides K Respiratory function in singleton and twin pregnancy BJOG 2002109765-9
bull 17 Clapp JF 3rd Seaward BL Sleamaker RH Hiser J Maternal physiologic adaptations to early human pregnancy Am J Obstet Gynecol 19881591456-60
bull 18 OrsquoDay MP Cardio-respiratory physiological adaptation of pregnancy Semin Perinatol 199721268-75
bull 19 Contreras G Gutierrez M Beroiza T Fantin A Oddo H Villarroel L et al Ventilatory drive and respiratory muscle function in pregnancy Am Rev Respir Dis 1991144837-41
bull 20 Turner M Aziz SR Management of the pregnant oral and maxillofac
bull 21 Sifakis S Pharmakides G Anemia in pregnancy Ann N Y Acad Sci 2000900125-36
bull 22 Branch DW Physiologic adaptations of pregnancy Am J Reprod Immunol 199228120-2
bull 23 Burrows RF Kelton JG Incidentally detected thrombocytopenia in healthy mothers and their infants N Engl J Med 1988319 142-5
bull 24 Hanly JG Antiphospholipid syndrome an overview CMAJ 200324(168)1675-82
bull 25 Heilmann L von Tempelhoff GF Pollow K Antiphospholipid syndrome in obstetrics Clin Appl Thromb Hemost 20039 143-50
bull 26 Sherman P Flaxman SM Nausea and vomiting of pregnancy in an evolutionary perspective Am J Obstet Gynecol 2002 185(Suppl)s190-7
bull 27 Koch KL Gastrointestinal factors in nausea and vomiting of pregnancy Am J Obstet Gynecol 2002185(Suppl)s198-203
bull 28 Koch KL Frissora CL Nausea and vomiting during pregnancy Gastroenterol Clin N Am 200332201-34
bull 29 Baron TH Ramirez B Richter JE Gastrointestinal motility disorders during pregnancy Ann Intern Med 1993118 366-75
bull 30 Richter JE Gastroesophageal reflux disease during pregnancy Gastroenterol Clin N Am 200332235-61
bull 31 Marrero JM Goggin PM de Caestecker JS Pearce JM Maxwell JD Determinants of pregnancy heartburn Br J Obstet Gynaecol 199299731-4
bull 32 Hamaoui E Hamaoui M Nutritional assessment and support during pregnancy Gastroenterol Clin N Am 20033259-121
bull 33 King JC Physiology of pregnancy and nutrient metabolism Am J Clin Nutr 200071(suppl)1218s-25s
bull 34 Casanueva E Pfeffer F Fernandez-Gaxiola AC Gutierrez- Valenzuela V Rothenberg SJ Iron and folate status before pregnancy and anemia during pregnancy Ann Nutr Metab 2003 4760-3
bull 35 Chrsquong CL Morgan M Hainsworth I Kingham JG Prospective study of liver dysfunction in Southwest Wales Gut 200251 876-80
bull 36 Rahman TM Wendon J Severe hepatic dysfunction in pregnancy QJM 200295343-57
bull 37 Knox TA Olans LB Liver disease in pregnancy N Engl J Med 1996335569-76
bull 38 Saftlas AF Olson DR Franks AL Atrash H Pokras R Epidemiology of preeclampsia and eclampsia in the United States 1979e1986 Am J Obstet Gynecol 1990163460-5
bull 39 Walker JJ Pre-eclampsia Lancet 20003561260-5
bull 40 Davidson JM Renal disorders in pregnancy Curr Opin Obstet Gynecol 200113109-14
bull 41 Dafnis E Sabatini S The effect of pregnancy on renal function physiology and pathophysiologyAmJMedSci 1992303184-205
bull 42 Davison JM Shiells EA Philips PR Lindheimer MD Serial evaluation of vasopressin release and thirst in human pregnancy Role of human chorionic gonadotrophin in the osmoregulatory changes of gestation J Clin Invest 198881798-806
bull 43 Glinoer D de Nayer P Bourdoux P Lemone M Robyn C van Steirteghem A et al Regulation of maternal thyroid during pregnancy J Clin Endocrinol Metab 199071276-87
bull 44 Wilson SG Retallack RW Kent JC Worth GK Gutteridge DH Serum free 125-dihydroxyvitamin D and the free 125- dihydroxyvitamin D index during a longitudinal study of human pregnancy and lactation Clin Endocrinol 199032613-22
bull 45 Rasmussen N Frolich A Hornnes PJ Hegedus L Serum ionized calcium and intact parathyroid hormone levels during pregnancy and postpartum Br J Obstet Gynaecol 199097857-9
bull 46 Guyton AC Textbook of medical physiology 8th ed Philadelphia W B Saunders 1991 p 915e28
bull 47 Trainer PJ Corticosteroids and pregnancy Semin Reprod Med 200220375-80
bull 48 Soory M Hormonal factors in periodontal disease Dent Update 200027380-3
bull 49 Hugoson A Gingivitis in pregnant women A longitudinal clinical study Odontol Revy 19712265-84
bull 50 Neville BW Damm DD Allen CM Bouquot JE Oral amp Maxillofacial Pathology 3rd ed Philadelphia W B Saunders 2002 p 329-30 447-9
bull 51 Tilakaratne A Soory M Ranasinghe AW Corea SM Ekanayake SL de Silva M Periodontal disease status during pregnancy and 3 months post-partum in rural population of Sri-Lankan women J Clin Periodontol 200027787-92
bull 52 Laine M Tenovuo J Lehtonen OP Ojanatko-Harri A Vilja P Tuohimaa P Pregnancy e related changes in human whole saliva Arch Oral Biol 198833913-7
bull 53 Yuan K Wing LY Lin MT Pathogenetic roles of angiogenic factors in pyogenic granulomas in pregnancy are modulated by female sex hormones J Periodontol 200273701-8
bull 54 Evans RD Briggs PF Tooth-surface loss related to pregnancyinduced vomiting Prim Dent Care 1994124-6
bull 55 Salvolini E Di Giorgio R Curatola A Mazzanti L Fratto G Biochemical modifications of human whole saliva induced by pregnancy Br J Obstet Gynaec 1998105656-60
bull 56 Mauldin JG Newman RB Preterm birth risk assessment Semin Perinatol 200125215-22
bull 57 Heine RP McGregor JA Goodwin TM Artal R Hayashi RH Robertson PA et al Serial salivary estriol to detect an increased risk of preterm birth Obstet Gynecol 200096490-7
bull 58 Kauh YC Zachian TF Melasma Adv Exp Med Biol 1999455 491-9
bull 59 Wong RC Ellis CN Physiologic skin changes in pregnancy J Am Acad Dermatol 198410929-40
bull 60 Errickson CV Matus NR Skin disorders of pregnancy Am Fam Physician 199449605-10
bull 61 Lopez NJ Smith PC Gutierrez J Periodontal therapy may reduce the risk of preterm low birth weight in women with periodontal disease a randomized controlled trial J Periodontol 200273911-24
bull 62 McGaw T Periodontal disease and preterm delivery of lowbirth- weight infants J Can Dent Assoc 200268165-9
bull 63 Richards AG Dental x-ray protection Dent Clin North Am 1968631-41
bull 64 1990 Recommendations of the International Commission on Radiological Protection Ann ICRP 1991211-201
bull 65 Hall EJ Radiation the two-edged sword cancer risks at high and low doses Cancer J 20006343-50
bull 66 Diethelm L Xu H Diagnostic imaging of the lung during pregnancy Clin Obstet Gynecol 19963936-55
bull 67 Brent RL The effects of embryonic and fetal exposure to x-rays microwaves and ultrasound ClinObstetGynecol 198326484-510
bull 68 National Council on Radiation Protection NCRP report no128 1998 Bethesda Md Author
bull 69 Wasylko L Matsui D Dykxhoorn SM Reider MJ Weinberg S A review of common dental treatments during pregnancy implications for patients and dental personnel J Can Dent Assoc 199864434-9
bull 70 Freeman JP Brand JW Radiation doses of commonly used dental radiographic surveys Oral Surg Oral Med Oral Pathol 199477285-9
bull 71 Kircos LTAngin LL Lorton LOrder ofmagnitude dose reduction in intraoral radiography J Am Dent Assoc 1987114344-7
bull 72 Updegrave WJ Simplified and standardized intraoral radiography with reduced tissue irradiation J Am Dent Assoc 197285861-9
bull 73 Wood RE Harris AM van der Merwe EJ Nortje CJ The leaded apron revisited does it reduce gonadal radiation dose in dental radiology Oral Surg Oral Med Oral Pathol 199171642-6
bull 74 An update on radiographic practices information and recommendations ADA Council on Scientific Affairs J Am Dent Assoc 2001132234-8
bull 75 Rayburn WF Recommending medications during pregnancy an evidence based approach Clin Obstet Gynecol 2002451-5
bull 76 Rathmell JP Viscomi C Ashburn MA Management of nonobstetric pain during pregnancy and lactation Anesth Analg 1997851074-87
bull 77 Teratology society public affairs committee FDA classification of drugs for teratogenic risk Teratology 199449446-7
bull 78 Moore PA Selecting drugs for the pregnant dental patient J Am Dent Assoc 19981291281-6
bull 79 Haas DA An update on analgesics for the management of acute postoperative dental pain J Can Dent Assoc 200268476-82
bull 80 Haas DA Pynn BR Sands TD Drug use for the pregnant or lactating patient Gen Dent 20004854-60
bull 81 Committee on Drugs American Academy of Pediatrics The transfer of drugs and other chemicals into human milk Pediatrics 199493137-50
bull 82 Nielsen GL Sorensen HT Larsen H Pedersen L Risk of adverse birth outcome and miscarriage in pregnant users of nonsteroidal anti-inflammatory drugs population based observational study and case-control study BMJ 2001322266-70
bull 83 Janssen N Genta M The effects of immunosuppressive and anti-inflammatory medications on fertility pregnancy and lactation Arch Intern Med 200016610-9
bull 84 Ostensen M Nonsteroidal anti-inflammatory drugs during pregnancy Scand J Rheumatol Suppl 1998107128-32
bull 85 USPDI -Drug information for the health care professional 22nd ed Greenwood Village CO Micromedex 2002 p 152-79
bull 86 Denson DD Coyle DE Thompson GA Santos D Turner PA Myers JA et al Bupivacaine protein binding in the term parturient effects of lactic acidosis Clin Pharmacol Ther 198435702-9
bull 87 Dillon DE Wagner CL Wiest D Newman RB Drug therapy in the nursing mother Obstet Gynecol Clin North Am 199724 675-96
bull 88 Dashe JS Gilstrap LC Antibiotic use in pregnancy Obstet Gynecol Clin North Am 199724617-29
bull 89 American College of Rheumatology Ad hoc Committee on Clinical Guidelines Guidelines for monitoring drug therapy in rheumatoid arthritis Arthritis Rheum 199639723-31
bull 90 Ng PC The fetal and neonatal hypothalamic-pituitary-adrenal axis Arch Dis Child Fetal Neonatal Ed 200082F250-4
bull 91 Crowley P Antenatal corticosteroidsmdashcurrent thinking BJOG 2003110(Suppl 20)77-8
bull 92 ACOG committee opinion antenatal corticosteroid therapy for fetal maturation Obstet Gynecol 200299871-3
bull 93 Ost L Wettrell G Bjorkhem I Rane A Prednisolone excretion in human milk J Pediatr 19851061008-11
bull 94 Rowland AS Baird DD Shore DL Weinberg CR Savitz DA Wilcox AJ Nitrous oxide and spontaneous abortion in female dental assistants Am J Epidemiol 1995141531-8
bull 95 McGlothlin JD Jensen PA Fischbach TJ Hughes RT Jones JH Control of anesthetic gases in dental operatories Scand J Work Environ Health 199218(Suppl 2)103-5
bull ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY Volume 97 Number 6 Suresh and Radfar 681
bull 96 Rosen MA Nitrous oxide for relief of labor pain a systematic review Am J Obstet Gynecol 2002186(Suppl Nature)S110-6
bull 97 Sands TD Pynn BR Management considerations for the pregnant or nursing emergency patient Ont Dent 199875 17-9
bull 98 Daya S Recurrent spontaneous early pregnancy loss and low dose aspirin Minerva Ginecol 200355441-9
bull 99 Sinclair C Handbook of obstetrical emergencies 1st ed Philadelphia WB Saunders 1996 p 29-39 69
bull 100 Tarsitano BF Rollings RE The pregnant dental patient evaluation and management Gen Dent 199341226-34
bull 101 Livingston MH Dlllinger TM Holder R Consideration in the management of the pregnant patient SCD Special Care in Dentistry 199818183-8
Thank you
- A Review on the principle of Dental Management of the Pregnant patient
- Slide 2
- Questions that a dentist may ask
- Stages of Pregnancy
- Slide 5
- Slide 6
- Physiologic Changes in Pregnancy
- Systemic changes in pregnancy
- FLAT SUPINE POSITIONING
- SUPINE HYPOTENSION SYNDROME (Vena Cava Compression)
- Supine Hypotension Syndrome
- Slide 12
- Supine Hypotension Syndrome
- Prevention of Supine Hypotensive Syndrome
- Treatment of Supine Hypotensive Syndrome
- How should the pregnant woman be positioned
- Slide 17
- Slide 18
- Slide 19
- Slide 20
- Slide 21
- Slide 22
- Slide 23
- Pregnancy Related Oral Health Problems
- Oral Problems in Pregnancy
- Pregnancy Gingivitis Pathophysiology
- Pregnancy Gingivitis
- Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Gum Problems - Pregnancy Granuloma
- Slide 31
- Gum Changes - Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Candidiasis
- Pregnancy Myths
- Other Oral Conditions in Pregnancy
- Changes During Pregnancy that Affect Oral Health
- Saliva changes
- Increased Bacteria
- Slide 40
- Enamel erosion caused by frequent vomiting
- Treatment for Acid Exposure
- Oral Diseases Can Effect Pregnancy
- Periodontal Disease and Preterm Labor
- Periodontal Disease and Low Birth Weight
- Periodontal Disease and Preeclampsia
- Periodontitis and Pre-eclampsia
- Dental Considerations
- Treatment Timing
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Slide 52
- Use of Radiation on Pregnant Patient
- Radiographs during Pregnancy
- Risks of Dental X-Rays
- FDA drug classification for pregnancy
- Slide 57
- FDA drug classification for pregnancy
- Slide 59
- Slide 60
- Slide 61
- Common Analgesics
- Analgesics
- Analgesics - continued
- Analgesics to Use During 1st and 2nd Trimester
- Analgesics to Avoid During the Third Trimester
- Sedation in Pregnancy
- Common Antibiotics
- Antibiotics
- Antibiotics To Use During Pregnancy
- Antibiotics to Avoid during Pregnancy
- The Problem With Tetracycline
- Other Antimicrobial Agents
- Local Anesthetic Use in Pregnancy
- Use of Local Anesthetics
- Ulcer healing drugs
- Slide 77
- Slide 78
- Slide 79
- Use of Nitrous Oxide Gas
- Common Preventives
- Are topical agents safe
- Pre-natal Fluoride
- Is it safe to use mercury restorations
- References
- REFERENCES
- Slide 87
- Slide 88
- Slide 89
- Slide 90
- Slide 91
- Slide 92
- Slide 93
- Slide 94
- Slide 95
- Slide 96
- Slide 97
- Slide 98
- Thank you
-
Systemic changes in pregnancy
Gastrointestinal system Gastric emptying amp intestinal transit times
are delayed
Heart burn reflux common
Nausea and vomiting common
Systemic changes in pregnancy
For pregnant patient with Hyper-emesis gravidarium ( excessive and uncontrolled vomiting) morning appointments should be avoided
They should be seated in a semi-supine or comfortable position
In case of vomiting the procedure should be stopped immediately amp the patient should be repositioned upright
When vomiting is over rinsing mouth with cold water or mouthwash is recommended
Systemic changes in pregnancybull Urinary System uarr GFR amp renal plasma flow by as much as
50 Nocturia ndashto mobilize the dependent
edema which accumulate during the day uarr Frequency from uarr renal flow plus reduced
bladder capacity from uterine growth It is advisable to ask the patient to void the
bladder just prior to starting the dental procedure
Systemic changes in pregnancyEndocrine Changes uarrEstrogen uarr progesterone uarrhuman
gonadotropin uarr thyroxin steroid and insulin level Estrogen amp progesterone are insulin
antagonists uarr level of these hormones lead to insulin resistance Thus insulin levels are elevated in pregnant in pregnant patient to compensate this resistance
About 45 of women fail to produce sufficient amount of insulin to overcome this antagonist action amp thus develop gestational diabetes
Systemic changes in pregnancy
Hematological changebull uarr red RBC uarrESR darrHbbull uarrWBCbull uarr circulatory catecholamin amp cortisol lead
to leucositosis bull uarr Coagulation factors except factor XI amp
XIII (anticloting factor) bull so pregnancy is a hypercoagulable state amp
uarr risk for thromboembolism
Systemic changes in pregnancy
bull Pregnant women with anti-phospholipid syndrome are at uarr risk for thrombo-embolisim
bull They are placed on subcutaneous low molecular weight heparin (LMWH)
bull These patients must be hospitalized for dental care
Pregnancy RelatedOral Health Problems
bull Pregnancy Gingivitisbull Pregnancy Epulis bull Increased Tooth Mobilitybull Dental Cariesbull Erosionbull Dental Problems in relation to Labor
and Delivery
Oral Problems in Pregnancy
bullPregnancy GingivitisbullMost common oral manifestation (50-100 of women)bullCaused by hormonal and vascular changes of pregnancy
Pregnancy Gingivitis Pathophysiology
bull Elevated circulating estrogen increases capillary permeability
bull Preexisting gingivitis may predispose to pregnancy gingivitis
Pregnancy Gingivitis
bullOccurs commonly in the 2nd to 8th monthsbullTendency to bleed very easilybullTreatment Scaling root-planing currettage OHI
Pregnancy Granuloma
bullOccurs in up to 5 of womenbullMost common in buccal maxillary anterior areasbullUsually starts in an area of gingivitis
Pregnancy Granuloma (continued)
bullRapid growth up to 2 cmbullSingle tumor-like growthbullusually in interdental papillaebullPurplish to bluish in color may be ulcerated- bleeds easily
Gum Problems - Pregnancy Granuloma
Gum Problems - Pregnancy Granuloma
Gum Changes - Pregnancy Granuloma
Pregnancy Granuloma (continued)
Treatment
bull Scaling and root planingbull Excision if it is too large or bleeds too
easilybull May regress spontaneously after
pregnancy
Candidiasis
bullWipes offbullUsually asymptomatic but may burnbullTreatment topical or systemic antifungals
Pregnancy MythsbullldquoA mother loses a tooth for every babyrdquobullNo evidence that aphthous ulcers are any more common in pregnancy
Other Oral Conditions in Pregnancy
bull Dry mouthbull Excessive salivationbull Tooth erosions associated with
severe GERD or hyperemesis
Changes During Pregnancy that Affect Oral Health
bull Hormonal Affects
ndash Increased tooth mobility
ndash Saliva changes
ndash Increased bacteria
ndash Gingival problems
Saliva changesbull Decreased buffers
bull Decreased minerals
bull Decreasing flow first and last trimester
bull Increased flow second trimester
bull More acidic
Increased Bacteriabull Increased acidity
ndash Increase in decay-causing bacteriabull Increased Snacking
ndash Morning sicknesslow blood sugarndash Between-meal snacks
bull Increase in amount and frequency of starchescarbohydrates ndash Crackers are commonly recommendedndash Promotes decay-causing bacteria
Changes During Pregnancy that Affect Oral Healthbull Morning sickness
ndash Difficulty with hygienebull Gingival diseasebull Tooth decay
ndash Vomitingbull Esophogeal Reflux (heartburn)bull Acid exposure
ndash Irritation of the gumsndash Weakening of tooth enamelndash Dental erosion
Enamel erosion caused by frequent vomiting
Treatment for Acid Exposure
bull Do NOT brush immediately after vomiting
bull Rinse ndash Water with baking sodandash Antacidndash Plain water
bull Eat some cheese
Oral Diseases Can Effect Pregnancy
bull Preterm low birth weight (LBW) linked to periodontal disease
bull Thorough calculus (tartar) removal in pregnant women with periodontitis may reduce pre-term births
Periodontal Disease and Preterm LaborbullMaternal periodontal disease is associated with increased risk of preterm laborbullAnaerobic oral gram-negative bacteria cause inflammatory responsebullInflammatory response stimulates prostaglandin and cytokine production to stimulate labor
Periodontal Disease and Low Birth Weight
bull Periodontal disease is associated with low birth weight
bull Evidence is not conclusivebull Biochemical mechanism similar cascade
as in preterm labor leading to placental blood flow restriction and necrosis
Periodontal Disease and Preeclampsia
bull Emerging databull Mechanism unclearbull Proposed mechanism
ndash Periodontal infection leads to inflammatory vascular damage
ndash Triggers cell damage in placenta
Periodontitis and Pre-eclampsia
bull Periodontal disease may be associated with pre-eclampsia (Boggess 2003)
bull PGE2 IL-1 and TNF-α from gingival crevicular fluid were higher in women with preeclampsia compared with healthy matched pregnant women (Oettinger-Barak 2003)
Dental Considerations
bull timing of treatment for pregnant patientsbull dental radiation exposurebull use of local anestheticsbull prescription of common antibiotics and
analgesicsbull nitrous oxide gas administration
Treatment Timing
bull First Trimesterndash Spontaneous miscarriages naturally occur
more often in 1st trimesterndash Avoid elective treatment that can be delayedndash Offer anticipatory guidance
bull Second Trimesterndash The optimal time for dental treatmentndash Organogenesis complete fetus not largendash Easier to prevent than treat established disease
bull Third Trimesterndash Late in term very uncomfortable (short visits)ndash Position slightly on left side
Timing of Dental Treatment During Pregnancy - From Little and Fallace
First Trimester
bull Plaque controlbull Oral hygiene instructionbull Scaling polishing curettagebull Avoid elective treatment urgent care
only
Timing of Dental Treatment During Pregnancy - From Little and Fallace
Second Trimester
bull Plaque controlbull Oral hygiene instructionbull Scaling polishing curettagebull Routine dental care
Timing of Dental Treatment During Pregnancy - From Little and Fallace
Third Trimester
bull Plaque controlbull Oral hygiene instructionbull Scaling polishing curettagebull Routine dental care (after middle of third
trimester elective care should be avoided)
Use of Radiation on Pregnant Patientbull Dose given and time of gestation are
importantbull doses lt 5-10 rads (cGy) not teratogenicbull fetus is most susceptible to radiation
between the 2nd and 6th week of gestationbull single dental x-ray exposes patient to 001
millirads of radiation In relative terms this amount is 40 times less than daily dose acquired from cosmic radiation Therefore diagnostic radiation should not be withheld during pregnancy
Radiographs during Pregnancy
bull Take as needed with optimal methods for reducing secondary radiation and exposure time
bull Always use a lead apronbull Exposure to fetus (with apron use) is 00001
centiGray(rad)bull Daily cosmic radiation - 0004 centiGray (rad)
Risks of Dental X-Rays
bull X-ray only if necessary (ie root canal therapy trauma)
bull When x-rays are indicated radiation exposure is extremely low
bull Exposure can be limited byndash Lead apron shielding ndash Modern fast film ndash Avoiding retakes
FDA drug classification for pregnancybull Combines risk statements including
congenital anomalies fetal effects perinatal risks and therapeutic risk-benefit ratio
bull Untreated disease or condition may pose more serious risks to both mother and fetus than any theoretical risks from the medication
bull Category A thru D and X
FDA drug classification for pregnancy
bull A = Controlled Studies in women fail to demonstrate a risk to the fetus in the first trimester and the possibility of fetal harm appears remote
FDA drug classification for pregnancy
bull B = Animal studies show no risk or if risk shown in animals controlled
trials in women showed no risk
FDA drug classification for pregnancy
bull C = Studies in animals with adverse effects and no human studies
OR no animal or human studies but benefits of use may outweigh potential harms
FDA drug classification for pregnancy
bull D = There is evidence of human fetal risk but benefits may outweigh risks
FDA drug classification for pregnancy
bull X = Contraindicated
Common Analgesics
bull paracetamol (B)bull Ibuprofen (BD) bull Oxycodone (BD) bull Hydrocodone and codeine
(CD)
avoid in third trimester
Analgesics
bull Paracetamol is the analgesic of choice for all stages of gestation
bull used to treat mild to moderate pain and fevers
bull short term usage is believed to be safebull avoid chronic and large doses of
paracetamol1048715
Analgesics - continuedbull Aspirin is nonteratogenic but may cause
maternal and fetal hemorrhagebull large and chronic doses during last trimester
may result in premature closure of ductus arteriosus fetal hypertension anemia and low birth weight
bull avoid ibuprofen in 3rd trimester because of possible adverse circulatory effects
bull short term use of codeine seems safebull avoid codeine late in gestation because of
possible fetal respiratory depression and withdrawal symptoms
Analgesics to Use During1st and 2nd Trimester
bull Category B (for best)bull Paracetamol Ibuprofenbull Naproxenbull Category C (use with caution)bull Paracetamol with codeine or
hydrocodonebull Paracetamol with oxycodone
Analgesics to Avoid During theThird Trimesterbull Causes delivery problemsbull Aspirin (C 3D)bull Ibuprofen (B3D)bull Naproxen (B3D)bull Causes neonatal respiratory
depression and opioid withdrawalbull Codeine (C3D)bull Hydrocodone (C3D)bull Oxycodone(C3D)
Sedation in Pregnancy
bull SedativesAnxiolytics (eg Diazepam ) are rated D and can cause oral clefts with prolonged exposure
bull Nitrous oxide should not be used in 1st trimester (If used in 2nd and 3rd do not go below 50 O2)
Common Antibioticsbull To treat oral abscess or cellulitis
ndash Penicillin (B) ndash Amoxicillin (B) ndash Cephalexin (B)ndash Erythromycin base (B) (Not estolate as it
cause cholestatic hepatitis)ndash Clindamycin (B)
Antibioticsbull penicillin V and amoxicillin is preferred drug
for mild to moderate infectionsbull widely used for many years with no ill effectsbull no studies show penicillin to be teratogenicbull amoxicillin extensively used without harming
the fetusbull Drug classes1048715 B penicillin cephalosporins erythromycin clindamycin Azithromycin D Tetracycline
Antibiotics To Use During Pregnancy
bull Penicillin Vbull Amoxicillinbull Erythromycin (base form)bull Cephalexin cephalosporinbull Clindamycinbull Metronidazole
Antibiotics to Avoid duringPregnancy
bull Doxycyclinebull Tetracyclinebull Erythromycin (estolate form)bull Vancomycin
The Problem With Tetracycline
bull Accumulates in bones and chelates calcium
bull Inhibits bone growthbull Discolors teeth
Other Antimicrobial Agentsbull OK to usebull Nystatin (B)bull Chlorhexidine rinse (B)bull Use with cautionbull Clotrimazole (C)bull Ketoconazole (C)bull Fluconazole (C)bull Do not usebull Doxycycline (D)
Local Anesthetic Use inPregnancy
bull Class Bbull Lidocaine (Xylocaine)bull Etidocainebull Prilocaine bull Class Cbull Procainebull Bupivicainebull Mepivicaine
Use of Local Anestheticsbull Lidocaine + vasoconstrictor most common
local anesthetic used in dentistrybull extensively used in pregnancy with no proven ill
effectsbull accidental intravascular injections of lidocaine
pass through the placenta but the concentrations are too low to harm fetus
bull prilocaine might cause methemoglobinemia
Ulcer healing drugsCimetidine bull FDA category B Famotidinebull FDA category BRanitidinebull FDA category Bbull not known to be harmful
Ulcer healing drugsOmeprazolebull FDA category BNot known to be
harmful Esomeprazolebull FDA category BLansoprazolebull FDA category BPantoprazolebull Avoid unless potential benefit
outweighs riskmdashfetotoxic in animals
Ulcer healing drugs
Misoprostolbull First second third trimesters Avoidmdash
potent uterine stimulant (has been used to induce abortion) and may be teratogenic
Ulcer healing drugs
Antacidsbull Almunium hydroxideMagnesium
hydroxidemdashFDA category B Calcium carbonatemdashFDA category C
SimetheconemdashFDA category C
Use of Nitrous Oxide Gas
bull used over 150 years bull safety is being debatedbull SHORT TERM exposure do not cause
birth defects or spontaneous abortionbull CHRONIC exposure may result in fetal
loss and infertilitybull literature suggests that nitrous oxide
should be avoided until more conclusive research is available
bull FDA Drug class not yet assigned
Common Preventives
bull Fluoridendash No increased risk during pregnancy
bull Xylitolndash No studies no harm reported
bull Chlorhexidinendash No increased risk during pregnancy
Are topical agents safe
bull Fluoridebull Toothpaste amp mouthrinse
bull Xylitol chewing gum bull Chlorhexidine (11 alcohol)bull No over the counter mouthrinses with
alcohol (Listerine 20 alcohol)
Pre-natal Fluoride
bull Daily 22 mg tablet of sodium fluoride during 3rd through 9th months
bull decreases caries rate in offspringbull Safe and effective
Glenn FB 1982
Is it safe to use mercury restorations
bull No evidence of harmful effect
bull Benefits outweigh risks
bull Canada Germany and New Zealand have some restrictions
bull Determine the best option
Referencesbull Wasylko L Matsui D Dykxhoorn SM Rieder MJ Weinberg
S A Review of Common Dental Treatments During Pregnancy J Canadian Dental Association 64434-439 1998
bull Little JW Donald AF Craig SM Rhodus NL Dental Management of the Medically Compromised Patient - 5th edition Mosby Toronto Pp434-442 1997
bull Livingston HM Dellinger TM Holder R Considerations in the management of the pregnant patient Special Care in Dentistry 185 pp183-188 1998
bull Larimore WL Petrie KA Drug use during pregnacy and lactation Primary Care Clinics in Office Practice 271 35-53 2000
bull Health Canada The Safety of DentalAmalgam Minister Of Supply and Services Canada 1996
REFERENCESbull 1 Weiss G Endocrinology of parturition J Clin
Endocrinol Metab 2000854421-5bull 2 Theunissen IM Parer JT Fluid and electrolytes in
pregnancy Clin Obstet Gynecol 1994373-15bull 3 Duvekot JJ Peeters LLH Renal hemodynamics and
volume homeostasis in pregnancy Obstet Gynecol Surv 199449830-9
bull 4 Barron WM Lindheimer MD Medical disorders during pregnancy 2nd ed St Louis Mosby 1995 p 129
bull 5 Thornburg KL Jacobson SL Giraud GD Morton MJ Hemodynamic changes in pregnancy Semin Perinatol 20002411-4
bull 6 Fiese R Herzog S Issues in dental and surgical management of the pregnant patient Oral Surg Oral Med Oral Pathol 198865292-7
bull 7 Martin C Varner MW Physiologic changes in pregnancysurgical implications Clin Obstet Gynecol 199437241-55
bull 8 Clark SL Cotton DB Lee W Bishop C Hill T Southwick J et al Central hemodynamic assessment of normal term pregnancy Am J Obstet Gynecol 19891611439-42
bull 9 Mabie WC Di Sessa TG Crocker LG Sibai BM Arheart KL A longitudinal study of cardiac output in normal human pregnancy Am J Obstet Gynecol 1994170849-56
bull 10 Clapp JF 3rd Capeless E Cardiovascular function before during and after the first and subsequent pregnancies Am J Cardiol 1997801469-73
bull 11 Duvekot JJ Peeters LL Maternal cardiovascular hemodynamic adaptation to pregnancy Obstet Gynecol Surv 199449(Suppl) S1-14
bull 12 Bhagwat AR Engel PJ Heart disease and pregnancy Cardiol Clin 199513163-78
bull 13 Lanni SM Tillinghast J Silver H Hemodynamic changes and baroreflex gain in the supine hypotensive syndrome Am J Obstet Gynecol 20021871636-41
bull 14 Little JW Falace DA Miller CS Rhodus NL Dental management of the medically compromised patient 6th ed St Louis Mosby 2002 p 303
bull 15 Garcia-Rio F Pino JM Gomez L Alvarez-Sala R Villasante C Villamor J Regulation of breathing and perception of dyspnea in healthy pregnant women Chest 1996110446-53
bull 16 McAuliffe F Kametas N Costello J Rafferty GF Greenough A Nicolaides K Respiratory function in singleton and twin pregnancy BJOG 2002109765-9
bull 17 Clapp JF 3rd Seaward BL Sleamaker RH Hiser J Maternal physiologic adaptations to early human pregnancy Am J Obstet Gynecol 19881591456-60
bull 18 OrsquoDay MP Cardio-respiratory physiological adaptation of pregnancy Semin Perinatol 199721268-75
bull 19 Contreras G Gutierrez M Beroiza T Fantin A Oddo H Villarroel L et al Ventilatory drive and respiratory muscle function in pregnancy Am Rev Respir Dis 1991144837-41
bull 20 Turner M Aziz SR Management of the pregnant oral and maxillofac
bull 21 Sifakis S Pharmakides G Anemia in pregnancy Ann N Y Acad Sci 2000900125-36
bull 22 Branch DW Physiologic adaptations of pregnancy Am J Reprod Immunol 199228120-2
bull 23 Burrows RF Kelton JG Incidentally detected thrombocytopenia in healthy mothers and their infants N Engl J Med 1988319 142-5
bull 24 Hanly JG Antiphospholipid syndrome an overview CMAJ 200324(168)1675-82
bull 25 Heilmann L von Tempelhoff GF Pollow K Antiphospholipid syndrome in obstetrics Clin Appl Thromb Hemost 20039 143-50
bull 26 Sherman P Flaxman SM Nausea and vomiting of pregnancy in an evolutionary perspective Am J Obstet Gynecol 2002 185(Suppl)s190-7
bull 27 Koch KL Gastrointestinal factors in nausea and vomiting of pregnancy Am J Obstet Gynecol 2002185(Suppl)s198-203
bull 28 Koch KL Frissora CL Nausea and vomiting during pregnancy Gastroenterol Clin N Am 200332201-34
bull 29 Baron TH Ramirez B Richter JE Gastrointestinal motility disorders during pregnancy Ann Intern Med 1993118 366-75
bull 30 Richter JE Gastroesophageal reflux disease during pregnancy Gastroenterol Clin N Am 200332235-61
bull 31 Marrero JM Goggin PM de Caestecker JS Pearce JM Maxwell JD Determinants of pregnancy heartburn Br J Obstet Gynaecol 199299731-4
bull 32 Hamaoui E Hamaoui M Nutritional assessment and support during pregnancy Gastroenterol Clin N Am 20033259-121
bull 33 King JC Physiology of pregnancy and nutrient metabolism Am J Clin Nutr 200071(suppl)1218s-25s
bull 34 Casanueva E Pfeffer F Fernandez-Gaxiola AC Gutierrez- Valenzuela V Rothenberg SJ Iron and folate status before pregnancy and anemia during pregnancy Ann Nutr Metab 2003 4760-3
bull 35 Chrsquong CL Morgan M Hainsworth I Kingham JG Prospective study of liver dysfunction in Southwest Wales Gut 200251 876-80
bull 36 Rahman TM Wendon J Severe hepatic dysfunction in pregnancy QJM 200295343-57
bull 37 Knox TA Olans LB Liver disease in pregnancy N Engl J Med 1996335569-76
bull 38 Saftlas AF Olson DR Franks AL Atrash H Pokras R Epidemiology of preeclampsia and eclampsia in the United States 1979e1986 Am J Obstet Gynecol 1990163460-5
bull 39 Walker JJ Pre-eclampsia Lancet 20003561260-5
bull 40 Davidson JM Renal disorders in pregnancy Curr Opin Obstet Gynecol 200113109-14
bull 41 Dafnis E Sabatini S The effect of pregnancy on renal function physiology and pathophysiologyAmJMedSci 1992303184-205
bull 42 Davison JM Shiells EA Philips PR Lindheimer MD Serial evaluation of vasopressin release and thirst in human pregnancy Role of human chorionic gonadotrophin in the osmoregulatory changes of gestation J Clin Invest 198881798-806
bull 43 Glinoer D de Nayer P Bourdoux P Lemone M Robyn C van Steirteghem A et al Regulation of maternal thyroid during pregnancy J Clin Endocrinol Metab 199071276-87
bull 44 Wilson SG Retallack RW Kent JC Worth GK Gutteridge DH Serum free 125-dihydroxyvitamin D and the free 125- dihydroxyvitamin D index during a longitudinal study of human pregnancy and lactation Clin Endocrinol 199032613-22
bull 45 Rasmussen N Frolich A Hornnes PJ Hegedus L Serum ionized calcium and intact parathyroid hormone levels during pregnancy and postpartum Br J Obstet Gynaecol 199097857-9
bull 46 Guyton AC Textbook of medical physiology 8th ed Philadelphia W B Saunders 1991 p 915e28
bull 47 Trainer PJ Corticosteroids and pregnancy Semin Reprod Med 200220375-80
bull 48 Soory M Hormonal factors in periodontal disease Dent Update 200027380-3
bull 49 Hugoson A Gingivitis in pregnant women A longitudinal clinical study Odontol Revy 19712265-84
bull 50 Neville BW Damm DD Allen CM Bouquot JE Oral amp Maxillofacial Pathology 3rd ed Philadelphia W B Saunders 2002 p 329-30 447-9
bull 51 Tilakaratne A Soory M Ranasinghe AW Corea SM Ekanayake SL de Silva M Periodontal disease status during pregnancy and 3 months post-partum in rural population of Sri-Lankan women J Clin Periodontol 200027787-92
bull 52 Laine M Tenovuo J Lehtonen OP Ojanatko-Harri A Vilja P Tuohimaa P Pregnancy e related changes in human whole saliva Arch Oral Biol 198833913-7
bull 53 Yuan K Wing LY Lin MT Pathogenetic roles of angiogenic factors in pyogenic granulomas in pregnancy are modulated by female sex hormones J Periodontol 200273701-8
bull 54 Evans RD Briggs PF Tooth-surface loss related to pregnancyinduced vomiting Prim Dent Care 1994124-6
bull 55 Salvolini E Di Giorgio R Curatola A Mazzanti L Fratto G Biochemical modifications of human whole saliva induced by pregnancy Br J Obstet Gynaec 1998105656-60
bull 56 Mauldin JG Newman RB Preterm birth risk assessment Semin Perinatol 200125215-22
bull 57 Heine RP McGregor JA Goodwin TM Artal R Hayashi RH Robertson PA et al Serial salivary estriol to detect an increased risk of preterm birth Obstet Gynecol 200096490-7
bull 58 Kauh YC Zachian TF Melasma Adv Exp Med Biol 1999455 491-9
bull 59 Wong RC Ellis CN Physiologic skin changes in pregnancy J Am Acad Dermatol 198410929-40
bull 60 Errickson CV Matus NR Skin disorders of pregnancy Am Fam Physician 199449605-10
bull 61 Lopez NJ Smith PC Gutierrez J Periodontal therapy may reduce the risk of preterm low birth weight in women with periodontal disease a randomized controlled trial J Periodontol 200273911-24
bull 62 McGaw T Periodontal disease and preterm delivery of lowbirth- weight infants J Can Dent Assoc 200268165-9
bull 63 Richards AG Dental x-ray protection Dent Clin North Am 1968631-41
bull 64 1990 Recommendations of the International Commission on Radiological Protection Ann ICRP 1991211-201
bull 65 Hall EJ Radiation the two-edged sword cancer risks at high and low doses Cancer J 20006343-50
bull 66 Diethelm L Xu H Diagnostic imaging of the lung during pregnancy Clin Obstet Gynecol 19963936-55
bull 67 Brent RL The effects of embryonic and fetal exposure to x-rays microwaves and ultrasound ClinObstetGynecol 198326484-510
bull 68 National Council on Radiation Protection NCRP report no128 1998 Bethesda Md Author
bull 69 Wasylko L Matsui D Dykxhoorn SM Reider MJ Weinberg S A review of common dental treatments during pregnancy implications for patients and dental personnel J Can Dent Assoc 199864434-9
bull 70 Freeman JP Brand JW Radiation doses of commonly used dental radiographic surveys Oral Surg Oral Med Oral Pathol 199477285-9
bull 71 Kircos LTAngin LL Lorton LOrder ofmagnitude dose reduction in intraoral radiography J Am Dent Assoc 1987114344-7
bull 72 Updegrave WJ Simplified and standardized intraoral radiography with reduced tissue irradiation J Am Dent Assoc 197285861-9
bull 73 Wood RE Harris AM van der Merwe EJ Nortje CJ The leaded apron revisited does it reduce gonadal radiation dose in dental radiology Oral Surg Oral Med Oral Pathol 199171642-6
bull 74 An update on radiographic practices information and recommendations ADA Council on Scientific Affairs J Am Dent Assoc 2001132234-8
bull 75 Rayburn WF Recommending medications during pregnancy an evidence based approach Clin Obstet Gynecol 2002451-5
bull 76 Rathmell JP Viscomi C Ashburn MA Management of nonobstetric pain during pregnancy and lactation Anesth Analg 1997851074-87
bull 77 Teratology society public affairs committee FDA classification of drugs for teratogenic risk Teratology 199449446-7
bull 78 Moore PA Selecting drugs for the pregnant dental patient J Am Dent Assoc 19981291281-6
bull 79 Haas DA An update on analgesics for the management of acute postoperative dental pain J Can Dent Assoc 200268476-82
bull 80 Haas DA Pynn BR Sands TD Drug use for the pregnant or lactating patient Gen Dent 20004854-60
bull 81 Committee on Drugs American Academy of Pediatrics The transfer of drugs and other chemicals into human milk Pediatrics 199493137-50
bull 82 Nielsen GL Sorensen HT Larsen H Pedersen L Risk of adverse birth outcome and miscarriage in pregnant users of nonsteroidal anti-inflammatory drugs population based observational study and case-control study BMJ 2001322266-70
bull 83 Janssen N Genta M The effects of immunosuppressive and anti-inflammatory medications on fertility pregnancy and lactation Arch Intern Med 200016610-9
bull 84 Ostensen M Nonsteroidal anti-inflammatory drugs during pregnancy Scand J Rheumatol Suppl 1998107128-32
bull 85 USPDI -Drug information for the health care professional 22nd ed Greenwood Village CO Micromedex 2002 p 152-79
bull 86 Denson DD Coyle DE Thompson GA Santos D Turner PA Myers JA et al Bupivacaine protein binding in the term parturient effects of lactic acidosis Clin Pharmacol Ther 198435702-9
bull 87 Dillon DE Wagner CL Wiest D Newman RB Drug therapy in the nursing mother Obstet Gynecol Clin North Am 199724 675-96
bull 88 Dashe JS Gilstrap LC Antibiotic use in pregnancy Obstet Gynecol Clin North Am 199724617-29
bull 89 American College of Rheumatology Ad hoc Committee on Clinical Guidelines Guidelines for monitoring drug therapy in rheumatoid arthritis Arthritis Rheum 199639723-31
bull 90 Ng PC The fetal and neonatal hypothalamic-pituitary-adrenal axis Arch Dis Child Fetal Neonatal Ed 200082F250-4
bull 91 Crowley P Antenatal corticosteroidsmdashcurrent thinking BJOG 2003110(Suppl 20)77-8
bull 92 ACOG committee opinion antenatal corticosteroid therapy for fetal maturation Obstet Gynecol 200299871-3
bull 93 Ost L Wettrell G Bjorkhem I Rane A Prednisolone excretion in human milk J Pediatr 19851061008-11
bull 94 Rowland AS Baird DD Shore DL Weinberg CR Savitz DA Wilcox AJ Nitrous oxide and spontaneous abortion in female dental assistants Am J Epidemiol 1995141531-8
bull 95 McGlothlin JD Jensen PA Fischbach TJ Hughes RT Jones JH Control of anesthetic gases in dental operatories Scand J Work Environ Health 199218(Suppl 2)103-5
bull ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY Volume 97 Number 6 Suresh and Radfar 681
bull 96 Rosen MA Nitrous oxide for relief of labor pain a systematic review Am J Obstet Gynecol 2002186(Suppl Nature)S110-6
bull 97 Sands TD Pynn BR Management considerations for the pregnant or nursing emergency patient Ont Dent 199875 17-9
bull 98 Daya S Recurrent spontaneous early pregnancy loss and low dose aspirin Minerva Ginecol 200355441-9
bull 99 Sinclair C Handbook of obstetrical emergencies 1st ed Philadelphia WB Saunders 1996 p 29-39 69
bull 100 Tarsitano BF Rollings RE The pregnant dental patient evaluation and management Gen Dent 199341226-34
bull 101 Livingston MH Dlllinger TM Holder R Consideration in the management of the pregnant patient SCD Special Care in Dentistry 199818183-8
Thank you
- A Review on the principle of Dental Management of the Pregnant patient
- Slide 2
- Questions that a dentist may ask
- Stages of Pregnancy
- Slide 5
- Slide 6
- Physiologic Changes in Pregnancy
- Systemic changes in pregnancy
- FLAT SUPINE POSITIONING
- SUPINE HYPOTENSION SYNDROME (Vena Cava Compression)
- Supine Hypotension Syndrome
- Slide 12
- Supine Hypotension Syndrome
- Prevention of Supine Hypotensive Syndrome
- Treatment of Supine Hypotensive Syndrome
- How should the pregnant woman be positioned
- Slide 17
- Slide 18
- Slide 19
- Slide 20
- Slide 21
- Slide 22
- Slide 23
- Pregnancy Related Oral Health Problems
- Oral Problems in Pregnancy
- Pregnancy Gingivitis Pathophysiology
- Pregnancy Gingivitis
- Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Gum Problems - Pregnancy Granuloma
- Slide 31
- Gum Changes - Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Candidiasis
- Pregnancy Myths
- Other Oral Conditions in Pregnancy
- Changes During Pregnancy that Affect Oral Health
- Saliva changes
- Increased Bacteria
- Slide 40
- Enamel erosion caused by frequent vomiting
- Treatment for Acid Exposure
- Oral Diseases Can Effect Pregnancy
- Periodontal Disease and Preterm Labor
- Periodontal Disease and Low Birth Weight
- Periodontal Disease and Preeclampsia
- Periodontitis and Pre-eclampsia
- Dental Considerations
- Treatment Timing
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Slide 52
- Use of Radiation on Pregnant Patient
- Radiographs during Pregnancy
- Risks of Dental X-Rays
- FDA drug classification for pregnancy
- Slide 57
- FDA drug classification for pregnancy
- Slide 59
- Slide 60
- Slide 61
- Common Analgesics
- Analgesics
- Analgesics - continued
- Analgesics to Use During 1st and 2nd Trimester
- Analgesics to Avoid During the Third Trimester
- Sedation in Pregnancy
- Common Antibiotics
- Antibiotics
- Antibiotics To Use During Pregnancy
- Antibiotics to Avoid during Pregnancy
- The Problem With Tetracycline
- Other Antimicrobial Agents
- Local Anesthetic Use in Pregnancy
- Use of Local Anesthetics
- Ulcer healing drugs
- Slide 77
- Slide 78
- Slide 79
- Use of Nitrous Oxide Gas
- Common Preventives
- Are topical agents safe
- Pre-natal Fluoride
- Is it safe to use mercury restorations
- References
- REFERENCES
- Slide 87
- Slide 88
- Slide 89
- Slide 90
- Slide 91
- Slide 92
- Slide 93
- Slide 94
- Slide 95
- Slide 96
- Slide 97
- Slide 98
- Thank you
-
Systemic changes in pregnancy
For pregnant patient with Hyper-emesis gravidarium ( excessive and uncontrolled vomiting) morning appointments should be avoided
They should be seated in a semi-supine or comfortable position
In case of vomiting the procedure should be stopped immediately amp the patient should be repositioned upright
When vomiting is over rinsing mouth with cold water or mouthwash is recommended
Systemic changes in pregnancybull Urinary System uarr GFR amp renal plasma flow by as much as
50 Nocturia ndashto mobilize the dependent
edema which accumulate during the day uarr Frequency from uarr renal flow plus reduced
bladder capacity from uterine growth It is advisable to ask the patient to void the
bladder just prior to starting the dental procedure
Systemic changes in pregnancyEndocrine Changes uarrEstrogen uarr progesterone uarrhuman
gonadotropin uarr thyroxin steroid and insulin level Estrogen amp progesterone are insulin
antagonists uarr level of these hormones lead to insulin resistance Thus insulin levels are elevated in pregnant in pregnant patient to compensate this resistance
About 45 of women fail to produce sufficient amount of insulin to overcome this antagonist action amp thus develop gestational diabetes
Systemic changes in pregnancy
Hematological changebull uarr red RBC uarrESR darrHbbull uarrWBCbull uarr circulatory catecholamin amp cortisol lead
to leucositosis bull uarr Coagulation factors except factor XI amp
XIII (anticloting factor) bull so pregnancy is a hypercoagulable state amp
uarr risk for thromboembolism
Systemic changes in pregnancy
bull Pregnant women with anti-phospholipid syndrome are at uarr risk for thrombo-embolisim
bull They are placed on subcutaneous low molecular weight heparin (LMWH)
bull These patients must be hospitalized for dental care
Pregnancy RelatedOral Health Problems
bull Pregnancy Gingivitisbull Pregnancy Epulis bull Increased Tooth Mobilitybull Dental Cariesbull Erosionbull Dental Problems in relation to Labor
and Delivery
Oral Problems in Pregnancy
bullPregnancy GingivitisbullMost common oral manifestation (50-100 of women)bullCaused by hormonal and vascular changes of pregnancy
Pregnancy Gingivitis Pathophysiology
bull Elevated circulating estrogen increases capillary permeability
bull Preexisting gingivitis may predispose to pregnancy gingivitis
Pregnancy Gingivitis
bullOccurs commonly in the 2nd to 8th monthsbullTendency to bleed very easilybullTreatment Scaling root-planing currettage OHI
Pregnancy Granuloma
bullOccurs in up to 5 of womenbullMost common in buccal maxillary anterior areasbullUsually starts in an area of gingivitis
Pregnancy Granuloma (continued)
bullRapid growth up to 2 cmbullSingle tumor-like growthbullusually in interdental papillaebullPurplish to bluish in color may be ulcerated- bleeds easily
Gum Problems - Pregnancy Granuloma
Gum Problems - Pregnancy Granuloma
Gum Changes - Pregnancy Granuloma
Pregnancy Granuloma (continued)
Treatment
bull Scaling and root planingbull Excision if it is too large or bleeds too
easilybull May regress spontaneously after
pregnancy
Candidiasis
bullWipes offbullUsually asymptomatic but may burnbullTreatment topical or systemic antifungals
Pregnancy MythsbullldquoA mother loses a tooth for every babyrdquobullNo evidence that aphthous ulcers are any more common in pregnancy
Other Oral Conditions in Pregnancy
bull Dry mouthbull Excessive salivationbull Tooth erosions associated with
severe GERD or hyperemesis
Changes During Pregnancy that Affect Oral Health
bull Hormonal Affects
ndash Increased tooth mobility
ndash Saliva changes
ndash Increased bacteria
ndash Gingival problems
Saliva changesbull Decreased buffers
bull Decreased minerals
bull Decreasing flow first and last trimester
bull Increased flow second trimester
bull More acidic
Increased Bacteriabull Increased acidity
ndash Increase in decay-causing bacteriabull Increased Snacking
ndash Morning sicknesslow blood sugarndash Between-meal snacks
bull Increase in amount and frequency of starchescarbohydrates ndash Crackers are commonly recommendedndash Promotes decay-causing bacteria
Changes During Pregnancy that Affect Oral Healthbull Morning sickness
ndash Difficulty with hygienebull Gingival diseasebull Tooth decay
ndash Vomitingbull Esophogeal Reflux (heartburn)bull Acid exposure
ndash Irritation of the gumsndash Weakening of tooth enamelndash Dental erosion
Enamel erosion caused by frequent vomiting
Treatment for Acid Exposure
bull Do NOT brush immediately after vomiting
bull Rinse ndash Water with baking sodandash Antacidndash Plain water
bull Eat some cheese
Oral Diseases Can Effect Pregnancy
bull Preterm low birth weight (LBW) linked to periodontal disease
bull Thorough calculus (tartar) removal in pregnant women with periodontitis may reduce pre-term births
Periodontal Disease and Preterm LaborbullMaternal periodontal disease is associated with increased risk of preterm laborbullAnaerobic oral gram-negative bacteria cause inflammatory responsebullInflammatory response stimulates prostaglandin and cytokine production to stimulate labor
Periodontal Disease and Low Birth Weight
bull Periodontal disease is associated with low birth weight
bull Evidence is not conclusivebull Biochemical mechanism similar cascade
as in preterm labor leading to placental blood flow restriction and necrosis
Periodontal Disease and Preeclampsia
bull Emerging databull Mechanism unclearbull Proposed mechanism
ndash Periodontal infection leads to inflammatory vascular damage
ndash Triggers cell damage in placenta
Periodontitis and Pre-eclampsia
bull Periodontal disease may be associated with pre-eclampsia (Boggess 2003)
bull PGE2 IL-1 and TNF-α from gingival crevicular fluid were higher in women with preeclampsia compared with healthy matched pregnant women (Oettinger-Barak 2003)
Dental Considerations
bull timing of treatment for pregnant patientsbull dental radiation exposurebull use of local anestheticsbull prescription of common antibiotics and
analgesicsbull nitrous oxide gas administration
Treatment Timing
bull First Trimesterndash Spontaneous miscarriages naturally occur
more often in 1st trimesterndash Avoid elective treatment that can be delayedndash Offer anticipatory guidance
bull Second Trimesterndash The optimal time for dental treatmentndash Organogenesis complete fetus not largendash Easier to prevent than treat established disease
bull Third Trimesterndash Late in term very uncomfortable (short visits)ndash Position slightly on left side
Timing of Dental Treatment During Pregnancy - From Little and Fallace
First Trimester
bull Plaque controlbull Oral hygiene instructionbull Scaling polishing curettagebull Avoid elective treatment urgent care
only
Timing of Dental Treatment During Pregnancy - From Little and Fallace
Second Trimester
bull Plaque controlbull Oral hygiene instructionbull Scaling polishing curettagebull Routine dental care
Timing of Dental Treatment During Pregnancy - From Little and Fallace
Third Trimester
bull Plaque controlbull Oral hygiene instructionbull Scaling polishing curettagebull Routine dental care (after middle of third
trimester elective care should be avoided)
Use of Radiation on Pregnant Patientbull Dose given and time of gestation are
importantbull doses lt 5-10 rads (cGy) not teratogenicbull fetus is most susceptible to radiation
between the 2nd and 6th week of gestationbull single dental x-ray exposes patient to 001
millirads of radiation In relative terms this amount is 40 times less than daily dose acquired from cosmic radiation Therefore diagnostic radiation should not be withheld during pregnancy
Radiographs during Pregnancy
bull Take as needed with optimal methods for reducing secondary radiation and exposure time
bull Always use a lead apronbull Exposure to fetus (with apron use) is 00001
centiGray(rad)bull Daily cosmic radiation - 0004 centiGray (rad)
Risks of Dental X-Rays
bull X-ray only if necessary (ie root canal therapy trauma)
bull When x-rays are indicated radiation exposure is extremely low
bull Exposure can be limited byndash Lead apron shielding ndash Modern fast film ndash Avoiding retakes
FDA drug classification for pregnancybull Combines risk statements including
congenital anomalies fetal effects perinatal risks and therapeutic risk-benefit ratio
bull Untreated disease or condition may pose more serious risks to both mother and fetus than any theoretical risks from the medication
bull Category A thru D and X
FDA drug classification for pregnancy
bull A = Controlled Studies in women fail to demonstrate a risk to the fetus in the first trimester and the possibility of fetal harm appears remote
FDA drug classification for pregnancy
bull B = Animal studies show no risk or if risk shown in animals controlled
trials in women showed no risk
FDA drug classification for pregnancy
bull C = Studies in animals with adverse effects and no human studies
OR no animal or human studies but benefits of use may outweigh potential harms
FDA drug classification for pregnancy
bull D = There is evidence of human fetal risk but benefits may outweigh risks
FDA drug classification for pregnancy
bull X = Contraindicated
Common Analgesics
bull paracetamol (B)bull Ibuprofen (BD) bull Oxycodone (BD) bull Hydrocodone and codeine
(CD)
avoid in third trimester
Analgesics
bull Paracetamol is the analgesic of choice for all stages of gestation
bull used to treat mild to moderate pain and fevers
bull short term usage is believed to be safebull avoid chronic and large doses of
paracetamol1048715
Analgesics - continuedbull Aspirin is nonteratogenic but may cause
maternal and fetal hemorrhagebull large and chronic doses during last trimester
may result in premature closure of ductus arteriosus fetal hypertension anemia and low birth weight
bull avoid ibuprofen in 3rd trimester because of possible adverse circulatory effects
bull short term use of codeine seems safebull avoid codeine late in gestation because of
possible fetal respiratory depression and withdrawal symptoms
Analgesics to Use During1st and 2nd Trimester
bull Category B (for best)bull Paracetamol Ibuprofenbull Naproxenbull Category C (use with caution)bull Paracetamol with codeine or
hydrocodonebull Paracetamol with oxycodone
Analgesics to Avoid During theThird Trimesterbull Causes delivery problemsbull Aspirin (C 3D)bull Ibuprofen (B3D)bull Naproxen (B3D)bull Causes neonatal respiratory
depression and opioid withdrawalbull Codeine (C3D)bull Hydrocodone (C3D)bull Oxycodone(C3D)
Sedation in Pregnancy
bull SedativesAnxiolytics (eg Diazepam ) are rated D and can cause oral clefts with prolonged exposure
bull Nitrous oxide should not be used in 1st trimester (If used in 2nd and 3rd do not go below 50 O2)
Common Antibioticsbull To treat oral abscess or cellulitis
ndash Penicillin (B) ndash Amoxicillin (B) ndash Cephalexin (B)ndash Erythromycin base (B) (Not estolate as it
cause cholestatic hepatitis)ndash Clindamycin (B)
Antibioticsbull penicillin V and amoxicillin is preferred drug
for mild to moderate infectionsbull widely used for many years with no ill effectsbull no studies show penicillin to be teratogenicbull amoxicillin extensively used without harming
the fetusbull Drug classes1048715 B penicillin cephalosporins erythromycin clindamycin Azithromycin D Tetracycline
Antibiotics To Use During Pregnancy
bull Penicillin Vbull Amoxicillinbull Erythromycin (base form)bull Cephalexin cephalosporinbull Clindamycinbull Metronidazole
Antibiotics to Avoid duringPregnancy
bull Doxycyclinebull Tetracyclinebull Erythromycin (estolate form)bull Vancomycin
The Problem With Tetracycline
bull Accumulates in bones and chelates calcium
bull Inhibits bone growthbull Discolors teeth
Other Antimicrobial Agentsbull OK to usebull Nystatin (B)bull Chlorhexidine rinse (B)bull Use with cautionbull Clotrimazole (C)bull Ketoconazole (C)bull Fluconazole (C)bull Do not usebull Doxycycline (D)
Local Anesthetic Use inPregnancy
bull Class Bbull Lidocaine (Xylocaine)bull Etidocainebull Prilocaine bull Class Cbull Procainebull Bupivicainebull Mepivicaine
Use of Local Anestheticsbull Lidocaine + vasoconstrictor most common
local anesthetic used in dentistrybull extensively used in pregnancy with no proven ill
effectsbull accidental intravascular injections of lidocaine
pass through the placenta but the concentrations are too low to harm fetus
bull prilocaine might cause methemoglobinemia
Ulcer healing drugsCimetidine bull FDA category B Famotidinebull FDA category BRanitidinebull FDA category Bbull not known to be harmful
Ulcer healing drugsOmeprazolebull FDA category BNot known to be
harmful Esomeprazolebull FDA category BLansoprazolebull FDA category BPantoprazolebull Avoid unless potential benefit
outweighs riskmdashfetotoxic in animals
Ulcer healing drugs
Misoprostolbull First second third trimesters Avoidmdash
potent uterine stimulant (has been used to induce abortion) and may be teratogenic
Ulcer healing drugs
Antacidsbull Almunium hydroxideMagnesium
hydroxidemdashFDA category B Calcium carbonatemdashFDA category C
SimetheconemdashFDA category C
Use of Nitrous Oxide Gas
bull used over 150 years bull safety is being debatedbull SHORT TERM exposure do not cause
birth defects or spontaneous abortionbull CHRONIC exposure may result in fetal
loss and infertilitybull literature suggests that nitrous oxide
should be avoided until more conclusive research is available
bull FDA Drug class not yet assigned
Common Preventives
bull Fluoridendash No increased risk during pregnancy
bull Xylitolndash No studies no harm reported
bull Chlorhexidinendash No increased risk during pregnancy
Are topical agents safe
bull Fluoridebull Toothpaste amp mouthrinse
bull Xylitol chewing gum bull Chlorhexidine (11 alcohol)bull No over the counter mouthrinses with
alcohol (Listerine 20 alcohol)
Pre-natal Fluoride
bull Daily 22 mg tablet of sodium fluoride during 3rd through 9th months
bull decreases caries rate in offspringbull Safe and effective
Glenn FB 1982
Is it safe to use mercury restorations
bull No evidence of harmful effect
bull Benefits outweigh risks
bull Canada Germany and New Zealand have some restrictions
bull Determine the best option
Referencesbull Wasylko L Matsui D Dykxhoorn SM Rieder MJ Weinberg
S A Review of Common Dental Treatments During Pregnancy J Canadian Dental Association 64434-439 1998
bull Little JW Donald AF Craig SM Rhodus NL Dental Management of the Medically Compromised Patient - 5th edition Mosby Toronto Pp434-442 1997
bull Livingston HM Dellinger TM Holder R Considerations in the management of the pregnant patient Special Care in Dentistry 185 pp183-188 1998
bull Larimore WL Petrie KA Drug use during pregnacy and lactation Primary Care Clinics in Office Practice 271 35-53 2000
bull Health Canada The Safety of DentalAmalgam Minister Of Supply and Services Canada 1996
REFERENCESbull 1 Weiss G Endocrinology of parturition J Clin
Endocrinol Metab 2000854421-5bull 2 Theunissen IM Parer JT Fluid and electrolytes in
pregnancy Clin Obstet Gynecol 1994373-15bull 3 Duvekot JJ Peeters LLH Renal hemodynamics and
volume homeostasis in pregnancy Obstet Gynecol Surv 199449830-9
bull 4 Barron WM Lindheimer MD Medical disorders during pregnancy 2nd ed St Louis Mosby 1995 p 129
bull 5 Thornburg KL Jacobson SL Giraud GD Morton MJ Hemodynamic changes in pregnancy Semin Perinatol 20002411-4
bull 6 Fiese R Herzog S Issues in dental and surgical management of the pregnant patient Oral Surg Oral Med Oral Pathol 198865292-7
bull 7 Martin C Varner MW Physiologic changes in pregnancysurgical implications Clin Obstet Gynecol 199437241-55
bull 8 Clark SL Cotton DB Lee W Bishop C Hill T Southwick J et al Central hemodynamic assessment of normal term pregnancy Am J Obstet Gynecol 19891611439-42
bull 9 Mabie WC Di Sessa TG Crocker LG Sibai BM Arheart KL A longitudinal study of cardiac output in normal human pregnancy Am J Obstet Gynecol 1994170849-56
bull 10 Clapp JF 3rd Capeless E Cardiovascular function before during and after the first and subsequent pregnancies Am J Cardiol 1997801469-73
bull 11 Duvekot JJ Peeters LL Maternal cardiovascular hemodynamic adaptation to pregnancy Obstet Gynecol Surv 199449(Suppl) S1-14
bull 12 Bhagwat AR Engel PJ Heart disease and pregnancy Cardiol Clin 199513163-78
bull 13 Lanni SM Tillinghast J Silver H Hemodynamic changes and baroreflex gain in the supine hypotensive syndrome Am J Obstet Gynecol 20021871636-41
bull 14 Little JW Falace DA Miller CS Rhodus NL Dental management of the medically compromised patient 6th ed St Louis Mosby 2002 p 303
bull 15 Garcia-Rio F Pino JM Gomez L Alvarez-Sala R Villasante C Villamor J Regulation of breathing and perception of dyspnea in healthy pregnant women Chest 1996110446-53
bull 16 McAuliffe F Kametas N Costello J Rafferty GF Greenough A Nicolaides K Respiratory function in singleton and twin pregnancy BJOG 2002109765-9
bull 17 Clapp JF 3rd Seaward BL Sleamaker RH Hiser J Maternal physiologic adaptations to early human pregnancy Am J Obstet Gynecol 19881591456-60
bull 18 OrsquoDay MP Cardio-respiratory physiological adaptation of pregnancy Semin Perinatol 199721268-75
bull 19 Contreras G Gutierrez M Beroiza T Fantin A Oddo H Villarroel L et al Ventilatory drive and respiratory muscle function in pregnancy Am Rev Respir Dis 1991144837-41
bull 20 Turner M Aziz SR Management of the pregnant oral and maxillofac
bull 21 Sifakis S Pharmakides G Anemia in pregnancy Ann N Y Acad Sci 2000900125-36
bull 22 Branch DW Physiologic adaptations of pregnancy Am J Reprod Immunol 199228120-2
bull 23 Burrows RF Kelton JG Incidentally detected thrombocytopenia in healthy mothers and their infants N Engl J Med 1988319 142-5
bull 24 Hanly JG Antiphospholipid syndrome an overview CMAJ 200324(168)1675-82
bull 25 Heilmann L von Tempelhoff GF Pollow K Antiphospholipid syndrome in obstetrics Clin Appl Thromb Hemost 20039 143-50
bull 26 Sherman P Flaxman SM Nausea and vomiting of pregnancy in an evolutionary perspective Am J Obstet Gynecol 2002 185(Suppl)s190-7
bull 27 Koch KL Gastrointestinal factors in nausea and vomiting of pregnancy Am J Obstet Gynecol 2002185(Suppl)s198-203
bull 28 Koch KL Frissora CL Nausea and vomiting during pregnancy Gastroenterol Clin N Am 200332201-34
bull 29 Baron TH Ramirez B Richter JE Gastrointestinal motility disorders during pregnancy Ann Intern Med 1993118 366-75
bull 30 Richter JE Gastroesophageal reflux disease during pregnancy Gastroenterol Clin N Am 200332235-61
bull 31 Marrero JM Goggin PM de Caestecker JS Pearce JM Maxwell JD Determinants of pregnancy heartburn Br J Obstet Gynaecol 199299731-4
bull 32 Hamaoui E Hamaoui M Nutritional assessment and support during pregnancy Gastroenterol Clin N Am 20033259-121
bull 33 King JC Physiology of pregnancy and nutrient metabolism Am J Clin Nutr 200071(suppl)1218s-25s
bull 34 Casanueva E Pfeffer F Fernandez-Gaxiola AC Gutierrez- Valenzuela V Rothenberg SJ Iron and folate status before pregnancy and anemia during pregnancy Ann Nutr Metab 2003 4760-3
bull 35 Chrsquong CL Morgan M Hainsworth I Kingham JG Prospective study of liver dysfunction in Southwest Wales Gut 200251 876-80
bull 36 Rahman TM Wendon J Severe hepatic dysfunction in pregnancy QJM 200295343-57
bull 37 Knox TA Olans LB Liver disease in pregnancy N Engl J Med 1996335569-76
bull 38 Saftlas AF Olson DR Franks AL Atrash H Pokras R Epidemiology of preeclampsia and eclampsia in the United States 1979e1986 Am J Obstet Gynecol 1990163460-5
bull 39 Walker JJ Pre-eclampsia Lancet 20003561260-5
bull 40 Davidson JM Renal disorders in pregnancy Curr Opin Obstet Gynecol 200113109-14
bull 41 Dafnis E Sabatini S The effect of pregnancy on renal function physiology and pathophysiologyAmJMedSci 1992303184-205
bull 42 Davison JM Shiells EA Philips PR Lindheimer MD Serial evaluation of vasopressin release and thirst in human pregnancy Role of human chorionic gonadotrophin in the osmoregulatory changes of gestation J Clin Invest 198881798-806
bull 43 Glinoer D de Nayer P Bourdoux P Lemone M Robyn C van Steirteghem A et al Regulation of maternal thyroid during pregnancy J Clin Endocrinol Metab 199071276-87
bull 44 Wilson SG Retallack RW Kent JC Worth GK Gutteridge DH Serum free 125-dihydroxyvitamin D and the free 125- dihydroxyvitamin D index during a longitudinal study of human pregnancy and lactation Clin Endocrinol 199032613-22
bull 45 Rasmussen N Frolich A Hornnes PJ Hegedus L Serum ionized calcium and intact parathyroid hormone levels during pregnancy and postpartum Br J Obstet Gynaecol 199097857-9
bull 46 Guyton AC Textbook of medical physiology 8th ed Philadelphia W B Saunders 1991 p 915e28
bull 47 Trainer PJ Corticosteroids and pregnancy Semin Reprod Med 200220375-80
bull 48 Soory M Hormonal factors in periodontal disease Dent Update 200027380-3
bull 49 Hugoson A Gingivitis in pregnant women A longitudinal clinical study Odontol Revy 19712265-84
bull 50 Neville BW Damm DD Allen CM Bouquot JE Oral amp Maxillofacial Pathology 3rd ed Philadelphia W B Saunders 2002 p 329-30 447-9
bull 51 Tilakaratne A Soory M Ranasinghe AW Corea SM Ekanayake SL de Silva M Periodontal disease status during pregnancy and 3 months post-partum in rural population of Sri-Lankan women J Clin Periodontol 200027787-92
bull 52 Laine M Tenovuo J Lehtonen OP Ojanatko-Harri A Vilja P Tuohimaa P Pregnancy e related changes in human whole saliva Arch Oral Biol 198833913-7
bull 53 Yuan K Wing LY Lin MT Pathogenetic roles of angiogenic factors in pyogenic granulomas in pregnancy are modulated by female sex hormones J Periodontol 200273701-8
bull 54 Evans RD Briggs PF Tooth-surface loss related to pregnancyinduced vomiting Prim Dent Care 1994124-6
bull 55 Salvolini E Di Giorgio R Curatola A Mazzanti L Fratto G Biochemical modifications of human whole saliva induced by pregnancy Br J Obstet Gynaec 1998105656-60
bull 56 Mauldin JG Newman RB Preterm birth risk assessment Semin Perinatol 200125215-22
bull 57 Heine RP McGregor JA Goodwin TM Artal R Hayashi RH Robertson PA et al Serial salivary estriol to detect an increased risk of preterm birth Obstet Gynecol 200096490-7
bull 58 Kauh YC Zachian TF Melasma Adv Exp Med Biol 1999455 491-9
bull 59 Wong RC Ellis CN Physiologic skin changes in pregnancy J Am Acad Dermatol 198410929-40
bull 60 Errickson CV Matus NR Skin disorders of pregnancy Am Fam Physician 199449605-10
bull 61 Lopez NJ Smith PC Gutierrez J Periodontal therapy may reduce the risk of preterm low birth weight in women with periodontal disease a randomized controlled trial J Periodontol 200273911-24
bull 62 McGaw T Periodontal disease and preterm delivery of lowbirth- weight infants J Can Dent Assoc 200268165-9
bull 63 Richards AG Dental x-ray protection Dent Clin North Am 1968631-41
bull 64 1990 Recommendations of the International Commission on Radiological Protection Ann ICRP 1991211-201
bull 65 Hall EJ Radiation the two-edged sword cancer risks at high and low doses Cancer J 20006343-50
bull 66 Diethelm L Xu H Diagnostic imaging of the lung during pregnancy Clin Obstet Gynecol 19963936-55
bull 67 Brent RL The effects of embryonic and fetal exposure to x-rays microwaves and ultrasound ClinObstetGynecol 198326484-510
bull 68 National Council on Radiation Protection NCRP report no128 1998 Bethesda Md Author
bull 69 Wasylko L Matsui D Dykxhoorn SM Reider MJ Weinberg S A review of common dental treatments during pregnancy implications for patients and dental personnel J Can Dent Assoc 199864434-9
bull 70 Freeman JP Brand JW Radiation doses of commonly used dental radiographic surveys Oral Surg Oral Med Oral Pathol 199477285-9
bull 71 Kircos LTAngin LL Lorton LOrder ofmagnitude dose reduction in intraoral radiography J Am Dent Assoc 1987114344-7
bull 72 Updegrave WJ Simplified and standardized intraoral radiography with reduced tissue irradiation J Am Dent Assoc 197285861-9
bull 73 Wood RE Harris AM van der Merwe EJ Nortje CJ The leaded apron revisited does it reduce gonadal radiation dose in dental radiology Oral Surg Oral Med Oral Pathol 199171642-6
bull 74 An update on radiographic practices information and recommendations ADA Council on Scientific Affairs J Am Dent Assoc 2001132234-8
bull 75 Rayburn WF Recommending medications during pregnancy an evidence based approach Clin Obstet Gynecol 2002451-5
bull 76 Rathmell JP Viscomi C Ashburn MA Management of nonobstetric pain during pregnancy and lactation Anesth Analg 1997851074-87
bull 77 Teratology society public affairs committee FDA classification of drugs for teratogenic risk Teratology 199449446-7
bull 78 Moore PA Selecting drugs for the pregnant dental patient J Am Dent Assoc 19981291281-6
bull 79 Haas DA An update on analgesics for the management of acute postoperative dental pain J Can Dent Assoc 200268476-82
bull 80 Haas DA Pynn BR Sands TD Drug use for the pregnant or lactating patient Gen Dent 20004854-60
bull 81 Committee on Drugs American Academy of Pediatrics The transfer of drugs and other chemicals into human milk Pediatrics 199493137-50
bull 82 Nielsen GL Sorensen HT Larsen H Pedersen L Risk of adverse birth outcome and miscarriage in pregnant users of nonsteroidal anti-inflammatory drugs population based observational study and case-control study BMJ 2001322266-70
bull 83 Janssen N Genta M The effects of immunosuppressive and anti-inflammatory medications on fertility pregnancy and lactation Arch Intern Med 200016610-9
bull 84 Ostensen M Nonsteroidal anti-inflammatory drugs during pregnancy Scand J Rheumatol Suppl 1998107128-32
bull 85 USPDI -Drug information for the health care professional 22nd ed Greenwood Village CO Micromedex 2002 p 152-79
bull 86 Denson DD Coyle DE Thompson GA Santos D Turner PA Myers JA et al Bupivacaine protein binding in the term parturient effects of lactic acidosis Clin Pharmacol Ther 198435702-9
bull 87 Dillon DE Wagner CL Wiest D Newman RB Drug therapy in the nursing mother Obstet Gynecol Clin North Am 199724 675-96
bull 88 Dashe JS Gilstrap LC Antibiotic use in pregnancy Obstet Gynecol Clin North Am 199724617-29
bull 89 American College of Rheumatology Ad hoc Committee on Clinical Guidelines Guidelines for monitoring drug therapy in rheumatoid arthritis Arthritis Rheum 199639723-31
bull 90 Ng PC The fetal and neonatal hypothalamic-pituitary-adrenal axis Arch Dis Child Fetal Neonatal Ed 200082F250-4
bull 91 Crowley P Antenatal corticosteroidsmdashcurrent thinking BJOG 2003110(Suppl 20)77-8
bull 92 ACOG committee opinion antenatal corticosteroid therapy for fetal maturation Obstet Gynecol 200299871-3
bull 93 Ost L Wettrell G Bjorkhem I Rane A Prednisolone excretion in human milk J Pediatr 19851061008-11
bull 94 Rowland AS Baird DD Shore DL Weinberg CR Savitz DA Wilcox AJ Nitrous oxide and spontaneous abortion in female dental assistants Am J Epidemiol 1995141531-8
bull 95 McGlothlin JD Jensen PA Fischbach TJ Hughes RT Jones JH Control of anesthetic gases in dental operatories Scand J Work Environ Health 199218(Suppl 2)103-5
bull ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY Volume 97 Number 6 Suresh and Radfar 681
bull 96 Rosen MA Nitrous oxide for relief of labor pain a systematic review Am J Obstet Gynecol 2002186(Suppl Nature)S110-6
bull 97 Sands TD Pynn BR Management considerations for the pregnant or nursing emergency patient Ont Dent 199875 17-9
bull 98 Daya S Recurrent spontaneous early pregnancy loss and low dose aspirin Minerva Ginecol 200355441-9
bull 99 Sinclair C Handbook of obstetrical emergencies 1st ed Philadelphia WB Saunders 1996 p 29-39 69
bull 100 Tarsitano BF Rollings RE The pregnant dental patient evaluation and management Gen Dent 199341226-34
bull 101 Livingston MH Dlllinger TM Holder R Consideration in the management of the pregnant patient SCD Special Care in Dentistry 199818183-8
Thank you
- A Review on the principle of Dental Management of the Pregnant patient
- Slide 2
- Questions that a dentist may ask
- Stages of Pregnancy
- Slide 5
- Slide 6
- Physiologic Changes in Pregnancy
- Systemic changes in pregnancy
- FLAT SUPINE POSITIONING
- SUPINE HYPOTENSION SYNDROME (Vena Cava Compression)
- Supine Hypotension Syndrome
- Slide 12
- Supine Hypotension Syndrome
- Prevention of Supine Hypotensive Syndrome
- Treatment of Supine Hypotensive Syndrome
- How should the pregnant woman be positioned
- Slide 17
- Slide 18
- Slide 19
- Slide 20
- Slide 21
- Slide 22
- Slide 23
- Pregnancy Related Oral Health Problems
- Oral Problems in Pregnancy
- Pregnancy Gingivitis Pathophysiology
- Pregnancy Gingivitis
- Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Gum Problems - Pregnancy Granuloma
- Slide 31
- Gum Changes - Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Candidiasis
- Pregnancy Myths
- Other Oral Conditions in Pregnancy
- Changes During Pregnancy that Affect Oral Health
- Saliva changes
- Increased Bacteria
- Slide 40
- Enamel erosion caused by frequent vomiting
- Treatment for Acid Exposure
- Oral Diseases Can Effect Pregnancy
- Periodontal Disease and Preterm Labor
- Periodontal Disease and Low Birth Weight
- Periodontal Disease and Preeclampsia
- Periodontitis and Pre-eclampsia
- Dental Considerations
- Treatment Timing
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Slide 52
- Use of Radiation on Pregnant Patient
- Radiographs during Pregnancy
- Risks of Dental X-Rays
- FDA drug classification for pregnancy
- Slide 57
- FDA drug classification for pregnancy
- Slide 59
- Slide 60
- Slide 61
- Common Analgesics
- Analgesics
- Analgesics - continued
- Analgesics to Use During 1st and 2nd Trimester
- Analgesics to Avoid During the Third Trimester
- Sedation in Pregnancy
- Common Antibiotics
- Antibiotics
- Antibiotics To Use During Pregnancy
- Antibiotics to Avoid during Pregnancy
- The Problem With Tetracycline
- Other Antimicrobial Agents
- Local Anesthetic Use in Pregnancy
- Use of Local Anesthetics
- Ulcer healing drugs
- Slide 77
- Slide 78
- Slide 79
- Use of Nitrous Oxide Gas
- Common Preventives
- Are topical agents safe
- Pre-natal Fluoride
- Is it safe to use mercury restorations
- References
- REFERENCES
- Slide 87
- Slide 88
- Slide 89
- Slide 90
- Slide 91
- Slide 92
- Slide 93
- Slide 94
- Slide 95
- Slide 96
- Slide 97
- Slide 98
- Thank you
-
Systemic changes in pregnancybull Urinary System uarr GFR amp renal plasma flow by as much as
50 Nocturia ndashto mobilize the dependent
edema which accumulate during the day uarr Frequency from uarr renal flow plus reduced
bladder capacity from uterine growth It is advisable to ask the patient to void the
bladder just prior to starting the dental procedure
Systemic changes in pregnancyEndocrine Changes uarrEstrogen uarr progesterone uarrhuman
gonadotropin uarr thyroxin steroid and insulin level Estrogen amp progesterone are insulin
antagonists uarr level of these hormones lead to insulin resistance Thus insulin levels are elevated in pregnant in pregnant patient to compensate this resistance
About 45 of women fail to produce sufficient amount of insulin to overcome this antagonist action amp thus develop gestational diabetes
Systemic changes in pregnancy
Hematological changebull uarr red RBC uarrESR darrHbbull uarrWBCbull uarr circulatory catecholamin amp cortisol lead
to leucositosis bull uarr Coagulation factors except factor XI amp
XIII (anticloting factor) bull so pregnancy is a hypercoagulable state amp
uarr risk for thromboembolism
Systemic changes in pregnancy
bull Pregnant women with anti-phospholipid syndrome are at uarr risk for thrombo-embolisim
bull They are placed on subcutaneous low molecular weight heparin (LMWH)
bull These patients must be hospitalized for dental care
Pregnancy RelatedOral Health Problems
bull Pregnancy Gingivitisbull Pregnancy Epulis bull Increased Tooth Mobilitybull Dental Cariesbull Erosionbull Dental Problems in relation to Labor
and Delivery
Oral Problems in Pregnancy
bullPregnancy GingivitisbullMost common oral manifestation (50-100 of women)bullCaused by hormonal and vascular changes of pregnancy
Pregnancy Gingivitis Pathophysiology
bull Elevated circulating estrogen increases capillary permeability
bull Preexisting gingivitis may predispose to pregnancy gingivitis
Pregnancy Gingivitis
bullOccurs commonly in the 2nd to 8th monthsbullTendency to bleed very easilybullTreatment Scaling root-planing currettage OHI
Pregnancy Granuloma
bullOccurs in up to 5 of womenbullMost common in buccal maxillary anterior areasbullUsually starts in an area of gingivitis
Pregnancy Granuloma (continued)
bullRapid growth up to 2 cmbullSingle tumor-like growthbullusually in interdental papillaebullPurplish to bluish in color may be ulcerated- bleeds easily
Gum Problems - Pregnancy Granuloma
Gum Problems - Pregnancy Granuloma
Gum Changes - Pregnancy Granuloma
Pregnancy Granuloma (continued)
Treatment
bull Scaling and root planingbull Excision if it is too large or bleeds too
easilybull May regress spontaneously after
pregnancy
Candidiasis
bullWipes offbullUsually asymptomatic but may burnbullTreatment topical or systemic antifungals
Pregnancy MythsbullldquoA mother loses a tooth for every babyrdquobullNo evidence that aphthous ulcers are any more common in pregnancy
Other Oral Conditions in Pregnancy
bull Dry mouthbull Excessive salivationbull Tooth erosions associated with
severe GERD or hyperemesis
Changes During Pregnancy that Affect Oral Health
bull Hormonal Affects
ndash Increased tooth mobility
ndash Saliva changes
ndash Increased bacteria
ndash Gingival problems
Saliva changesbull Decreased buffers
bull Decreased minerals
bull Decreasing flow first and last trimester
bull Increased flow second trimester
bull More acidic
Increased Bacteriabull Increased acidity
ndash Increase in decay-causing bacteriabull Increased Snacking
ndash Morning sicknesslow blood sugarndash Between-meal snacks
bull Increase in amount and frequency of starchescarbohydrates ndash Crackers are commonly recommendedndash Promotes decay-causing bacteria
Changes During Pregnancy that Affect Oral Healthbull Morning sickness
ndash Difficulty with hygienebull Gingival diseasebull Tooth decay
ndash Vomitingbull Esophogeal Reflux (heartburn)bull Acid exposure
ndash Irritation of the gumsndash Weakening of tooth enamelndash Dental erosion
Enamel erosion caused by frequent vomiting
Treatment for Acid Exposure
bull Do NOT brush immediately after vomiting
bull Rinse ndash Water with baking sodandash Antacidndash Plain water
bull Eat some cheese
Oral Diseases Can Effect Pregnancy
bull Preterm low birth weight (LBW) linked to periodontal disease
bull Thorough calculus (tartar) removal in pregnant women with periodontitis may reduce pre-term births
Periodontal Disease and Preterm LaborbullMaternal periodontal disease is associated with increased risk of preterm laborbullAnaerobic oral gram-negative bacteria cause inflammatory responsebullInflammatory response stimulates prostaglandin and cytokine production to stimulate labor
Periodontal Disease and Low Birth Weight
bull Periodontal disease is associated with low birth weight
bull Evidence is not conclusivebull Biochemical mechanism similar cascade
as in preterm labor leading to placental blood flow restriction and necrosis
Periodontal Disease and Preeclampsia
bull Emerging databull Mechanism unclearbull Proposed mechanism
ndash Periodontal infection leads to inflammatory vascular damage
ndash Triggers cell damage in placenta
Periodontitis and Pre-eclampsia
bull Periodontal disease may be associated with pre-eclampsia (Boggess 2003)
bull PGE2 IL-1 and TNF-α from gingival crevicular fluid were higher in women with preeclampsia compared with healthy matched pregnant women (Oettinger-Barak 2003)
Dental Considerations
bull timing of treatment for pregnant patientsbull dental radiation exposurebull use of local anestheticsbull prescription of common antibiotics and
analgesicsbull nitrous oxide gas administration
Treatment Timing
bull First Trimesterndash Spontaneous miscarriages naturally occur
more often in 1st trimesterndash Avoid elective treatment that can be delayedndash Offer anticipatory guidance
bull Second Trimesterndash The optimal time for dental treatmentndash Organogenesis complete fetus not largendash Easier to prevent than treat established disease
bull Third Trimesterndash Late in term very uncomfortable (short visits)ndash Position slightly on left side
Timing of Dental Treatment During Pregnancy - From Little and Fallace
First Trimester
bull Plaque controlbull Oral hygiene instructionbull Scaling polishing curettagebull Avoid elective treatment urgent care
only
Timing of Dental Treatment During Pregnancy - From Little and Fallace
Second Trimester
bull Plaque controlbull Oral hygiene instructionbull Scaling polishing curettagebull Routine dental care
Timing of Dental Treatment During Pregnancy - From Little and Fallace
Third Trimester
bull Plaque controlbull Oral hygiene instructionbull Scaling polishing curettagebull Routine dental care (after middle of third
trimester elective care should be avoided)
Use of Radiation on Pregnant Patientbull Dose given and time of gestation are
importantbull doses lt 5-10 rads (cGy) not teratogenicbull fetus is most susceptible to radiation
between the 2nd and 6th week of gestationbull single dental x-ray exposes patient to 001
millirads of radiation In relative terms this amount is 40 times less than daily dose acquired from cosmic radiation Therefore diagnostic radiation should not be withheld during pregnancy
Radiographs during Pregnancy
bull Take as needed with optimal methods for reducing secondary radiation and exposure time
bull Always use a lead apronbull Exposure to fetus (with apron use) is 00001
centiGray(rad)bull Daily cosmic radiation - 0004 centiGray (rad)
Risks of Dental X-Rays
bull X-ray only if necessary (ie root canal therapy trauma)
bull When x-rays are indicated radiation exposure is extremely low
bull Exposure can be limited byndash Lead apron shielding ndash Modern fast film ndash Avoiding retakes
FDA drug classification for pregnancybull Combines risk statements including
congenital anomalies fetal effects perinatal risks and therapeutic risk-benefit ratio
bull Untreated disease or condition may pose more serious risks to both mother and fetus than any theoretical risks from the medication
bull Category A thru D and X
FDA drug classification for pregnancy
bull A = Controlled Studies in women fail to demonstrate a risk to the fetus in the first trimester and the possibility of fetal harm appears remote
FDA drug classification for pregnancy
bull B = Animal studies show no risk or if risk shown in animals controlled
trials in women showed no risk
FDA drug classification for pregnancy
bull C = Studies in animals with adverse effects and no human studies
OR no animal or human studies but benefits of use may outweigh potential harms
FDA drug classification for pregnancy
bull D = There is evidence of human fetal risk but benefits may outweigh risks
FDA drug classification for pregnancy
bull X = Contraindicated
Common Analgesics
bull paracetamol (B)bull Ibuprofen (BD) bull Oxycodone (BD) bull Hydrocodone and codeine
(CD)
avoid in third trimester
Analgesics
bull Paracetamol is the analgesic of choice for all stages of gestation
bull used to treat mild to moderate pain and fevers
bull short term usage is believed to be safebull avoid chronic and large doses of
paracetamol1048715
Analgesics - continuedbull Aspirin is nonteratogenic but may cause
maternal and fetal hemorrhagebull large and chronic doses during last trimester
may result in premature closure of ductus arteriosus fetal hypertension anemia and low birth weight
bull avoid ibuprofen in 3rd trimester because of possible adverse circulatory effects
bull short term use of codeine seems safebull avoid codeine late in gestation because of
possible fetal respiratory depression and withdrawal symptoms
Analgesics to Use During1st and 2nd Trimester
bull Category B (for best)bull Paracetamol Ibuprofenbull Naproxenbull Category C (use with caution)bull Paracetamol with codeine or
hydrocodonebull Paracetamol with oxycodone
Analgesics to Avoid During theThird Trimesterbull Causes delivery problemsbull Aspirin (C 3D)bull Ibuprofen (B3D)bull Naproxen (B3D)bull Causes neonatal respiratory
depression and opioid withdrawalbull Codeine (C3D)bull Hydrocodone (C3D)bull Oxycodone(C3D)
Sedation in Pregnancy
bull SedativesAnxiolytics (eg Diazepam ) are rated D and can cause oral clefts with prolonged exposure
bull Nitrous oxide should not be used in 1st trimester (If used in 2nd and 3rd do not go below 50 O2)
Common Antibioticsbull To treat oral abscess or cellulitis
ndash Penicillin (B) ndash Amoxicillin (B) ndash Cephalexin (B)ndash Erythromycin base (B) (Not estolate as it
cause cholestatic hepatitis)ndash Clindamycin (B)
Antibioticsbull penicillin V and amoxicillin is preferred drug
for mild to moderate infectionsbull widely used for many years with no ill effectsbull no studies show penicillin to be teratogenicbull amoxicillin extensively used without harming
the fetusbull Drug classes1048715 B penicillin cephalosporins erythromycin clindamycin Azithromycin D Tetracycline
Antibiotics To Use During Pregnancy
bull Penicillin Vbull Amoxicillinbull Erythromycin (base form)bull Cephalexin cephalosporinbull Clindamycinbull Metronidazole
Antibiotics to Avoid duringPregnancy
bull Doxycyclinebull Tetracyclinebull Erythromycin (estolate form)bull Vancomycin
The Problem With Tetracycline
bull Accumulates in bones and chelates calcium
bull Inhibits bone growthbull Discolors teeth
Other Antimicrobial Agentsbull OK to usebull Nystatin (B)bull Chlorhexidine rinse (B)bull Use with cautionbull Clotrimazole (C)bull Ketoconazole (C)bull Fluconazole (C)bull Do not usebull Doxycycline (D)
Local Anesthetic Use inPregnancy
bull Class Bbull Lidocaine (Xylocaine)bull Etidocainebull Prilocaine bull Class Cbull Procainebull Bupivicainebull Mepivicaine
Use of Local Anestheticsbull Lidocaine + vasoconstrictor most common
local anesthetic used in dentistrybull extensively used in pregnancy with no proven ill
effectsbull accidental intravascular injections of lidocaine
pass through the placenta but the concentrations are too low to harm fetus
bull prilocaine might cause methemoglobinemia
Ulcer healing drugsCimetidine bull FDA category B Famotidinebull FDA category BRanitidinebull FDA category Bbull not known to be harmful
Ulcer healing drugsOmeprazolebull FDA category BNot known to be
harmful Esomeprazolebull FDA category BLansoprazolebull FDA category BPantoprazolebull Avoid unless potential benefit
outweighs riskmdashfetotoxic in animals
Ulcer healing drugs
Misoprostolbull First second third trimesters Avoidmdash
potent uterine stimulant (has been used to induce abortion) and may be teratogenic
Ulcer healing drugs
Antacidsbull Almunium hydroxideMagnesium
hydroxidemdashFDA category B Calcium carbonatemdashFDA category C
SimetheconemdashFDA category C
Use of Nitrous Oxide Gas
bull used over 150 years bull safety is being debatedbull SHORT TERM exposure do not cause
birth defects or spontaneous abortionbull CHRONIC exposure may result in fetal
loss and infertilitybull literature suggests that nitrous oxide
should be avoided until more conclusive research is available
bull FDA Drug class not yet assigned
Common Preventives
bull Fluoridendash No increased risk during pregnancy
bull Xylitolndash No studies no harm reported
bull Chlorhexidinendash No increased risk during pregnancy
Are topical agents safe
bull Fluoridebull Toothpaste amp mouthrinse
bull Xylitol chewing gum bull Chlorhexidine (11 alcohol)bull No over the counter mouthrinses with
alcohol (Listerine 20 alcohol)
Pre-natal Fluoride
bull Daily 22 mg tablet of sodium fluoride during 3rd through 9th months
bull decreases caries rate in offspringbull Safe and effective
Glenn FB 1982
Is it safe to use mercury restorations
bull No evidence of harmful effect
bull Benefits outweigh risks
bull Canada Germany and New Zealand have some restrictions
bull Determine the best option
Referencesbull Wasylko L Matsui D Dykxhoorn SM Rieder MJ Weinberg
S A Review of Common Dental Treatments During Pregnancy J Canadian Dental Association 64434-439 1998
bull Little JW Donald AF Craig SM Rhodus NL Dental Management of the Medically Compromised Patient - 5th edition Mosby Toronto Pp434-442 1997
bull Livingston HM Dellinger TM Holder R Considerations in the management of the pregnant patient Special Care in Dentistry 185 pp183-188 1998
bull Larimore WL Petrie KA Drug use during pregnacy and lactation Primary Care Clinics in Office Practice 271 35-53 2000
bull Health Canada The Safety of DentalAmalgam Minister Of Supply and Services Canada 1996
REFERENCESbull 1 Weiss G Endocrinology of parturition J Clin
Endocrinol Metab 2000854421-5bull 2 Theunissen IM Parer JT Fluid and electrolytes in
pregnancy Clin Obstet Gynecol 1994373-15bull 3 Duvekot JJ Peeters LLH Renal hemodynamics and
volume homeostasis in pregnancy Obstet Gynecol Surv 199449830-9
bull 4 Barron WM Lindheimer MD Medical disorders during pregnancy 2nd ed St Louis Mosby 1995 p 129
bull 5 Thornburg KL Jacobson SL Giraud GD Morton MJ Hemodynamic changes in pregnancy Semin Perinatol 20002411-4
bull 6 Fiese R Herzog S Issues in dental and surgical management of the pregnant patient Oral Surg Oral Med Oral Pathol 198865292-7
bull 7 Martin C Varner MW Physiologic changes in pregnancysurgical implications Clin Obstet Gynecol 199437241-55
bull 8 Clark SL Cotton DB Lee W Bishop C Hill T Southwick J et al Central hemodynamic assessment of normal term pregnancy Am J Obstet Gynecol 19891611439-42
bull 9 Mabie WC Di Sessa TG Crocker LG Sibai BM Arheart KL A longitudinal study of cardiac output in normal human pregnancy Am J Obstet Gynecol 1994170849-56
bull 10 Clapp JF 3rd Capeless E Cardiovascular function before during and after the first and subsequent pregnancies Am J Cardiol 1997801469-73
bull 11 Duvekot JJ Peeters LL Maternal cardiovascular hemodynamic adaptation to pregnancy Obstet Gynecol Surv 199449(Suppl) S1-14
bull 12 Bhagwat AR Engel PJ Heart disease and pregnancy Cardiol Clin 199513163-78
bull 13 Lanni SM Tillinghast J Silver H Hemodynamic changes and baroreflex gain in the supine hypotensive syndrome Am J Obstet Gynecol 20021871636-41
bull 14 Little JW Falace DA Miller CS Rhodus NL Dental management of the medically compromised patient 6th ed St Louis Mosby 2002 p 303
bull 15 Garcia-Rio F Pino JM Gomez L Alvarez-Sala R Villasante C Villamor J Regulation of breathing and perception of dyspnea in healthy pregnant women Chest 1996110446-53
bull 16 McAuliffe F Kametas N Costello J Rafferty GF Greenough A Nicolaides K Respiratory function in singleton and twin pregnancy BJOG 2002109765-9
bull 17 Clapp JF 3rd Seaward BL Sleamaker RH Hiser J Maternal physiologic adaptations to early human pregnancy Am J Obstet Gynecol 19881591456-60
bull 18 OrsquoDay MP Cardio-respiratory physiological adaptation of pregnancy Semin Perinatol 199721268-75
bull 19 Contreras G Gutierrez M Beroiza T Fantin A Oddo H Villarroel L et al Ventilatory drive and respiratory muscle function in pregnancy Am Rev Respir Dis 1991144837-41
bull 20 Turner M Aziz SR Management of the pregnant oral and maxillofac
bull 21 Sifakis S Pharmakides G Anemia in pregnancy Ann N Y Acad Sci 2000900125-36
bull 22 Branch DW Physiologic adaptations of pregnancy Am J Reprod Immunol 199228120-2
bull 23 Burrows RF Kelton JG Incidentally detected thrombocytopenia in healthy mothers and their infants N Engl J Med 1988319 142-5
bull 24 Hanly JG Antiphospholipid syndrome an overview CMAJ 200324(168)1675-82
bull 25 Heilmann L von Tempelhoff GF Pollow K Antiphospholipid syndrome in obstetrics Clin Appl Thromb Hemost 20039 143-50
bull 26 Sherman P Flaxman SM Nausea and vomiting of pregnancy in an evolutionary perspective Am J Obstet Gynecol 2002 185(Suppl)s190-7
bull 27 Koch KL Gastrointestinal factors in nausea and vomiting of pregnancy Am J Obstet Gynecol 2002185(Suppl)s198-203
bull 28 Koch KL Frissora CL Nausea and vomiting during pregnancy Gastroenterol Clin N Am 200332201-34
bull 29 Baron TH Ramirez B Richter JE Gastrointestinal motility disorders during pregnancy Ann Intern Med 1993118 366-75
bull 30 Richter JE Gastroesophageal reflux disease during pregnancy Gastroenterol Clin N Am 200332235-61
bull 31 Marrero JM Goggin PM de Caestecker JS Pearce JM Maxwell JD Determinants of pregnancy heartburn Br J Obstet Gynaecol 199299731-4
bull 32 Hamaoui E Hamaoui M Nutritional assessment and support during pregnancy Gastroenterol Clin N Am 20033259-121
bull 33 King JC Physiology of pregnancy and nutrient metabolism Am J Clin Nutr 200071(suppl)1218s-25s
bull 34 Casanueva E Pfeffer F Fernandez-Gaxiola AC Gutierrez- Valenzuela V Rothenberg SJ Iron and folate status before pregnancy and anemia during pregnancy Ann Nutr Metab 2003 4760-3
bull 35 Chrsquong CL Morgan M Hainsworth I Kingham JG Prospective study of liver dysfunction in Southwest Wales Gut 200251 876-80
bull 36 Rahman TM Wendon J Severe hepatic dysfunction in pregnancy QJM 200295343-57
bull 37 Knox TA Olans LB Liver disease in pregnancy N Engl J Med 1996335569-76
bull 38 Saftlas AF Olson DR Franks AL Atrash H Pokras R Epidemiology of preeclampsia and eclampsia in the United States 1979e1986 Am J Obstet Gynecol 1990163460-5
bull 39 Walker JJ Pre-eclampsia Lancet 20003561260-5
bull 40 Davidson JM Renal disorders in pregnancy Curr Opin Obstet Gynecol 200113109-14
bull 41 Dafnis E Sabatini S The effect of pregnancy on renal function physiology and pathophysiologyAmJMedSci 1992303184-205
bull 42 Davison JM Shiells EA Philips PR Lindheimer MD Serial evaluation of vasopressin release and thirst in human pregnancy Role of human chorionic gonadotrophin in the osmoregulatory changes of gestation J Clin Invest 198881798-806
bull 43 Glinoer D de Nayer P Bourdoux P Lemone M Robyn C van Steirteghem A et al Regulation of maternal thyroid during pregnancy J Clin Endocrinol Metab 199071276-87
bull 44 Wilson SG Retallack RW Kent JC Worth GK Gutteridge DH Serum free 125-dihydroxyvitamin D and the free 125- dihydroxyvitamin D index during a longitudinal study of human pregnancy and lactation Clin Endocrinol 199032613-22
bull 45 Rasmussen N Frolich A Hornnes PJ Hegedus L Serum ionized calcium and intact parathyroid hormone levels during pregnancy and postpartum Br J Obstet Gynaecol 199097857-9
bull 46 Guyton AC Textbook of medical physiology 8th ed Philadelphia W B Saunders 1991 p 915e28
bull 47 Trainer PJ Corticosteroids and pregnancy Semin Reprod Med 200220375-80
bull 48 Soory M Hormonal factors in periodontal disease Dent Update 200027380-3
bull 49 Hugoson A Gingivitis in pregnant women A longitudinal clinical study Odontol Revy 19712265-84
bull 50 Neville BW Damm DD Allen CM Bouquot JE Oral amp Maxillofacial Pathology 3rd ed Philadelphia W B Saunders 2002 p 329-30 447-9
bull 51 Tilakaratne A Soory M Ranasinghe AW Corea SM Ekanayake SL de Silva M Periodontal disease status during pregnancy and 3 months post-partum in rural population of Sri-Lankan women J Clin Periodontol 200027787-92
bull 52 Laine M Tenovuo J Lehtonen OP Ojanatko-Harri A Vilja P Tuohimaa P Pregnancy e related changes in human whole saliva Arch Oral Biol 198833913-7
bull 53 Yuan K Wing LY Lin MT Pathogenetic roles of angiogenic factors in pyogenic granulomas in pregnancy are modulated by female sex hormones J Periodontol 200273701-8
bull 54 Evans RD Briggs PF Tooth-surface loss related to pregnancyinduced vomiting Prim Dent Care 1994124-6
bull 55 Salvolini E Di Giorgio R Curatola A Mazzanti L Fratto G Biochemical modifications of human whole saliva induced by pregnancy Br J Obstet Gynaec 1998105656-60
bull 56 Mauldin JG Newman RB Preterm birth risk assessment Semin Perinatol 200125215-22
bull 57 Heine RP McGregor JA Goodwin TM Artal R Hayashi RH Robertson PA et al Serial salivary estriol to detect an increased risk of preterm birth Obstet Gynecol 200096490-7
bull 58 Kauh YC Zachian TF Melasma Adv Exp Med Biol 1999455 491-9
bull 59 Wong RC Ellis CN Physiologic skin changes in pregnancy J Am Acad Dermatol 198410929-40
bull 60 Errickson CV Matus NR Skin disorders of pregnancy Am Fam Physician 199449605-10
bull 61 Lopez NJ Smith PC Gutierrez J Periodontal therapy may reduce the risk of preterm low birth weight in women with periodontal disease a randomized controlled trial J Periodontol 200273911-24
bull 62 McGaw T Periodontal disease and preterm delivery of lowbirth- weight infants J Can Dent Assoc 200268165-9
bull 63 Richards AG Dental x-ray protection Dent Clin North Am 1968631-41
bull 64 1990 Recommendations of the International Commission on Radiological Protection Ann ICRP 1991211-201
bull 65 Hall EJ Radiation the two-edged sword cancer risks at high and low doses Cancer J 20006343-50
bull 66 Diethelm L Xu H Diagnostic imaging of the lung during pregnancy Clin Obstet Gynecol 19963936-55
bull 67 Brent RL The effects of embryonic and fetal exposure to x-rays microwaves and ultrasound ClinObstetGynecol 198326484-510
bull 68 National Council on Radiation Protection NCRP report no128 1998 Bethesda Md Author
bull 69 Wasylko L Matsui D Dykxhoorn SM Reider MJ Weinberg S A review of common dental treatments during pregnancy implications for patients and dental personnel J Can Dent Assoc 199864434-9
bull 70 Freeman JP Brand JW Radiation doses of commonly used dental radiographic surveys Oral Surg Oral Med Oral Pathol 199477285-9
bull 71 Kircos LTAngin LL Lorton LOrder ofmagnitude dose reduction in intraoral radiography J Am Dent Assoc 1987114344-7
bull 72 Updegrave WJ Simplified and standardized intraoral radiography with reduced tissue irradiation J Am Dent Assoc 197285861-9
bull 73 Wood RE Harris AM van der Merwe EJ Nortje CJ The leaded apron revisited does it reduce gonadal radiation dose in dental radiology Oral Surg Oral Med Oral Pathol 199171642-6
bull 74 An update on radiographic practices information and recommendations ADA Council on Scientific Affairs J Am Dent Assoc 2001132234-8
bull 75 Rayburn WF Recommending medications during pregnancy an evidence based approach Clin Obstet Gynecol 2002451-5
bull 76 Rathmell JP Viscomi C Ashburn MA Management of nonobstetric pain during pregnancy and lactation Anesth Analg 1997851074-87
bull 77 Teratology society public affairs committee FDA classification of drugs for teratogenic risk Teratology 199449446-7
bull 78 Moore PA Selecting drugs for the pregnant dental patient J Am Dent Assoc 19981291281-6
bull 79 Haas DA An update on analgesics for the management of acute postoperative dental pain J Can Dent Assoc 200268476-82
bull 80 Haas DA Pynn BR Sands TD Drug use for the pregnant or lactating patient Gen Dent 20004854-60
bull 81 Committee on Drugs American Academy of Pediatrics The transfer of drugs and other chemicals into human milk Pediatrics 199493137-50
bull 82 Nielsen GL Sorensen HT Larsen H Pedersen L Risk of adverse birth outcome and miscarriage in pregnant users of nonsteroidal anti-inflammatory drugs population based observational study and case-control study BMJ 2001322266-70
bull 83 Janssen N Genta M The effects of immunosuppressive and anti-inflammatory medications on fertility pregnancy and lactation Arch Intern Med 200016610-9
bull 84 Ostensen M Nonsteroidal anti-inflammatory drugs during pregnancy Scand J Rheumatol Suppl 1998107128-32
bull 85 USPDI -Drug information for the health care professional 22nd ed Greenwood Village CO Micromedex 2002 p 152-79
bull 86 Denson DD Coyle DE Thompson GA Santos D Turner PA Myers JA et al Bupivacaine protein binding in the term parturient effects of lactic acidosis Clin Pharmacol Ther 198435702-9
bull 87 Dillon DE Wagner CL Wiest D Newman RB Drug therapy in the nursing mother Obstet Gynecol Clin North Am 199724 675-96
bull 88 Dashe JS Gilstrap LC Antibiotic use in pregnancy Obstet Gynecol Clin North Am 199724617-29
bull 89 American College of Rheumatology Ad hoc Committee on Clinical Guidelines Guidelines for monitoring drug therapy in rheumatoid arthritis Arthritis Rheum 199639723-31
bull 90 Ng PC The fetal and neonatal hypothalamic-pituitary-adrenal axis Arch Dis Child Fetal Neonatal Ed 200082F250-4
bull 91 Crowley P Antenatal corticosteroidsmdashcurrent thinking BJOG 2003110(Suppl 20)77-8
bull 92 ACOG committee opinion antenatal corticosteroid therapy for fetal maturation Obstet Gynecol 200299871-3
bull 93 Ost L Wettrell G Bjorkhem I Rane A Prednisolone excretion in human milk J Pediatr 19851061008-11
bull 94 Rowland AS Baird DD Shore DL Weinberg CR Savitz DA Wilcox AJ Nitrous oxide and spontaneous abortion in female dental assistants Am J Epidemiol 1995141531-8
bull 95 McGlothlin JD Jensen PA Fischbach TJ Hughes RT Jones JH Control of anesthetic gases in dental operatories Scand J Work Environ Health 199218(Suppl 2)103-5
bull ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY Volume 97 Number 6 Suresh and Radfar 681
bull 96 Rosen MA Nitrous oxide for relief of labor pain a systematic review Am J Obstet Gynecol 2002186(Suppl Nature)S110-6
bull 97 Sands TD Pynn BR Management considerations for the pregnant or nursing emergency patient Ont Dent 199875 17-9
bull 98 Daya S Recurrent spontaneous early pregnancy loss and low dose aspirin Minerva Ginecol 200355441-9
bull 99 Sinclair C Handbook of obstetrical emergencies 1st ed Philadelphia WB Saunders 1996 p 29-39 69
bull 100 Tarsitano BF Rollings RE The pregnant dental patient evaluation and management Gen Dent 199341226-34
bull 101 Livingston MH Dlllinger TM Holder R Consideration in the management of the pregnant patient SCD Special Care in Dentistry 199818183-8
Thank you
- A Review on the principle of Dental Management of the Pregnant patient
- Slide 2
- Questions that a dentist may ask
- Stages of Pregnancy
- Slide 5
- Slide 6
- Physiologic Changes in Pregnancy
- Systemic changes in pregnancy
- FLAT SUPINE POSITIONING
- SUPINE HYPOTENSION SYNDROME (Vena Cava Compression)
- Supine Hypotension Syndrome
- Slide 12
- Supine Hypotension Syndrome
- Prevention of Supine Hypotensive Syndrome
- Treatment of Supine Hypotensive Syndrome
- How should the pregnant woman be positioned
- Slide 17
- Slide 18
- Slide 19
- Slide 20
- Slide 21
- Slide 22
- Slide 23
- Pregnancy Related Oral Health Problems
- Oral Problems in Pregnancy
- Pregnancy Gingivitis Pathophysiology
- Pregnancy Gingivitis
- Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Gum Problems - Pregnancy Granuloma
- Slide 31
- Gum Changes - Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Candidiasis
- Pregnancy Myths
- Other Oral Conditions in Pregnancy
- Changes During Pregnancy that Affect Oral Health
- Saliva changes
- Increased Bacteria
- Slide 40
- Enamel erosion caused by frequent vomiting
- Treatment for Acid Exposure
- Oral Diseases Can Effect Pregnancy
- Periodontal Disease and Preterm Labor
- Periodontal Disease and Low Birth Weight
- Periodontal Disease and Preeclampsia
- Periodontitis and Pre-eclampsia
- Dental Considerations
- Treatment Timing
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Slide 52
- Use of Radiation on Pregnant Patient
- Radiographs during Pregnancy
- Risks of Dental X-Rays
- FDA drug classification for pregnancy
- Slide 57
- FDA drug classification for pregnancy
- Slide 59
- Slide 60
- Slide 61
- Common Analgesics
- Analgesics
- Analgesics - continued
- Analgesics to Use During 1st and 2nd Trimester
- Analgesics to Avoid During the Third Trimester
- Sedation in Pregnancy
- Common Antibiotics
- Antibiotics
- Antibiotics To Use During Pregnancy
- Antibiotics to Avoid during Pregnancy
- The Problem With Tetracycline
- Other Antimicrobial Agents
- Local Anesthetic Use in Pregnancy
- Use of Local Anesthetics
- Ulcer healing drugs
- Slide 77
- Slide 78
- Slide 79
- Use of Nitrous Oxide Gas
- Common Preventives
- Are topical agents safe
- Pre-natal Fluoride
- Is it safe to use mercury restorations
- References
- REFERENCES
- Slide 87
- Slide 88
- Slide 89
- Slide 90
- Slide 91
- Slide 92
- Slide 93
- Slide 94
- Slide 95
- Slide 96
- Slide 97
- Slide 98
- Thank you
-
Systemic changes in pregnancyEndocrine Changes uarrEstrogen uarr progesterone uarrhuman
gonadotropin uarr thyroxin steroid and insulin level Estrogen amp progesterone are insulin
antagonists uarr level of these hormones lead to insulin resistance Thus insulin levels are elevated in pregnant in pregnant patient to compensate this resistance
About 45 of women fail to produce sufficient amount of insulin to overcome this antagonist action amp thus develop gestational diabetes
Systemic changes in pregnancy
Hematological changebull uarr red RBC uarrESR darrHbbull uarrWBCbull uarr circulatory catecholamin amp cortisol lead
to leucositosis bull uarr Coagulation factors except factor XI amp
XIII (anticloting factor) bull so pregnancy is a hypercoagulable state amp
uarr risk for thromboembolism
Systemic changes in pregnancy
bull Pregnant women with anti-phospholipid syndrome are at uarr risk for thrombo-embolisim
bull They are placed on subcutaneous low molecular weight heparin (LMWH)
bull These patients must be hospitalized for dental care
Pregnancy RelatedOral Health Problems
bull Pregnancy Gingivitisbull Pregnancy Epulis bull Increased Tooth Mobilitybull Dental Cariesbull Erosionbull Dental Problems in relation to Labor
and Delivery
Oral Problems in Pregnancy
bullPregnancy GingivitisbullMost common oral manifestation (50-100 of women)bullCaused by hormonal and vascular changes of pregnancy
Pregnancy Gingivitis Pathophysiology
bull Elevated circulating estrogen increases capillary permeability
bull Preexisting gingivitis may predispose to pregnancy gingivitis
Pregnancy Gingivitis
bullOccurs commonly in the 2nd to 8th monthsbullTendency to bleed very easilybullTreatment Scaling root-planing currettage OHI
Pregnancy Granuloma
bullOccurs in up to 5 of womenbullMost common in buccal maxillary anterior areasbullUsually starts in an area of gingivitis
Pregnancy Granuloma (continued)
bullRapid growth up to 2 cmbullSingle tumor-like growthbullusually in interdental papillaebullPurplish to bluish in color may be ulcerated- bleeds easily
Gum Problems - Pregnancy Granuloma
Gum Problems - Pregnancy Granuloma
Gum Changes - Pregnancy Granuloma
Pregnancy Granuloma (continued)
Treatment
bull Scaling and root planingbull Excision if it is too large or bleeds too
easilybull May regress spontaneously after
pregnancy
Candidiasis
bullWipes offbullUsually asymptomatic but may burnbullTreatment topical or systemic antifungals
Pregnancy MythsbullldquoA mother loses a tooth for every babyrdquobullNo evidence that aphthous ulcers are any more common in pregnancy
Other Oral Conditions in Pregnancy
bull Dry mouthbull Excessive salivationbull Tooth erosions associated with
severe GERD or hyperemesis
Changes During Pregnancy that Affect Oral Health
bull Hormonal Affects
ndash Increased tooth mobility
ndash Saliva changes
ndash Increased bacteria
ndash Gingival problems
Saliva changesbull Decreased buffers
bull Decreased minerals
bull Decreasing flow first and last trimester
bull Increased flow second trimester
bull More acidic
Increased Bacteriabull Increased acidity
ndash Increase in decay-causing bacteriabull Increased Snacking
ndash Morning sicknesslow blood sugarndash Between-meal snacks
bull Increase in amount and frequency of starchescarbohydrates ndash Crackers are commonly recommendedndash Promotes decay-causing bacteria
Changes During Pregnancy that Affect Oral Healthbull Morning sickness
ndash Difficulty with hygienebull Gingival diseasebull Tooth decay
ndash Vomitingbull Esophogeal Reflux (heartburn)bull Acid exposure
ndash Irritation of the gumsndash Weakening of tooth enamelndash Dental erosion
Enamel erosion caused by frequent vomiting
Treatment for Acid Exposure
bull Do NOT brush immediately after vomiting
bull Rinse ndash Water with baking sodandash Antacidndash Plain water
bull Eat some cheese
Oral Diseases Can Effect Pregnancy
bull Preterm low birth weight (LBW) linked to periodontal disease
bull Thorough calculus (tartar) removal in pregnant women with periodontitis may reduce pre-term births
Periodontal Disease and Preterm LaborbullMaternal periodontal disease is associated with increased risk of preterm laborbullAnaerobic oral gram-negative bacteria cause inflammatory responsebullInflammatory response stimulates prostaglandin and cytokine production to stimulate labor
Periodontal Disease and Low Birth Weight
bull Periodontal disease is associated with low birth weight
bull Evidence is not conclusivebull Biochemical mechanism similar cascade
as in preterm labor leading to placental blood flow restriction and necrosis
Periodontal Disease and Preeclampsia
bull Emerging databull Mechanism unclearbull Proposed mechanism
ndash Periodontal infection leads to inflammatory vascular damage
ndash Triggers cell damage in placenta
Periodontitis and Pre-eclampsia
bull Periodontal disease may be associated with pre-eclampsia (Boggess 2003)
bull PGE2 IL-1 and TNF-α from gingival crevicular fluid were higher in women with preeclampsia compared with healthy matched pregnant women (Oettinger-Barak 2003)
Dental Considerations
bull timing of treatment for pregnant patientsbull dental radiation exposurebull use of local anestheticsbull prescription of common antibiotics and
analgesicsbull nitrous oxide gas administration
Treatment Timing
bull First Trimesterndash Spontaneous miscarriages naturally occur
more often in 1st trimesterndash Avoid elective treatment that can be delayedndash Offer anticipatory guidance
bull Second Trimesterndash The optimal time for dental treatmentndash Organogenesis complete fetus not largendash Easier to prevent than treat established disease
bull Third Trimesterndash Late in term very uncomfortable (short visits)ndash Position slightly on left side
Timing of Dental Treatment During Pregnancy - From Little and Fallace
First Trimester
bull Plaque controlbull Oral hygiene instructionbull Scaling polishing curettagebull Avoid elective treatment urgent care
only
Timing of Dental Treatment During Pregnancy - From Little and Fallace
Second Trimester
bull Plaque controlbull Oral hygiene instructionbull Scaling polishing curettagebull Routine dental care
Timing of Dental Treatment During Pregnancy - From Little and Fallace
Third Trimester
bull Plaque controlbull Oral hygiene instructionbull Scaling polishing curettagebull Routine dental care (after middle of third
trimester elective care should be avoided)
Use of Radiation on Pregnant Patientbull Dose given and time of gestation are
importantbull doses lt 5-10 rads (cGy) not teratogenicbull fetus is most susceptible to radiation
between the 2nd and 6th week of gestationbull single dental x-ray exposes patient to 001
millirads of radiation In relative terms this amount is 40 times less than daily dose acquired from cosmic radiation Therefore diagnostic radiation should not be withheld during pregnancy
Radiographs during Pregnancy
bull Take as needed with optimal methods for reducing secondary radiation and exposure time
bull Always use a lead apronbull Exposure to fetus (with apron use) is 00001
centiGray(rad)bull Daily cosmic radiation - 0004 centiGray (rad)
Risks of Dental X-Rays
bull X-ray only if necessary (ie root canal therapy trauma)
bull When x-rays are indicated radiation exposure is extremely low
bull Exposure can be limited byndash Lead apron shielding ndash Modern fast film ndash Avoiding retakes
FDA drug classification for pregnancybull Combines risk statements including
congenital anomalies fetal effects perinatal risks and therapeutic risk-benefit ratio
bull Untreated disease or condition may pose more serious risks to both mother and fetus than any theoretical risks from the medication
bull Category A thru D and X
FDA drug classification for pregnancy
bull A = Controlled Studies in women fail to demonstrate a risk to the fetus in the first trimester and the possibility of fetal harm appears remote
FDA drug classification for pregnancy
bull B = Animal studies show no risk or if risk shown in animals controlled
trials in women showed no risk
FDA drug classification for pregnancy
bull C = Studies in animals with adverse effects and no human studies
OR no animal or human studies but benefits of use may outweigh potential harms
FDA drug classification for pregnancy
bull D = There is evidence of human fetal risk but benefits may outweigh risks
FDA drug classification for pregnancy
bull X = Contraindicated
Common Analgesics
bull paracetamol (B)bull Ibuprofen (BD) bull Oxycodone (BD) bull Hydrocodone and codeine
(CD)
avoid in third trimester
Analgesics
bull Paracetamol is the analgesic of choice for all stages of gestation
bull used to treat mild to moderate pain and fevers
bull short term usage is believed to be safebull avoid chronic and large doses of
paracetamol1048715
Analgesics - continuedbull Aspirin is nonteratogenic but may cause
maternal and fetal hemorrhagebull large and chronic doses during last trimester
may result in premature closure of ductus arteriosus fetal hypertension anemia and low birth weight
bull avoid ibuprofen in 3rd trimester because of possible adverse circulatory effects
bull short term use of codeine seems safebull avoid codeine late in gestation because of
possible fetal respiratory depression and withdrawal symptoms
Analgesics to Use During1st and 2nd Trimester
bull Category B (for best)bull Paracetamol Ibuprofenbull Naproxenbull Category C (use with caution)bull Paracetamol with codeine or
hydrocodonebull Paracetamol with oxycodone
Analgesics to Avoid During theThird Trimesterbull Causes delivery problemsbull Aspirin (C 3D)bull Ibuprofen (B3D)bull Naproxen (B3D)bull Causes neonatal respiratory
depression and opioid withdrawalbull Codeine (C3D)bull Hydrocodone (C3D)bull Oxycodone(C3D)
Sedation in Pregnancy
bull SedativesAnxiolytics (eg Diazepam ) are rated D and can cause oral clefts with prolonged exposure
bull Nitrous oxide should not be used in 1st trimester (If used in 2nd and 3rd do not go below 50 O2)
Common Antibioticsbull To treat oral abscess or cellulitis
ndash Penicillin (B) ndash Amoxicillin (B) ndash Cephalexin (B)ndash Erythromycin base (B) (Not estolate as it
cause cholestatic hepatitis)ndash Clindamycin (B)
Antibioticsbull penicillin V and amoxicillin is preferred drug
for mild to moderate infectionsbull widely used for many years with no ill effectsbull no studies show penicillin to be teratogenicbull amoxicillin extensively used without harming
the fetusbull Drug classes1048715 B penicillin cephalosporins erythromycin clindamycin Azithromycin D Tetracycline
Antibiotics To Use During Pregnancy
bull Penicillin Vbull Amoxicillinbull Erythromycin (base form)bull Cephalexin cephalosporinbull Clindamycinbull Metronidazole
Antibiotics to Avoid duringPregnancy
bull Doxycyclinebull Tetracyclinebull Erythromycin (estolate form)bull Vancomycin
The Problem With Tetracycline
bull Accumulates in bones and chelates calcium
bull Inhibits bone growthbull Discolors teeth
Other Antimicrobial Agentsbull OK to usebull Nystatin (B)bull Chlorhexidine rinse (B)bull Use with cautionbull Clotrimazole (C)bull Ketoconazole (C)bull Fluconazole (C)bull Do not usebull Doxycycline (D)
Local Anesthetic Use inPregnancy
bull Class Bbull Lidocaine (Xylocaine)bull Etidocainebull Prilocaine bull Class Cbull Procainebull Bupivicainebull Mepivicaine
Use of Local Anestheticsbull Lidocaine + vasoconstrictor most common
local anesthetic used in dentistrybull extensively used in pregnancy with no proven ill
effectsbull accidental intravascular injections of lidocaine
pass through the placenta but the concentrations are too low to harm fetus
bull prilocaine might cause methemoglobinemia
Ulcer healing drugsCimetidine bull FDA category B Famotidinebull FDA category BRanitidinebull FDA category Bbull not known to be harmful
Ulcer healing drugsOmeprazolebull FDA category BNot known to be
harmful Esomeprazolebull FDA category BLansoprazolebull FDA category BPantoprazolebull Avoid unless potential benefit
outweighs riskmdashfetotoxic in animals
Ulcer healing drugs
Misoprostolbull First second third trimesters Avoidmdash
potent uterine stimulant (has been used to induce abortion) and may be teratogenic
Ulcer healing drugs
Antacidsbull Almunium hydroxideMagnesium
hydroxidemdashFDA category B Calcium carbonatemdashFDA category C
SimetheconemdashFDA category C
Use of Nitrous Oxide Gas
bull used over 150 years bull safety is being debatedbull SHORT TERM exposure do not cause
birth defects or spontaneous abortionbull CHRONIC exposure may result in fetal
loss and infertilitybull literature suggests that nitrous oxide
should be avoided until more conclusive research is available
bull FDA Drug class not yet assigned
Common Preventives
bull Fluoridendash No increased risk during pregnancy
bull Xylitolndash No studies no harm reported
bull Chlorhexidinendash No increased risk during pregnancy
Are topical agents safe
bull Fluoridebull Toothpaste amp mouthrinse
bull Xylitol chewing gum bull Chlorhexidine (11 alcohol)bull No over the counter mouthrinses with
alcohol (Listerine 20 alcohol)
Pre-natal Fluoride
bull Daily 22 mg tablet of sodium fluoride during 3rd through 9th months
bull decreases caries rate in offspringbull Safe and effective
Glenn FB 1982
Is it safe to use mercury restorations
bull No evidence of harmful effect
bull Benefits outweigh risks
bull Canada Germany and New Zealand have some restrictions
bull Determine the best option
Referencesbull Wasylko L Matsui D Dykxhoorn SM Rieder MJ Weinberg
S A Review of Common Dental Treatments During Pregnancy J Canadian Dental Association 64434-439 1998
bull Little JW Donald AF Craig SM Rhodus NL Dental Management of the Medically Compromised Patient - 5th edition Mosby Toronto Pp434-442 1997
bull Livingston HM Dellinger TM Holder R Considerations in the management of the pregnant patient Special Care in Dentistry 185 pp183-188 1998
bull Larimore WL Petrie KA Drug use during pregnacy and lactation Primary Care Clinics in Office Practice 271 35-53 2000
bull Health Canada The Safety of DentalAmalgam Minister Of Supply and Services Canada 1996
REFERENCESbull 1 Weiss G Endocrinology of parturition J Clin
Endocrinol Metab 2000854421-5bull 2 Theunissen IM Parer JT Fluid and electrolytes in
pregnancy Clin Obstet Gynecol 1994373-15bull 3 Duvekot JJ Peeters LLH Renal hemodynamics and
volume homeostasis in pregnancy Obstet Gynecol Surv 199449830-9
bull 4 Barron WM Lindheimer MD Medical disorders during pregnancy 2nd ed St Louis Mosby 1995 p 129
bull 5 Thornburg KL Jacobson SL Giraud GD Morton MJ Hemodynamic changes in pregnancy Semin Perinatol 20002411-4
bull 6 Fiese R Herzog S Issues in dental and surgical management of the pregnant patient Oral Surg Oral Med Oral Pathol 198865292-7
bull 7 Martin C Varner MW Physiologic changes in pregnancysurgical implications Clin Obstet Gynecol 199437241-55
bull 8 Clark SL Cotton DB Lee W Bishop C Hill T Southwick J et al Central hemodynamic assessment of normal term pregnancy Am J Obstet Gynecol 19891611439-42
bull 9 Mabie WC Di Sessa TG Crocker LG Sibai BM Arheart KL A longitudinal study of cardiac output in normal human pregnancy Am J Obstet Gynecol 1994170849-56
bull 10 Clapp JF 3rd Capeless E Cardiovascular function before during and after the first and subsequent pregnancies Am J Cardiol 1997801469-73
bull 11 Duvekot JJ Peeters LL Maternal cardiovascular hemodynamic adaptation to pregnancy Obstet Gynecol Surv 199449(Suppl) S1-14
bull 12 Bhagwat AR Engel PJ Heart disease and pregnancy Cardiol Clin 199513163-78
bull 13 Lanni SM Tillinghast J Silver H Hemodynamic changes and baroreflex gain in the supine hypotensive syndrome Am J Obstet Gynecol 20021871636-41
bull 14 Little JW Falace DA Miller CS Rhodus NL Dental management of the medically compromised patient 6th ed St Louis Mosby 2002 p 303
bull 15 Garcia-Rio F Pino JM Gomez L Alvarez-Sala R Villasante C Villamor J Regulation of breathing and perception of dyspnea in healthy pregnant women Chest 1996110446-53
bull 16 McAuliffe F Kametas N Costello J Rafferty GF Greenough A Nicolaides K Respiratory function in singleton and twin pregnancy BJOG 2002109765-9
bull 17 Clapp JF 3rd Seaward BL Sleamaker RH Hiser J Maternal physiologic adaptations to early human pregnancy Am J Obstet Gynecol 19881591456-60
bull 18 OrsquoDay MP Cardio-respiratory physiological adaptation of pregnancy Semin Perinatol 199721268-75
bull 19 Contreras G Gutierrez M Beroiza T Fantin A Oddo H Villarroel L et al Ventilatory drive and respiratory muscle function in pregnancy Am Rev Respir Dis 1991144837-41
bull 20 Turner M Aziz SR Management of the pregnant oral and maxillofac
bull 21 Sifakis S Pharmakides G Anemia in pregnancy Ann N Y Acad Sci 2000900125-36
bull 22 Branch DW Physiologic adaptations of pregnancy Am J Reprod Immunol 199228120-2
bull 23 Burrows RF Kelton JG Incidentally detected thrombocytopenia in healthy mothers and their infants N Engl J Med 1988319 142-5
bull 24 Hanly JG Antiphospholipid syndrome an overview CMAJ 200324(168)1675-82
bull 25 Heilmann L von Tempelhoff GF Pollow K Antiphospholipid syndrome in obstetrics Clin Appl Thromb Hemost 20039 143-50
bull 26 Sherman P Flaxman SM Nausea and vomiting of pregnancy in an evolutionary perspective Am J Obstet Gynecol 2002 185(Suppl)s190-7
bull 27 Koch KL Gastrointestinal factors in nausea and vomiting of pregnancy Am J Obstet Gynecol 2002185(Suppl)s198-203
bull 28 Koch KL Frissora CL Nausea and vomiting during pregnancy Gastroenterol Clin N Am 200332201-34
bull 29 Baron TH Ramirez B Richter JE Gastrointestinal motility disorders during pregnancy Ann Intern Med 1993118 366-75
bull 30 Richter JE Gastroesophageal reflux disease during pregnancy Gastroenterol Clin N Am 200332235-61
bull 31 Marrero JM Goggin PM de Caestecker JS Pearce JM Maxwell JD Determinants of pregnancy heartburn Br J Obstet Gynaecol 199299731-4
bull 32 Hamaoui E Hamaoui M Nutritional assessment and support during pregnancy Gastroenterol Clin N Am 20033259-121
bull 33 King JC Physiology of pregnancy and nutrient metabolism Am J Clin Nutr 200071(suppl)1218s-25s
bull 34 Casanueva E Pfeffer F Fernandez-Gaxiola AC Gutierrez- Valenzuela V Rothenberg SJ Iron and folate status before pregnancy and anemia during pregnancy Ann Nutr Metab 2003 4760-3
bull 35 Chrsquong CL Morgan M Hainsworth I Kingham JG Prospective study of liver dysfunction in Southwest Wales Gut 200251 876-80
bull 36 Rahman TM Wendon J Severe hepatic dysfunction in pregnancy QJM 200295343-57
bull 37 Knox TA Olans LB Liver disease in pregnancy N Engl J Med 1996335569-76
bull 38 Saftlas AF Olson DR Franks AL Atrash H Pokras R Epidemiology of preeclampsia and eclampsia in the United States 1979e1986 Am J Obstet Gynecol 1990163460-5
bull 39 Walker JJ Pre-eclampsia Lancet 20003561260-5
bull 40 Davidson JM Renal disorders in pregnancy Curr Opin Obstet Gynecol 200113109-14
bull 41 Dafnis E Sabatini S The effect of pregnancy on renal function physiology and pathophysiologyAmJMedSci 1992303184-205
bull 42 Davison JM Shiells EA Philips PR Lindheimer MD Serial evaluation of vasopressin release and thirst in human pregnancy Role of human chorionic gonadotrophin in the osmoregulatory changes of gestation J Clin Invest 198881798-806
bull 43 Glinoer D de Nayer P Bourdoux P Lemone M Robyn C van Steirteghem A et al Regulation of maternal thyroid during pregnancy J Clin Endocrinol Metab 199071276-87
bull 44 Wilson SG Retallack RW Kent JC Worth GK Gutteridge DH Serum free 125-dihydroxyvitamin D and the free 125- dihydroxyvitamin D index during a longitudinal study of human pregnancy and lactation Clin Endocrinol 199032613-22
bull 45 Rasmussen N Frolich A Hornnes PJ Hegedus L Serum ionized calcium and intact parathyroid hormone levels during pregnancy and postpartum Br J Obstet Gynaecol 199097857-9
bull 46 Guyton AC Textbook of medical physiology 8th ed Philadelphia W B Saunders 1991 p 915e28
bull 47 Trainer PJ Corticosteroids and pregnancy Semin Reprod Med 200220375-80
bull 48 Soory M Hormonal factors in periodontal disease Dent Update 200027380-3
bull 49 Hugoson A Gingivitis in pregnant women A longitudinal clinical study Odontol Revy 19712265-84
bull 50 Neville BW Damm DD Allen CM Bouquot JE Oral amp Maxillofacial Pathology 3rd ed Philadelphia W B Saunders 2002 p 329-30 447-9
bull 51 Tilakaratne A Soory M Ranasinghe AW Corea SM Ekanayake SL de Silva M Periodontal disease status during pregnancy and 3 months post-partum in rural population of Sri-Lankan women J Clin Periodontol 200027787-92
bull 52 Laine M Tenovuo J Lehtonen OP Ojanatko-Harri A Vilja P Tuohimaa P Pregnancy e related changes in human whole saliva Arch Oral Biol 198833913-7
bull 53 Yuan K Wing LY Lin MT Pathogenetic roles of angiogenic factors in pyogenic granulomas in pregnancy are modulated by female sex hormones J Periodontol 200273701-8
bull 54 Evans RD Briggs PF Tooth-surface loss related to pregnancyinduced vomiting Prim Dent Care 1994124-6
bull 55 Salvolini E Di Giorgio R Curatola A Mazzanti L Fratto G Biochemical modifications of human whole saliva induced by pregnancy Br J Obstet Gynaec 1998105656-60
bull 56 Mauldin JG Newman RB Preterm birth risk assessment Semin Perinatol 200125215-22
bull 57 Heine RP McGregor JA Goodwin TM Artal R Hayashi RH Robertson PA et al Serial salivary estriol to detect an increased risk of preterm birth Obstet Gynecol 200096490-7
bull 58 Kauh YC Zachian TF Melasma Adv Exp Med Biol 1999455 491-9
bull 59 Wong RC Ellis CN Physiologic skin changes in pregnancy J Am Acad Dermatol 198410929-40
bull 60 Errickson CV Matus NR Skin disorders of pregnancy Am Fam Physician 199449605-10
bull 61 Lopez NJ Smith PC Gutierrez J Periodontal therapy may reduce the risk of preterm low birth weight in women with periodontal disease a randomized controlled trial J Periodontol 200273911-24
bull 62 McGaw T Periodontal disease and preterm delivery of lowbirth- weight infants J Can Dent Assoc 200268165-9
bull 63 Richards AG Dental x-ray protection Dent Clin North Am 1968631-41
bull 64 1990 Recommendations of the International Commission on Radiological Protection Ann ICRP 1991211-201
bull 65 Hall EJ Radiation the two-edged sword cancer risks at high and low doses Cancer J 20006343-50
bull 66 Diethelm L Xu H Diagnostic imaging of the lung during pregnancy Clin Obstet Gynecol 19963936-55
bull 67 Brent RL The effects of embryonic and fetal exposure to x-rays microwaves and ultrasound ClinObstetGynecol 198326484-510
bull 68 National Council on Radiation Protection NCRP report no128 1998 Bethesda Md Author
bull 69 Wasylko L Matsui D Dykxhoorn SM Reider MJ Weinberg S A review of common dental treatments during pregnancy implications for patients and dental personnel J Can Dent Assoc 199864434-9
bull 70 Freeman JP Brand JW Radiation doses of commonly used dental radiographic surveys Oral Surg Oral Med Oral Pathol 199477285-9
bull 71 Kircos LTAngin LL Lorton LOrder ofmagnitude dose reduction in intraoral radiography J Am Dent Assoc 1987114344-7
bull 72 Updegrave WJ Simplified and standardized intraoral radiography with reduced tissue irradiation J Am Dent Assoc 197285861-9
bull 73 Wood RE Harris AM van der Merwe EJ Nortje CJ The leaded apron revisited does it reduce gonadal radiation dose in dental radiology Oral Surg Oral Med Oral Pathol 199171642-6
bull 74 An update on radiographic practices information and recommendations ADA Council on Scientific Affairs J Am Dent Assoc 2001132234-8
bull 75 Rayburn WF Recommending medications during pregnancy an evidence based approach Clin Obstet Gynecol 2002451-5
bull 76 Rathmell JP Viscomi C Ashburn MA Management of nonobstetric pain during pregnancy and lactation Anesth Analg 1997851074-87
bull 77 Teratology society public affairs committee FDA classification of drugs for teratogenic risk Teratology 199449446-7
bull 78 Moore PA Selecting drugs for the pregnant dental patient J Am Dent Assoc 19981291281-6
bull 79 Haas DA An update on analgesics for the management of acute postoperative dental pain J Can Dent Assoc 200268476-82
bull 80 Haas DA Pynn BR Sands TD Drug use for the pregnant or lactating patient Gen Dent 20004854-60
bull 81 Committee on Drugs American Academy of Pediatrics The transfer of drugs and other chemicals into human milk Pediatrics 199493137-50
bull 82 Nielsen GL Sorensen HT Larsen H Pedersen L Risk of adverse birth outcome and miscarriage in pregnant users of nonsteroidal anti-inflammatory drugs population based observational study and case-control study BMJ 2001322266-70
bull 83 Janssen N Genta M The effects of immunosuppressive and anti-inflammatory medications on fertility pregnancy and lactation Arch Intern Med 200016610-9
bull 84 Ostensen M Nonsteroidal anti-inflammatory drugs during pregnancy Scand J Rheumatol Suppl 1998107128-32
bull 85 USPDI -Drug information for the health care professional 22nd ed Greenwood Village CO Micromedex 2002 p 152-79
bull 86 Denson DD Coyle DE Thompson GA Santos D Turner PA Myers JA et al Bupivacaine protein binding in the term parturient effects of lactic acidosis Clin Pharmacol Ther 198435702-9
bull 87 Dillon DE Wagner CL Wiest D Newman RB Drug therapy in the nursing mother Obstet Gynecol Clin North Am 199724 675-96
bull 88 Dashe JS Gilstrap LC Antibiotic use in pregnancy Obstet Gynecol Clin North Am 199724617-29
bull 89 American College of Rheumatology Ad hoc Committee on Clinical Guidelines Guidelines for monitoring drug therapy in rheumatoid arthritis Arthritis Rheum 199639723-31
bull 90 Ng PC The fetal and neonatal hypothalamic-pituitary-adrenal axis Arch Dis Child Fetal Neonatal Ed 200082F250-4
bull 91 Crowley P Antenatal corticosteroidsmdashcurrent thinking BJOG 2003110(Suppl 20)77-8
bull 92 ACOG committee opinion antenatal corticosteroid therapy for fetal maturation Obstet Gynecol 200299871-3
bull 93 Ost L Wettrell G Bjorkhem I Rane A Prednisolone excretion in human milk J Pediatr 19851061008-11
bull 94 Rowland AS Baird DD Shore DL Weinberg CR Savitz DA Wilcox AJ Nitrous oxide and spontaneous abortion in female dental assistants Am J Epidemiol 1995141531-8
bull 95 McGlothlin JD Jensen PA Fischbach TJ Hughes RT Jones JH Control of anesthetic gases in dental operatories Scand J Work Environ Health 199218(Suppl 2)103-5
bull ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY Volume 97 Number 6 Suresh and Radfar 681
bull 96 Rosen MA Nitrous oxide for relief of labor pain a systematic review Am J Obstet Gynecol 2002186(Suppl Nature)S110-6
bull 97 Sands TD Pynn BR Management considerations for the pregnant or nursing emergency patient Ont Dent 199875 17-9
bull 98 Daya S Recurrent spontaneous early pregnancy loss and low dose aspirin Minerva Ginecol 200355441-9
bull 99 Sinclair C Handbook of obstetrical emergencies 1st ed Philadelphia WB Saunders 1996 p 29-39 69
bull 100 Tarsitano BF Rollings RE The pregnant dental patient evaluation and management Gen Dent 199341226-34
bull 101 Livingston MH Dlllinger TM Holder R Consideration in the management of the pregnant patient SCD Special Care in Dentistry 199818183-8
Thank you
- A Review on the principle of Dental Management of the Pregnant patient
- Slide 2
- Questions that a dentist may ask
- Stages of Pregnancy
- Slide 5
- Slide 6
- Physiologic Changes in Pregnancy
- Systemic changes in pregnancy
- FLAT SUPINE POSITIONING
- SUPINE HYPOTENSION SYNDROME (Vena Cava Compression)
- Supine Hypotension Syndrome
- Slide 12
- Supine Hypotension Syndrome
- Prevention of Supine Hypotensive Syndrome
- Treatment of Supine Hypotensive Syndrome
- How should the pregnant woman be positioned
- Slide 17
- Slide 18
- Slide 19
- Slide 20
- Slide 21
- Slide 22
- Slide 23
- Pregnancy Related Oral Health Problems
- Oral Problems in Pregnancy
- Pregnancy Gingivitis Pathophysiology
- Pregnancy Gingivitis
- Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Gum Problems - Pregnancy Granuloma
- Slide 31
- Gum Changes - Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Candidiasis
- Pregnancy Myths
- Other Oral Conditions in Pregnancy
- Changes During Pregnancy that Affect Oral Health
- Saliva changes
- Increased Bacteria
- Slide 40
- Enamel erosion caused by frequent vomiting
- Treatment for Acid Exposure
- Oral Diseases Can Effect Pregnancy
- Periodontal Disease and Preterm Labor
- Periodontal Disease and Low Birth Weight
- Periodontal Disease and Preeclampsia
- Periodontitis and Pre-eclampsia
- Dental Considerations
- Treatment Timing
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Slide 52
- Use of Radiation on Pregnant Patient
- Radiographs during Pregnancy
- Risks of Dental X-Rays
- FDA drug classification for pregnancy
- Slide 57
- FDA drug classification for pregnancy
- Slide 59
- Slide 60
- Slide 61
- Common Analgesics
- Analgesics
- Analgesics - continued
- Analgesics to Use During 1st and 2nd Trimester
- Analgesics to Avoid During the Third Trimester
- Sedation in Pregnancy
- Common Antibiotics
- Antibiotics
- Antibiotics To Use During Pregnancy
- Antibiotics to Avoid during Pregnancy
- The Problem With Tetracycline
- Other Antimicrobial Agents
- Local Anesthetic Use in Pregnancy
- Use of Local Anesthetics
- Ulcer healing drugs
- Slide 77
- Slide 78
- Slide 79
- Use of Nitrous Oxide Gas
- Common Preventives
- Are topical agents safe
- Pre-natal Fluoride
- Is it safe to use mercury restorations
- References
- REFERENCES
- Slide 87
- Slide 88
- Slide 89
- Slide 90
- Slide 91
- Slide 92
- Slide 93
- Slide 94
- Slide 95
- Slide 96
- Slide 97
- Slide 98
- Thank you
-
Systemic changes in pregnancy
Hematological changebull uarr red RBC uarrESR darrHbbull uarrWBCbull uarr circulatory catecholamin amp cortisol lead
to leucositosis bull uarr Coagulation factors except factor XI amp
XIII (anticloting factor) bull so pregnancy is a hypercoagulable state amp
uarr risk for thromboembolism
Systemic changes in pregnancy
bull Pregnant women with anti-phospholipid syndrome are at uarr risk for thrombo-embolisim
bull They are placed on subcutaneous low molecular weight heparin (LMWH)
bull These patients must be hospitalized for dental care
Pregnancy RelatedOral Health Problems
bull Pregnancy Gingivitisbull Pregnancy Epulis bull Increased Tooth Mobilitybull Dental Cariesbull Erosionbull Dental Problems in relation to Labor
and Delivery
Oral Problems in Pregnancy
bullPregnancy GingivitisbullMost common oral manifestation (50-100 of women)bullCaused by hormonal and vascular changes of pregnancy
Pregnancy Gingivitis Pathophysiology
bull Elevated circulating estrogen increases capillary permeability
bull Preexisting gingivitis may predispose to pregnancy gingivitis
Pregnancy Gingivitis
bullOccurs commonly in the 2nd to 8th monthsbullTendency to bleed very easilybullTreatment Scaling root-planing currettage OHI
Pregnancy Granuloma
bullOccurs in up to 5 of womenbullMost common in buccal maxillary anterior areasbullUsually starts in an area of gingivitis
Pregnancy Granuloma (continued)
bullRapid growth up to 2 cmbullSingle tumor-like growthbullusually in interdental papillaebullPurplish to bluish in color may be ulcerated- bleeds easily
Gum Problems - Pregnancy Granuloma
Gum Problems - Pregnancy Granuloma
Gum Changes - Pregnancy Granuloma
Pregnancy Granuloma (continued)
Treatment
bull Scaling and root planingbull Excision if it is too large or bleeds too
easilybull May regress spontaneously after
pregnancy
Candidiasis
bullWipes offbullUsually asymptomatic but may burnbullTreatment topical or systemic antifungals
Pregnancy MythsbullldquoA mother loses a tooth for every babyrdquobullNo evidence that aphthous ulcers are any more common in pregnancy
Other Oral Conditions in Pregnancy
bull Dry mouthbull Excessive salivationbull Tooth erosions associated with
severe GERD or hyperemesis
Changes During Pregnancy that Affect Oral Health
bull Hormonal Affects
ndash Increased tooth mobility
ndash Saliva changes
ndash Increased bacteria
ndash Gingival problems
Saliva changesbull Decreased buffers
bull Decreased minerals
bull Decreasing flow first and last trimester
bull Increased flow second trimester
bull More acidic
Increased Bacteriabull Increased acidity
ndash Increase in decay-causing bacteriabull Increased Snacking
ndash Morning sicknesslow blood sugarndash Between-meal snacks
bull Increase in amount and frequency of starchescarbohydrates ndash Crackers are commonly recommendedndash Promotes decay-causing bacteria
Changes During Pregnancy that Affect Oral Healthbull Morning sickness
ndash Difficulty with hygienebull Gingival diseasebull Tooth decay
ndash Vomitingbull Esophogeal Reflux (heartburn)bull Acid exposure
ndash Irritation of the gumsndash Weakening of tooth enamelndash Dental erosion
Enamel erosion caused by frequent vomiting
Treatment for Acid Exposure
bull Do NOT brush immediately after vomiting
bull Rinse ndash Water with baking sodandash Antacidndash Plain water
bull Eat some cheese
Oral Diseases Can Effect Pregnancy
bull Preterm low birth weight (LBW) linked to periodontal disease
bull Thorough calculus (tartar) removal in pregnant women with periodontitis may reduce pre-term births
Periodontal Disease and Preterm LaborbullMaternal periodontal disease is associated with increased risk of preterm laborbullAnaerobic oral gram-negative bacteria cause inflammatory responsebullInflammatory response stimulates prostaglandin and cytokine production to stimulate labor
Periodontal Disease and Low Birth Weight
bull Periodontal disease is associated with low birth weight
bull Evidence is not conclusivebull Biochemical mechanism similar cascade
as in preterm labor leading to placental blood flow restriction and necrosis
Periodontal Disease and Preeclampsia
bull Emerging databull Mechanism unclearbull Proposed mechanism
ndash Periodontal infection leads to inflammatory vascular damage
ndash Triggers cell damage in placenta
Periodontitis and Pre-eclampsia
bull Periodontal disease may be associated with pre-eclampsia (Boggess 2003)
bull PGE2 IL-1 and TNF-α from gingival crevicular fluid were higher in women with preeclampsia compared with healthy matched pregnant women (Oettinger-Barak 2003)
Dental Considerations
bull timing of treatment for pregnant patientsbull dental radiation exposurebull use of local anestheticsbull prescription of common antibiotics and
analgesicsbull nitrous oxide gas administration
Treatment Timing
bull First Trimesterndash Spontaneous miscarriages naturally occur
more often in 1st trimesterndash Avoid elective treatment that can be delayedndash Offer anticipatory guidance
bull Second Trimesterndash The optimal time for dental treatmentndash Organogenesis complete fetus not largendash Easier to prevent than treat established disease
bull Third Trimesterndash Late in term very uncomfortable (short visits)ndash Position slightly on left side
Timing of Dental Treatment During Pregnancy - From Little and Fallace
First Trimester
bull Plaque controlbull Oral hygiene instructionbull Scaling polishing curettagebull Avoid elective treatment urgent care
only
Timing of Dental Treatment During Pregnancy - From Little and Fallace
Second Trimester
bull Plaque controlbull Oral hygiene instructionbull Scaling polishing curettagebull Routine dental care
Timing of Dental Treatment During Pregnancy - From Little and Fallace
Third Trimester
bull Plaque controlbull Oral hygiene instructionbull Scaling polishing curettagebull Routine dental care (after middle of third
trimester elective care should be avoided)
Use of Radiation on Pregnant Patientbull Dose given and time of gestation are
importantbull doses lt 5-10 rads (cGy) not teratogenicbull fetus is most susceptible to radiation
between the 2nd and 6th week of gestationbull single dental x-ray exposes patient to 001
millirads of radiation In relative terms this amount is 40 times less than daily dose acquired from cosmic radiation Therefore diagnostic radiation should not be withheld during pregnancy
Radiographs during Pregnancy
bull Take as needed with optimal methods for reducing secondary radiation and exposure time
bull Always use a lead apronbull Exposure to fetus (with apron use) is 00001
centiGray(rad)bull Daily cosmic radiation - 0004 centiGray (rad)
Risks of Dental X-Rays
bull X-ray only if necessary (ie root canal therapy trauma)
bull When x-rays are indicated radiation exposure is extremely low
bull Exposure can be limited byndash Lead apron shielding ndash Modern fast film ndash Avoiding retakes
FDA drug classification for pregnancybull Combines risk statements including
congenital anomalies fetal effects perinatal risks and therapeutic risk-benefit ratio
bull Untreated disease or condition may pose more serious risks to both mother and fetus than any theoretical risks from the medication
bull Category A thru D and X
FDA drug classification for pregnancy
bull A = Controlled Studies in women fail to demonstrate a risk to the fetus in the first trimester and the possibility of fetal harm appears remote
FDA drug classification for pregnancy
bull B = Animal studies show no risk or if risk shown in animals controlled
trials in women showed no risk
FDA drug classification for pregnancy
bull C = Studies in animals with adverse effects and no human studies
OR no animal or human studies but benefits of use may outweigh potential harms
FDA drug classification for pregnancy
bull D = There is evidence of human fetal risk but benefits may outweigh risks
FDA drug classification for pregnancy
bull X = Contraindicated
Common Analgesics
bull paracetamol (B)bull Ibuprofen (BD) bull Oxycodone (BD) bull Hydrocodone and codeine
(CD)
avoid in third trimester
Analgesics
bull Paracetamol is the analgesic of choice for all stages of gestation
bull used to treat mild to moderate pain and fevers
bull short term usage is believed to be safebull avoid chronic and large doses of
paracetamol1048715
Analgesics - continuedbull Aspirin is nonteratogenic but may cause
maternal and fetal hemorrhagebull large and chronic doses during last trimester
may result in premature closure of ductus arteriosus fetal hypertension anemia and low birth weight
bull avoid ibuprofen in 3rd trimester because of possible adverse circulatory effects
bull short term use of codeine seems safebull avoid codeine late in gestation because of
possible fetal respiratory depression and withdrawal symptoms
Analgesics to Use During1st and 2nd Trimester
bull Category B (for best)bull Paracetamol Ibuprofenbull Naproxenbull Category C (use with caution)bull Paracetamol with codeine or
hydrocodonebull Paracetamol with oxycodone
Analgesics to Avoid During theThird Trimesterbull Causes delivery problemsbull Aspirin (C 3D)bull Ibuprofen (B3D)bull Naproxen (B3D)bull Causes neonatal respiratory
depression and opioid withdrawalbull Codeine (C3D)bull Hydrocodone (C3D)bull Oxycodone(C3D)
Sedation in Pregnancy
bull SedativesAnxiolytics (eg Diazepam ) are rated D and can cause oral clefts with prolonged exposure
bull Nitrous oxide should not be used in 1st trimester (If used in 2nd and 3rd do not go below 50 O2)
Common Antibioticsbull To treat oral abscess or cellulitis
ndash Penicillin (B) ndash Amoxicillin (B) ndash Cephalexin (B)ndash Erythromycin base (B) (Not estolate as it
cause cholestatic hepatitis)ndash Clindamycin (B)
Antibioticsbull penicillin V and amoxicillin is preferred drug
for mild to moderate infectionsbull widely used for many years with no ill effectsbull no studies show penicillin to be teratogenicbull amoxicillin extensively used without harming
the fetusbull Drug classes1048715 B penicillin cephalosporins erythromycin clindamycin Azithromycin D Tetracycline
Antibiotics To Use During Pregnancy
bull Penicillin Vbull Amoxicillinbull Erythromycin (base form)bull Cephalexin cephalosporinbull Clindamycinbull Metronidazole
Antibiotics to Avoid duringPregnancy
bull Doxycyclinebull Tetracyclinebull Erythromycin (estolate form)bull Vancomycin
The Problem With Tetracycline
bull Accumulates in bones and chelates calcium
bull Inhibits bone growthbull Discolors teeth
Other Antimicrobial Agentsbull OK to usebull Nystatin (B)bull Chlorhexidine rinse (B)bull Use with cautionbull Clotrimazole (C)bull Ketoconazole (C)bull Fluconazole (C)bull Do not usebull Doxycycline (D)
Local Anesthetic Use inPregnancy
bull Class Bbull Lidocaine (Xylocaine)bull Etidocainebull Prilocaine bull Class Cbull Procainebull Bupivicainebull Mepivicaine
Use of Local Anestheticsbull Lidocaine + vasoconstrictor most common
local anesthetic used in dentistrybull extensively used in pregnancy with no proven ill
effectsbull accidental intravascular injections of lidocaine
pass through the placenta but the concentrations are too low to harm fetus
bull prilocaine might cause methemoglobinemia
Ulcer healing drugsCimetidine bull FDA category B Famotidinebull FDA category BRanitidinebull FDA category Bbull not known to be harmful
Ulcer healing drugsOmeprazolebull FDA category BNot known to be
harmful Esomeprazolebull FDA category BLansoprazolebull FDA category BPantoprazolebull Avoid unless potential benefit
outweighs riskmdashfetotoxic in animals
Ulcer healing drugs
Misoprostolbull First second third trimesters Avoidmdash
potent uterine stimulant (has been used to induce abortion) and may be teratogenic
Ulcer healing drugs
Antacidsbull Almunium hydroxideMagnesium
hydroxidemdashFDA category B Calcium carbonatemdashFDA category C
SimetheconemdashFDA category C
Use of Nitrous Oxide Gas
bull used over 150 years bull safety is being debatedbull SHORT TERM exposure do not cause
birth defects or spontaneous abortionbull CHRONIC exposure may result in fetal
loss and infertilitybull literature suggests that nitrous oxide
should be avoided until more conclusive research is available
bull FDA Drug class not yet assigned
Common Preventives
bull Fluoridendash No increased risk during pregnancy
bull Xylitolndash No studies no harm reported
bull Chlorhexidinendash No increased risk during pregnancy
Are topical agents safe
bull Fluoridebull Toothpaste amp mouthrinse
bull Xylitol chewing gum bull Chlorhexidine (11 alcohol)bull No over the counter mouthrinses with
alcohol (Listerine 20 alcohol)
Pre-natal Fluoride
bull Daily 22 mg tablet of sodium fluoride during 3rd through 9th months
bull decreases caries rate in offspringbull Safe and effective
Glenn FB 1982
Is it safe to use mercury restorations
bull No evidence of harmful effect
bull Benefits outweigh risks
bull Canada Germany and New Zealand have some restrictions
bull Determine the best option
Referencesbull Wasylko L Matsui D Dykxhoorn SM Rieder MJ Weinberg
S A Review of Common Dental Treatments During Pregnancy J Canadian Dental Association 64434-439 1998
bull Little JW Donald AF Craig SM Rhodus NL Dental Management of the Medically Compromised Patient - 5th edition Mosby Toronto Pp434-442 1997
bull Livingston HM Dellinger TM Holder R Considerations in the management of the pregnant patient Special Care in Dentistry 185 pp183-188 1998
bull Larimore WL Petrie KA Drug use during pregnacy and lactation Primary Care Clinics in Office Practice 271 35-53 2000
bull Health Canada The Safety of DentalAmalgam Minister Of Supply and Services Canada 1996
REFERENCESbull 1 Weiss G Endocrinology of parturition J Clin
Endocrinol Metab 2000854421-5bull 2 Theunissen IM Parer JT Fluid and electrolytes in
pregnancy Clin Obstet Gynecol 1994373-15bull 3 Duvekot JJ Peeters LLH Renal hemodynamics and
volume homeostasis in pregnancy Obstet Gynecol Surv 199449830-9
bull 4 Barron WM Lindheimer MD Medical disorders during pregnancy 2nd ed St Louis Mosby 1995 p 129
bull 5 Thornburg KL Jacobson SL Giraud GD Morton MJ Hemodynamic changes in pregnancy Semin Perinatol 20002411-4
bull 6 Fiese R Herzog S Issues in dental and surgical management of the pregnant patient Oral Surg Oral Med Oral Pathol 198865292-7
bull 7 Martin C Varner MW Physiologic changes in pregnancysurgical implications Clin Obstet Gynecol 199437241-55
bull 8 Clark SL Cotton DB Lee W Bishop C Hill T Southwick J et al Central hemodynamic assessment of normal term pregnancy Am J Obstet Gynecol 19891611439-42
bull 9 Mabie WC Di Sessa TG Crocker LG Sibai BM Arheart KL A longitudinal study of cardiac output in normal human pregnancy Am J Obstet Gynecol 1994170849-56
bull 10 Clapp JF 3rd Capeless E Cardiovascular function before during and after the first and subsequent pregnancies Am J Cardiol 1997801469-73
bull 11 Duvekot JJ Peeters LL Maternal cardiovascular hemodynamic adaptation to pregnancy Obstet Gynecol Surv 199449(Suppl) S1-14
bull 12 Bhagwat AR Engel PJ Heart disease and pregnancy Cardiol Clin 199513163-78
bull 13 Lanni SM Tillinghast J Silver H Hemodynamic changes and baroreflex gain in the supine hypotensive syndrome Am J Obstet Gynecol 20021871636-41
bull 14 Little JW Falace DA Miller CS Rhodus NL Dental management of the medically compromised patient 6th ed St Louis Mosby 2002 p 303
bull 15 Garcia-Rio F Pino JM Gomez L Alvarez-Sala R Villasante C Villamor J Regulation of breathing and perception of dyspnea in healthy pregnant women Chest 1996110446-53
bull 16 McAuliffe F Kametas N Costello J Rafferty GF Greenough A Nicolaides K Respiratory function in singleton and twin pregnancy BJOG 2002109765-9
bull 17 Clapp JF 3rd Seaward BL Sleamaker RH Hiser J Maternal physiologic adaptations to early human pregnancy Am J Obstet Gynecol 19881591456-60
bull 18 OrsquoDay MP Cardio-respiratory physiological adaptation of pregnancy Semin Perinatol 199721268-75
bull 19 Contreras G Gutierrez M Beroiza T Fantin A Oddo H Villarroel L et al Ventilatory drive and respiratory muscle function in pregnancy Am Rev Respir Dis 1991144837-41
bull 20 Turner M Aziz SR Management of the pregnant oral and maxillofac
bull 21 Sifakis S Pharmakides G Anemia in pregnancy Ann N Y Acad Sci 2000900125-36
bull 22 Branch DW Physiologic adaptations of pregnancy Am J Reprod Immunol 199228120-2
bull 23 Burrows RF Kelton JG Incidentally detected thrombocytopenia in healthy mothers and their infants N Engl J Med 1988319 142-5
bull 24 Hanly JG Antiphospholipid syndrome an overview CMAJ 200324(168)1675-82
bull 25 Heilmann L von Tempelhoff GF Pollow K Antiphospholipid syndrome in obstetrics Clin Appl Thromb Hemost 20039 143-50
bull 26 Sherman P Flaxman SM Nausea and vomiting of pregnancy in an evolutionary perspective Am J Obstet Gynecol 2002 185(Suppl)s190-7
bull 27 Koch KL Gastrointestinal factors in nausea and vomiting of pregnancy Am J Obstet Gynecol 2002185(Suppl)s198-203
bull 28 Koch KL Frissora CL Nausea and vomiting during pregnancy Gastroenterol Clin N Am 200332201-34
bull 29 Baron TH Ramirez B Richter JE Gastrointestinal motility disorders during pregnancy Ann Intern Med 1993118 366-75
bull 30 Richter JE Gastroesophageal reflux disease during pregnancy Gastroenterol Clin N Am 200332235-61
bull 31 Marrero JM Goggin PM de Caestecker JS Pearce JM Maxwell JD Determinants of pregnancy heartburn Br J Obstet Gynaecol 199299731-4
bull 32 Hamaoui E Hamaoui M Nutritional assessment and support during pregnancy Gastroenterol Clin N Am 20033259-121
bull 33 King JC Physiology of pregnancy and nutrient metabolism Am J Clin Nutr 200071(suppl)1218s-25s
bull 34 Casanueva E Pfeffer F Fernandez-Gaxiola AC Gutierrez- Valenzuela V Rothenberg SJ Iron and folate status before pregnancy and anemia during pregnancy Ann Nutr Metab 2003 4760-3
bull 35 Chrsquong CL Morgan M Hainsworth I Kingham JG Prospective study of liver dysfunction in Southwest Wales Gut 200251 876-80
bull 36 Rahman TM Wendon J Severe hepatic dysfunction in pregnancy QJM 200295343-57
bull 37 Knox TA Olans LB Liver disease in pregnancy N Engl J Med 1996335569-76
bull 38 Saftlas AF Olson DR Franks AL Atrash H Pokras R Epidemiology of preeclampsia and eclampsia in the United States 1979e1986 Am J Obstet Gynecol 1990163460-5
bull 39 Walker JJ Pre-eclampsia Lancet 20003561260-5
bull 40 Davidson JM Renal disorders in pregnancy Curr Opin Obstet Gynecol 200113109-14
bull 41 Dafnis E Sabatini S The effect of pregnancy on renal function physiology and pathophysiologyAmJMedSci 1992303184-205
bull 42 Davison JM Shiells EA Philips PR Lindheimer MD Serial evaluation of vasopressin release and thirst in human pregnancy Role of human chorionic gonadotrophin in the osmoregulatory changes of gestation J Clin Invest 198881798-806
bull 43 Glinoer D de Nayer P Bourdoux P Lemone M Robyn C van Steirteghem A et al Regulation of maternal thyroid during pregnancy J Clin Endocrinol Metab 199071276-87
bull 44 Wilson SG Retallack RW Kent JC Worth GK Gutteridge DH Serum free 125-dihydroxyvitamin D and the free 125- dihydroxyvitamin D index during a longitudinal study of human pregnancy and lactation Clin Endocrinol 199032613-22
bull 45 Rasmussen N Frolich A Hornnes PJ Hegedus L Serum ionized calcium and intact parathyroid hormone levels during pregnancy and postpartum Br J Obstet Gynaecol 199097857-9
bull 46 Guyton AC Textbook of medical physiology 8th ed Philadelphia W B Saunders 1991 p 915e28
bull 47 Trainer PJ Corticosteroids and pregnancy Semin Reprod Med 200220375-80
bull 48 Soory M Hormonal factors in periodontal disease Dent Update 200027380-3
bull 49 Hugoson A Gingivitis in pregnant women A longitudinal clinical study Odontol Revy 19712265-84
bull 50 Neville BW Damm DD Allen CM Bouquot JE Oral amp Maxillofacial Pathology 3rd ed Philadelphia W B Saunders 2002 p 329-30 447-9
bull 51 Tilakaratne A Soory M Ranasinghe AW Corea SM Ekanayake SL de Silva M Periodontal disease status during pregnancy and 3 months post-partum in rural population of Sri-Lankan women J Clin Periodontol 200027787-92
bull 52 Laine M Tenovuo J Lehtonen OP Ojanatko-Harri A Vilja P Tuohimaa P Pregnancy e related changes in human whole saliva Arch Oral Biol 198833913-7
bull 53 Yuan K Wing LY Lin MT Pathogenetic roles of angiogenic factors in pyogenic granulomas in pregnancy are modulated by female sex hormones J Periodontol 200273701-8
bull 54 Evans RD Briggs PF Tooth-surface loss related to pregnancyinduced vomiting Prim Dent Care 1994124-6
bull 55 Salvolini E Di Giorgio R Curatola A Mazzanti L Fratto G Biochemical modifications of human whole saliva induced by pregnancy Br J Obstet Gynaec 1998105656-60
bull 56 Mauldin JG Newman RB Preterm birth risk assessment Semin Perinatol 200125215-22
bull 57 Heine RP McGregor JA Goodwin TM Artal R Hayashi RH Robertson PA et al Serial salivary estriol to detect an increased risk of preterm birth Obstet Gynecol 200096490-7
bull 58 Kauh YC Zachian TF Melasma Adv Exp Med Biol 1999455 491-9
bull 59 Wong RC Ellis CN Physiologic skin changes in pregnancy J Am Acad Dermatol 198410929-40
bull 60 Errickson CV Matus NR Skin disorders of pregnancy Am Fam Physician 199449605-10
bull 61 Lopez NJ Smith PC Gutierrez J Periodontal therapy may reduce the risk of preterm low birth weight in women with periodontal disease a randomized controlled trial J Periodontol 200273911-24
bull 62 McGaw T Periodontal disease and preterm delivery of lowbirth- weight infants J Can Dent Assoc 200268165-9
bull 63 Richards AG Dental x-ray protection Dent Clin North Am 1968631-41
bull 64 1990 Recommendations of the International Commission on Radiological Protection Ann ICRP 1991211-201
bull 65 Hall EJ Radiation the two-edged sword cancer risks at high and low doses Cancer J 20006343-50
bull 66 Diethelm L Xu H Diagnostic imaging of the lung during pregnancy Clin Obstet Gynecol 19963936-55
bull 67 Brent RL The effects of embryonic and fetal exposure to x-rays microwaves and ultrasound ClinObstetGynecol 198326484-510
bull 68 National Council on Radiation Protection NCRP report no128 1998 Bethesda Md Author
bull 69 Wasylko L Matsui D Dykxhoorn SM Reider MJ Weinberg S A review of common dental treatments during pregnancy implications for patients and dental personnel J Can Dent Assoc 199864434-9
bull 70 Freeman JP Brand JW Radiation doses of commonly used dental radiographic surveys Oral Surg Oral Med Oral Pathol 199477285-9
bull 71 Kircos LTAngin LL Lorton LOrder ofmagnitude dose reduction in intraoral radiography J Am Dent Assoc 1987114344-7
bull 72 Updegrave WJ Simplified and standardized intraoral radiography with reduced tissue irradiation J Am Dent Assoc 197285861-9
bull 73 Wood RE Harris AM van der Merwe EJ Nortje CJ The leaded apron revisited does it reduce gonadal radiation dose in dental radiology Oral Surg Oral Med Oral Pathol 199171642-6
bull 74 An update on radiographic practices information and recommendations ADA Council on Scientific Affairs J Am Dent Assoc 2001132234-8
bull 75 Rayburn WF Recommending medications during pregnancy an evidence based approach Clin Obstet Gynecol 2002451-5
bull 76 Rathmell JP Viscomi C Ashburn MA Management of nonobstetric pain during pregnancy and lactation Anesth Analg 1997851074-87
bull 77 Teratology society public affairs committee FDA classification of drugs for teratogenic risk Teratology 199449446-7
bull 78 Moore PA Selecting drugs for the pregnant dental patient J Am Dent Assoc 19981291281-6
bull 79 Haas DA An update on analgesics for the management of acute postoperative dental pain J Can Dent Assoc 200268476-82
bull 80 Haas DA Pynn BR Sands TD Drug use for the pregnant or lactating patient Gen Dent 20004854-60
bull 81 Committee on Drugs American Academy of Pediatrics The transfer of drugs and other chemicals into human milk Pediatrics 199493137-50
bull 82 Nielsen GL Sorensen HT Larsen H Pedersen L Risk of adverse birth outcome and miscarriage in pregnant users of nonsteroidal anti-inflammatory drugs population based observational study and case-control study BMJ 2001322266-70
bull 83 Janssen N Genta M The effects of immunosuppressive and anti-inflammatory medications on fertility pregnancy and lactation Arch Intern Med 200016610-9
bull 84 Ostensen M Nonsteroidal anti-inflammatory drugs during pregnancy Scand J Rheumatol Suppl 1998107128-32
bull 85 USPDI -Drug information for the health care professional 22nd ed Greenwood Village CO Micromedex 2002 p 152-79
bull 86 Denson DD Coyle DE Thompson GA Santos D Turner PA Myers JA et al Bupivacaine protein binding in the term parturient effects of lactic acidosis Clin Pharmacol Ther 198435702-9
bull 87 Dillon DE Wagner CL Wiest D Newman RB Drug therapy in the nursing mother Obstet Gynecol Clin North Am 199724 675-96
bull 88 Dashe JS Gilstrap LC Antibiotic use in pregnancy Obstet Gynecol Clin North Am 199724617-29
bull 89 American College of Rheumatology Ad hoc Committee on Clinical Guidelines Guidelines for monitoring drug therapy in rheumatoid arthritis Arthritis Rheum 199639723-31
bull 90 Ng PC The fetal and neonatal hypothalamic-pituitary-adrenal axis Arch Dis Child Fetal Neonatal Ed 200082F250-4
bull 91 Crowley P Antenatal corticosteroidsmdashcurrent thinking BJOG 2003110(Suppl 20)77-8
bull 92 ACOG committee opinion antenatal corticosteroid therapy for fetal maturation Obstet Gynecol 200299871-3
bull 93 Ost L Wettrell G Bjorkhem I Rane A Prednisolone excretion in human milk J Pediatr 19851061008-11
bull 94 Rowland AS Baird DD Shore DL Weinberg CR Savitz DA Wilcox AJ Nitrous oxide and spontaneous abortion in female dental assistants Am J Epidemiol 1995141531-8
bull 95 McGlothlin JD Jensen PA Fischbach TJ Hughes RT Jones JH Control of anesthetic gases in dental operatories Scand J Work Environ Health 199218(Suppl 2)103-5
bull ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY Volume 97 Number 6 Suresh and Radfar 681
bull 96 Rosen MA Nitrous oxide for relief of labor pain a systematic review Am J Obstet Gynecol 2002186(Suppl Nature)S110-6
bull 97 Sands TD Pynn BR Management considerations for the pregnant or nursing emergency patient Ont Dent 199875 17-9
bull 98 Daya S Recurrent spontaneous early pregnancy loss and low dose aspirin Minerva Ginecol 200355441-9
bull 99 Sinclair C Handbook of obstetrical emergencies 1st ed Philadelphia WB Saunders 1996 p 29-39 69
bull 100 Tarsitano BF Rollings RE The pregnant dental patient evaluation and management Gen Dent 199341226-34
bull 101 Livingston MH Dlllinger TM Holder R Consideration in the management of the pregnant patient SCD Special Care in Dentistry 199818183-8
Thank you
- A Review on the principle of Dental Management of the Pregnant patient
- Slide 2
- Questions that a dentist may ask
- Stages of Pregnancy
- Slide 5
- Slide 6
- Physiologic Changes in Pregnancy
- Systemic changes in pregnancy
- FLAT SUPINE POSITIONING
- SUPINE HYPOTENSION SYNDROME (Vena Cava Compression)
- Supine Hypotension Syndrome
- Slide 12
- Supine Hypotension Syndrome
- Prevention of Supine Hypotensive Syndrome
- Treatment of Supine Hypotensive Syndrome
- How should the pregnant woman be positioned
- Slide 17
- Slide 18
- Slide 19
- Slide 20
- Slide 21
- Slide 22
- Slide 23
- Pregnancy Related Oral Health Problems
- Oral Problems in Pregnancy
- Pregnancy Gingivitis Pathophysiology
- Pregnancy Gingivitis
- Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Gum Problems - Pregnancy Granuloma
- Slide 31
- Gum Changes - Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Candidiasis
- Pregnancy Myths
- Other Oral Conditions in Pregnancy
- Changes During Pregnancy that Affect Oral Health
- Saliva changes
- Increased Bacteria
- Slide 40
- Enamel erosion caused by frequent vomiting
- Treatment for Acid Exposure
- Oral Diseases Can Effect Pregnancy
- Periodontal Disease and Preterm Labor
- Periodontal Disease and Low Birth Weight
- Periodontal Disease and Preeclampsia
- Periodontitis and Pre-eclampsia
- Dental Considerations
- Treatment Timing
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Slide 52
- Use of Radiation on Pregnant Patient
- Radiographs during Pregnancy
- Risks of Dental X-Rays
- FDA drug classification for pregnancy
- Slide 57
- FDA drug classification for pregnancy
- Slide 59
- Slide 60
- Slide 61
- Common Analgesics
- Analgesics
- Analgesics - continued
- Analgesics to Use During 1st and 2nd Trimester
- Analgesics to Avoid During the Third Trimester
- Sedation in Pregnancy
- Common Antibiotics
- Antibiotics
- Antibiotics To Use During Pregnancy
- Antibiotics to Avoid during Pregnancy
- The Problem With Tetracycline
- Other Antimicrobial Agents
- Local Anesthetic Use in Pregnancy
- Use of Local Anesthetics
- Ulcer healing drugs
- Slide 77
- Slide 78
- Slide 79
- Use of Nitrous Oxide Gas
- Common Preventives
- Are topical agents safe
- Pre-natal Fluoride
- Is it safe to use mercury restorations
- References
- REFERENCES
- Slide 87
- Slide 88
- Slide 89
- Slide 90
- Slide 91
- Slide 92
- Slide 93
- Slide 94
- Slide 95
- Slide 96
- Slide 97
- Slide 98
- Thank you
-
Systemic changes in pregnancy
bull Pregnant women with anti-phospholipid syndrome are at uarr risk for thrombo-embolisim
bull They are placed on subcutaneous low molecular weight heparin (LMWH)
bull These patients must be hospitalized for dental care
Pregnancy RelatedOral Health Problems
bull Pregnancy Gingivitisbull Pregnancy Epulis bull Increased Tooth Mobilitybull Dental Cariesbull Erosionbull Dental Problems in relation to Labor
and Delivery
Oral Problems in Pregnancy
bullPregnancy GingivitisbullMost common oral manifestation (50-100 of women)bullCaused by hormonal and vascular changes of pregnancy
Pregnancy Gingivitis Pathophysiology
bull Elevated circulating estrogen increases capillary permeability
bull Preexisting gingivitis may predispose to pregnancy gingivitis
Pregnancy Gingivitis
bullOccurs commonly in the 2nd to 8th monthsbullTendency to bleed very easilybullTreatment Scaling root-planing currettage OHI
Pregnancy Granuloma
bullOccurs in up to 5 of womenbullMost common in buccal maxillary anterior areasbullUsually starts in an area of gingivitis
Pregnancy Granuloma (continued)
bullRapid growth up to 2 cmbullSingle tumor-like growthbullusually in interdental papillaebullPurplish to bluish in color may be ulcerated- bleeds easily
Gum Problems - Pregnancy Granuloma
Gum Problems - Pregnancy Granuloma
Gum Changes - Pregnancy Granuloma
Pregnancy Granuloma (continued)
Treatment
bull Scaling and root planingbull Excision if it is too large or bleeds too
easilybull May regress spontaneously after
pregnancy
Candidiasis
bullWipes offbullUsually asymptomatic but may burnbullTreatment topical or systemic antifungals
Pregnancy MythsbullldquoA mother loses a tooth for every babyrdquobullNo evidence that aphthous ulcers are any more common in pregnancy
Other Oral Conditions in Pregnancy
bull Dry mouthbull Excessive salivationbull Tooth erosions associated with
severe GERD or hyperemesis
Changes During Pregnancy that Affect Oral Health
bull Hormonal Affects
ndash Increased tooth mobility
ndash Saliva changes
ndash Increased bacteria
ndash Gingival problems
Saliva changesbull Decreased buffers
bull Decreased minerals
bull Decreasing flow first and last trimester
bull Increased flow second trimester
bull More acidic
Increased Bacteriabull Increased acidity
ndash Increase in decay-causing bacteriabull Increased Snacking
ndash Morning sicknesslow blood sugarndash Between-meal snacks
bull Increase in amount and frequency of starchescarbohydrates ndash Crackers are commonly recommendedndash Promotes decay-causing bacteria
Changes During Pregnancy that Affect Oral Healthbull Morning sickness
ndash Difficulty with hygienebull Gingival diseasebull Tooth decay
ndash Vomitingbull Esophogeal Reflux (heartburn)bull Acid exposure
ndash Irritation of the gumsndash Weakening of tooth enamelndash Dental erosion
Enamel erosion caused by frequent vomiting
Treatment for Acid Exposure
bull Do NOT brush immediately after vomiting
bull Rinse ndash Water with baking sodandash Antacidndash Plain water
bull Eat some cheese
Oral Diseases Can Effect Pregnancy
bull Preterm low birth weight (LBW) linked to periodontal disease
bull Thorough calculus (tartar) removal in pregnant women with periodontitis may reduce pre-term births
Periodontal Disease and Preterm LaborbullMaternal periodontal disease is associated with increased risk of preterm laborbullAnaerobic oral gram-negative bacteria cause inflammatory responsebullInflammatory response stimulates prostaglandin and cytokine production to stimulate labor
Periodontal Disease and Low Birth Weight
bull Periodontal disease is associated with low birth weight
bull Evidence is not conclusivebull Biochemical mechanism similar cascade
as in preterm labor leading to placental blood flow restriction and necrosis
Periodontal Disease and Preeclampsia
bull Emerging databull Mechanism unclearbull Proposed mechanism
ndash Periodontal infection leads to inflammatory vascular damage
ndash Triggers cell damage in placenta
Periodontitis and Pre-eclampsia
bull Periodontal disease may be associated with pre-eclampsia (Boggess 2003)
bull PGE2 IL-1 and TNF-α from gingival crevicular fluid were higher in women with preeclampsia compared with healthy matched pregnant women (Oettinger-Barak 2003)
Dental Considerations
bull timing of treatment for pregnant patientsbull dental radiation exposurebull use of local anestheticsbull prescription of common antibiotics and
analgesicsbull nitrous oxide gas administration
Treatment Timing
bull First Trimesterndash Spontaneous miscarriages naturally occur
more often in 1st trimesterndash Avoid elective treatment that can be delayedndash Offer anticipatory guidance
bull Second Trimesterndash The optimal time for dental treatmentndash Organogenesis complete fetus not largendash Easier to prevent than treat established disease
bull Third Trimesterndash Late in term very uncomfortable (short visits)ndash Position slightly on left side
Timing of Dental Treatment During Pregnancy - From Little and Fallace
First Trimester
bull Plaque controlbull Oral hygiene instructionbull Scaling polishing curettagebull Avoid elective treatment urgent care
only
Timing of Dental Treatment During Pregnancy - From Little and Fallace
Second Trimester
bull Plaque controlbull Oral hygiene instructionbull Scaling polishing curettagebull Routine dental care
Timing of Dental Treatment During Pregnancy - From Little and Fallace
Third Trimester
bull Plaque controlbull Oral hygiene instructionbull Scaling polishing curettagebull Routine dental care (after middle of third
trimester elective care should be avoided)
Use of Radiation on Pregnant Patientbull Dose given and time of gestation are
importantbull doses lt 5-10 rads (cGy) not teratogenicbull fetus is most susceptible to radiation
between the 2nd and 6th week of gestationbull single dental x-ray exposes patient to 001
millirads of radiation In relative terms this amount is 40 times less than daily dose acquired from cosmic radiation Therefore diagnostic radiation should not be withheld during pregnancy
Radiographs during Pregnancy
bull Take as needed with optimal methods for reducing secondary radiation and exposure time
bull Always use a lead apronbull Exposure to fetus (with apron use) is 00001
centiGray(rad)bull Daily cosmic radiation - 0004 centiGray (rad)
Risks of Dental X-Rays
bull X-ray only if necessary (ie root canal therapy trauma)
bull When x-rays are indicated radiation exposure is extremely low
bull Exposure can be limited byndash Lead apron shielding ndash Modern fast film ndash Avoiding retakes
FDA drug classification for pregnancybull Combines risk statements including
congenital anomalies fetal effects perinatal risks and therapeutic risk-benefit ratio
bull Untreated disease or condition may pose more serious risks to both mother and fetus than any theoretical risks from the medication
bull Category A thru D and X
FDA drug classification for pregnancy
bull A = Controlled Studies in women fail to demonstrate a risk to the fetus in the first trimester and the possibility of fetal harm appears remote
FDA drug classification for pregnancy
bull B = Animal studies show no risk or if risk shown in animals controlled
trials in women showed no risk
FDA drug classification for pregnancy
bull C = Studies in animals with adverse effects and no human studies
OR no animal or human studies but benefits of use may outweigh potential harms
FDA drug classification for pregnancy
bull D = There is evidence of human fetal risk but benefits may outweigh risks
FDA drug classification for pregnancy
bull X = Contraindicated
Common Analgesics
bull paracetamol (B)bull Ibuprofen (BD) bull Oxycodone (BD) bull Hydrocodone and codeine
(CD)
avoid in third trimester
Analgesics
bull Paracetamol is the analgesic of choice for all stages of gestation
bull used to treat mild to moderate pain and fevers
bull short term usage is believed to be safebull avoid chronic and large doses of
paracetamol1048715
Analgesics - continuedbull Aspirin is nonteratogenic but may cause
maternal and fetal hemorrhagebull large and chronic doses during last trimester
may result in premature closure of ductus arteriosus fetal hypertension anemia and low birth weight
bull avoid ibuprofen in 3rd trimester because of possible adverse circulatory effects
bull short term use of codeine seems safebull avoid codeine late in gestation because of
possible fetal respiratory depression and withdrawal symptoms
Analgesics to Use During1st and 2nd Trimester
bull Category B (for best)bull Paracetamol Ibuprofenbull Naproxenbull Category C (use with caution)bull Paracetamol with codeine or
hydrocodonebull Paracetamol with oxycodone
Analgesics to Avoid During theThird Trimesterbull Causes delivery problemsbull Aspirin (C 3D)bull Ibuprofen (B3D)bull Naproxen (B3D)bull Causes neonatal respiratory
depression and opioid withdrawalbull Codeine (C3D)bull Hydrocodone (C3D)bull Oxycodone(C3D)
Sedation in Pregnancy
bull SedativesAnxiolytics (eg Diazepam ) are rated D and can cause oral clefts with prolonged exposure
bull Nitrous oxide should not be used in 1st trimester (If used in 2nd and 3rd do not go below 50 O2)
Common Antibioticsbull To treat oral abscess or cellulitis
ndash Penicillin (B) ndash Amoxicillin (B) ndash Cephalexin (B)ndash Erythromycin base (B) (Not estolate as it
cause cholestatic hepatitis)ndash Clindamycin (B)
Antibioticsbull penicillin V and amoxicillin is preferred drug
for mild to moderate infectionsbull widely used for many years with no ill effectsbull no studies show penicillin to be teratogenicbull amoxicillin extensively used without harming
the fetusbull Drug classes1048715 B penicillin cephalosporins erythromycin clindamycin Azithromycin D Tetracycline
Antibiotics To Use During Pregnancy
bull Penicillin Vbull Amoxicillinbull Erythromycin (base form)bull Cephalexin cephalosporinbull Clindamycinbull Metronidazole
Antibiotics to Avoid duringPregnancy
bull Doxycyclinebull Tetracyclinebull Erythromycin (estolate form)bull Vancomycin
The Problem With Tetracycline
bull Accumulates in bones and chelates calcium
bull Inhibits bone growthbull Discolors teeth
Other Antimicrobial Agentsbull OK to usebull Nystatin (B)bull Chlorhexidine rinse (B)bull Use with cautionbull Clotrimazole (C)bull Ketoconazole (C)bull Fluconazole (C)bull Do not usebull Doxycycline (D)
Local Anesthetic Use inPregnancy
bull Class Bbull Lidocaine (Xylocaine)bull Etidocainebull Prilocaine bull Class Cbull Procainebull Bupivicainebull Mepivicaine
Use of Local Anestheticsbull Lidocaine + vasoconstrictor most common
local anesthetic used in dentistrybull extensively used in pregnancy with no proven ill
effectsbull accidental intravascular injections of lidocaine
pass through the placenta but the concentrations are too low to harm fetus
bull prilocaine might cause methemoglobinemia
Ulcer healing drugsCimetidine bull FDA category B Famotidinebull FDA category BRanitidinebull FDA category Bbull not known to be harmful
Ulcer healing drugsOmeprazolebull FDA category BNot known to be
harmful Esomeprazolebull FDA category BLansoprazolebull FDA category BPantoprazolebull Avoid unless potential benefit
outweighs riskmdashfetotoxic in animals
Ulcer healing drugs
Misoprostolbull First second third trimesters Avoidmdash
potent uterine stimulant (has been used to induce abortion) and may be teratogenic
Ulcer healing drugs
Antacidsbull Almunium hydroxideMagnesium
hydroxidemdashFDA category B Calcium carbonatemdashFDA category C
SimetheconemdashFDA category C
Use of Nitrous Oxide Gas
bull used over 150 years bull safety is being debatedbull SHORT TERM exposure do not cause
birth defects or spontaneous abortionbull CHRONIC exposure may result in fetal
loss and infertilitybull literature suggests that nitrous oxide
should be avoided until more conclusive research is available
bull FDA Drug class not yet assigned
Common Preventives
bull Fluoridendash No increased risk during pregnancy
bull Xylitolndash No studies no harm reported
bull Chlorhexidinendash No increased risk during pregnancy
Are topical agents safe
bull Fluoridebull Toothpaste amp mouthrinse
bull Xylitol chewing gum bull Chlorhexidine (11 alcohol)bull No over the counter mouthrinses with
alcohol (Listerine 20 alcohol)
Pre-natal Fluoride
bull Daily 22 mg tablet of sodium fluoride during 3rd through 9th months
bull decreases caries rate in offspringbull Safe and effective
Glenn FB 1982
Is it safe to use mercury restorations
bull No evidence of harmful effect
bull Benefits outweigh risks
bull Canada Germany and New Zealand have some restrictions
bull Determine the best option
Referencesbull Wasylko L Matsui D Dykxhoorn SM Rieder MJ Weinberg
S A Review of Common Dental Treatments During Pregnancy J Canadian Dental Association 64434-439 1998
bull Little JW Donald AF Craig SM Rhodus NL Dental Management of the Medically Compromised Patient - 5th edition Mosby Toronto Pp434-442 1997
bull Livingston HM Dellinger TM Holder R Considerations in the management of the pregnant patient Special Care in Dentistry 185 pp183-188 1998
bull Larimore WL Petrie KA Drug use during pregnacy and lactation Primary Care Clinics in Office Practice 271 35-53 2000
bull Health Canada The Safety of DentalAmalgam Minister Of Supply and Services Canada 1996
REFERENCESbull 1 Weiss G Endocrinology of parturition J Clin
Endocrinol Metab 2000854421-5bull 2 Theunissen IM Parer JT Fluid and electrolytes in
pregnancy Clin Obstet Gynecol 1994373-15bull 3 Duvekot JJ Peeters LLH Renal hemodynamics and
volume homeostasis in pregnancy Obstet Gynecol Surv 199449830-9
bull 4 Barron WM Lindheimer MD Medical disorders during pregnancy 2nd ed St Louis Mosby 1995 p 129
bull 5 Thornburg KL Jacobson SL Giraud GD Morton MJ Hemodynamic changes in pregnancy Semin Perinatol 20002411-4
bull 6 Fiese R Herzog S Issues in dental and surgical management of the pregnant patient Oral Surg Oral Med Oral Pathol 198865292-7
bull 7 Martin C Varner MW Physiologic changes in pregnancysurgical implications Clin Obstet Gynecol 199437241-55
bull 8 Clark SL Cotton DB Lee W Bishop C Hill T Southwick J et al Central hemodynamic assessment of normal term pregnancy Am J Obstet Gynecol 19891611439-42
bull 9 Mabie WC Di Sessa TG Crocker LG Sibai BM Arheart KL A longitudinal study of cardiac output in normal human pregnancy Am J Obstet Gynecol 1994170849-56
bull 10 Clapp JF 3rd Capeless E Cardiovascular function before during and after the first and subsequent pregnancies Am J Cardiol 1997801469-73
bull 11 Duvekot JJ Peeters LL Maternal cardiovascular hemodynamic adaptation to pregnancy Obstet Gynecol Surv 199449(Suppl) S1-14
bull 12 Bhagwat AR Engel PJ Heart disease and pregnancy Cardiol Clin 199513163-78
bull 13 Lanni SM Tillinghast J Silver H Hemodynamic changes and baroreflex gain in the supine hypotensive syndrome Am J Obstet Gynecol 20021871636-41
bull 14 Little JW Falace DA Miller CS Rhodus NL Dental management of the medically compromised patient 6th ed St Louis Mosby 2002 p 303
bull 15 Garcia-Rio F Pino JM Gomez L Alvarez-Sala R Villasante C Villamor J Regulation of breathing and perception of dyspnea in healthy pregnant women Chest 1996110446-53
bull 16 McAuliffe F Kametas N Costello J Rafferty GF Greenough A Nicolaides K Respiratory function in singleton and twin pregnancy BJOG 2002109765-9
bull 17 Clapp JF 3rd Seaward BL Sleamaker RH Hiser J Maternal physiologic adaptations to early human pregnancy Am J Obstet Gynecol 19881591456-60
bull 18 OrsquoDay MP Cardio-respiratory physiological adaptation of pregnancy Semin Perinatol 199721268-75
bull 19 Contreras G Gutierrez M Beroiza T Fantin A Oddo H Villarroel L et al Ventilatory drive and respiratory muscle function in pregnancy Am Rev Respir Dis 1991144837-41
bull 20 Turner M Aziz SR Management of the pregnant oral and maxillofac
bull 21 Sifakis S Pharmakides G Anemia in pregnancy Ann N Y Acad Sci 2000900125-36
bull 22 Branch DW Physiologic adaptations of pregnancy Am J Reprod Immunol 199228120-2
bull 23 Burrows RF Kelton JG Incidentally detected thrombocytopenia in healthy mothers and their infants N Engl J Med 1988319 142-5
bull 24 Hanly JG Antiphospholipid syndrome an overview CMAJ 200324(168)1675-82
bull 25 Heilmann L von Tempelhoff GF Pollow K Antiphospholipid syndrome in obstetrics Clin Appl Thromb Hemost 20039 143-50
bull 26 Sherman P Flaxman SM Nausea and vomiting of pregnancy in an evolutionary perspective Am J Obstet Gynecol 2002 185(Suppl)s190-7
bull 27 Koch KL Gastrointestinal factors in nausea and vomiting of pregnancy Am J Obstet Gynecol 2002185(Suppl)s198-203
bull 28 Koch KL Frissora CL Nausea and vomiting during pregnancy Gastroenterol Clin N Am 200332201-34
bull 29 Baron TH Ramirez B Richter JE Gastrointestinal motility disorders during pregnancy Ann Intern Med 1993118 366-75
bull 30 Richter JE Gastroesophageal reflux disease during pregnancy Gastroenterol Clin N Am 200332235-61
bull 31 Marrero JM Goggin PM de Caestecker JS Pearce JM Maxwell JD Determinants of pregnancy heartburn Br J Obstet Gynaecol 199299731-4
bull 32 Hamaoui E Hamaoui M Nutritional assessment and support during pregnancy Gastroenterol Clin N Am 20033259-121
bull 33 King JC Physiology of pregnancy and nutrient metabolism Am J Clin Nutr 200071(suppl)1218s-25s
bull 34 Casanueva E Pfeffer F Fernandez-Gaxiola AC Gutierrez- Valenzuela V Rothenberg SJ Iron and folate status before pregnancy and anemia during pregnancy Ann Nutr Metab 2003 4760-3
bull 35 Chrsquong CL Morgan M Hainsworth I Kingham JG Prospective study of liver dysfunction in Southwest Wales Gut 200251 876-80
bull 36 Rahman TM Wendon J Severe hepatic dysfunction in pregnancy QJM 200295343-57
bull 37 Knox TA Olans LB Liver disease in pregnancy N Engl J Med 1996335569-76
bull 38 Saftlas AF Olson DR Franks AL Atrash H Pokras R Epidemiology of preeclampsia and eclampsia in the United States 1979e1986 Am J Obstet Gynecol 1990163460-5
bull 39 Walker JJ Pre-eclampsia Lancet 20003561260-5
bull 40 Davidson JM Renal disorders in pregnancy Curr Opin Obstet Gynecol 200113109-14
bull 41 Dafnis E Sabatini S The effect of pregnancy on renal function physiology and pathophysiologyAmJMedSci 1992303184-205
bull 42 Davison JM Shiells EA Philips PR Lindheimer MD Serial evaluation of vasopressin release and thirst in human pregnancy Role of human chorionic gonadotrophin in the osmoregulatory changes of gestation J Clin Invest 198881798-806
bull 43 Glinoer D de Nayer P Bourdoux P Lemone M Robyn C van Steirteghem A et al Regulation of maternal thyroid during pregnancy J Clin Endocrinol Metab 199071276-87
bull 44 Wilson SG Retallack RW Kent JC Worth GK Gutteridge DH Serum free 125-dihydroxyvitamin D and the free 125- dihydroxyvitamin D index during a longitudinal study of human pregnancy and lactation Clin Endocrinol 199032613-22
bull 45 Rasmussen N Frolich A Hornnes PJ Hegedus L Serum ionized calcium and intact parathyroid hormone levels during pregnancy and postpartum Br J Obstet Gynaecol 199097857-9
bull 46 Guyton AC Textbook of medical physiology 8th ed Philadelphia W B Saunders 1991 p 915e28
bull 47 Trainer PJ Corticosteroids and pregnancy Semin Reprod Med 200220375-80
bull 48 Soory M Hormonal factors in periodontal disease Dent Update 200027380-3
bull 49 Hugoson A Gingivitis in pregnant women A longitudinal clinical study Odontol Revy 19712265-84
bull 50 Neville BW Damm DD Allen CM Bouquot JE Oral amp Maxillofacial Pathology 3rd ed Philadelphia W B Saunders 2002 p 329-30 447-9
bull 51 Tilakaratne A Soory M Ranasinghe AW Corea SM Ekanayake SL de Silva M Periodontal disease status during pregnancy and 3 months post-partum in rural population of Sri-Lankan women J Clin Periodontol 200027787-92
bull 52 Laine M Tenovuo J Lehtonen OP Ojanatko-Harri A Vilja P Tuohimaa P Pregnancy e related changes in human whole saliva Arch Oral Biol 198833913-7
bull 53 Yuan K Wing LY Lin MT Pathogenetic roles of angiogenic factors in pyogenic granulomas in pregnancy are modulated by female sex hormones J Periodontol 200273701-8
bull 54 Evans RD Briggs PF Tooth-surface loss related to pregnancyinduced vomiting Prim Dent Care 1994124-6
bull 55 Salvolini E Di Giorgio R Curatola A Mazzanti L Fratto G Biochemical modifications of human whole saliva induced by pregnancy Br J Obstet Gynaec 1998105656-60
bull 56 Mauldin JG Newman RB Preterm birth risk assessment Semin Perinatol 200125215-22
bull 57 Heine RP McGregor JA Goodwin TM Artal R Hayashi RH Robertson PA et al Serial salivary estriol to detect an increased risk of preterm birth Obstet Gynecol 200096490-7
bull 58 Kauh YC Zachian TF Melasma Adv Exp Med Biol 1999455 491-9
bull 59 Wong RC Ellis CN Physiologic skin changes in pregnancy J Am Acad Dermatol 198410929-40
bull 60 Errickson CV Matus NR Skin disorders of pregnancy Am Fam Physician 199449605-10
bull 61 Lopez NJ Smith PC Gutierrez J Periodontal therapy may reduce the risk of preterm low birth weight in women with periodontal disease a randomized controlled trial J Periodontol 200273911-24
bull 62 McGaw T Periodontal disease and preterm delivery of lowbirth- weight infants J Can Dent Assoc 200268165-9
bull 63 Richards AG Dental x-ray protection Dent Clin North Am 1968631-41
bull 64 1990 Recommendations of the International Commission on Radiological Protection Ann ICRP 1991211-201
bull 65 Hall EJ Radiation the two-edged sword cancer risks at high and low doses Cancer J 20006343-50
bull 66 Diethelm L Xu H Diagnostic imaging of the lung during pregnancy Clin Obstet Gynecol 19963936-55
bull 67 Brent RL The effects of embryonic and fetal exposure to x-rays microwaves and ultrasound ClinObstetGynecol 198326484-510
bull 68 National Council on Radiation Protection NCRP report no128 1998 Bethesda Md Author
bull 69 Wasylko L Matsui D Dykxhoorn SM Reider MJ Weinberg S A review of common dental treatments during pregnancy implications for patients and dental personnel J Can Dent Assoc 199864434-9
bull 70 Freeman JP Brand JW Radiation doses of commonly used dental radiographic surveys Oral Surg Oral Med Oral Pathol 199477285-9
bull 71 Kircos LTAngin LL Lorton LOrder ofmagnitude dose reduction in intraoral radiography J Am Dent Assoc 1987114344-7
bull 72 Updegrave WJ Simplified and standardized intraoral radiography with reduced tissue irradiation J Am Dent Assoc 197285861-9
bull 73 Wood RE Harris AM van der Merwe EJ Nortje CJ The leaded apron revisited does it reduce gonadal radiation dose in dental radiology Oral Surg Oral Med Oral Pathol 199171642-6
bull 74 An update on radiographic practices information and recommendations ADA Council on Scientific Affairs J Am Dent Assoc 2001132234-8
bull 75 Rayburn WF Recommending medications during pregnancy an evidence based approach Clin Obstet Gynecol 2002451-5
bull 76 Rathmell JP Viscomi C Ashburn MA Management of nonobstetric pain during pregnancy and lactation Anesth Analg 1997851074-87
bull 77 Teratology society public affairs committee FDA classification of drugs for teratogenic risk Teratology 199449446-7
bull 78 Moore PA Selecting drugs for the pregnant dental patient J Am Dent Assoc 19981291281-6
bull 79 Haas DA An update on analgesics for the management of acute postoperative dental pain J Can Dent Assoc 200268476-82
bull 80 Haas DA Pynn BR Sands TD Drug use for the pregnant or lactating patient Gen Dent 20004854-60
bull 81 Committee on Drugs American Academy of Pediatrics The transfer of drugs and other chemicals into human milk Pediatrics 199493137-50
bull 82 Nielsen GL Sorensen HT Larsen H Pedersen L Risk of adverse birth outcome and miscarriage in pregnant users of nonsteroidal anti-inflammatory drugs population based observational study and case-control study BMJ 2001322266-70
bull 83 Janssen N Genta M The effects of immunosuppressive and anti-inflammatory medications on fertility pregnancy and lactation Arch Intern Med 200016610-9
bull 84 Ostensen M Nonsteroidal anti-inflammatory drugs during pregnancy Scand J Rheumatol Suppl 1998107128-32
bull 85 USPDI -Drug information for the health care professional 22nd ed Greenwood Village CO Micromedex 2002 p 152-79
bull 86 Denson DD Coyle DE Thompson GA Santos D Turner PA Myers JA et al Bupivacaine protein binding in the term parturient effects of lactic acidosis Clin Pharmacol Ther 198435702-9
bull 87 Dillon DE Wagner CL Wiest D Newman RB Drug therapy in the nursing mother Obstet Gynecol Clin North Am 199724 675-96
bull 88 Dashe JS Gilstrap LC Antibiotic use in pregnancy Obstet Gynecol Clin North Am 199724617-29
bull 89 American College of Rheumatology Ad hoc Committee on Clinical Guidelines Guidelines for monitoring drug therapy in rheumatoid arthritis Arthritis Rheum 199639723-31
bull 90 Ng PC The fetal and neonatal hypothalamic-pituitary-adrenal axis Arch Dis Child Fetal Neonatal Ed 200082F250-4
bull 91 Crowley P Antenatal corticosteroidsmdashcurrent thinking BJOG 2003110(Suppl 20)77-8
bull 92 ACOG committee opinion antenatal corticosteroid therapy for fetal maturation Obstet Gynecol 200299871-3
bull 93 Ost L Wettrell G Bjorkhem I Rane A Prednisolone excretion in human milk J Pediatr 19851061008-11
bull 94 Rowland AS Baird DD Shore DL Weinberg CR Savitz DA Wilcox AJ Nitrous oxide and spontaneous abortion in female dental assistants Am J Epidemiol 1995141531-8
bull 95 McGlothlin JD Jensen PA Fischbach TJ Hughes RT Jones JH Control of anesthetic gases in dental operatories Scand J Work Environ Health 199218(Suppl 2)103-5
bull ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY Volume 97 Number 6 Suresh and Radfar 681
bull 96 Rosen MA Nitrous oxide for relief of labor pain a systematic review Am J Obstet Gynecol 2002186(Suppl Nature)S110-6
bull 97 Sands TD Pynn BR Management considerations for the pregnant or nursing emergency patient Ont Dent 199875 17-9
bull 98 Daya S Recurrent spontaneous early pregnancy loss and low dose aspirin Minerva Ginecol 200355441-9
bull 99 Sinclair C Handbook of obstetrical emergencies 1st ed Philadelphia WB Saunders 1996 p 29-39 69
bull 100 Tarsitano BF Rollings RE The pregnant dental patient evaluation and management Gen Dent 199341226-34
bull 101 Livingston MH Dlllinger TM Holder R Consideration in the management of the pregnant patient SCD Special Care in Dentistry 199818183-8
Thank you
- A Review on the principle of Dental Management of the Pregnant patient
- Slide 2
- Questions that a dentist may ask
- Stages of Pregnancy
- Slide 5
- Slide 6
- Physiologic Changes in Pregnancy
- Systemic changes in pregnancy
- FLAT SUPINE POSITIONING
- SUPINE HYPOTENSION SYNDROME (Vena Cava Compression)
- Supine Hypotension Syndrome
- Slide 12
- Supine Hypotension Syndrome
- Prevention of Supine Hypotensive Syndrome
- Treatment of Supine Hypotensive Syndrome
- How should the pregnant woman be positioned
- Slide 17
- Slide 18
- Slide 19
- Slide 20
- Slide 21
- Slide 22
- Slide 23
- Pregnancy Related Oral Health Problems
- Oral Problems in Pregnancy
- Pregnancy Gingivitis Pathophysiology
- Pregnancy Gingivitis
- Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Gum Problems - Pregnancy Granuloma
- Slide 31
- Gum Changes - Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Candidiasis
- Pregnancy Myths
- Other Oral Conditions in Pregnancy
- Changes During Pregnancy that Affect Oral Health
- Saliva changes
- Increased Bacteria
- Slide 40
- Enamel erosion caused by frequent vomiting
- Treatment for Acid Exposure
- Oral Diseases Can Effect Pregnancy
- Periodontal Disease and Preterm Labor
- Periodontal Disease and Low Birth Weight
- Periodontal Disease and Preeclampsia
- Periodontitis and Pre-eclampsia
- Dental Considerations
- Treatment Timing
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Slide 52
- Use of Radiation on Pregnant Patient
- Radiographs during Pregnancy
- Risks of Dental X-Rays
- FDA drug classification for pregnancy
- Slide 57
- FDA drug classification for pregnancy
- Slide 59
- Slide 60
- Slide 61
- Common Analgesics
- Analgesics
- Analgesics - continued
- Analgesics to Use During 1st and 2nd Trimester
- Analgesics to Avoid During the Third Trimester
- Sedation in Pregnancy
- Common Antibiotics
- Antibiotics
- Antibiotics To Use During Pregnancy
- Antibiotics to Avoid during Pregnancy
- The Problem With Tetracycline
- Other Antimicrobial Agents
- Local Anesthetic Use in Pregnancy
- Use of Local Anesthetics
- Ulcer healing drugs
- Slide 77
- Slide 78
- Slide 79
- Use of Nitrous Oxide Gas
- Common Preventives
- Are topical agents safe
- Pre-natal Fluoride
- Is it safe to use mercury restorations
- References
- REFERENCES
- Slide 87
- Slide 88
- Slide 89
- Slide 90
- Slide 91
- Slide 92
- Slide 93
- Slide 94
- Slide 95
- Slide 96
- Slide 97
- Slide 98
- Thank you
-
Pregnancy RelatedOral Health Problems
bull Pregnancy Gingivitisbull Pregnancy Epulis bull Increased Tooth Mobilitybull Dental Cariesbull Erosionbull Dental Problems in relation to Labor
and Delivery
Oral Problems in Pregnancy
bullPregnancy GingivitisbullMost common oral manifestation (50-100 of women)bullCaused by hormonal and vascular changes of pregnancy
Pregnancy Gingivitis Pathophysiology
bull Elevated circulating estrogen increases capillary permeability
bull Preexisting gingivitis may predispose to pregnancy gingivitis
Pregnancy Gingivitis
bullOccurs commonly in the 2nd to 8th monthsbullTendency to bleed very easilybullTreatment Scaling root-planing currettage OHI
Pregnancy Granuloma
bullOccurs in up to 5 of womenbullMost common in buccal maxillary anterior areasbullUsually starts in an area of gingivitis
Pregnancy Granuloma (continued)
bullRapid growth up to 2 cmbullSingle tumor-like growthbullusually in interdental papillaebullPurplish to bluish in color may be ulcerated- bleeds easily
Gum Problems - Pregnancy Granuloma
Gum Problems - Pregnancy Granuloma
Gum Changes - Pregnancy Granuloma
Pregnancy Granuloma (continued)
Treatment
bull Scaling and root planingbull Excision if it is too large or bleeds too
easilybull May regress spontaneously after
pregnancy
Candidiasis
bullWipes offbullUsually asymptomatic but may burnbullTreatment topical or systemic antifungals
Pregnancy MythsbullldquoA mother loses a tooth for every babyrdquobullNo evidence that aphthous ulcers are any more common in pregnancy
Other Oral Conditions in Pregnancy
bull Dry mouthbull Excessive salivationbull Tooth erosions associated with
severe GERD or hyperemesis
Changes During Pregnancy that Affect Oral Health
bull Hormonal Affects
ndash Increased tooth mobility
ndash Saliva changes
ndash Increased bacteria
ndash Gingival problems
Saliva changesbull Decreased buffers
bull Decreased minerals
bull Decreasing flow first and last trimester
bull Increased flow second trimester
bull More acidic
Increased Bacteriabull Increased acidity
ndash Increase in decay-causing bacteriabull Increased Snacking
ndash Morning sicknesslow blood sugarndash Between-meal snacks
bull Increase in amount and frequency of starchescarbohydrates ndash Crackers are commonly recommendedndash Promotes decay-causing bacteria
Changes During Pregnancy that Affect Oral Healthbull Morning sickness
ndash Difficulty with hygienebull Gingival diseasebull Tooth decay
ndash Vomitingbull Esophogeal Reflux (heartburn)bull Acid exposure
ndash Irritation of the gumsndash Weakening of tooth enamelndash Dental erosion
Enamel erosion caused by frequent vomiting
Treatment for Acid Exposure
bull Do NOT brush immediately after vomiting
bull Rinse ndash Water with baking sodandash Antacidndash Plain water
bull Eat some cheese
Oral Diseases Can Effect Pregnancy
bull Preterm low birth weight (LBW) linked to periodontal disease
bull Thorough calculus (tartar) removal in pregnant women with periodontitis may reduce pre-term births
Periodontal Disease and Preterm LaborbullMaternal periodontal disease is associated with increased risk of preterm laborbullAnaerobic oral gram-negative bacteria cause inflammatory responsebullInflammatory response stimulates prostaglandin and cytokine production to stimulate labor
Periodontal Disease and Low Birth Weight
bull Periodontal disease is associated with low birth weight
bull Evidence is not conclusivebull Biochemical mechanism similar cascade
as in preterm labor leading to placental blood flow restriction and necrosis
Periodontal Disease and Preeclampsia
bull Emerging databull Mechanism unclearbull Proposed mechanism
ndash Periodontal infection leads to inflammatory vascular damage
ndash Triggers cell damage in placenta
Periodontitis and Pre-eclampsia
bull Periodontal disease may be associated with pre-eclampsia (Boggess 2003)
bull PGE2 IL-1 and TNF-α from gingival crevicular fluid were higher in women with preeclampsia compared with healthy matched pregnant women (Oettinger-Barak 2003)
Dental Considerations
bull timing of treatment for pregnant patientsbull dental radiation exposurebull use of local anestheticsbull prescription of common antibiotics and
analgesicsbull nitrous oxide gas administration
Treatment Timing
bull First Trimesterndash Spontaneous miscarriages naturally occur
more often in 1st trimesterndash Avoid elective treatment that can be delayedndash Offer anticipatory guidance
bull Second Trimesterndash The optimal time for dental treatmentndash Organogenesis complete fetus not largendash Easier to prevent than treat established disease
bull Third Trimesterndash Late in term very uncomfortable (short visits)ndash Position slightly on left side
Timing of Dental Treatment During Pregnancy - From Little and Fallace
First Trimester
bull Plaque controlbull Oral hygiene instructionbull Scaling polishing curettagebull Avoid elective treatment urgent care
only
Timing of Dental Treatment During Pregnancy - From Little and Fallace
Second Trimester
bull Plaque controlbull Oral hygiene instructionbull Scaling polishing curettagebull Routine dental care
Timing of Dental Treatment During Pregnancy - From Little and Fallace
Third Trimester
bull Plaque controlbull Oral hygiene instructionbull Scaling polishing curettagebull Routine dental care (after middle of third
trimester elective care should be avoided)
Use of Radiation on Pregnant Patientbull Dose given and time of gestation are
importantbull doses lt 5-10 rads (cGy) not teratogenicbull fetus is most susceptible to radiation
between the 2nd and 6th week of gestationbull single dental x-ray exposes patient to 001
millirads of radiation In relative terms this amount is 40 times less than daily dose acquired from cosmic radiation Therefore diagnostic radiation should not be withheld during pregnancy
Radiographs during Pregnancy
bull Take as needed with optimal methods for reducing secondary radiation and exposure time
bull Always use a lead apronbull Exposure to fetus (with apron use) is 00001
centiGray(rad)bull Daily cosmic radiation - 0004 centiGray (rad)
Risks of Dental X-Rays
bull X-ray only if necessary (ie root canal therapy trauma)
bull When x-rays are indicated radiation exposure is extremely low
bull Exposure can be limited byndash Lead apron shielding ndash Modern fast film ndash Avoiding retakes
FDA drug classification for pregnancybull Combines risk statements including
congenital anomalies fetal effects perinatal risks and therapeutic risk-benefit ratio
bull Untreated disease or condition may pose more serious risks to both mother and fetus than any theoretical risks from the medication
bull Category A thru D and X
FDA drug classification for pregnancy
bull A = Controlled Studies in women fail to demonstrate a risk to the fetus in the first trimester and the possibility of fetal harm appears remote
FDA drug classification for pregnancy
bull B = Animal studies show no risk or if risk shown in animals controlled
trials in women showed no risk
FDA drug classification for pregnancy
bull C = Studies in animals with adverse effects and no human studies
OR no animal or human studies but benefits of use may outweigh potential harms
FDA drug classification for pregnancy
bull D = There is evidence of human fetal risk but benefits may outweigh risks
FDA drug classification for pregnancy
bull X = Contraindicated
Common Analgesics
bull paracetamol (B)bull Ibuprofen (BD) bull Oxycodone (BD) bull Hydrocodone and codeine
(CD)
avoid in third trimester
Analgesics
bull Paracetamol is the analgesic of choice for all stages of gestation
bull used to treat mild to moderate pain and fevers
bull short term usage is believed to be safebull avoid chronic and large doses of
paracetamol1048715
Analgesics - continuedbull Aspirin is nonteratogenic but may cause
maternal and fetal hemorrhagebull large and chronic doses during last trimester
may result in premature closure of ductus arteriosus fetal hypertension anemia and low birth weight
bull avoid ibuprofen in 3rd trimester because of possible adverse circulatory effects
bull short term use of codeine seems safebull avoid codeine late in gestation because of
possible fetal respiratory depression and withdrawal symptoms
Analgesics to Use During1st and 2nd Trimester
bull Category B (for best)bull Paracetamol Ibuprofenbull Naproxenbull Category C (use with caution)bull Paracetamol with codeine or
hydrocodonebull Paracetamol with oxycodone
Analgesics to Avoid During theThird Trimesterbull Causes delivery problemsbull Aspirin (C 3D)bull Ibuprofen (B3D)bull Naproxen (B3D)bull Causes neonatal respiratory
depression and opioid withdrawalbull Codeine (C3D)bull Hydrocodone (C3D)bull Oxycodone(C3D)
Sedation in Pregnancy
bull SedativesAnxiolytics (eg Diazepam ) are rated D and can cause oral clefts with prolonged exposure
bull Nitrous oxide should not be used in 1st trimester (If used in 2nd and 3rd do not go below 50 O2)
Common Antibioticsbull To treat oral abscess or cellulitis
ndash Penicillin (B) ndash Amoxicillin (B) ndash Cephalexin (B)ndash Erythromycin base (B) (Not estolate as it
cause cholestatic hepatitis)ndash Clindamycin (B)
Antibioticsbull penicillin V and amoxicillin is preferred drug
for mild to moderate infectionsbull widely used for many years with no ill effectsbull no studies show penicillin to be teratogenicbull amoxicillin extensively used without harming
the fetusbull Drug classes1048715 B penicillin cephalosporins erythromycin clindamycin Azithromycin D Tetracycline
Antibiotics To Use During Pregnancy
bull Penicillin Vbull Amoxicillinbull Erythromycin (base form)bull Cephalexin cephalosporinbull Clindamycinbull Metronidazole
Antibiotics to Avoid duringPregnancy
bull Doxycyclinebull Tetracyclinebull Erythromycin (estolate form)bull Vancomycin
The Problem With Tetracycline
bull Accumulates in bones and chelates calcium
bull Inhibits bone growthbull Discolors teeth
Other Antimicrobial Agentsbull OK to usebull Nystatin (B)bull Chlorhexidine rinse (B)bull Use with cautionbull Clotrimazole (C)bull Ketoconazole (C)bull Fluconazole (C)bull Do not usebull Doxycycline (D)
Local Anesthetic Use inPregnancy
bull Class Bbull Lidocaine (Xylocaine)bull Etidocainebull Prilocaine bull Class Cbull Procainebull Bupivicainebull Mepivicaine
Use of Local Anestheticsbull Lidocaine + vasoconstrictor most common
local anesthetic used in dentistrybull extensively used in pregnancy with no proven ill
effectsbull accidental intravascular injections of lidocaine
pass through the placenta but the concentrations are too low to harm fetus
bull prilocaine might cause methemoglobinemia
Ulcer healing drugsCimetidine bull FDA category B Famotidinebull FDA category BRanitidinebull FDA category Bbull not known to be harmful
Ulcer healing drugsOmeprazolebull FDA category BNot known to be
harmful Esomeprazolebull FDA category BLansoprazolebull FDA category BPantoprazolebull Avoid unless potential benefit
outweighs riskmdashfetotoxic in animals
Ulcer healing drugs
Misoprostolbull First second third trimesters Avoidmdash
potent uterine stimulant (has been used to induce abortion) and may be teratogenic
Ulcer healing drugs
Antacidsbull Almunium hydroxideMagnesium
hydroxidemdashFDA category B Calcium carbonatemdashFDA category C
SimetheconemdashFDA category C
Use of Nitrous Oxide Gas
bull used over 150 years bull safety is being debatedbull SHORT TERM exposure do not cause
birth defects or spontaneous abortionbull CHRONIC exposure may result in fetal
loss and infertilitybull literature suggests that nitrous oxide
should be avoided until more conclusive research is available
bull FDA Drug class not yet assigned
Common Preventives
bull Fluoridendash No increased risk during pregnancy
bull Xylitolndash No studies no harm reported
bull Chlorhexidinendash No increased risk during pregnancy
Are topical agents safe
bull Fluoridebull Toothpaste amp mouthrinse
bull Xylitol chewing gum bull Chlorhexidine (11 alcohol)bull No over the counter mouthrinses with
alcohol (Listerine 20 alcohol)
Pre-natal Fluoride
bull Daily 22 mg tablet of sodium fluoride during 3rd through 9th months
bull decreases caries rate in offspringbull Safe and effective
Glenn FB 1982
Is it safe to use mercury restorations
bull No evidence of harmful effect
bull Benefits outweigh risks
bull Canada Germany and New Zealand have some restrictions
bull Determine the best option
Referencesbull Wasylko L Matsui D Dykxhoorn SM Rieder MJ Weinberg
S A Review of Common Dental Treatments During Pregnancy J Canadian Dental Association 64434-439 1998
bull Little JW Donald AF Craig SM Rhodus NL Dental Management of the Medically Compromised Patient - 5th edition Mosby Toronto Pp434-442 1997
bull Livingston HM Dellinger TM Holder R Considerations in the management of the pregnant patient Special Care in Dentistry 185 pp183-188 1998
bull Larimore WL Petrie KA Drug use during pregnacy and lactation Primary Care Clinics in Office Practice 271 35-53 2000
bull Health Canada The Safety of DentalAmalgam Minister Of Supply and Services Canada 1996
REFERENCESbull 1 Weiss G Endocrinology of parturition J Clin
Endocrinol Metab 2000854421-5bull 2 Theunissen IM Parer JT Fluid and electrolytes in
pregnancy Clin Obstet Gynecol 1994373-15bull 3 Duvekot JJ Peeters LLH Renal hemodynamics and
volume homeostasis in pregnancy Obstet Gynecol Surv 199449830-9
bull 4 Barron WM Lindheimer MD Medical disorders during pregnancy 2nd ed St Louis Mosby 1995 p 129
bull 5 Thornburg KL Jacobson SL Giraud GD Morton MJ Hemodynamic changes in pregnancy Semin Perinatol 20002411-4
bull 6 Fiese R Herzog S Issues in dental and surgical management of the pregnant patient Oral Surg Oral Med Oral Pathol 198865292-7
bull 7 Martin C Varner MW Physiologic changes in pregnancysurgical implications Clin Obstet Gynecol 199437241-55
bull 8 Clark SL Cotton DB Lee W Bishop C Hill T Southwick J et al Central hemodynamic assessment of normal term pregnancy Am J Obstet Gynecol 19891611439-42
bull 9 Mabie WC Di Sessa TG Crocker LG Sibai BM Arheart KL A longitudinal study of cardiac output in normal human pregnancy Am J Obstet Gynecol 1994170849-56
bull 10 Clapp JF 3rd Capeless E Cardiovascular function before during and after the first and subsequent pregnancies Am J Cardiol 1997801469-73
bull 11 Duvekot JJ Peeters LL Maternal cardiovascular hemodynamic adaptation to pregnancy Obstet Gynecol Surv 199449(Suppl) S1-14
bull 12 Bhagwat AR Engel PJ Heart disease and pregnancy Cardiol Clin 199513163-78
bull 13 Lanni SM Tillinghast J Silver H Hemodynamic changes and baroreflex gain in the supine hypotensive syndrome Am J Obstet Gynecol 20021871636-41
bull 14 Little JW Falace DA Miller CS Rhodus NL Dental management of the medically compromised patient 6th ed St Louis Mosby 2002 p 303
bull 15 Garcia-Rio F Pino JM Gomez L Alvarez-Sala R Villasante C Villamor J Regulation of breathing and perception of dyspnea in healthy pregnant women Chest 1996110446-53
bull 16 McAuliffe F Kametas N Costello J Rafferty GF Greenough A Nicolaides K Respiratory function in singleton and twin pregnancy BJOG 2002109765-9
bull 17 Clapp JF 3rd Seaward BL Sleamaker RH Hiser J Maternal physiologic adaptations to early human pregnancy Am J Obstet Gynecol 19881591456-60
bull 18 OrsquoDay MP Cardio-respiratory physiological adaptation of pregnancy Semin Perinatol 199721268-75
bull 19 Contreras G Gutierrez M Beroiza T Fantin A Oddo H Villarroel L et al Ventilatory drive and respiratory muscle function in pregnancy Am Rev Respir Dis 1991144837-41
bull 20 Turner M Aziz SR Management of the pregnant oral and maxillofac
bull 21 Sifakis S Pharmakides G Anemia in pregnancy Ann N Y Acad Sci 2000900125-36
bull 22 Branch DW Physiologic adaptations of pregnancy Am J Reprod Immunol 199228120-2
bull 23 Burrows RF Kelton JG Incidentally detected thrombocytopenia in healthy mothers and their infants N Engl J Med 1988319 142-5
bull 24 Hanly JG Antiphospholipid syndrome an overview CMAJ 200324(168)1675-82
bull 25 Heilmann L von Tempelhoff GF Pollow K Antiphospholipid syndrome in obstetrics Clin Appl Thromb Hemost 20039 143-50
bull 26 Sherman P Flaxman SM Nausea and vomiting of pregnancy in an evolutionary perspective Am J Obstet Gynecol 2002 185(Suppl)s190-7
bull 27 Koch KL Gastrointestinal factors in nausea and vomiting of pregnancy Am J Obstet Gynecol 2002185(Suppl)s198-203
bull 28 Koch KL Frissora CL Nausea and vomiting during pregnancy Gastroenterol Clin N Am 200332201-34
bull 29 Baron TH Ramirez B Richter JE Gastrointestinal motility disorders during pregnancy Ann Intern Med 1993118 366-75
bull 30 Richter JE Gastroesophageal reflux disease during pregnancy Gastroenterol Clin N Am 200332235-61
bull 31 Marrero JM Goggin PM de Caestecker JS Pearce JM Maxwell JD Determinants of pregnancy heartburn Br J Obstet Gynaecol 199299731-4
bull 32 Hamaoui E Hamaoui M Nutritional assessment and support during pregnancy Gastroenterol Clin N Am 20033259-121
bull 33 King JC Physiology of pregnancy and nutrient metabolism Am J Clin Nutr 200071(suppl)1218s-25s
bull 34 Casanueva E Pfeffer F Fernandez-Gaxiola AC Gutierrez- Valenzuela V Rothenberg SJ Iron and folate status before pregnancy and anemia during pregnancy Ann Nutr Metab 2003 4760-3
bull 35 Chrsquong CL Morgan M Hainsworth I Kingham JG Prospective study of liver dysfunction in Southwest Wales Gut 200251 876-80
bull 36 Rahman TM Wendon J Severe hepatic dysfunction in pregnancy QJM 200295343-57
bull 37 Knox TA Olans LB Liver disease in pregnancy N Engl J Med 1996335569-76
bull 38 Saftlas AF Olson DR Franks AL Atrash H Pokras R Epidemiology of preeclampsia and eclampsia in the United States 1979e1986 Am J Obstet Gynecol 1990163460-5
bull 39 Walker JJ Pre-eclampsia Lancet 20003561260-5
bull 40 Davidson JM Renal disorders in pregnancy Curr Opin Obstet Gynecol 200113109-14
bull 41 Dafnis E Sabatini S The effect of pregnancy on renal function physiology and pathophysiologyAmJMedSci 1992303184-205
bull 42 Davison JM Shiells EA Philips PR Lindheimer MD Serial evaluation of vasopressin release and thirst in human pregnancy Role of human chorionic gonadotrophin in the osmoregulatory changes of gestation J Clin Invest 198881798-806
bull 43 Glinoer D de Nayer P Bourdoux P Lemone M Robyn C van Steirteghem A et al Regulation of maternal thyroid during pregnancy J Clin Endocrinol Metab 199071276-87
bull 44 Wilson SG Retallack RW Kent JC Worth GK Gutteridge DH Serum free 125-dihydroxyvitamin D and the free 125- dihydroxyvitamin D index during a longitudinal study of human pregnancy and lactation Clin Endocrinol 199032613-22
bull 45 Rasmussen N Frolich A Hornnes PJ Hegedus L Serum ionized calcium and intact parathyroid hormone levels during pregnancy and postpartum Br J Obstet Gynaecol 199097857-9
bull 46 Guyton AC Textbook of medical physiology 8th ed Philadelphia W B Saunders 1991 p 915e28
bull 47 Trainer PJ Corticosteroids and pregnancy Semin Reprod Med 200220375-80
bull 48 Soory M Hormonal factors in periodontal disease Dent Update 200027380-3
bull 49 Hugoson A Gingivitis in pregnant women A longitudinal clinical study Odontol Revy 19712265-84
bull 50 Neville BW Damm DD Allen CM Bouquot JE Oral amp Maxillofacial Pathology 3rd ed Philadelphia W B Saunders 2002 p 329-30 447-9
bull 51 Tilakaratne A Soory M Ranasinghe AW Corea SM Ekanayake SL de Silva M Periodontal disease status during pregnancy and 3 months post-partum in rural population of Sri-Lankan women J Clin Periodontol 200027787-92
bull 52 Laine M Tenovuo J Lehtonen OP Ojanatko-Harri A Vilja P Tuohimaa P Pregnancy e related changes in human whole saliva Arch Oral Biol 198833913-7
bull 53 Yuan K Wing LY Lin MT Pathogenetic roles of angiogenic factors in pyogenic granulomas in pregnancy are modulated by female sex hormones J Periodontol 200273701-8
bull 54 Evans RD Briggs PF Tooth-surface loss related to pregnancyinduced vomiting Prim Dent Care 1994124-6
bull 55 Salvolini E Di Giorgio R Curatola A Mazzanti L Fratto G Biochemical modifications of human whole saliva induced by pregnancy Br J Obstet Gynaec 1998105656-60
bull 56 Mauldin JG Newman RB Preterm birth risk assessment Semin Perinatol 200125215-22
bull 57 Heine RP McGregor JA Goodwin TM Artal R Hayashi RH Robertson PA et al Serial salivary estriol to detect an increased risk of preterm birth Obstet Gynecol 200096490-7
bull 58 Kauh YC Zachian TF Melasma Adv Exp Med Biol 1999455 491-9
bull 59 Wong RC Ellis CN Physiologic skin changes in pregnancy J Am Acad Dermatol 198410929-40
bull 60 Errickson CV Matus NR Skin disorders of pregnancy Am Fam Physician 199449605-10
bull 61 Lopez NJ Smith PC Gutierrez J Periodontal therapy may reduce the risk of preterm low birth weight in women with periodontal disease a randomized controlled trial J Periodontol 200273911-24
bull 62 McGaw T Periodontal disease and preterm delivery of lowbirth- weight infants J Can Dent Assoc 200268165-9
bull 63 Richards AG Dental x-ray protection Dent Clin North Am 1968631-41
bull 64 1990 Recommendations of the International Commission on Radiological Protection Ann ICRP 1991211-201
bull 65 Hall EJ Radiation the two-edged sword cancer risks at high and low doses Cancer J 20006343-50
bull 66 Diethelm L Xu H Diagnostic imaging of the lung during pregnancy Clin Obstet Gynecol 19963936-55
bull 67 Brent RL The effects of embryonic and fetal exposure to x-rays microwaves and ultrasound ClinObstetGynecol 198326484-510
bull 68 National Council on Radiation Protection NCRP report no128 1998 Bethesda Md Author
bull 69 Wasylko L Matsui D Dykxhoorn SM Reider MJ Weinberg S A review of common dental treatments during pregnancy implications for patients and dental personnel J Can Dent Assoc 199864434-9
bull 70 Freeman JP Brand JW Radiation doses of commonly used dental radiographic surveys Oral Surg Oral Med Oral Pathol 199477285-9
bull 71 Kircos LTAngin LL Lorton LOrder ofmagnitude dose reduction in intraoral radiography J Am Dent Assoc 1987114344-7
bull 72 Updegrave WJ Simplified and standardized intraoral radiography with reduced tissue irradiation J Am Dent Assoc 197285861-9
bull 73 Wood RE Harris AM van der Merwe EJ Nortje CJ The leaded apron revisited does it reduce gonadal radiation dose in dental radiology Oral Surg Oral Med Oral Pathol 199171642-6
bull 74 An update on radiographic practices information and recommendations ADA Council on Scientific Affairs J Am Dent Assoc 2001132234-8
bull 75 Rayburn WF Recommending medications during pregnancy an evidence based approach Clin Obstet Gynecol 2002451-5
bull 76 Rathmell JP Viscomi C Ashburn MA Management of nonobstetric pain during pregnancy and lactation Anesth Analg 1997851074-87
bull 77 Teratology society public affairs committee FDA classification of drugs for teratogenic risk Teratology 199449446-7
bull 78 Moore PA Selecting drugs for the pregnant dental patient J Am Dent Assoc 19981291281-6
bull 79 Haas DA An update on analgesics for the management of acute postoperative dental pain J Can Dent Assoc 200268476-82
bull 80 Haas DA Pynn BR Sands TD Drug use for the pregnant or lactating patient Gen Dent 20004854-60
bull 81 Committee on Drugs American Academy of Pediatrics The transfer of drugs and other chemicals into human milk Pediatrics 199493137-50
bull 82 Nielsen GL Sorensen HT Larsen H Pedersen L Risk of adverse birth outcome and miscarriage in pregnant users of nonsteroidal anti-inflammatory drugs population based observational study and case-control study BMJ 2001322266-70
bull 83 Janssen N Genta M The effects of immunosuppressive and anti-inflammatory medications on fertility pregnancy and lactation Arch Intern Med 200016610-9
bull 84 Ostensen M Nonsteroidal anti-inflammatory drugs during pregnancy Scand J Rheumatol Suppl 1998107128-32
bull 85 USPDI -Drug information for the health care professional 22nd ed Greenwood Village CO Micromedex 2002 p 152-79
bull 86 Denson DD Coyle DE Thompson GA Santos D Turner PA Myers JA et al Bupivacaine protein binding in the term parturient effects of lactic acidosis Clin Pharmacol Ther 198435702-9
bull 87 Dillon DE Wagner CL Wiest D Newman RB Drug therapy in the nursing mother Obstet Gynecol Clin North Am 199724 675-96
bull 88 Dashe JS Gilstrap LC Antibiotic use in pregnancy Obstet Gynecol Clin North Am 199724617-29
bull 89 American College of Rheumatology Ad hoc Committee on Clinical Guidelines Guidelines for monitoring drug therapy in rheumatoid arthritis Arthritis Rheum 199639723-31
bull 90 Ng PC The fetal and neonatal hypothalamic-pituitary-adrenal axis Arch Dis Child Fetal Neonatal Ed 200082F250-4
bull 91 Crowley P Antenatal corticosteroidsmdashcurrent thinking BJOG 2003110(Suppl 20)77-8
bull 92 ACOG committee opinion antenatal corticosteroid therapy for fetal maturation Obstet Gynecol 200299871-3
bull 93 Ost L Wettrell G Bjorkhem I Rane A Prednisolone excretion in human milk J Pediatr 19851061008-11
bull 94 Rowland AS Baird DD Shore DL Weinberg CR Savitz DA Wilcox AJ Nitrous oxide and spontaneous abortion in female dental assistants Am J Epidemiol 1995141531-8
bull 95 McGlothlin JD Jensen PA Fischbach TJ Hughes RT Jones JH Control of anesthetic gases in dental operatories Scand J Work Environ Health 199218(Suppl 2)103-5
bull ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY Volume 97 Number 6 Suresh and Radfar 681
bull 96 Rosen MA Nitrous oxide for relief of labor pain a systematic review Am J Obstet Gynecol 2002186(Suppl Nature)S110-6
bull 97 Sands TD Pynn BR Management considerations for the pregnant or nursing emergency patient Ont Dent 199875 17-9
bull 98 Daya S Recurrent spontaneous early pregnancy loss and low dose aspirin Minerva Ginecol 200355441-9
bull 99 Sinclair C Handbook of obstetrical emergencies 1st ed Philadelphia WB Saunders 1996 p 29-39 69
bull 100 Tarsitano BF Rollings RE The pregnant dental patient evaluation and management Gen Dent 199341226-34
bull 101 Livingston MH Dlllinger TM Holder R Consideration in the management of the pregnant patient SCD Special Care in Dentistry 199818183-8
Thank you
- A Review on the principle of Dental Management of the Pregnant patient
- Slide 2
- Questions that a dentist may ask
- Stages of Pregnancy
- Slide 5
- Slide 6
- Physiologic Changes in Pregnancy
- Systemic changes in pregnancy
- FLAT SUPINE POSITIONING
- SUPINE HYPOTENSION SYNDROME (Vena Cava Compression)
- Supine Hypotension Syndrome
- Slide 12
- Supine Hypotension Syndrome
- Prevention of Supine Hypotensive Syndrome
- Treatment of Supine Hypotensive Syndrome
- How should the pregnant woman be positioned
- Slide 17
- Slide 18
- Slide 19
- Slide 20
- Slide 21
- Slide 22
- Slide 23
- Pregnancy Related Oral Health Problems
- Oral Problems in Pregnancy
- Pregnancy Gingivitis Pathophysiology
- Pregnancy Gingivitis
- Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Gum Problems - Pregnancy Granuloma
- Slide 31
- Gum Changes - Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Candidiasis
- Pregnancy Myths
- Other Oral Conditions in Pregnancy
- Changes During Pregnancy that Affect Oral Health
- Saliva changes
- Increased Bacteria
- Slide 40
- Enamel erosion caused by frequent vomiting
- Treatment for Acid Exposure
- Oral Diseases Can Effect Pregnancy
- Periodontal Disease and Preterm Labor
- Periodontal Disease and Low Birth Weight
- Periodontal Disease and Preeclampsia
- Periodontitis and Pre-eclampsia
- Dental Considerations
- Treatment Timing
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Slide 52
- Use of Radiation on Pregnant Patient
- Radiographs during Pregnancy
- Risks of Dental X-Rays
- FDA drug classification for pregnancy
- Slide 57
- FDA drug classification for pregnancy
- Slide 59
- Slide 60
- Slide 61
- Common Analgesics
- Analgesics
- Analgesics - continued
- Analgesics to Use During 1st and 2nd Trimester
- Analgesics to Avoid During the Third Trimester
- Sedation in Pregnancy
- Common Antibiotics
- Antibiotics
- Antibiotics To Use During Pregnancy
- Antibiotics to Avoid during Pregnancy
- The Problem With Tetracycline
- Other Antimicrobial Agents
- Local Anesthetic Use in Pregnancy
- Use of Local Anesthetics
- Ulcer healing drugs
- Slide 77
- Slide 78
- Slide 79
- Use of Nitrous Oxide Gas
- Common Preventives
- Are topical agents safe
- Pre-natal Fluoride
- Is it safe to use mercury restorations
- References
- REFERENCES
- Slide 87
- Slide 88
- Slide 89
- Slide 90
- Slide 91
- Slide 92
- Slide 93
- Slide 94
- Slide 95
- Slide 96
- Slide 97
- Slide 98
- Thank you
-
Oral Problems in Pregnancy
bullPregnancy GingivitisbullMost common oral manifestation (50-100 of women)bullCaused by hormonal and vascular changes of pregnancy
Pregnancy Gingivitis Pathophysiology
bull Elevated circulating estrogen increases capillary permeability
bull Preexisting gingivitis may predispose to pregnancy gingivitis
Pregnancy Gingivitis
bullOccurs commonly in the 2nd to 8th monthsbullTendency to bleed very easilybullTreatment Scaling root-planing currettage OHI
Pregnancy Granuloma
bullOccurs in up to 5 of womenbullMost common in buccal maxillary anterior areasbullUsually starts in an area of gingivitis
Pregnancy Granuloma (continued)
bullRapid growth up to 2 cmbullSingle tumor-like growthbullusually in interdental papillaebullPurplish to bluish in color may be ulcerated- bleeds easily
Gum Problems - Pregnancy Granuloma
Gum Problems - Pregnancy Granuloma
Gum Changes - Pregnancy Granuloma
Pregnancy Granuloma (continued)
Treatment
bull Scaling and root planingbull Excision if it is too large or bleeds too
easilybull May regress spontaneously after
pregnancy
Candidiasis
bullWipes offbullUsually asymptomatic but may burnbullTreatment topical or systemic antifungals
Pregnancy MythsbullldquoA mother loses a tooth for every babyrdquobullNo evidence that aphthous ulcers are any more common in pregnancy
Other Oral Conditions in Pregnancy
bull Dry mouthbull Excessive salivationbull Tooth erosions associated with
severe GERD or hyperemesis
Changes During Pregnancy that Affect Oral Health
bull Hormonal Affects
ndash Increased tooth mobility
ndash Saliva changes
ndash Increased bacteria
ndash Gingival problems
Saliva changesbull Decreased buffers
bull Decreased minerals
bull Decreasing flow first and last trimester
bull Increased flow second trimester
bull More acidic
Increased Bacteriabull Increased acidity
ndash Increase in decay-causing bacteriabull Increased Snacking
ndash Morning sicknesslow blood sugarndash Between-meal snacks
bull Increase in amount and frequency of starchescarbohydrates ndash Crackers are commonly recommendedndash Promotes decay-causing bacteria
Changes During Pregnancy that Affect Oral Healthbull Morning sickness
ndash Difficulty with hygienebull Gingival diseasebull Tooth decay
ndash Vomitingbull Esophogeal Reflux (heartburn)bull Acid exposure
ndash Irritation of the gumsndash Weakening of tooth enamelndash Dental erosion
Enamel erosion caused by frequent vomiting
Treatment for Acid Exposure
bull Do NOT brush immediately after vomiting
bull Rinse ndash Water with baking sodandash Antacidndash Plain water
bull Eat some cheese
Oral Diseases Can Effect Pregnancy
bull Preterm low birth weight (LBW) linked to periodontal disease
bull Thorough calculus (tartar) removal in pregnant women with periodontitis may reduce pre-term births
Periodontal Disease and Preterm LaborbullMaternal periodontal disease is associated with increased risk of preterm laborbullAnaerobic oral gram-negative bacteria cause inflammatory responsebullInflammatory response stimulates prostaglandin and cytokine production to stimulate labor
Periodontal Disease and Low Birth Weight
bull Periodontal disease is associated with low birth weight
bull Evidence is not conclusivebull Biochemical mechanism similar cascade
as in preterm labor leading to placental blood flow restriction and necrosis
Periodontal Disease and Preeclampsia
bull Emerging databull Mechanism unclearbull Proposed mechanism
ndash Periodontal infection leads to inflammatory vascular damage
ndash Triggers cell damage in placenta
Periodontitis and Pre-eclampsia
bull Periodontal disease may be associated with pre-eclampsia (Boggess 2003)
bull PGE2 IL-1 and TNF-α from gingival crevicular fluid were higher in women with preeclampsia compared with healthy matched pregnant women (Oettinger-Barak 2003)
Dental Considerations
bull timing of treatment for pregnant patientsbull dental radiation exposurebull use of local anestheticsbull prescription of common antibiotics and
analgesicsbull nitrous oxide gas administration
Treatment Timing
bull First Trimesterndash Spontaneous miscarriages naturally occur
more often in 1st trimesterndash Avoid elective treatment that can be delayedndash Offer anticipatory guidance
bull Second Trimesterndash The optimal time for dental treatmentndash Organogenesis complete fetus not largendash Easier to prevent than treat established disease
bull Third Trimesterndash Late in term very uncomfortable (short visits)ndash Position slightly on left side
Timing of Dental Treatment During Pregnancy - From Little and Fallace
First Trimester
bull Plaque controlbull Oral hygiene instructionbull Scaling polishing curettagebull Avoid elective treatment urgent care
only
Timing of Dental Treatment During Pregnancy - From Little and Fallace
Second Trimester
bull Plaque controlbull Oral hygiene instructionbull Scaling polishing curettagebull Routine dental care
Timing of Dental Treatment During Pregnancy - From Little and Fallace
Third Trimester
bull Plaque controlbull Oral hygiene instructionbull Scaling polishing curettagebull Routine dental care (after middle of third
trimester elective care should be avoided)
Use of Radiation on Pregnant Patientbull Dose given and time of gestation are
importantbull doses lt 5-10 rads (cGy) not teratogenicbull fetus is most susceptible to radiation
between the 2nd and 6th week of gestationbull single dental x-ray exposes patient to 001
millirads of radiation In relative terms this amount is 40 times less than daily dose acquired from cosmic radiation Therefore diagnostic radiation should not be withheld during pregnancy
Radiographs during Pregnancy
bull Take as needed with optimal methods for reducing secondary radiation and exposure time
bull Always use a lead apronbull Exposure to fetus (with apron use) is 00001
centiGray(rad)bull Daily cosmic radiation - 0004 centiGray (rad)
Risks of Dental X-Rays
bull X-ray only if necessary (ie root canal therapy trauma)
bull When x-rays are indicated radiation exposure is extremely low
bull Exposure can be limited byndash Lead apron shielding ndash Modern fast film ndash Avoiding retakes
FDA drug classification for pregnancybull Combines risk statements including
congenital anomalies fetal effects perinatal risks and therapeutic risk-benefit ratio
bull Untreated disease or condition may pose more serious risks to both mother and fetus than any theoretical risks from the medication
bull Category A thru D and X
FDA drug classification for pregnancy
bull A = Controlled Studies in women fail to demonstrate a risk to the fetus in the first trimester and the possibility of fetal harm appears remote
FDA drug classification for pregnancy
bull B = Animal studies show no risk or if risk shown in animals controlled
trials in women showed no risk
FDA drug classification for pregnancy
bull C = Studies in animals with adverse effects and no human studies
OR no animal or human studies but benefits of use may outweigh potential harms
FDA drug classification for pregnancy
bull D = There is evidence of human fetal risk but benefits may outweigh risks
FDA drug classification for pregnancy
bull X = Contraindicated
Common Analgesics
bull paracetamol (B)bull Ibuprofen (BD) bull Oxycodone (BD) bull Hydrocodone and codeine
(CD)
avoid in third trimester
Analgesics
bull Paracetamol is the analgesic of choice for all stages of gestation
bull used to treat mild to moderate pain and fevers
bull short term usage is believed to be safebull avoid chronic and large doses of
paracetamol1048715
Analgesics - continuedbull Aspirin is nonteratogenic but may cause
maternal and fetal hemorrhagebull large and chronic doses during last trimester
may result in premature closure of ductus arteriosus fetal hypertension anemia and low birth weight
bull avoid ibuprofen in 3rd trimester because of possible adverse circulatory effects
bull short term use of codeine seems safebull avoid codeine late in gestation because of
possible fetal respiratory depression and withdrawal symptoms
Analgesics to Use During1st and 2nd Trimester
bull Category B (for best)bull Paracetamol Ibuprofenbull Naproxenbull Category C (use with caution)bull Paracetamol with codeine or
hydrocodonebull Paracetamol with oxycodone
Analgesics to Avoid During theThird Trimesterbull Causes delivery problemsbull Aspirin (C 3D)bull Ibuprofen (B3D)bull Naproxen (B3D)bull Causes neonatal respiratory
depression and opioid withdrawalbull Codeine (C3D)bull Hydrocodone (C3D)bull Oxycodone(C3D)
Sedation in Pregnancy
bull SedativesAnxiolytics (eg Diazepam ) are rated D and can cause oral clefts with prolonged exposure
bull Nitrous oxide should not be used in 1st trimester (If used in 2nd and 3rd do not go below 50 O2)
Common Antibioticsbull To treat oral abscess or cellulitis
ndash Penicillin (B) ndash Amoxicillin (B) ndash Cephalexin (B)ndash Erythromycin base (B) (Not estolate as it
cause cholestatic hepatitis)ndash Clindamycin (B)
Antibioticsbull penicillin V and amoxicillin is preferred drug
for mild to moderate infectionsbull widely used for many years with no ill effectsbull no studies show penicillin to be teratogenicbull amoxicillin extensively used without harming
the fetusbull Drug classes1048715 B penicillin cephalosporins erythromycin clindamycin Azithromycin D Tetracycline
Antibiotics To Use During Pregnancy
bull Penicillin Vbull Amoxicillinbull Erythromycin (base form)bull Cephalexin cephalosporinbull Clindamycinbull Metronidazole
Antibiotics to Avoid duringPregnancy
bull Doxycyclinebull Tetracyclinebull Erythromycin (estolate form)bull Vancomycin
The Problem With Tetracycline
bull Accumulates in bones and chelates calcium
bull Inhibits bone growthbull Discolors teeth
Other Antimicrobial Agentsbull OK to usebull Nystatin (B)bull Chlorhexidine rinse (B)bull Use with cautionbull Clotrimazole (C)bull Ketoconazole (C)bull Fluconazole (C)bull Do not usebull Doxycycline (D)
Local Anesthetic Use inPregnancy
bull Class Bbull Lidocaine (Xylocaine)bull Etidocainebull Prilocaine bull Class Cbull Procainebull Bupivicainebull Mepivicaine
Use of Local Anestheticsbull Lidocaine + vasoconstrictor most common
local anesthetic used in dentistrybull extensively used in pregnancy with no proven ill
effectsbull accidental intravascular injections of lidocaine
pass through the placenta but the concentrations are too low to harm fetus
bull prilocaine might cause methemoglobinemia
Ulcer healing drugsCimetidine bull FDA category B Famotidinebull FDA category BRanitidinebull FDA category Bbull not known to be harmful
Ulcer healing drugsOmeprazolebull FDA category BNot known to be
harmful Esomeprazolebull FDA category BLansoprazolebull FDA category BPantoprazolebull Avoid unless potential benefit
outweighs riskmdashfetotoxic in animals
Ulcer healing drugs
Misoprostolbull First second third trimesters Avoidmdash
potent uterine stimulant (has been used to induce abortion) and may be teratogenic
Ulcer healing drugs
Antacidsbull Almunium hydroxideMagnesium
hydroxidemdashFDA category B Calcium carbonatemdashFDA category C
SimetheconemdashFDA category C
Use of Nitrous Oxide Gas
bull used over 150 years bull safety is being debatedbull SHORT TERM exposure do not cause
birth defects or spontaneous abortionbull CHRONIC exposure may result in fetal
loss and infertilitybull literature suggests that nitrous oxide
should be avoided until more conclusive research is available
bull FDA Drug class not yet assigned
Common Preventives
bull Fluoridendash No increased risk during pregnancy
bull Xylitolndash No studies no harm reported
bull Chlorhexidinendash No increased risk during pregnancy
Are topical agents safe
bull Fluoridebull Toothpaste amp mouthrinse
bull Xylitol chewing gum bull Chlorhexidine (11 alcohol)bull No over the counter mouthrinses with
alcohol (Listerine 20 alcohol)
Pre-natal Fluoride
bull Daily 22 mg tablet of sodium fluoride during 3rd through 9th months
bull decreases caries rate in offspringbull Safe and effective
Glenn FB 1982
Is it safe to use mercury restorations
bull No evidence of harmful effect
bull Benefits outweigh risks
bull Canada Germany and New Zealand have some restrictions
bull Determine the best option
Referencesbull Wasylko L Matsui D Dykxhoorn SM Rieder MJ Weinberg
S A Review of Common Dental Treatments During Pregnancy J Canadian Dental Association 64434-439 1998
bull Little JW Donald AF Craig SM Rhodus NL Dental Management of the Medically Compromised Patient - 5th edition Mosby Toronto Pp434-442 1997
bull Livingston HM Dellinger TM Holder R Considerations in the management of the pregnant patient Special Care in Dentistry 185 pp183-188 1998
bull Larimore WL Petrie KA Drug use during pregnacy and lactation Primary Care Clinics in Office Practice 271 35-53 2000
bull Health Canada The Safety of DentalAmalgam Minister Of Supply and Services Canada 1996
REFERENCESbull 1 Weiss G Endocrinology of parturition J Clin
Endocrinol Metab 2000854421-5bull 2 Theunissen IM Parer JT Fluid and electrolytes in
pregnancy Clin Obstet Gynecol 1994373-15bull 3 Duvekot JJ Peeters LLH Renal hemodynamics and
volume homeostasis in pregnancy Obstet Gynecol Surv 199449830-9
bull 4 Barron WM Lindheimer MD Medical disorders during pregnancy 2nd ed St Louis Mosby 1995 p 129
bull 5 Thornburg KL Jacobson SL Giraud GD Morton MJ Hemodynamic changes in pregnancy Semin Perinatol 20002411-4
bull 6 Fiese R Herzog S Issues in dental and surgical management of the pregnant patient Oral Surg Oral Med Oral Pathol 198865292-7
bull 7 Martin C Varner MW Physiologic changes in pregnancysurgical implications Clin Obstet Gynecol 199437241-55
bull 8 Clark SL Cotton DB Lee W Bishop C Hill T Southwick J et al Central hemodynamic assessment of normal term pregnancy Am J Obstet Gynecol 19891611439-42
bull 9 Mabie WC Di Sessa TG Crocker LG Sibai BM Arheart KL A longitudinal study of cardiac output in normal human pregnancy Am J Obstet Gynecol 1994170849-56
bull 10 Clapp JF 3rd Capeless E Cardiovascular function before during and after the first and subsequent pregnancies Am J Cardiol 1997801469-73
bull 11 Duvekot JJ Peeters LL Maternal cardiovascular hemodynamic adaptation to pregnancy Obstet Gynecol Surv 199449(Suppl) S1-14
bull 12 Bhagwat AR Engel PJ Heart disease and pregnancy Cardiol Clin 199513163-78
bull 13 Lanni SM Tillinghast J Silver H Hemodynamic changes and baroreflex gain in the supine hypotensive syndrome Am J Obstet Gynecol 20021871636-41
bull 14 Little JW Falace DA Miller CS Rhodus NL Dental management of the medically compromised patient 6th ed St Louis Mosby 2002 p 303
bull 15 Garcia-Rio F Pino JM Gomez L Alvarez-Sala R Villasante C Villamor J Regulation of breathing and perception of dyspnea in healthy pregnant women Chest 1996110446-53
bull 16 McAuliffe F Kametas N Costello J Rafferty GF Greenough A Nicolaides K Respiratory function in singleton and twin pregnancy BJOG 2002109765-9
bull 17 Clapp JF 3rd Seaward BL Sleamaker RH Hiser J Maternal physiologic adaptations to early human pregnancy Am J Obstet Gynecol 19881591456-60
bull 18 OrsquoDay MP Cardio-respiratory physiological adaptation of pregnancy Semin Perinatol 199721268-75
bull 19 Contreras G Gutierrez M Beroiza T Fantin A Oddo H Villarroel L et al Ventilatory drive and respiratory muscle function in pregnancy Am Rev Respir Dis 1991144837-41
bull 20 Turner M Aziz SR Management of the pregnant oral and maxillofac
bull 21 Sifakis S Pharmakides G Anemia in pregnancy Ann N Y Acad Sci 2000900125-36
bull 22 Branch DW Physiologic adaptations of pregnancy Am J Reprod Immunol 199228120-2
bull 23 Burrows RF Kelton JG Incidentally detected thrombocytopenia in healthy mothers and their infants N Engl J Med 1988319 142-5
bull 24 Hanly JG Antiphospholipid syndrome an overview CMAJ 200324(168)1675-82
bull 25 Heilmann L von Tempelhoff GF Pollow K Antiphospholipid syndrome in obstetrics Clin Appl Thromb Hemost 20039 143-50
bull 26 Sherman P Flaxman SM Nausea and vomiting of pregnancy in an evolutionary perspective Am J Obstet Gynecol 2002 185(Suppl)s190-7
bull 27 Koch KL Gastrointestinal factors in nausea and vomiting of pregnancy Am J Obstet Gynecol 2002185(Suppl)s198-203
bull 28 Koch KL Frissora CL Nausea and vomiting during pregnancy Gastroenterol Clin N Am 200332201-34
bull 29 Baron TH Ramirez B Richter JE Gastrointestinal motility disorders during pregnancy Ann Intern Med 1993118 366-75
bull 30 Richter JE Gastroesophageal reflux disease during pregnancy Gastroenterol Clin N Am 200332235-61
bull 31 Marrero JM Goggin PM de Caestecker JS Pearce JM Maxwell JD Determinants of pregnancy heartburn Br J Obstet Gynaecol 199299731-4
bull 32 Hamaoui E Hamaoui M Nutritional assessment and support during pregnancy Gastroenterol Clin N Am 20033259-121
bull 33 King JC Physiology of pregnancy and nutrient metabolism Am J Clin Nutr 200071(suppl)1218s-25s
bull 34 Casanueva E Pfeffer F Fernandez-Gaxiola AC Gutierrez- Valenzuela V Rothenberg SJ Iron and folate status before pregnancy and anemia during pregnancy Ann Nutr Metab 2003 4760-3
bull 35 Chrsquong CL Morgan M Hainsworth I Kingham JG Prospective study of liver dysfunction in Southwest Wales Gut 200251 876-80
bull 36 Rahman TM Wendon J Severe hepatic dysfunction in pregnancy QJM 200295343-57
bull 37 Knox TA Olans LB Liver disease in pregnancy N Engl J Med 1996335569-76
bull 38 Saftlas AF Olson DR Franks AL Atrash H Pokras R Epidemiology of preeclampsia and eclampsia in the United States 1979e1986 Am J Obstet Gynecol 1990163460-5
bull 39 Walker JJ Pre-eclampsia Lancet 20003561260-5
bull 40 Davidson JM Renal disorders in pregnancy Curr Opin Obstet Gynecol 200113109-14
bull 41 Dafnis E Sabatini S The effect of pregnancy on renal function physiology and pathophysiologyAmJMedSci 1992303184-205
bull 42 Davison JM Shiells EA Philips PR Lindheimer MD Serial evaluation of vasopressin release and thirst in human pregnancy Role of human chorionic gonadotrophin in the osmoregulatory changes of gestation J Clin Invest 198881798-806
bull 43 Glinoer D de Nayer P Bourdoux P Lemone M Robyn C van Steirteghem A et al Regulation of maternal thyroid during pregnancy J Clin Endocrinol Metab 199071276-87
bull 44 Wilson SG Retallack RW Kent JC Worth GK Gutteridge DH Serum free 125-dihydroxyvitamin D and the free 125- dihydroxyvitamin D index during a longitudinal study of human pregnancy and lactation Clin Endocrinol 199032613-22
bull 45 Rasmussen N Frolich A Hornnes PJ Hegedus L Serum ionized calcium and intact parathyroid hormone levels during pregnancy and postpartum Br J Obstet Gynaecol 199097857-9
bull 46 Guyton AC Textbook of medical physiology 8th ed Philadelphia W B Saunders 1991 p 915e28
bull 47 Trainer PJ Corticosteroids and pregnancy Semin Reprod Med 200220375-80
bull 48 Soory M Hormonal factors in periodontal disease Dent Update 200027380-3
bull 49 Hugoson A Gingivitis in pregnant women A longitudinal clinical study Odontol Revy 19712265-84
bull 50 Neville BW Damm DD Allen CM Bouquot JE Oral amp Maxillofacial Pathology 3rd ed Philadelphia W B Saunders 2002 p 329-30 447-9
bull 51 Tilakaratne A Soory M Ranasinghe AW Corea SM Ekanayake SL de Silva M Periodontal disease status during pregnancy and 3 months post-partum in rural population of Sri-Lankan women J Clin Periodontol 200027787-92
bull 52 Laine M Tenovuo J Lehtonen OP Ojanatko-Harri A Vilja P Tuohimaa P Pregnancy e related changes in human whole saliva Arch Oral Biol 198833913-7
bull 53 Yuan K Wing LY Lin MT Pathogenetic roles of angiogenic factors in pyogenic granulomas in pregnancy are modulated by female sex hormones J Periodontol 200273701-8
bull 54 Evans RD Briggs PF Tooth-surface loss related to pregnancyinduced vomiting Prim Dent Care 1994124-6
bull 55 Salvolini E Di Giorgio R Curatola A Mazzanti L Fratto G Biochemical modifications of human whole saliva induced by pregnancy Br J Obstet Gynaec 1998105656-60
bull 56 Mauldin JG Newman RB Preterm birth risk assessment Semin Perinatol 200125215-22
bull 57 Heine RP McGregor JA Goodwin TM Artal R Hayashi RH Robertson PA et al Serial salivary estriol to detect an increased risk of preterm birth Obstet Gynecol 200096490-7
bull 58 Kauh YC Zachian TF Melasma Adv Exp Med Biol 1999455 491-9
bull 59 Wong RC Ellis CN Physiologic skin changes in pregnancy J Am Acad Dermatol 198410929-40
bull 60 Errickson CV Matus NR Skin disorders of pregnancy Am Fam Physician 199449605-10
bull 61 Lopez NJ Smith PC Gutierrez J Periodontal therapy may reduce the risk of preterm low birth weight in women with periodontal disease a randomized controlled trial J Periodontol 200273911-24
bull 62 McGaw T Periodontal disease and preterm delivery of lowbirth- weight infants J Can Dent Assoc 200268165-9
bull 63 Richards AG Dental x-ray protection Dent Clin North Am 1968631-41
bull 64 1990 Recommendations of the International Commission on Radiological Protection Ann ICRP 1991211-201
bull 65 Hall EJ Radiation the two-edged sword cancer risks at high and low doses Cancer J 20006343-50
bull 66 Diethelm L Xu H Diagnostic imaging of the lung during pregnancy Clin Obstet Gynecol 19963936-55
bull 67 Brent RL The effects of embryonic and fetal exposure to x-rays microwaves and ultrasound ClinObstetGynecol 198326484-510
bull 68 National Council on Radiation Protection NCRP report no128 1998 Bethesda Md Author
bull 69 Wasylko L Matsui D Dykxhoorn SM Reider MJ Weinberg S A review of common dental treatments during pregnancy implications for patients and dental personnel J Can Dent Assoc 199864434-9
bull 70 Freeman JP Brand JW Radiation doses of commonly used dental radiographic surveys Oral Surg Oral Med Oral Pathol 199477285-9
bull 71 Kircos LTAngin LL Lorton LOrder ofmagnitude dose reduction in intraoral radiography J Am Dent Assoc 1987114344-7
bull 72 Updegrave WJ Simplified and standardized intraoral radiography with reduced tissue irradiation J Am Dent Assoc 197285861-9
bull 73 Wood RE Harris AM van der Merwe EJ Nortje CJ The leaded apron revisited does it reduce gonadal radiation dose in dental radiology Oral Surg Oral Med Oral Pathol 199171642-6
bull 74 An update on radiographic practices information and recommendations ADA Council on Scientific Affairs J Am Dent Assoc 2001132234-8
bull 75 Rayburn WF Recommending medications during pregnancy an evidence based approach Clin Obstet Gynecol 2002451-5
bull 76 Rathmell JP Viscomi C Ashburn MA Management of nonobstetric pain during pregnancy and lactation Anesth Analg 1997851074-87
bull 77 Teratology society public affairs committee FDA classification of drugs for teratogenic risk Teratology 199449446-7
bull 78 Moore PA Selecting drugs for the pregnant dental patient J Am Dent Assoc 19981291281-6
bull 79 Haas DA An update on analgesics for the management of acute postoperative dental pain J Can Dent Assoc 200268476-82
bull 80 Haas DA Pynn BR Sands TD Drug use for the pregnant or lactating patient Gen Dent 20004854-60
bull 81 Committee on Drugs American Academy of Pediatrics The transfer of drugs and other chemicals into human milk Pediatrics 199493137-50
bull 82 Nielsen GL Sorensen HT Larsen H Pedersen L Risk of adverse birth outcome and miscarriage in pregnant users of nonsteroidal anti-inflammatory drugs population based observational study and case-control study BMJ 2001322266-70
bull 83 Janssen N Genta M The effects of immunosuppressive and anti-inflammatory medications on fertility pregnancy and lactation Arch Intern Med 200016610-9
bull 84 Ostensen M Nonsteroidal anti-inflammatory drugs during pregnancy Scand J Rheumatol Suppl 1998107128-32
bull 85 USPDI -Drug information for the health care professional 22nd ed Greenwood Village CO Micromedex 2002 p 152-79
bull 86 Denson DD Coyle DE Thompson GA Santos D Turner PA Myers JA et al Bupivacaine protein binding in the term parturient effects of lactic acidosis Clin Pharmacol Ther 198435702-9
bull 87 Dillon DE Wagner CL Wiest D Newman RB Drug therapy in the nursing mother Obstet Gynecol Clin North Am 199724 675-96
bull 88 Dashe JS Gilstrap LC Antibiotic use in pregnancy Obstet Gynecol Clin North Am 199724617-29
bull 89 American College of Rheumatology Ad hoc Committee on Clinical Guidelines Guidelines for monitoring drug therapy in rheumatoid arthritis Arthritis Rheum 199639723-31
bull 90 Ng PC The fetal and neonatal hypothalamic-pituitary-adrenal axis Arch Dis Child Fetal Neonatal Ed 200082F250-4
bull 91 Crowley P Antenatal corticosteroidsmdashcurrent thinking BJOG 2003110(Suppl 20)77-8
bull 92 ACOG committee opinion antenatal corticosteroid therapy for fetal maturation Obstet Gynecol 200299871-3
bull 93 Ost L Wettrell G Bjorkhem I Rane A Prednisolone excretion in human milk J Pediatr 19851061008-11
bull 94 Rowland AS Baird DD Shore DL Weinberg CR Savitz DA Wilcox AJ Nitrous oxide and spontaneous abortion in female dental assistants Am J Epidemiol 1995141531-8
bull 95 McGlothlin JD Jensen PA Fischbach TJ Hughes RT Jones JH Control of anesthetic gases in dental operatories Scand J Work Environ Health 199218(Suppl 2)103-5
bull ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY Volume 97 Number 6 Suresh and Radfar 681
bull 96 Rosen MA Nitrous oxide for relief of labor pain a systematic review Am J Obstet Gynecol 2002186(Suppl Nature)S110-6
bull 97 Sands TD Pynn BR Management considerations for the pregnant or nursing emergency patient Ont Dent 199875 17-9
bull 98 Daya S Recurrent spontaneous early pregnancy loss and low dose aspirin Minerva Ginecol 200355441-9
bull 99 Sinclair C Handbook of obstetrical emergencies 1st ed Philadelphia WB Saunders 1996 p 29-39 69
bull 100 Tarsitano BF Rollings RE The pregnant dental patient evaluation and management Gen Dent 199341226-34
bull 101 Livingston MH Dlllinger TM Holder R Consideration in the management of the pregnant patient SCD Special Care in Dentistry 199818183-8
Thank you
- A Review on the principle of Dental Management of the Pregnant patient
- Slide 2
- Questions that a dentist may ask
- Stages of Pregnancy
- Slide 5
- Slide 6
- Physiologic Changes in Pregnancy
- Systemic changes in pregnancy
- FLAT SUPINE POSITIONING
- SUPINE HYPOTENSION SYNDROME (Vena Cava Compression)
- Supine Hypotension Syndrome
- Slide 12
- Supine Hypotension Syndrome
- Prevention of Supine Hypotensive Syndrome
- Treatment of Supine Hypotensive Syndrome
- How should the pregnant woman be positioned
- Slide 17
- Slide 18
- Slide 19
- Slide 20
- Slide 21
- Slide 22
- Slide 23
- Pregnancy Related Oral Health Problems
- Oral Problems in Pregnancy
- Pregnancy Gingivitis Pathophysiology
- Pregnancy Gingivitis
- Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Gum Problems - Pregnancy Granuloma
- Slide 31
- Gum Changes - Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Candidiasis
- Pregnancy Myths
- Other Oral Conditions in Pregnancy
- Changes During Pregnancy that Affect Oral Health
- Saliva changes
- Increased Bacteria
- Slide 40
- Enamel erosion caused by frequent vomiting
- Treatment for Acid Exposure
- Oral Diseases Can Effect Pregnancy
- Periodontal Disease and Preterm Labor
- Periodontal Disease and Low Birth Weight
- Periodontal Disease and Preeclampsia
- Periodontitis and Pre-eclampsia
- Dental Considerations
- Treatment Timing
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Slide 52
- Use of Radiation on Pregnant Patient
- Radiographs during Pregnancy
- Risks of Dental X-Rays
- FDA drug classification for pregnancy
- Slide 57
- FDA drug classification for pregnancy
- Slide 59
- Slide 60
- Slide 61
- Common Analgesics
- Analgesics
- Analgesics - continued
- Analgesics to Use During 1st and 2nd Trimester
- Analgesics to Avoid During the Third Trimester
- Sedation in Pregnancy
- Common Antibiotics
- Antibiotics
- Antibiotics To Use During Pregnancy
- Antibiotics to Avoid during Pregnancy
- The Problem With Tetracycline
- Other Antimicrobial Agents
- Local Anesthetic Use in Pregnancy
- Use of Local Anesthetics
- Ulcer healing drugs
- Slide 77
- Slide 78
- Slide 79
- Use of Nitrous Oxide Gas
- Common Preventives
- Are topical agents safe
- Pre-natal Fluoride
- Is it safe to use mercury restorations
- References
- REFERENCES
- Slide 87
- Slide 88
- Slide 89
- Slide 90
- Slide 91
- Slide 92
- Slide 93
- Slide 94
- Slide 95
- Slide 96
- Slide 97
- Slide 98
- Thank you
-
Pregnancy Gingivitis Pathophysiology
bull Elevated circulating estrogen increases capillary permeability
bull Preexisting gingivitis may predispose to pregnancy gingivitis
Pregnancy Gingivitis
bullOccurs commonly in the 2nd to 8th monthsbullTendency to bleed very easilybullTreatment Scaling root-planing currettage OHI
Pregnancy Granuloma
bullOccurs in up to 5 of womenbullMost common in buccal maxillary anterior areasbullUsually starts in an area of gingivitis
Pregnancy Granuloma (continued)
bullRapid growth up to 2 cmbullSingle tumor-like growthbullusually in interdental papillaebullPurplish to bluish in color may be ulcerated- bleeds easily
Gum Problems - Pregnancy Granuloma
Gum Problems - Pregnancy Granuloma
Gum Changes - Pregnancy Granuloma
Pregnancy Granuloma (continued)
Treatment
bull Scaling and root planingbull Excision if it is too large or bleeds too
easilybull May regress spontaneously after
pregnancy
Candidiasis
bullWipes offbullUsually asymptomatic but may burnbullTreatment topical or systemic antifungals
Pregnancy MythsbullldquoA mother loses a tooth for every babyrdquobullNo evidence that aphthous ulcers are any more common in pregnancy
Other Oral Conditions in Pregnancy
bull Dry mouthbull Excessive salivationbull Tooth erosions associated with
severe GERD or hyperemesis
Changes During Pregnancy that Affect Oral Health
bull Hormonal Affects
ndash Increased tooth mobility
ndash Saliva changes
ndash Increased bacteria
ndash Gingival problems
Saliva changesbull Decreased buffers
bull Decreased minerals
bull Decreasing flow first and last trimester
bull Increased flow second trimester
bull More acidic
Increased Bacteriabull Increased acidity
ndash Increase in decay-causing bacteriabull Increased Snacking
ndash Morning sicknesslow blood sugarndash Between-meal snacks
bull Increase in amount and frequency of starchescarbohydrates ndash Crackers are commonly recommendedndash Promotes decay-causing bacteria
Changes During Pregnancy that Affect Oral Healthbull Morning sickness
ndash Difficulty with hygienebull Gingival diseasebull Tooth decay
ndash Vomitingbull Esophogeal Reflux (heartburn)bull Acid exposure
ndash Irritation of the gumsndash Weakening of tooth enamelndash Dental erosion
Enamel erosion caused by frequent vomiting
Treatment for Acid Exposure
bull Do NOT brush immediately after vomiting
bull Rinse ndash Water with baking sodandash Antacidndash Plain water
bull Eat some cheese
Oral Diseases Can Effect Pregnancy
bull Preterm low birth weight (LBW) linked to periodontal disease
bull Thorough calculus (tartar) removal in pregnant women with periodontitis may reduce pre-term births
Periodontal Disease and Preterm LaborbullMaternal periodontal disease is associated with increased risk of preterm laborbullAnaerobic oral gram-negative bacteria cause inflammatory responsebullInflammatory response stimulates prostaglandin and cytokine production to stimulate labor
Periodontal Disease and Low Birth Weight
bull Periodontal disease is associated with low birth weight
bull Evidence is not conclusivebull Biochemical mechanism similar cascade
as in preterm labor leading to placental blood flow restriction and necrosis
Periodontal Disease and Preeclampsia
bull Emerging databull Mechanism unclearbull Proposed mechanism
ndash Periodontal infection leads to inflammatory vascular damage
ndash Triggers cell damage in placenta
Periodontitis and Pre-eclampsia
bull Periodontal disease may be associated with pre-eclampsia (Boggess 2003)
bull PGE2 IL-1 and TNF-α from gingival crevicular fluid were higher in women with preeclampsia compared with healthy matched pregnant women (Oettinger-Barak 2003)
Dental Considerations
bull timing of treatment for pregnant patientsbull dental radiation exposurebull use of local anestheticsbull prescription of common antibiotics and
analgesicsbull nitrous oxide gas administration
Treatment Timing
bull First Trimesterndash Spontaneous miscarriages naturally occur
more often in 1st trimesterndash Avoid elective treatment that can be delayedndash Offer anticipatory guidance
bull Second Trimesterndash The optimal time for dental treatmentndash Organogenesis complete fetus not largendash Easier to prevent than treat established disease
bull Third Trimesterndash Late in term very uncomfortable (short visits)ndash Position slightly on left side
Timing of Dental Treatment During Pregnancy - From Little and Fallace
First Trimester
bull Plaque controlbull Oral hygiene instructionbull Scaling polishing curettagebull Avoid elective treatment urgent care
only
Timing of Dental Treatment During Pregnancy - From Little and Fallace
Second Trimester
bull Plaque controlbull Oral hygiene instructionbull Scaling polishing curettagebull Routine dental care
Timing of Dental Treatment During Pregnancy - From Little and Fallace
Third Trimester
bull Plaque controlbull Oral hygiene instructionbull Scaling polishing curettagebull Routine dental care (after middle of third
trimester elective care should be avoided)
Use of Radiation on Pregnant Patientbull Dose given and time of gestation are
importantbull doses lt 5-10 rads (cGy) not teratogenicbull fetus is most susceptible to radiation
between the 2nd and 6th week of gestationbull single dental x-ray exposes patient to 001
millirads of radiation In relative terms this amount is 40 times less than daily dose acquired from cosmic radiation Therefore diagnostic radiation should not be withheld during pregnancy
Radiographs during Pregnancy
bull Take as needed with optimal methods for reducing secondary radiation and exposure time
bull Always use a lead apronbull Exposure to fetus (with apron use) is 00001
centiGray(rad)bull Daily cosmic radiation - 0004 centiGray (rad)
Risks of Dental X-Rays
bull X-ray only if necessary (ie root canal therapy trauma)
bull When x-rays are indicated radiation exposure is extremely low
bull Exposure can be limited byndash Lead apron shielding ndash Modern fast film ndash Avoiding retakes
FDA drug classification for pregnancybull Combines risk statements including
congenital anomalies fetal effects perinatal risks and therapeutic risk-benefit ratio
bull Untreated disease or condition may pose more serious risks to both mother and fetus than any theoretical risks from the medication
bull Category A thru D and X
FDA drug classification for pregnancy
bull A = Controlled Studies in women fail to demonstrate a risk to the fetus in the first trimester and the possibility of fetal harm appears remote
FDA drug classification for pregnancy
bull B = Animal studies show no risk or if risk shown in animals controlled
trials in women showed no risk
FDA drug classification for pregnancy
bull C = Studies in animals with adverse effects and no human studies
OR no animal or human studies but benefits of use may outweigh potential harms
FDA drug classification for pregnancy
bull D = There is evidence of human fetal risk but benefits may outweigh risks
FDA drug classification for pregnancy
bull X = Contraindicated
Common Analgesics
bull paracetamol (B)bull Ibuprofen (BD) bull Oxycodone (BD) bull Hydrocodone and codeine
(CD)
avoid in third trimester
Analgesics
bull Paracetamol is the analgesic of choice for all stages of gestation
bull used to treat mild to moderate pain and fevers
bull short term usage is believed to be safebull avoid chronic and large doses of
paracetamol1048715
Analgesics - continuedbull Aspirin is nonteratogenic but may cause
maternal and fetal hemorrhagebull large and chronic doses during last trimester
may result in premature closure of ductus arteriosus fetal hypertension anemia and low birth weight
bull avoid ibuprofen in 3rd trimester because of possible adverse circulatory effects
bull short term use of codeine seems safebull avoid codeine late in gestation because of
possible fetal respiratory depression and withdrawal symptoms
Analgesics to Use During1st and 2nd Trimester
bull Category B (for best)bull Paracetamol Ibuprofenbull Naproxenbull Category C (use with caution)bull Paracetamol with codeine or
hydrocodonebull Paracetamol with oxycodone
Analgesics to Avoid During theThird Trimesterbull Causes delivery problemsbull Aspirin (C 3D)bull Ibuprofen (B3D)bull Naproxen (B3D)bull Causes neonatal respiratory
depression and opioid withdrawalbull Codeine (C3D)bull Hydrocodone (C3D)bull Oxycodone(C3D)
Sedation in Pregnancy
bull SedativesAnxiolytics (eg Diazepam ) are rated D and can cause oral clefts with prolonged exposure
bull Nitrous oxide should not be used in 1st trimester (If used in 2nd and 3rd do not go below 50 O2)
Common Antibioticsbull To treat oral abscess or cellulitis
ndash Penicillin (B) ndash Amoxicillin (B) ndash Cephalexin (B)ndash Erythromycin base (B) (Not estolate as it
cause cholestatic hepatitis)ndash Clindamycin (B)
Antibioticsbull penicillin V and amoxicillin is preferred drug
for mild to moderate infectionsbull widely used for many years with no ill effectsbull no studies show penicillin to be teratogenicbull amoxicillin extensively used without harming
the fetusbull Drug classes1048715 B penicillin cephalosporins erythromycin clindamycin Azithromycin D Tetracycline
Antibiotics To Use During Pregnancy
bull Penicillin Vbull Amoxicillinbull Erythromycin (base form)bull Cephalexin cephalosporinbull Clindamycinbull Metronidazole
Antibiotics to Avoid duringPregnancy
bull Doxycyclinebull Tetracyclinebull Erythromycin (estolate form)bull Vancomycin
The Problem With Tetracycline
bull Accumulates in bones and chelates calcium
bull Inhibits bone growthbull Discolors teeth
Other Antimicrobial Agentsbull OK to usebull Nystatin (B)bull Chlorhexidine rinse (B)bull Use with cautionbull Clotrimazole (C)bull Ketoconazole (C)bull Fluconazole (C)bull Do not usebull Doxycycline (D)
Local Anesthetic Use inPregnancy
bull Class Bbull Lidocaine (Xylocaine)bull Etidocainebull Prilocaine bull Class Cbull Procainebull Bupivicainebull Mepivicaine
Use of Local Anestheticsbull Lidocaine + vasoconstrictor most common
local anesthetic used in dentistrybull extensively used in pregnancy with no proven ill
effectsbull accidental intravascular injections of lidocaine
pass through the placenta but the concentrations are too low to harm fetus
bull prilocaine might cause methemoglobinemia
Ulcer healing drugsCimetidine bull FDA category B Famotidinebull FDA category BRanitidinebull FDA category Bbull not known to be harmful
Ulcer healing drugsOmeprazolebull FDA category BNot known to be
harmful Esomeprazolebull FDA category BLansoprazolebull FDA category BPantoprazolebull Avoid unless potential benefit
outweighs riskmdashfetotoxic in animals
Ulcer healing drugs
Misoprostolbull First second third trimesters Avoidmdash
potent uterine stimulant (has been used to induce abortion) and may be teratogenic
Ulcer healing drugs
Antacidsbull Almunium hydroxideMagnesium
hydroxidemdashFDA category B Calcium carbonatemdashFDA category C
SimetheconemdashFDA category C
Use of Nitrous Oxide Gas
bull used over 150 years bull safety is being debatedbull SHORT TERM exposure do not cause
birth defects or spontaneous abortionbull CHRONIC exposure may result in fetal
loss and infertilitybull literature suggests that nitrous oxide
should be avoided until more conclusive research is available
bull FDA Drug class not yet assigned
Common Preventives
bull Fluoridendash No increased risk during pregnancy
bull Xylitolndash No studies no harm reported
bull Chlorhexidinendash No increased risk during pregnancy
Are topical agents safe
bull Fluoridebull Toothpaste amp mouthrinse
bull Xylitol chewing gum bull Chlorhexidine (11 alcohol)bull No over the counter mouthrinses with
alcohol (Listerine 20 alcohol)
Pre-natal Fluoride
bull Daily 22 mg tablet of sodium fluoride during 3rd through 9th months
bull decreases caries rate in offspringbull Safe and effective
Glenn FB 1982
Is it safe to use mercury restorations
bull No evidence of harmful effect
bull Benefits outweigh risks
bull Canada Germany and New Zealand have some restrictions
bull Determine the best option
Referencesbull Wasylko L Matsui D Dykxhoorn SM Rieder MJ Weinberg
S A Review of Common Dental Treatments During Pregnancy J Canadian Dental Association 64434-439 1998
bull Little JW Donald AF Craig SM Rhodus NL Dental Management of the Medically Compromised Patient - 5th edition Mosby Toronto Pp434-442 1997
bull Livingston HM Dellinger TM Holder R Considerations in the management of the pregnant patient Special Care in Dentistry 185 pp183-188 1998
bull Larimore WL Petrie KA Drug use during pregnacy and lactation Primary Care Clinics in Office Practice 271 35-53 2000
bull Health Canada The Safety of DentalAmalgam Minister Of Supply and Services Canada 1996
REFERENCESbull 1 Weiss G Endocrinology of parturition J Clin
Endocrinol Metab 2000854421-5bull 2 Theunissen IM Parer JT Fluid and electrolytes in
pregnancy Clin Obstet Gynecol 1994373-15bull 3 Duvekot JJ Peeters LLH Renal hemodynamics and
volume homeostasis in pregnancy Obstet Gynecol Surv 199449830-9
bull 4 Barron WM Lindheimer MD Medical disorders during pregnancy 2nd ed St Louis Mosby 1995 p 129
bull 5 Thornburg KL Jacobson SL Giraud GD Morton MJ Hemodynamic changes in pregnancy Semin Perinatol 20002411-4
bull 6 Fiese R Herzog S Issues in dental and surgical management of the pregnant patient Oral Surg Oral Med Oral Pathol 198865292-7
bull 7 Martin C Varner MW Physiologic changes in pregnancysurgical implications Clin Obstet Gynecol 199437241-55
bull 8 Clark SL Cotton DB Lee W Bishop C Hill T Southwick J et al Central hemodynamic assessment of normal term pregnancy Am J Obstet Gynecol 19891611439-42
bull 9 Mabie WC Di Sessa TG Crocker LG Sibai BM Arheart KL A longitudinal study of cardiac output in normal human pregnancy Am J Obstet Gynecol 1994170849-56
bull 10 Clapp JF 3rd Capeless E Cardiovascular function before during and after the first and subsequent pregnancies Am J Cardiol 1997801469-73
bull 11 Duvekot JJ Peeters LL Maternal cardiovascular hemodynamic adaptation to pregnancy Obstet Gynecol Surv 199449(Suppl) S1-14
bull 12 Bhagwat AR Engel PJ Heart disease and pregnancy Cardiol Clin 199513163-78
bull 13 Lanni SM Tillinghast J Silver H Hemodynamic changes and baroreflex gain in the supine hypotensive syndrome Am J Obstet Gynecol 20021871636-41
bull 14 Little JW Falace DA Miller CS Rhodus NL Dental management of the medically compromised patient 6th ed St Louis Mosby 2002 p 303
bull 15 Garcia-Rio F Pino JM Gomez L Alvarez-Sala R Villasante C Villamor J Regulation of breathing and perception of dyspnea in healthy pregnant women Chest 1996110446-53
bull 16 McAuliffe F Kametas N Costello J Rafferty GF Greenough A Nicolaides K Respiratory function in singleton and twin pregnancy BJOG 2002109765-9
bull 17 Clapp JF 3rd Seaward BL Sleamaker RH Hiser J Maternal physiologic adaptations to early human pregnancy Am J Obstet Gynecol 19881591456-60
bull 18 OrsquoDay MP Cardio-respiratory physiological adaptation of pregnancy Semin Perinatol 199721268-75
bull 19 Contreras G Gutierrez M Beroiza T Fantin A Oddo H Villarroel L et al Ventilatory drive and respiratory muscle function in pregnancy Am Rev Respir Dis 1991144837-41
bull 20 Turner M Aziz SR Management of the pregnant oral and maxillofac
bull 21 Sifakis S Pharmakides G Anemia in pregnancy Ann N Y Acad Sci 2000900125-36
bull 22 Branch DW Physiologic adaptations of pregnancy Am J Reprod Immunol 199228120-2
bull 23 Burrows RF Kelton JG Incidentally detected thrombocytopenia in healthy mothers and their infants N Engl J Med 1988319 142-5
bull 24 Hanly JG Antiphospholipid syndrome an overview CMAJ 200324(168)1675-82
bull 25 Heilmann L von Tempelhoff GF Pollow K Antiphospholipid syndrome in obstetrics Clin Appl Thromb Hemost 20039 143-50
bull 26 Sherman P Flaxman SM Nausea and vomiting of pregnancy in an evolutionary perspective Am J Obstet Gynecol 2002 185(Suppl)s190-7
bull 27 Koch KL Gastrointestinal factors in nausea and vomiting of pregnancy Am J Obstet Gynecol 2002185(Suppl)s198-203
bull 28 Koch KL Frissora CL Nausea and vomiting during pregnancy Gastroenterol Clin N Am 200332201-34
bull 29 Baron TH Ramirez B Richter JE Gastrointestinal motility disorders during pregnancy Ann Intern Med 1993118 366-75
bull 30 Richter JE Gastroesophageal reflux disease during pregnancy Gastroenterol Clin N Am 200332235-61
bull 31 Marrero JM Goggin PM de Caestecker JS Pearce JM Maxwell JD Determinants of pregnancy heartburn Br J Obstet Gynaecol 199299731-4
bull 32 Hamaoui E Hamaoui M Nutritional assessment and support during pregnancy Gastroenterol Clin N Am 20033259-121
bull 33 King JC Physiology of pregnancy and nutrient metabolism Am J Clin Nutr 200071(suppl)1218s-25s
bull 34 Casanueva E Pfeffer F Fernandez-Gaxiola AC Gutierrez- Valenzuela V Rothenberg SJ Iron and folate status before pregnancy and anemia during pregnancy Ann Nutr Metab 2003 4760-3
bull 35 Chrsquong CL Morgan M Hainsworth I Kingham JG Prospective study of liver dysfunction in Southwest Wales Gut 200251 876-80
bull 36 Rahman TM Wendon J Severe hepatic dysfunction in pregnancy QJM 200295343-57
bull 37 Knox TA Olans LB Liver disease in pregnancy N Engl J Med 1996335569-76
bull 38 Saftlas AF Olson DR Franks AL Atrash H Pokras R Epidemiology of preeclampsia and eclampsia in the United States 1979e1986 Am J Obstet Gynecol 1990163460-5
bull 39 Walker JJ Pre-eclampsia Lancet 20003561260-5
bull 40 Davidson JM Renal disorders in pregnancy Curr Opin Obstet Gynecol 200113109-14
bull 41 Dafnis E Sabatini S The effect of pregnancy on renal function physiology and pathophysiologyAmJMedSci 1992303184-205
bull 42 Davison JM Shiells EA Philips PR Lindheimer MD Serial evaluation of vasopressin release and thirst in human pregnancy Role of human chorionic gonadotrophin in the osmoregulatory changes of gestation J Clin Invest 198881798-806
bull 43 Glinoer D de Nayer P Bourdoux P Lemone M Robyn C van Steirteghem A et al Regulation of maternal thyroid during pregnancy J Clin Endocrinol Metab 199071276-87
bull 44 Wilson SG Retallack RW Kent JC Worth GK Gutteridge DH Serum free 125-dihydroxyvitamin D and the free 125- dihydroxyvitamin D index during a longitudinal study of human pregnancy and lactation Clin Endocrinol 199032613-22
bull 45 Rasmussen N Frolich A Hornnes PJ Hegedus L Serum ionized calcium and intact parathyroid hormone levels during pregnancy and postpartum Br J Obstet Gynaecol 199097857-9
bull 46 Guyton AC Textbook of medical physiology 8th ed Philadelphia W B Saunders 1991 p 915e28
bull 47 Trainer PJ Corticosteroids and pregnancy Semin Reprod Med 200220375-80
bull 48 Soory M Hormonal factors in periodontal disease Dent Update 200027380-3
bull 49 Hugoson A Gingivitis in pregnant women A longitudinal clinical study Odontol Revy 19712265-84
bull 50 Neville BW Damm DD Allen CM Bouquot JE Oral amp Maxillofacial Pathology 3rd ed Philadelphia W B Saunders 2002 p 329-30 447-9
bull 51 Tilakaratne A Soory M Ranasinghe AW Corea SM Ekanayake SL de Silva M Periodontal disease status during pregnancy and 3 months post-partum in rural population of Sri-Lankan women J Clin Periodontol 200027787-92
bull 52 Laine M Tenovuo J Lehtonen OP Ojanatko-Harri A Vilja P Tuohimaa P Pregnancy e related changes in human whole saliva Arch Oral Biol 198833913-7
bull 53 Yuan K Wing LY Lin MT Pathogenetic roles of angiogenic factors in pyogenic granulomas in pregnancy are modulated by female sex hormones J Periodontol 200273701-8
bull 54 Evans RD Briggs PF Tooth-surface loss related to pregnancyinduced vomiting Prim Dent Care 1994124-6
bull 55 Salvolini E Di Giorgio R Curatola A Mazzanti L Fratto G Biochemical modifications of human whole saliva induced by pregnancy Br J Obstet Gynaec 1998105656-60
bull 56 Mauldin JG Newman RB Preterm birth risk assessment Semin Perinatol 200125215-22
bull 57 Heine RP McGregor JA Goodwin TM Artal R Hayashi RH Robertson PA et al Serial salivary estriol to detect an increased risk of preterm birth Obstet Gynecol 200096490-7
bull 58 Kauh YC Zachian TF Melasma Adv Exp Med Biol 1999455 491-9
bull 59 Wong RC Ellis CN Physiologic skin changes in pregnancy J Am Acad Dermatol 198410929-40
bull 60 Errickson CV Matus NR Skin disorders of pregnancy Am Fam Physician 199449605-10
bull 61 Lopez NJ Smith PC Gutierrez J Periodontal therapy may reduce the risk of preterm low birth weight in women with periodontal disease a randomized controlled trial J Periodontol 200273911-24
bull 62 McGaw T Periodontal disease and preterm delivery of lowbirth- weight infants J Can Dent Assoc 200268165-9
bull 63 Richards AG Dental x-ray protection Dent Clin North Am 1968631-41
bull 64 1990 Recommendations of the International Commission on Radiological Protection Ann ICRP 1991211-201
bull 65 Hall EJ Radiation the two-edged sword cancer risks at high and low doses Cancer J 20006343-50
bull 66 Diethelm L Xu H Diagnostic imaging of the lung during pregnancy Clin Obstet Gynecol 19963936-55
bull 67 Brent RL The effects of embryonic and fetal exposure to x-rays microwaves and ultrasound ClinObstetGynecol 198326484-510
bull 68 National Council on Radiation Protection NCRP report no128 1998 Bethesda Md Author
bull 69 Wasylko L Matsui D Dykxhoorn SM Reider MJ Weinberg S A review of common dental treatments during pregnancy implications for patients and dental personnel J Can Dent Assoc 199864434-9
bull 70 Freeman JP Brand JW Radiation doses of commonly used dental radiographic surveys Oral Surg Oral Med Oral Pathol 199477285-9
bull 71 Kircos LTAngin LL Lorton LOrder ofmagnitude dose reduction in intraoral radiography J Am Dent Assoc 1987114344-7
bull 72 Updegrave WJ Simplified and standardized intraoral radiography with reduced tissue irradiation J Am Dent Assoc 197285861-9
bull 73 Wood RE Harris AM van der Merwe EJ Nortje CJ The leaded apron revisited does it reduce gonadal radiation dose in dental radiology Oral Surg Oral Med Oral Pathol 199171642-6
bull 74 An update on radiographic practices information and recommendations ADA Council on Scientific Affairs J Am Dent Assoc 2001132234-8
bull 75 Rayburn WF Recommending medications during pregnancy an evidence based approach Clin Obstet Gynecol 2002451-5
bull 76 Rathmell JP Viscomi C Ashburn MA Management of nonobstetric pain during pregnancy and lactation Anesth Analg 1997851074-87
bull 77 Teratology society public affairs committee FDA classification of drugs for teratogenic risk Teratology 199449446-7
bull 78 Moore PA Selecting drugs for the pregnant dental patient J Am Dent Assoc 19981291281-6
bull 79 Haas DA An update on analgesics for the management of acute postoperative dental pain J Can Dent Assoc 200268476-82
bull 80 Haas DA Pynn BR Sands TD Drug use for the pregnant or lactating patient Gen Dent 20004854-60
bull 81 Committee on Drugs American Academy of Pediatrics The transfer of drugs and other chemicals into human milk Pediatrics 199493137-50
bull 82 Nielsen GL Sorensen HT Larsen H Pedersen L Risk of adverse birth outcome and miscarriage in pregnant users of nonsteroidal anti-inflammatory drugs population based observational study and case-control study BMJ 2001322266-70
bull 83 Janssen N Genta M The effects of immunosuppressive and anti-inflammatory medications on fertility pregnancy and lactation Arch Intern Med 200016610-9
bull 84 Ostensen M Nonsteroidal anti-inflammatory drugs during pregnancy Scand J Rheumatol Suppl 1998107128-32
bull 85 USPDI -Drug information for the health care professional 22nd ed Greenwood Village CO Micromedex 2002 p 152-79
bull 86 Denson DD Coyle DE Thompson GA Santos D Turner PA Myers JA et al Bupivacaine protein binding in the term parturient effects of lactic acidosis Clin Pharmacol Ther 198435702-9
bull 87 Dillon DE Wagner CL Wiest D Newman RB Drug therapy in the nursing mother Obstet Gynecol Clin North Am 199724 675-96
bull 88 Dashe JS Gilstrap LC Antibiotic use in pregnancy Obstet Gynecol Clin North Am 199724617-29
bull 89 American College of Rheumatology Ad hoc Committee on Clinical Guidelines Guidelines for monitoring drug therapy in rheumatoid arthritis Arthritis Rheum 199639723-31
bull 90 Ng PC The fetal and neonatal hypothalamic-pituitary-adrenal axis Arch Dis Child Fetal Neonatal Ed 200082F250-4
bull 91 Crowley P Antenatal corticosteroidsmdashcurrent thinking BJOG 2003110(Suppl 20)77-8
bull 92 ACOG committee opinion antenatal corticosteroid therapy for fetal maturation Obstet Gynecol 200299871-3
bull 93 Ost L Wettrell G Bjorkhem I Rane A Prednisolone excretion in human milk J Pediatr 19851061008-11
bull 94 Rowland AS Baird DD Shore DL Weinberg CR Savitz DA Wilcox AJ Nitrous oxide and spontaneous abortion in female dental assistants Am J Epidemiol 1995141531-8
bull 95 McGlothlin JD Jensen PA Fischbach TJ Hughes RT Jones JH Control of anesthetic gases in dental operatories Scand J Work Environ Health 199218(Suppl 2)103-5
bull ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY Volume 97 Number 6 Suresh and Radfar 681
bull 96 Rosen MA Nitrous oxide for relief of labor pain a systematic review Am J Obstet Gynecol 2002186(Suppl Nature)S110-6
bull 97 Sands TD Pynn BR Management considerations for the pregnant or nursing emergency patient Ont Dent 199875 17-9
bull 98 Daya S Recurrent spontaneous early pregnancy loss and low dose aspirin Minerva Ginecol 200355441-9
bull 99 Sinclair C Handbook of obstetrical emergencies 1st ed Philadelphia WB Saunders 1996 p 29-39 69
bull 100 Tarsitano BF Rollings RE The pregnant dental patient evaluation and management Gen Dent 199341226-34
bull 101 Livingston MH Dlllinger TM Holder R Consideration in the management of the pregnant patient SCD Special Care in Dentistry 199818183-8
Thank you
- A Review on the principle of Dental Management of the Pregnant patient
- Slide 2
- Questions that a dentist may ask
- Stages of Pregnancy
- Slide 5
- Slide 6
- Physiologic Changes in Pregnancy
- Systemic changes in pregnancy
- FLAT SUPINE POSITIONING
- SUPINE HYPOTENSION SYNDROME (Vena Cava Compression)
- Supine Hypotension Syndrome
- Slide 12
- Supine Hypotension Syndrome
- Prevention of Supine Hypotensive Syndrome
- Treatment of Supine Hypotensive Syndrome
- How should the pregnant woman be positioned
- Slide 17
- Slide 18
- Slide 19
- Slide 20
- Slide 21
- Slide 22
- Slide 23
- Pregnancy Related Oral Health Problems
- Oral Problems in Pregnancy
- Pregnancy Gingivitis Pathophysiology
- Pregnancy Gingivitis
- Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Gum Problems - Pregnancy Granuloma
- Slide 31
- Gum Changes - Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Candidiasis
- Pregnancy Myths
- Other Oral Conditions in Pregnancy
- Changes During Pregnancy that Affect Oral Health
- Saliva changes
- Increased Bacteria
- Slide 40
- Enamel erosion caused by frequent vomiting
- Treatment for Acid Exposure
- Oral Diseases Can Effect Pregnancy
- Periodontal Disease and Preterm Labor
- Periodontal Disease and Low Birth Weight
- Periodontal Disease and Preeclampsia
- Periodontitis and Pre-eclampsia
- Dental Considerations
- Treatment Timing
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Slide 52
- Use of Radiation on Pregnant Patient
- Radiographs during Pregnancy
- Risks of Dental X-Rays
- FDA drug classification for pregnancy
- Slide 57
- FDA drug classification for pregnancy
- Slide 59
- Slide 60
- Slide 61
- Common Analgesics
- Analgesics
- Analgesics - continued
- Analgesics to Use During 1st and 2nd Trimester
- Analgesics to Avoid During the Third Trimester
- Sedation in Pregnancy
- Common Antibiotics
- Antibiotics
- Antibiotics To Use During Pregnancy
- Antibiotics to Avoid during Pregnancy
- The Problem With Tetracycline
- Other Antimicrobial Agents
- Local Anesthetic Use in Pregnancy
- Use of Local Anesthetics
- Ulcer healing drugs
- Slide 77
- Slide 78
- Slide 79
- Use of Nitrous Oxide Gas
- Common Preventives
- Are topical agents safe
- Pre-natal Fluoride
- Is it safe to use mercury restorations
- References
- REFERENCES
- Slide 87
- Slide 88
- Slide 89
- Slide 90
- Slide 91
- Slide 92
- Slide 93
- Slide 94
- Slide 95
- Slide 96
- Slide 97
- Slide 98
- Thank you
-
Pregnancy Gingivitis
bullOccurs commonly in the 2nd to 8th monthsbullTendency to bleed very easilybullTreatment Scaling root-planing currettage OHI
Pregnancy Granuloma
bullOccurs in up to 5 of womenbullMost common in buccal maxillary anterior areasbullUsually starts in an area of gingivitis
Pregnancy Granuloma (continued)
bullRapid growth up to 2 cmbullSingle tumor-like growthbullusually in interdental papillaebullPurplish to bluish in color may be ulcerated- bleeds easily
Gum Problems - Pregnancy Granuloma
Gum Problems - Pregnancy Granuloma
Gum Changes - Pregnancy Granuloma
Pregnancy Granuloma (continued)
Treatment
bull Scaling and root planingbull Excision if it is too large or bleeds too
easilybull May regress spontaneously after
pregnancy
Candidiasis
bullWipes offbullUsually asymptomatic but may burnbullTreatment topical or systemic antifungals
Pregnancy MythsbullldquoA mother loses a tooth for every babyrdquobullNo evidence that aphthous ulcers are any more common in pregnancy
Other Oral Conditions in Pregnancy
bull Dry mouthbull Excessive salivationbull Tooth erosions associated with
severe GERD or hyperemesis
Changes During Pregnancy that Affect Oral Health
bull Hormonal Affects
ndash Increased tooth mobility
ndash Saliva changes
ndash Increased bacteria
ndash Gingival problems
Saliva changesbull Decreased buffers
bull Decreased minerals
bull Decreasing flow first and last trimester
bull Increased flow second trimester
bull More acidic
Increased Bacteriabull Increased acidity
ndash Increase in decay-causing bacteriabull Increased Snacking
ndash Morning sicknesslow blood sugarndash Between-meal snacks
bull Increase in amount and frequency of starchescarbohydrates ndash Crackers are commonly recommendedndash Promotes decay-causing bacteria
Changes During Pregnancy that Affect Oral Healthbull Morning sickness
ndash Difficulty with hygienebull Gingival diseasebull Tooth decay
ndash Vomitingbull Esophogeal Reflux (heartburn)bull Acid exposure
ndash Irritation of the gumsndash Weakening of tooth enamelndash Dental erosion
Enamel erosion caused by frequent vomiting
Treatment for Acid Exposure
bull Do NOT brush immediately after vomiting
bull Rinse ndash Water with baking sodandash Antacidndash Plain water
bull Eat some cheese
Oral Diseases Can Effect Pregnancy
bull Preterm low birth weight (LBW) linked to periodontal disease
bull Thorough calculus (tartar) removal in pregnant women with periodontitis may reduce pre-term births
Periodontal Disease and Preterm LaborbullMaternal periodontal disease is associated with increased risk of preterm laborbullAnaerobic oral gram-negative bacteria cause inflammatory responsebullInflammatory response stimulates prostaglandin and cytokine production to stimulate labor
Periodontal Disease and Low Birth Weight
bull Periodontal disease is associated with low birth weight
bull Evidence is not conclusivebull Biochemical mechanism similar cascade
as in preterm labor leading to placental blood flow restriction and necrosis
Periodontal Disease and Preeclampsia
bull Emerging databull Mechanism unclearbull Proposed mechanism
ndash Periodontal infection leads to inflammatory vascular damage
ndash Triggers cell damage in placenta
Periodontitis and Pre-eclampsia
bull Periodontal disease may be associated with pre-eclampsia (Boggess 2003)
bull PGE2 IL-1 and TNF-α from gingival crevicular fluid were higher in women with preeclampsia compared with healthy matched pregnant women (Oettinger-Barak 2003)
Dental Considerations
bull timing of treatment for pregnant patientsbull dental radiation exposurebull use of local anestheticsbull prescription of common antibiotics and
analgesicsbull nitrous oxide gas administration
Treatment Timing
bull First Trimesterndash Spontaneous miscarriages naturally occur
more often in 1st trimesterndash Avoid elective treatment that can be delayedndash Offer anticipatory guidance
bull Second Trimesterndash The optimal time for dental treatmentndash Organogenesis complete fetus not largendash Easier to prevent than treat established disease
bull Third Trimesterndash Late in term very uncomfortable (short visits)ndash Position slightly on left side
Timing of Dental Treatment During Pregnancy - From Little and Fallace
First Trimester
bull Plaque controlbull Oral hygiene instructionbull Scaling polishing curettagebull Avoid elective treatment urgent care
only
Timing of Dental Treatment During Pregnancy - From Little and Fallace
Second Trimester
bull Plaque controlbull Oral hygiene instructionbull Scaling polishing curettagebull Routine dental care
Timing of Dental Treatment During Pregnancy - From Little and Fallace
Third Trimester
bull Plaque controlbull Oral hygiene instructionbull Scaling polishing curettagebull Routine dental care (after middle of third
trimester elective care should be avoided)
Use of Radiation on Pregnant Patientbull Dose given and time of gestation are
importantbull doses lt 5-10 rads (cGy) not teratogenicbull fetus is most susceptible to radiation
between the 2nd and 6th week of gestationbull single dental x-ray exposes patient to 001
millirads of radiation In relative terms this amount is 40 times less than daily dose acquired from cosmic radiation Therefore diagnostic radiation should not be withheld during pregnancy
Radiographs during Pregnancy
bull Take as needed with optimal methods for reducing secondary radiation and exposure time
bull Always use a lead apronbull Exposure to fetus (with apron use) is 00001
centiGray(rad)bull Daily cosmic radiation - 0004 centiGray (rad)
Risks of Dental X-Rays
bull X-ray only if necessary (ie root canal therapy trauma)
bull When x-rays are indicated radiation exposure is extremely low
bull Exposure can be limited byndash Lead apron shielding ndash Modern fast film ndash Avoiding retakes
FDA drug classification for pregnancybull Combines risk statements including
congenital anomalies fetal effects perinatal risks and therapeutic risk-benefit ratio
bull Untreated disease or condition may pose more serious risks to both mother and fetus than any theoretical risks from the medication
bull Category A thru D and X
FDA drug classification for pregnancy
bull A = Controlled Studies in women fail to demonstrate a risk to the fetus in the first trimester and the possibility of fetal harm appears remote
FDA drug classification for pregnancy
bull B = Animal studies show no risk or if risk shown in animals controlled
trials in women showed no risk
FDA drug classification for pregnancy
bull C = Studies in animals with adverse effects and no human studies
OR no animal or human studies but benefits of use may outweigh potential harms
FDA drug classification for pregnancy
bull D = There is evidence of human fetal risk but benefits may outweigh risks
FDA drug classification for pregnancy
bull X = Contraindicated
Common Analgesics
bull paracetamol (B)bull Ibuprofen (BD) bull Oxycodone (BD) bull Hydrocodone and codeine
(CD)
avoid in third trimester
Analgesics
bull Paracetamol is the analgesic of choice for all stages of gestation
bull used to treat mild to moderate pain and fevers
bull short term usage is believed to be safebull avoid chronic and large doses of
paracetamol1048715
Analgesics - continuedbull Aspirin is nonteratogenic but may cause
maternal and fetal hemorrhagebull large and chronic doses during last trimester
may result in premature closure of ductus arteriosus fetal hypertension anemia and low birth weight
bull avoid ibuprofen in 3rd trimester because of possible adverse circulatory effects
bull short term use of codeine seems safebull avoid codeine late in gestation because of
possible fetal respiratory depression and withdrawal symptoms
Analgesics to Use During1st and 2nd Trimester
bull Category B (for best)bull Paracetamol Ibuprofenbull Naproxenbull Category C (use with caution)bull Paracetamol with codeine or
hydrocodonebull Paracetamol with oxycodone
Analgesics to Avoid During theThird Trimesterbull Causes delivery problemsbull Aspirin (C 3D)bull Ibuprofen (B3D)bull Naproxen (B3D)bull Causes neonatal respiratory
depression and opioid withdrawalbull Codeine (C3D)bull Hydrocodone (C3D)bull Oxycodone(C3D)
Sedation in Pregnancy
bull SedativesAnxiolytics (eg Diazepam ) are rated D and can cause oral clefts with prolonged exposure
bull Nitrous oxide should not be used in 1st trimester (If used in 2nd and 3rd do not go below 50 O2)
Common Antibioticsbull To treat oral abscess or cellulitis
ndash Penicillin (B) ndash Amoxicillin (B) ndash Cephalexin (B)ndash Erythromycin base (B) (Not estolate as it
cause cholestatic hepatitis)ndash Clindamycin (B)
Antibioticsbull penicillin V and amoxicillin is preferred drug
for mild to moderate infectionsbull widely used for many years with no ill effectsbull no studies show penicillin to be teratogenicbull amoxicillin extensively used without harming
the fetusbull Drug classes1048715 B penicillin cephalosporins erythromycin clindamycin Azithromycin D Tetracycline
Antibiotics To Use During Pregnancy
bull Penicillin Vbull Amoxicillinbull Erythromycin (base form)bull Cephalexin cephalosporinbull Clindamycinbull Metronidazole
Antibiotics to Avoid duringPregnancy
bull Doxycyclinebull Tetracyclinebull Erythromycin (estolate form)bull Vancomycin
The Problem With Tetracycline
bull Accumulates in bones and chelates calcium
bull Inhibits bone growthbull Discolors teeth
Other Antimicrobial Agentsbull OK to usebull Nystatin (B)bull Chlorhexidine rinse (B)bull Use with cautionbull Clotrimazole (C)bull Ketoconazole (C)bull Fluconazole (C)bull Do not usebull Doxycycline (D)
Local Anesthetic Use inPregnancy
bull Class Bbull Lidocaine (Xylocaine)bull Etidocainebull Prilocaine bull Class Cbull Procainebull Bupivicainebull Mepivicaine
Use of Local Anestheticsbull Lidocaine + vasoconstrictor most common
local anesthetic used in dentistrybull extensively used in pregnancy with no proven ill
effectsbull accidental intravascular injections of lidocaine
pass through the placenta but the concentrations are too low to harm fetus
bull prilocaine might cause methemoglobinemia
Ulcer healing drugsCimetidine bull FDA category B Famotidinebull FDA category BRanitidinebull FDA category Bbull not known to be harmful
Ulcer healing drugsOmeprazolebull FDA category BNot known to be
harmful Esomeprazolebull FDA category BLansoprazolebull FDA category BPantoprazolebull Avoid unless potential benefit
outweighs riskmdashfetotoxic in animals
Ulcer healing drugs
Misoprostolbull First second third trimesters Avoidmdash
potent uterine stimulant (has been used to induce abortion) and may be teratogenic
Ulcer healing drugs
Antacidsbull Almunium hydroxideMagnesium
hydroxidemdashFDA category B Calcium carbonatemdashFDA category C
SimetheconemdashFDA category C
Use of Nitrous Oxide Gas
bull used over 150 years bull safety is being debatedbull SHORT TERM exposure do not cause
birth defects or spontaneous abortionbull CHRONIC exposure may result in fetal
loss and infertilitybull literature suggests that nitrous oxide
should be avoided until more conclusive research is available
bull FDA Drug class not yet assigned
Common Preventives
bull Fluoridendash No increased risk during pregnancy
bull Xylitolndash No studies no harm reported
bull Chlorhexidinendash No increased risk during pregnancy
Are topical agents safe
bull Fluoridebull Toothpaste amp mouthrinse
bull Xylitol chewing gum bull Chlorhexidine (11 alcohol)bull No over the counter mouthrinses with
alcohol (Listerine 20 alcohol)
Pre-natal Fluoride
bull Daily 22 mg tablet of sodium fluoride during 3rd through 9th months
bull decreases caries rate in offspringbull Safe and effective
Glenn FB 1982
Is it safe to use mercury restorations
bull No evidence of harmful effect
bull Benefits outweigh risks
bull Canada Germany and New Zealand have some restrictions
bull Determine the best option
Referencesbull Wasylko L Matsui D Dykxhoorn SM Rieder MJ Weinberg
S A Review of Common Dental Treatments During Pregnancy J Canadian Dental Association 64434-439 1998
bull Little JW Donald AF Craig SM Rhodus NL Dental Management of the Medically Compromised Patient - 5th edition Mosby Toronto Pp434-442 1997
bull Livingston HM Dellinger TM Holder R Considerations in the management of the pregnant patient Special Care in Dentistry 185 pp183-188 1998
bull Larimore WL Petrie KA Drug use during pregnacy and lactation Primary Care Clinics in Office Practice 271 35-53 2000
bull Health Canada The Safety of DentalAmalgam Minister Of Supply and Services Canada 1996
REFERENCESbull 1 Weiss G Endocrinology of parturition J Clin
Endocrinol Metab 2000854421-5bull 2 Theunissen IM Parer JT Fluid and electrolytes in
pregnancy Clin Obstet Gynecol 1994373-15bull 3 Duvekot JJ Peeters LLH Renal hemodynamics and
volume homeostasis in pregnancy Obstet Gynecol Surv 199449830-9
bull 4 Barron WM Lindheimer MD Medical disorders during pregnancy 2nd ed St Louis Mosby 1995 p 129
bull 5 Thornburg KL Jacobson SL Giraud GD Morton MJ Hemodynamic changes in pregnancy Semin Perinatol 20002411-4
bull 6 Fiese R Herzog S Issues in dental and surgical management of the pregnant patient Oral Surg Oral Med Oral Pathol 198865292-7
bull 7 Martin C Varner MW Physiologic changes in pregnancysurgical implications Clin Obstet Gynecol 199437241-55
bull 8 Clark SL Cotton DB Lee W Bishop C Hill T Southwick J et al Central hemodynamic assessment of normal term pregnancy Am J Obstet Gynecol 19891611439-42
bull 9 Mabie WC Di Sessa TG Crocker LG Sibai BM Arheart KL A longitudinal study of cardiac output in normal human pregnancy Am J Obstet Gynecol 1994170849-56
bull 10 Clapp JF 3rd Capeless E Cardiovascular function before during and after the first and subsequent pregnancies Am J Cardiol 1997801469-73
bull 11 Duvekot JJ Peeters LL Maternal cardiovascular hemodynamic adaptation to pregnancy Obstet Gynecol Surv 199449(Suppl) S1-14
bull 12 Bhagwat AR Engel PJ Heart disease and pregnancy Cardiol Clin 199513163-78
bull 13 Lanni SM Tillinghast J Silver H Hemodynamic changes and baroreflex gain in the supine hypotensive syndrome Am J Obstet Gynecol 20021871636-41
bull 14 Little JW Falace DA Miller CS Rhodus NL Dental management of the medically compromised patient 6th ed St Louis Mosby 2002 p 303
bull 15 Garcia-Rio F Pino JM Gomez L Alvarez-Sala R Villasante C Villamor J Regulation of breathing and perception of dyspnea in healthy pregnant women Chest 1996110446-53
bull 16 McAuliffe F Kametas N Costello J Rafferty GF Greenough A Nicolaides K Respiratory function in singleton and twin pregnancy BJOG 2002109765-9
bull 17 Clapp JF 3rd Seaward BL Sleamaker RH Hiser J Maternal physiologic adaptations to early human pregnancy Am J Obstet Gynecol 19881591456-60
bull 18 OrsquoDay MP Cardio-respiratory physiological adaptation of pregnancy Semin Perinatol 199721268-75
bull 19 Contreras G Gutierrez M Beroiza T Fantin A Oddo H Villarroel L et al Ventilatory drive and respiratory muscle function in pregnancy Am Rev Respir Dis 1991144837-41
bull 20 Turner M Aziz SR Management of the pregnant oral and maxillofac
bull 21 Sifakis S Pharmakides G Anemia in pregnancy Ann N Y Acad Sci 2000900125-36
bull 22 Branch DW Physiologic adaptations of pregnancy Am J Reprod Immunol 199228120-2
bull 23 Burrows RF Kelton JG Incidentally detected thrombocytopenia in healthy mothers and their infants N Engl J Med 1988319 142-5
bull 24 Hanly JG Antiphospholipid syndrome an overview CMAJ 200324(168)1675-82
bull 25 Heilmann L von Tempelhoff GF Pollow K Antiphospholipid syndrome in obstetrics Clin Appl Thromb Hemost 20039 143-50
bull 26 Sherman P Flaxman SM Nausea and vomiting of pregnancy in an evolutionary perspective Am J Obstet Gynecol 2002 185(Suppl)s190-7
bull 27 Koch KL Gastrointestinal factors in nausea and vomiting of pregnancy Am J Obstet Gynecol 2002185(Suppl)s198-203
bull 28 Koch KL Frissora CL Nausea and vomiting during pregnancy Gastroenterol Clin N Am 200332201-34
bull 29 Baron TH Ramirez B Richter JE Gastrointestinal motility disorders during pregnancy Ann Intern Med 1993118 366-75
bull 30 Richter JE Gastroesophageal reflux disease during pregnancy Gastroenterol Clin N Am 200332235-61
bull 31 Marrero JM Goggin PM de Caestecker JS Pearce JM Maxwell JD Determinants of pregnancy heartburn Br J Obstet Gynaecol 199299731-4
bull 32 Hamaoui E Hamaoui M Nutritional assessment and support during pregnancy Gastroenterol Clin N Am 20033259-121
bull 33 King JC Physiology of pregnancy and nutrient metabolism Am J Clin Nutr 200071(suppl)1218s-25s
bull 34 Casanueva E Pfeffer F Fernandez-Gaxiola AC Gutierrez- Valenzuela V Rothenberg SJ Iron and folate status before pregnancy and anemia during pregnancy Ann Nutr Metab 2003 4760-3
bull 35 Chrsquong CL Morgan M Hainsworth I Kingham JG Prospective study of liver dysfunction in Southwest Wales Gut 200251 876-80
bull 36 Rahman TM Wendon J Severe hepatic dysfunction in pregnancy QJM 200295343-57
bull 37 Knox TA Olans LB Liver disease in pregnancy N Engl J Med 1996335569-76
bull 38 Saftlas AF Olson DR Franks AL Atrash H Pokras R Epidemiology of preeclampsia and eclampsia in the United States 1979e1986 Am J Obstet Gynecol 1990163460-5
bull 39 Walker JJ Pre-eclampsia Lancet 20003561260-5
bull 40 Davidson JM Renal disorders in pregnancy Curr Opin Obstet Gynecol 200113109-14
bull 41 Dafnis E Sabatini S The effect of pregnancy on renal function physiology and pathophysiologyAmJMedSci 1992303184-205
bull 42 Davison JM Shiells EA Philips PR Lindheimer MD Serial evaluation of vasopressin release and thirst in human pregnancy Role of human chorionic gonadotrophin in the osmoregulatory changes of gestation J Clin Invest 198881798-806
bull 43 Glinoer D de Nayer P Bourdoux P Lemone M Robyn C van Steirteghem A et al Regulation of maternal thyroid during pregnancy J Clin Endocrinol Metab 199071276-87
bull 44 Wilson SG Retallack RW Kent JC Worth GK Gutteridge DH Serum free 125-dihydroxyvitamin D and the free 125- dihydroxyvitamin D index during a longitudinal study of human pregnancy and lactation Clin Endocrinol 199032613-22
bull 45 Rasmussen N Frolich A Hornnes PJ Hegedus L Serum ionized calcium and intact parathyroid hormone levels during pregnancy and postpartum Br J Obstet Gynaecol 199097857-9
bull 46 Guyton AC Textbook of medical physiology 8th ed Philadelphia W B Saunders 1991 p 915e28
bull 47 Trainer PJ Corticosteroids and pregnancy Semin Reprod Med 200220375-80
bull 48 Soory M Hormonal factors in periodontal disease Dent Update 200027380-3
bull 49 Hugoson A Gingivitis in pregnant women A longitudinal clinical study Odontol Revy 19712265-84
bull 50 Neville BW Damm DD Allen CM Bouquot JE Oral amp Maxillofacial Pathology 3rd ed Philadelphia W B Saunders 2002 p 329-30 447-9
bull 51 Tilakaratne A Soory M Ranasinghe AW Corea SM Ekanayake SL de Silva M Periodontal disease status during pregnancy and 3 months post-partum in rural population of Sri-Lankan women J Clin Periodontol 200027787-92
bull 52 Laine M Tenovuo J Lehtonen OP Ojanatko-Harri A Vilja P Tuohimaa P Pregnancy e related changes in human whole saliva Arch Oral Biol 198833913-7
bull 53 Yuan K Wing LY Lin MT Pathogenetic roles of angiogenic factors in pyogenic granulomas in pregnancy are modulated by female sex hormones J Periodontol 200273701-8
bull 54 Evans RD Briggs PF Tooth-surface loss related to pregnancyinduced vomiting Prim Dent Care 1994124-6
bull 55 Salvolini E Di Giorgio R Curatola A Mazzanti L Fratto G Biochemical modifications of human whole saliva induced by pregnancy Br J Obstet Gynaec 1998105656-60
bull 56 Mauldin JG Newman RB Preterm birth risk assessment Semin Perinatol 200125215-22
bull 57 Heine RP McGregor JA Goodwin TM Artal R Hayashi RH Robertson PA et al Serial salivary estriol to detect an increased risk of preterm birth Obstet Gynecol 200096490-7
bull 58 Kauh YC Zachian TF Melasma Adv Exp Med Biol 1999455 491-9
bull 59 Wong RC Ellis CN Physiologic skin changes in pregnancy J Am Acad Dermatol 198410929-40
bull 60 Errickson CV Matus NR Skin disorders of pregnancy Am Fam Physician 199449605-10
bull 61 Lopez NJ Smith PC Gutierrez J Periodontal therapy may reduce the risk of preterm low birth weight in women with periodontal disease a randomized controlled trial J Periodontol 200273911-24
bull 62 McGaw T Periodontal disease and preterm delivery of lowbirth- weight infants J Can Dent Assoc 200268165-9
bull 63 Richards AG Dental x-ray protection Dent Clin North Am 1968631-41
bull 64 1990 Recommendations of the International Commission on Radiological Protection Ann ICRP 1991211-201
bull 65 Hall EJ Radiation the two-edged sword cancer risks at high and low doses Cancer J 20006343-50
bull 66 Diethelm L Xu H Diagnostic imaging of the lung during pregnancy Clin Obstet Gynecol 19963936-55
bull 67 Brent RL The effects of embryonic and fetal exposure to x-rays microwaves and ultrasound ClinObstetGynecol 198326484-510
bull 68 National Council on Radiation Protection NCRP report no128 1998 Bethesda Md Author
bull 69 Wasylko L Matsui D Dykxhoorn SM Reider MJ Weinberg S A review of common dental treatments during pregnancy implications for patients and dental personnel J Can Dent Assoc 199864434-9
bull 70 Freeman JP Brand JW Radiation doses of commonly used dental radiographic surveys Oral Surg Oral Med Oral Pathol 199477285-9
bull 71 Kircos LTAngin LL Lorton LOrder ofmagnitude dose reduction in intraoral radiography J Am Dent Assoc 1987114344-7
bull 72 Updegrave WJ Simplified and standardized intraoral radiography with reduced tissue irradiation J Am Dent Assoc 197285861-9
bull 73 Wood RE Harris AM van der Merwe EJ Nortje CJ The leaded apron revisited does it reduce gonadal radiation dose in dental radiology Oral Surg Oral Med Oral Pathol 199171642-6
bull 74 An update on radiographic practices information and recommendations ADA Council on Scientific Affairs J Am Dent Assoc 2001132234-8
bull 75 Rayburn WF Recommending medications during pregnancy an evidence based approach Clin Obstet Gynecol 2002451-5
bull 76 Rathmell JP Viscomi C Ashburn MA Management of nonobstetric pain during pregnancy and lactation Anesth Analg 1997851074-87
bull 77 Teratology society public affairs committee FDA classification of drugs for teratogenic risk Teratology 199449446-7
bull 78 Moore PA Selecting drugs for the pregnant dental patient J Am Dent Assoc 19981291281-6
bull 79 Haas DA An update on analgesics for the management of acute postoperative dental pain J Can Dent Assoc 200268476-82
bull 80 Haas DA Pynn BR Sands TD Drug use for the pregnant or lactating patient Gen Dent 20004854-60
bull 81 Committee on Drugs American Academy of Pediatrics The transfer of drugs and other chemicals into human milk Pediatrics 199493137-50
bull 82 Nielsen GL Sorensen HT Larsen H Pedersen L Risk of adverse birth outcome and miscarriage in pregnant users of nonsteroidal anti-inflammatory drugs population based observational study and case-control study BMJ 2001322266-70
bull 83 Janssen N Genta M The effects of immunosuppressive and anti-inflammatory medications on fertility pregnancy and lactation Arch Intern Med 200016610-9
bull 84 Ostensen M Nonsteroidal anti-inflammatory drugs during pregnancy Scand J Rheumatol Suppl 1998107128-32
bull 85 USPDI -Drug information for the health care professional 22nd ed Greenwood Village CO Micromedex 2002 p 152-79
bull 86 Denson DD Coyle DE Thompson GA Santos D Turner PA Myers JA et al Bupivacaine protein binding in the term parturient effects of lactic acidosis Clin Pharmacol Ther 198435702-9
bull 87 Dillon DE Wagner CL Wiest D Newman RB Drug therapy in the nursing mother Obstet Gynecol Clin North Am 199724 675-96
bull 88 Dashe JS Gilstrap LC Antibiotic use in pregnancy Obstet Gynecol Clin North Am 199724617-29
bull 89 American College of Rheumatology Ad hoc Committee on Clinical Guidelines Guidelines for monitoring drug therapy in rheumatoid arthritis Arthritis Rheum 199639723-31
bull 90 Ng PC The fetal and neonatal hypothalamic-pituitary-adrenal axis Arch Dis Child Fetal Neonatal Ed 200082F250-4
bull 91 Crowley P Antenatal corticosteroidsmdashcurrent thinking BJOG 2003110(Suppl 20)77-8
bull 92 ACOG committee opinion antenatal corticosteroid therapy for fetal maturation Obstet Gynecol 200299871-3
bull 93 Ost L Wettrell G Bjorkhem I Rane A Prednisolone excretion in human milk J Pediatr 19851061008-11
bull 94 Rowland AS Baird DD Shore DL Weinberg CR Savitz DA Wilcox AJ Nitrous oxide and spontaneous abortion in female dental assistants Am J Epidemiol 1995141531-8
bull 95 McGlothlin JD Jensen PA Fischbach TJ Hughes RT Jones JH Control of anesthetic gases in dental operatories Scand J Work Environ Health 199218(Suppl 2)103-5
bull ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY Volume 97 Number 6 Suresh and Radfar 681
bull 96 Rosen MA Nitrous oxide for relief of labor pain a systematic review Am J Obstet Gynecol 2002186(Suppl Nature)S110-6
bull 97 Sands TD Pynn BR Management considerations for the pregnant or nursing emergency patient Ont Dent 199875 17-9
bull 98 Daya S Recurrent spontaneous early pregnancy loss and low dose aspirin Minerva Ginecol 200355441-9
bull 99 Sinclair C Handbook of obstetrical emergencies 1st ed Philadelphia WB Saunders 1996 p 29-39 69
bull 100 Tarsitano BF Rollings RE The pregnant dental patient evaluation and management Gen Dent 199341226-34
bull 101 Livingston MH Dlllinger TM Holder R Consideration in the management of the pregnant patient SCD Special Care in Dentistry 199818183-8
Thank you
- A Review on the principle of Dental Management of the Pregnant patient
- Slide 2
- Questions that a dentist may ask
- Stages of Pregnancy
- Slide 5
- Slide 6
- Physiologic Changes in Pregnancy
- Systemic changes in pregnancy
- FLAT SUPINE POSITIONING
- SUPINE HYPOTENSION SYNDROME (Vena Cava Compression)
- Supine Hypotension Syndrome
- Slide 12
- Supine Hypotension Syndrome
- Prevention of Supine Hypotensive Syndrome
- Treatment of Supine Hypotensive Syndrome
- How should the pregnant woman be positioned
- Slide 17
- Slide 18
- Slide 19
- Slide 20
- Slide 21
- Slide 22
- Slide 23
- Pregnancy Related Oral Health Problems
- Oral Problems in Pregnancy
- Pregnancy Gingivitis Pathophysiology
- Pregnancy Gingivitis
- Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Gum Problems - Pregnancy Granuloma
- Slide 31
- Gum Changes - Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Candidiasis
- Pregnancy Myths
- Other Oral Conditions in Pregnancy
- Changes During Pregnancy that Affect Oral Health
- Saliva changes
- Increased Bacteria
- Slide 40
- Enamel erosion caused by frequent vomiting
- Treatment for Acid Exposure
- Oral Diseases Can Effect Pregnancy
- Periodontal Disease and Preterm Labor
- Periodontal Disease and Low Birth Weight
- Periodontal Disease and Preeclampsia
- Periodontitis and Pre-eclampsia
- Dental Considerations
- Treatment Timing
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Slide 52
- Use of Radiation on Pregnant Patient
- Radiographs during Pregnancy
- Risks of Dental X-Rays
- FDA drug classification for pregnancy
- Slide 57
- FDA drug classification for pregnancy
- Slide 59
- Slide 60
- Slide 61
- Common Analgesics
- Analgesics
- Analgesics - continued
- Analgesics to Use During 1st and 2nd Trimester
- Analgesics to Avoid During the Third Trimester
- Sedation in Pregnancy
- Common Antibiotics
- Antibiotics
- Antibiotics To Use During Pregnancy
- Antibiotics to Avoid during Pregnancy
- The Problem With Tetracycline
- Other Antimicrobial Agents
- Local Anesthetic Use in Pregnancy
- Use of Local Anesthetics
- Ulcer healing drugs
- Slide 77
- Slide 78
- Slide 79
- Use of Nitrous Oxide Gas
- Common Preventives
- Are topical agents safe
- Pre-natal Fluoride
- Is it safe to use mercury restorations
- References
- REFERENCES
- Slide 87
- Slide 88
- Slide 89
- Slide 90
- Slide 91
- Slide 92
- Slide 93
- Slide 94
- Slide 95
- Slide 96
- Slide 97
- Slide 98
- Thank you
-
Pregnancy Granuloma
bullOccurs in up to 5 of womenbullMost common in buccal maxillary anterior areasbullUsually starts in an area of gingivitis
Pregnancy Granuloma (continued)
bullRapid growth up to 2 cmbullSingle tumor-like growthbullusually in interdental papillaebullPurplish to bluish in color may be ulcerated- bleeds easily
Gum Problems - Pregnancy Granuloma
Gum Problems - Pregnancy Granuloma
Gum Changes - Pregnancy Granuloma
Pregnancy Granuloma (continued)
Treatment
bull Scaling and root planingbull Excision if it is too large or bleeds too
easilybull May regress spontaneously after
pregnancy
Candidiasis
bullWipes offbullUsually asymptomatic but may burnbullTreatment topical or systemic antifungals
Pregnancy MythsbullldquoA mother loses a tooth for every babyrdquobullNo evidence that aphthous ulcers are any more common in pregnancy
Other Oral Conditions in Pregnancy
bull Dry mouthbull Excessive salivationbull Tooth erosions associated with
severe GERD or hyperemesis
Changes During Pregnancy that Affect Oral Health
bull Hormonal Affects
ndash Increased tooth mobility
ndash Saliva changes
ndash Increased bacteria
ndash Gingival problems
Saliva changesbull Decreased buffers
bull Decreased minerals
bull Decreasing flow first and last trimester
bull Increased flow second trimester
bull More acidic
Increased Bacteriabull Increased acidity
ndash Increase in decay-causing bacteriabull Increased Snacking
ndash Morning sicknesslow blood sugarndash Between-meal snacks
bull Increase in amount and frequency of starchescarbohydrates ndash Crackers are commonly recommendedndash Promotes decay-causing bacteria
Changes During Pregnancy that Affect Oral Healthbull Morning sickness
ndash Difficulty with hygienebull Gingival diseasebull Tooth decay
ndash Vomitingbull Esophogeal Reflux (heartburn)bull Acid exposure
ndash Irritation of the gumsndash Weakening of tooth enamelndash Dental erosion
Enamel erosion caused by frequent vomiting
Treatment for Acid Exposure
bull Do NOT brush immediately after vomiting
bull Rinse ndash Water with baking sodandash Antacidndash Plain water
bull Eat some cheese
Oral Diseases Can Effect Pregnancy
bull Preterm low birth weight (LBW) linked to periodontal disease
bull Thorough calculus (tartar) removal in pregnant women with periodontitis may reduce pre-term births
Periodontal Disease and Preterm LaborbullMaternal periodontal disease is associated with increased risk of preterm laborbullAnaerobic oral gram-negative bacteria cause inflammatory responsebullInflammatory response stimulates prostaglandin and cytokine production to stimulate labor
Periodontal Disease and Low Birth Weight
bull Periodontal disease is associated with low birth weight
bull Evidence is not conclusivebull Biochemical mechanism similar cascade
as in preterm labor leading to placental blood flow restriction and necrosis
Periodontal Disease and Preeclampsia
bull Emerging databull Mechanism unclearbull Proposed mechanism
ndash Periodontal infection leads to inflammatory vascular damage
ndash Triggers cell damage in placenta
Periodontitis and Pre-eclampsia
bull Periodontal disease may be associated with pre-eclampsia (Boggess 2003)
bull PGE2 IL-1 and TNF-α from gingival crevicular fluid were higher in women with preeclampsia compared with healthy matched pregnant women (Oettinger-Barak 2003)
Dental Considerations
bull timing of treatment for pregnant patientsbull dental radiation exposurebull use of local anestheticsbull prescription of common antibiotics and
analgesicsbull nitrous oxide gas administration
Treatment Timing
bull First Trimesterndash Spontaneous miscarriages naturally occur
more often in 1st trimesterndash Avoid elective treatment that can be delayedndash Offer anticipatory guidance
bull Second Trimesterndash The optimal time for dental treatmentndash Organogenesis complete fetus not largendash Easier to prevent than treat established disease
bull Third Trimesterndash Late in term very uncomfortable (short visits)ndash Position slightly on left side
Timing of Dental Treatment During Pregnancy - From Little and Fallace
First Trimester
bull Plaque controlbull Oral hygiene instructionbull Scaling polishing curettagebull Avoid elective treatment urgent care
only
Timing of Dental Treatment During Pregnancy - From Little and Fallace
Second Trimester
bull Plaque controlbull Oral hygiene instructionbull Scaling polishing curettagebull Routine dental care
Timing of Dental Treatment During Pregnancy - From Little and Fallace
Third Trimester
bull Plaque controlbull Oral hygiene instructionbull Scaling polishing curettagebull Routine dental care (after middle of third
trimester elective care should be avoided)
Use of Radiation on Pregnant Patientbull Dose given and time of gestation are
importantbull doses lt 5-10 rads (cGy) not teratogenicbull fetus is most susceptible to radiation
between the 2nd and 6th week of gestationbull single dental x-ray exposes patient to 001
millirads of radiation In relative terms this amount is 40 times less than daily dose acquired from cosmic radiation Therefore diagnostic radiation should not be withheld during pregnancy
Radiographs during Pregnancy
bull Take as needed with optimal methods for reducing secondary radiation and exposure time
bull Always use a lead apronbull Exposure to fetus (with apron use) is 00001
centiGray(rad)bull Daily cosmic radiation - 0004 centiGray (rad)
Risks of Dental X-Rays
bull X-ray only if necessary (ie root canal therapy trauma)
bull When x-rays are indicated radiation exposure is extremely low
bull Exposure can be limited byndash Lead apron shielding ndash Modern fast film ndash Avoiding retakes
FDA drug classification for pregnancybull Combines risk statements including
congenital anomalies fetal effects perinatal risks and therapeutic risk-benefit ratio
bull Untreated disease or condition may pose more serious risks to both mother and fetus than any theoretical risks from the medication
bull Category A thru D and X
FDA drug classification for pregnancy
bull A = Controlled Studies in women fail to demonstrate a risk to the fetus in the first trimester and the possibility of fetal harm appears remote
FDA drug classification for pregnancy
bull B = Animal studies show no risk or if risk shown in animals controlled
trials in women showed no risk
FDA drug classification for pregnancy
bull C = Studies in animals with adverse effects and no human studies
OR no animal or human studies but benefits of use may outweigh potential harms
FDA drug classification for pregnancy
bull D = There is evidence of human fetal risk but benefits may outweigh risks
FDA drug classification for pregnancy
bull X = Contraindicated
Common Analgesics
bull paracetamol (B)bull Ibuprofen (BD) bull Oxycodone (BD) bull Hydrocodone and codeine
(CD)
avoid in third trimester
Analgesics
bull Paracetamol is the analgesic of choice for all stages of gestation
bull used to treat mild to moderate pain and fevers
bull short term usage is believed to be safebull avoid chronic and large doses of
paracetamol1048715
Analgesics - continuedbull Aspirin is nonteratogenic but may cause
maternal and fetal hemorrhagebull large and chronic doses during last trimester
may result in premature closure of ductus arteriosus fetal hypertension anemia and low birth weight
bull avoid ibuprofen in 3rd trimester because of possible adverse circulatory effects
bull short term use of codeine seems safebull avoid codeine late in gestation because of
possible fetal respiratory depression and withdrawal symptoms
Analgesics to Use During1st and 2nd Trimester
bull Category B (for best)bull Paracetamol Ibuprofenbull Naproxenbull Category C (use with caution)bull Paracetamol with codeine or
hydrocodonebull Paracetamol with oxycodone
Analgesics to Avoid During theThird Trimesterbull Causes delivery problemsbull Aspirin (C 3D)bull Ibuprofen (B3D)bull Naproxen (B3D)bull Causes neonatal respiratory
depression and opioid withdrawalbull Codeine (C3D)bull Hydrocodone (C3D)bull Oxycodone(C3D)
Sedation in Pregnancy
bull SedativesAnxiolytics (eg Diazepam ) are rated D and can cause oral clefts with prolonged exposure
bull Nitrous oxide should not be used in 1st trimester (If used in 2nd and 3rd do not go below 50 O2)
Common Antibioticsbull To treat oral abscess or cellulitis
ndash Penicillin (B) ndash Amoxicillin (B) ndash Cephalexin (B)ndash Erythromycin base (B) (Not estolate as it
cause cholestatic hepatitis)ndash Clindamycin (B)
Antibioticsbull penicillin V and amoxicillin is preferred drug
for mild to moderate infectionsbull widely used for many years with no ill effectsbull no studies show penicillin to be teratogenicbull amoxicillin extensively used without harming
the fetusbull Drug classes1048715 B penicillin cephalosporins erythromycin clindamycin Azithromycin D Tetracycline
Antibiotics To Use During Pregnancy
bull Penicillin Vbull Amoxicillinbull Erythromycin (base form)bull Cephalexin cephalosporinbull Clindamycinbull Metronidazole
Antibiotics to Avoid duringPregnancy
bull Doxycyclinebull Tetracyclinebull Erythromycin (estolate form)bull Vancomycin
The Problem With Tetracycline
bull Accumulates in bones and chelates calcium
bull Inhibits bone growthbull Discolors teeth
Other Antimicrobial Agentsbull OK to usebull Nystatin (B)bull Chlorhexidine rinse (B)bull Use with cautionbull Clotrimazole (C)bull Ketoconazole (C)bull Fluconazole (C)bull Do not usebull Doxycycline (D)
Local Anesthetic Use inPregnancy
bull Class Bbull Lidocaine (Xylocaine)bull Etidocainebull Prilocaine bull Class Cbull Procainebull Bupivicainebull Mepivicaine
Use of Local Anestheticsbull Lidocaine + vasoconstrictor most common
local anesthetic used in dentistrybull extensively used in pregnancy with no proven ill
effectsbull accidental intravascular injections of lidocaine
pass through the placenta but the concentrations are too low to harm fetus
bull prilocaine might cause methemoglobinemia
Ulcer healing drugsCimetidine bull FDA category B Famotidinebull FDA category BRanitidinebull FDA category Bbull not known to be harmful
Ulcer healing drugsOmeprazolebull FDA category BNot known to be
harmful Esomeprazolebull FDA category BLansoprazolebull FDA category BPantoprazolebull Avoid unless potential benefit
outweighs riskmdashfetotoxic in animals
Ulcer healing drugs
Misoprostolbull First second third trimesters Avoidmdash
potent uterine stimulant (has been used to induce abortion) and may be teratogenic
Ulcer healing drugs
Antacidsbull Almunium hydroxideMagnesium
hydroxidemdashFDA category B Calcium carbonatemdashFDA category C
SimetheconemdashFDA category C
Use of Nitrous Oxide Gas
bull used over 150 years bull safety is being debatedbull SHORT TERM exposure do not cause
birth defects or spontaneous abortionbull CHRONIC exposure may result in fetal
loss and infertilitybull literature suggests that nitrous oxide
should be avoided until more conclusive research is available
bull FDA Drug class not yet assigned
Common Preventives
bull Fluoridendash No increased risk during pregnancy
bull Xylitolndash No studies no harm reported
bull Chlorhexidinendash No increased risk during pregnancy
Are topical agents safe
bull Fluoridebull Toothpaste amp mouthrinse
bull Xylitol chewing gum bull Chlorhexidine (11 alcohol)bull No over the counter mouthrinses with
alcohol (Listerine 20 alcohol)
Pre-natal Fluoride
bull Daily 22 mg tablet of sodium fluoride during 3rd through 9th months
bull decreases caries rate in offspringbull Safe and effective
Glenn FB 1982
Is it safe to use mercury restorations
bull No evidence of harmful effect
bull Benefits outweigh risks
bull Canada Germany and New Zealand have some restrictions
bull Determine the best option
Referencesbull Wasylko L Matsui D Dykxhoorn SM Rieder MJ Weinberg
S A Review of Common Dental Treatments During Pregnancy J Canadian Dental Association 64434-439 1998
bull Little JW Donald AF Craig SM Rhodus NL Dental Management of the Medically Compromised Patient - 5th edition Mosby Toronto Pp434-442 1997
bull Livingston HM Dellinger TM Holder R Considerations in the management of the pregnant patient Special Care in Dentistry 185 pp183-188 1998
bull Larimore WL Petrie KA Drug use during pregnacy and lactation Primary Care Clinics in Office Practice 271 35-53 2000
bull Health Canada The Safety of DentalAmalgam Minister Of Supply and Services Canada 1996
REFERENCESbull 1 Weiss G Endocrinology of parturition J Clin
Endocrinol Metab 2000854421-5bull 2 Theunissen IM Parer JT Fluid and electrolytes in
pregnancy Clin Obstet Gynecol 1994373-15bull 3 Duvekot JJ Peeters LLH Renal hemodynamics and
volume homeostasis in pregnancy Obstet Gynecol Surv 199449830-9
bull 4 Barron WM Lindheimer MD Medical disorders during pregnancy 2nd ed St Louis Mosby 1995 p 129
bull 5 Thornburg KL Jacobson SL Giraud GD Morton MJ Hemodynamic changes in pregnancy Semin Perinatol 20002411-4
bull 6 Fiese R Herzog S Issues in dental and surgical management of the pregnant patient Oral Surg Oral Med Oral Pathol 198865292-7
bull 7 Martin C Varner MW Physiologic changes in pregnancysurgical implications Clin Obstet Gynecol 199437241-55
bull 8 Clark SL Cotton DB Lee W Bishop C Hill T Southwick J et al Central hemodynamic assessment of normal term pregnancy Am J Obstet Gynecol 19891611439-42
bull 9 Mabie WC Di Sessa TG Crocker LG Sibai BM Arheart KL A longitudinal study of cardiac output in normal human pregnancy Am J Obstet Gynecol 1994170849-56
bull 10 Clapp JF 3rd Capeless E Cardiovascular function before during and after the first and subsequent pregnancies Am J Cardiol 1997801469-73
bull 11 Duvekot JJ Peeters LL Maternal cardiovascular hemodynamic adaptation to pregnancy Obstet Gynecol Surv 199449(Suppl) S1-14
bull 12 Bhagwat AR Engel PJ Heart disease and pregnancy Cardiol Clin 199513163-78
bull 13 Lanni SM Tillinghast J Silver H Hemodynamic changes and baroreflex gain in the supine hypotensive syndrome Am J Obstet Gynecol 20021871636-41
bull 14 Little JW Falace DA Miller CS Rhodus NL Dental management of the medically compromised patient 6th ed St Louis Mosby 2002 p 303
bull 15 Garcia-Rio F Pino JM Gomez L Alvarez-Sala R Villasante C Villamor J Regulation of breathing and perception of dyspnea in healthy pregnant women Chest 1996110446-53
bull 16 McAuliffe F Kametas N Costello J Rafferty GF Greenough A Nicolaides K Respiratory function in singleton and twin pregnancy BJOG 2002109765-9
bull 17 Clapp JF 3rd Seaward BL Sleamaker RH Hiser J Maternal physiologic adaptations to early human pregnancy Am J Obstet Gynecol 19881591456-60
bull 18 OrsquoDay MP Cardio-respiratory physiological adaptation of pregnancy Semin Perinatol 199721268-75
bull 19 Contreras G Gutierrez M Beroiza T Fantin A Oddo H Villarroel L et al Ventilatory drive and respiratory muscle function in pregnancy Am Rev Respir Dis 1991144837-41
bull 20 Turner M Aziz SR Management of the pregnant oral and maxillofac
bull 21 Sifakis S Pharmakides G Anemia in pregnancy Ann N Y Acad Sci 2000900125-36
bull 22 Branch DW Physiologic adaptations of pregnancy Am J Reprod Immunol 199228120-2
bull 23 Burrows RF Kelton JG Incidentally detected thrombocytopenia in healthy mothers and their infants N Engl J Med 1988319 142-5
bull 24 Hanly JG Antiphospholipid syndrome an overview CMAJ 200324(168)1675-82
bull 25 Heilmann L von Tempelhoff GF Pollow K Antiphospholipid syndrome in obstetrics Clin Appl Thromb Hemost 20039 143-50
bull 26 Sherman P Flaxman SM Nausea and vomiting of pregnancy in an evolutionary perspective Am J Obstet Gynecol 2002 185(Suppl)s190-7
bull 27 Koch KL Gastrointestinal factors in nausea and vomiting of pregnancy Am J Obstet Gynecol 2002185(Suppl)s198-203
bull 28 Koch KL Frissora CL Nausea and vomiting during pregnancy Gastroenterol Clin N Am 200332201-34
bull 29 Baron TH Ramirez B Richter JE Gastrointestinal motility disorders during pregnancy Ann Intern Med 1993118 366-75
bull 30 Richter JE Gastroesophageal reflux disease during pregnancy Gastroenterol Clin N Am 200332235-61
bull 31 Marrero JM Goggin PM de Caestecker JS Pearce JM Maxwell JD Determinants of pregnancy heartburn Br J Obstet Gynaecol 199299731-4
bull 32 Hamaoui E Hamaoui M Nutritional assessment and support during pregnancy Gastroenterol Clin N Am 20033259-121
bull 33 King JC Physiology of pregnancy and nutrient metabolism Am J Clin Nutr 200071(suppl)1218s-25s
bull 34 Casanueva E Pfeffer F Fernandez-Gaxiola AC Gutierrez- Valenzuela V Rothenberg SJ Iron and folate status before pregnancy and anemia during pregnancy Ann Nutr Metab 2003 4760-3
bull 35 Chrsquong CL Morgan M Hainsworth I Kingham JG Prospective study of liver dysfunction in Southwest Wales Gut 200251 876-80
bull 36 Rahman TM Wendon J Severe hepatic dysfunction in pregnancy QJM 200295343-57
bull 37 Knox TA Olans LB Liver disease in pregnancy N Engl J Med 1996335569-76
bull 38 Saftlas AF Olson DR Franks AL Atrash H Pokras R Epidemiology of preeclampsia and eclampsia in the United States 1979e1986 Am J Obstet Gynecol 1990163460-5
bull 39 Walker JJ Pre-eclampsia Lancet 20003561260-5
bull 40 Davidson JM Renal disorders in pregnancy Curr Opin Obstet Gynecol 200113109-14
bull 41 Dafnis E Sabatini S The effect of pregnancy on renal function physiology and pathophysiologyAmJMedSci 1992303184-205
bull 42 Davison JM Shiells EA Philips PR Lindheimer MD Serial evaluation of vasopressin release and thirst in human pregnancy Role of human chorionic gonadotrophin in the osmoregulatory changes of gestation J Clin Invest 198881798-806
bull 43 Glinoer D de Nayer P Bourdoux P Lemone M Robyn C van Steirteghem A et al Regulation of maternal thyroid during pregnancy J Clin Endocrinol Metab 199071276-87
bull 44 Wilson SG Retallack RW Kent JC Worth GK Gutteridge DH Serum free 125-dihydroxyvitamin D and the free 125- dihydroxyvitamin D index during a longitudinal study of human pregnancy and lactation Clin Endocrinol 199032613-22
bull 45 Rasmussen N Frolich A Hornnes PJ Hegedus L Serum ionized calcium and intact parathyroid hormone levels during pregnancy and postpartum Br J Obstet Gynaecol 199097857-9
bull 46 Guyton AC Textbook of medical physiology 8th ed Philadelphia W B Saunders 1991 p 915e28
bull 47 Trainer PJ Corticosteroids and pregnancy Semin Reprod Med 200220375-80
bull 48 Soory M Hormonal factors in periodontal disease Dent Update 200027380-3
bull 49 Hugoson A Gingivitis in pregnant women A longitudinal clinical study Odontol Revy 19712265-84
bull 50 Neville BW Damm DD Allen CM Bouquot JE Oral amp Maxillofacial Pathology 3rd ed Philadelphia W B Saunders 2002 p 329-30 447-9
bull 51 Tilakaratne A Soory M Ranasinghe AW Corea SM Ekanayake SL de Silva M Periodontal disease status during pregnancy and 3 months post-partum in rural population of Sri-Lankan women J Clin Periodontol 200027787-92
bull 52 Laine M Tenovuo J Lehtonen OP Ojanatko-Harri A Vilja P Tuohimaa P Pregnancy e related changes in human whole saliva Arch Oral Biol 198833913-7
bull 53 Yuan K Wing LY Lin MT Pathogenetic roles of angiogenic factors in pyogenic granulomas in pregnancy are modulated by female sex hormones J Periodontol 200273701-8
bull 54 Evans RD Briggs PF Tooth-surface loss related to pregnancyinduced vomiting Prim Dent Care 1994124-6
bull 55 Salvolini E Di Giorgio R Curatola A Mazzanti L Fratto G Biochemical modifications of human whole saliva induced by pregnancy Br J Obstet Gynaec 1998105656-60
bull 56 Mauldin JG Newman RB Preterm birth risk assessment Semin Perinatol 200125215-22
bull 57 Heine RP McGregor JA Goodwin TM Artal R Hayashi RH Robertson PA et al Serial salivary estriol to detect an increased risk of preterm birth Obstet Gynecol 200096490-7
bull 58 Kauh YC Zachian TF Melasma Adv Exp Med Biol 1999455 491-9
bull 59 Wong RC Ellis CN Physiologic skin changes in pregnancy J Am Acad Dermatol 198410929-40
bull 60 Errickson CV Matus NR Skin disorders of pregnancy Am Fam Physician 199449605-10
bull 61 Lopez NJ Smith PC Gutierrez J Periodontal therapy may reduce the risk of preterm low birth weight in women with periodontal disease a randomized controlled trial J Periodontol 200273911-24
bull 62 McGaw T Periodontal disease and preterm delivery of lowbirth- weight infants J Can Dent Assoc 200268165-9
bull 63 Richards AG Dental x-ray protection Dent Clin North Am 1968631-41
bull 64 1990 Recommendations of the International Commission on Radiological Protection Ann ICRP 1991211-201
bull 65 Hall EJ Radiation the two-edged sword cancer risks at high and low doses Cancer J 20006343-50
bull 66 Diethelm L Xu H Diagnostic imaging of the lung during pregnancy Clin Obstet Gynecol 19963936-55
bull 67 Brent RL The effects of embryonic and fetal exposure to x-rays microwaves and ultrasound ClinObstetGynecol 198326484-510
bull 68 National Council on Radiation Protection NCRP report no128 1998 Bethesda Md Author
bull 69 Wasylko L Matsui D Dykxhoorn SM Reider MJ Weinberg S A review of common dental treatments during pregnancy implications for patients and dental personnel J Can Dent Assoc 199864434-9
bull 70 Freeman JP Brand JW Radiation doses of commonly used dental radiographic surveys Oral Surg Oral Med Oral Pathol 199477285-9
bull 71 Kircos LTAngin LL Lorton LOrder ofmagnitude dose reduction in intraoral radiography J Am Dent Assoc 1987114344-7
bull 72 Updegrave WJ Simplified and standardized intraoral radiography with reduced tissue irradiation J Am Dent Assoc 197285861-9
bull 73 Wood RE Harris AM van der Merwe EJ Nortje CJ The leaded apron revisited does it reduce gonadal radiation dose in dental radiology Oral Surg Oral Med Oral Pathol 199171642-6
bull 74 An update on radiographic practices information and recommendations ADA Council on Scientific Affairs J Am Dent Assoc 2001132234-8
bull 75 Rayburn WF Recommending medications during pregnancy an evidence based approach Clin Obstet Gynecol 2002451-5
bull 76 Rathmell JP Viscomi C Ashburn MA Management of nonobstetric pain during pregnancy and lactation Anesth Analg 1997851074-87
bull 77 Teratology society public affairs committee FDA classification of drugs for teratogenic risk Teratology 199449446-7
bull 78 Moore PA Selecting drugs for the pregnant dental patient J Am Dent Assoc 19981291281-6
bull 79 Haas DA An update on analgesics for the management of acute postoperative dental pain J Can Dent Assoc 200268476-82
bull 80 Haas DA Pynn BR Sands TD Drug use for the pregnant or lactating patient Gen Dent 20004854-60
bull 81 Committee on Drugs American Academy of Pediatrics The transfer of drugs and other chemicals into human milk Pediatrics 199493137-50
bull 82 Nielsen GL Sorensen HT Larsen H Pedersen L Risk of adverse birth outcome and miscarriage in pregnant users of nonsteroidal anti-inflammatory drugs population based observational study and case-control study BMJ 2001322266-70
bull 83 Janssen N Genta M The effects of immunosuppressive and anti-inflammatory medications on fertility pregnancy and lactation Arch Intern Med 200016610-9
bull 84 Ostensen M Nonsteroidal anti-inflammatory drugs during pregnancy Scand J Rheumatol Suppl 1998107128-32
bull 85 USPDI -Drug information for the health care professional 22nd ed Greenwood Village CO Micromedex 2002 p 152-79
bull 86 Denson DD Coyle DE Thompson GA Santos D Turner PA Myers JA et al Bupivacaine protein binding in the term parturient effects of lactic acidosis Clin Pharmacol Ther 198435702-9
bull 87 Dillon DE Wagner CL Wiest D Newman RB Drug therapy in the nursing mother Obstet Gynecol Clin North Am 199724 675-96
bull 88 Dashe JS Gilstrap LC Antibiotic use in pregnancy Obstet Gynecol Clin North Am 199724617-29
bull 89 American College of Rheumatology Ad hoc Committee on Clinical Guidelines Guidelines for monitoring drug therapy in rheumatoid arthritis Arthritis Rheum 199639723-31
bull 90 Ng PC The fetal and neonatal hypothalamic-pituitary-adrenal axis Arch Dis Child Fetal Neonatal Ed 200082F250-4
bull 91 Crowley P Antenatal corticosteroidsmdashcurrent thinking BJOG 2003110(Suppl 20)77-8
bull 92 ACOG committee opinion antenatal corticosteroid therapy for fetal maturation Obstet Gynecol 200299871-3
bull 93 Ost L Wettrell G Bjorkhem I Rane A Prednisolone excretion in human milk J Pediatr 19851061008-11
bull 94 Rowland AS Baird DD Shore DL Weinberg CR Savitz DA Wilcox AJ Nitrous oxide and spontaneous abortion in female dental assistants Am J Epidemiol 1995141531-8
bull 95 McGlothlin JD Jensen PA Fischbach TJ Hughes RT Jones JH Control of anesthetic gases in dental operatories Scand J Work Environ Health 199218(Suppl 2)103-5
bull ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY Volume 97 Number 6 Suresh and Radfar 681
bull 96 Rosen MA Nitrous oxide for relief of labor pain a systematic review Am J Obstet Gynecol 2002186(Suppl Nature)S110-6
bull 97 Sands TD Pynn BR Management considerations for the pregnant or nursing emergency patient Ont Dent 199875 17-9
bull 98 Daya S Recurrent spontaneous early pregnancy loss and low dose aspirin Minerva Ginecol 200355441-9
bull 99 Sinclair C Handbook of obstetrical emergencies 1st ed Philadelphia WB Saunders 1996 p 29-39 69
bull 100 Tarsitano BF Rollings RE The pregnant dental patient evaluation and management Gen Dent 199341226-34
bull 101 Livingston MH Dlllinger TM Holder R Consideration in the management of the pregnant patient SCD Special Care in Dentistry 199818183-8
Thank you
- A Review on the principle of Dental Management of the Pregnant patient
- Slide 2
- Questions that a dentist may ask
- Stages of Pregnancy
- Slide 5
- Slide 6
- Physiologic Changes in Pregnancy
- Systemic changes in pregnancy
- FLAT SUPINE POSITIONING
- SUPINE HYPOTENSION SYNDROME (Vena Cava Compression)
- Supine Hypotension Syndrome
- Slide 12
- Supine Hypotension Syndrome
- Prevention of Supine Hypotensive Syndrome
- Treatment of Supine Hypotensive Syndrome
- How should the pregnant woman be positioned
- Slide 17
- Slide 18
- Slide 19
- Slide 20
- Slide 21
- Slide 22
- Slide 23
- Pregnancy Related Oral Health Problems
- Oral Problems in Pregnancy
- Pregnancy Gingivitis Pathophysiology
- Pregnancy Gingivitis
- Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Gum Problems - Pregnancy Granuloma
- Slide 31
- Gum Changes - Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Candidiasis
- Pregnancy Myths
- Other Oral Conditions in Pregnancy
- Changes During Pregnancy that Affect Oral Health
- Saliva changes
- Increased Bacteria
- Slide 40
- Enamel erosion caused by frequent vomiting
- Treatment for Acid Exposure
- Oral Diseases Can Effect Pregnancy
- Periodontal Disease and Preterm Labor
- Periodontal Disease and Low Birth Weight
- Periodontal Disease and Preeclampsia
- Periodontitis and Pre-eclampsia
- Dental Considerations
- Treatment Timing
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Slide 52
- Use of Radiation on Pregnant Patient
- Radiographs during Pregnancy
- Risks of Dental X-Rays
- FDA drug classification for pregnancy
- Slide 57
- FDA drug classification for pregnancy
- Slide 59
- Slide 60
- Slide 61
- Common Analgesics
- Analgesics
- Analgesics - continued
- Analgesics to Use During 1st and 2nd Trimester
- Analgesics to Avoid During the Third Trimester
- Sedation in Pregnancy
- Common Antibiotics
- Antibiotics
- Antibiotics To Use During Pregnancy
- Antibiotics to Avoid during Pregnancy
- The Problem With Tetracycline
- Other Antimicrobial Agents
- Local Anesthetic Use in Pregnancy
- Use of Local Anesthetics
- Ulcer healing drugs
- Slide 77
- Slide 78
- Slide 79
- Use of Nitrous Oxide Gas
- Common Preventives
- Are topical agents safe
- Pre-natal Fluoride
- Is it safe to use mercury restorations
- References
- REFERENCES
- Slide 87
- Slide 88
- Slide 89
- Slide 90
- Slide 91
- Slide 92
- Slide 93
- Slide 94
- Slide 95
- Slide 96
- Slide 97
- Slide 98
- Thank you
-
Pregnancy Granuloma (continued)
bullRapid growth up to 2 cmbullSingle tumor-like growthbullusually in interdental papillaebullPurplish to bluish in color may be ulcerated- bleeds easily
Gum Problems - Pregnancy Granuloma
Gum Problems - Pregnancy Granuloma
Gum Changes - Pregnancy Granuloma
Pregnancy Granuloma (continued)
Treatment
bull Scaling and root planingbull Excision if it is too large or bleeds too
easilybull May regress spontaneously after
pregnancy
Candidiasis
bullWipes offbullUsually asymptomatic but may burnbullTreatment topical or systemic antifungals
Pregnancy MythsbullldquoA mother loses a tooth for every babyrdquobullNo evidence that aphthous ulcers are any more common in pregnancy
Other Oral Conditions in Pregnancy
bull Dry mouthbull Excessive salivationbull Tooth erosions associated with
severe GERD or hyperemesis
Changes During Pregnancy that Affect Oral Health
bull Hormonal Affects
ndash Increased tooth mobility
ndash Saliva changes
ndash Increased bacteria
ndash Gingival problems
Saliva changesbull Decreased buffers
bull Decreased minerals
bull Decreasing flow first and last trimester
bull Increased flow second trimester
bull More acidic
Increased Bacteriabull Increased acidity
ndash Increase in decay-causing bacteriabull Increased Snacking
ndash Morning sicknesslow blood sugarndash Between-meal snacks
bull Increase in amount and frequency of starchescarbohydrates ndash Crackers are commonly recommendedndash Promotes decay-causing bacteria
Changes During Pregnancy that Affect Oral Healthbull Morning sickness
ndash Difficulty with hygienebull Gingival diseasebull Tooth decay
ndash Vomitingbull Esophogeal Reflux (heartburn)bull Acid exposure
ndash Irritation of the gumsndash Weakening of tooth enamelndash Dental erosion
Enamel erosion caused by frequent vomiting
Treatment for Acid Exposure
bull Do NOT brush immediately after vomiting
bull Rinse ndash Water with baking sodandash Antacidndash Plain water
bull Eat some cheese
Oral Diseases Can Effect Pregnancy
bull Preterm low birth weight (LBW) linked to periodontal disease
bull Thorough calculus (tartar) removal in pregnant women with periodontitis may reduce pre-term births
Periodontal Disease and Preterm LaborbullMaternal periodontal disease is associated with increased risk of preterm laborbullAnaerobic oral gram-negative bacteria cause inflammatory responsebullInflammatory response stimulates prostaglandin and cytokine production to stimulate labor
Periodontal Disease and Low Birth Weight
bull Periodontal disease is associated with low birth weight
bull Evidence is not conclusivebull Biochemical mechanism similar cascade
as in preterm labor leading to placental blood flow restriction and necrosis
Periodontal Disease and Preeclampsia
bull Emerging databull Mechanism unclearbull Proposed mechanism
ndash Periodontal infection leads to inflammatory vascular damage
ndash Triggers cell damage in placenta
Periodontitis and Pre-eclampsia
bull Periodontal disease may be associated with pre-eclampsia (Boggess 2003)
bull PGE2 IL-1 and TNF-α from gingival crevicular fluid were higher in women with preeclampsia compared with healthy matched pregnant women (Oettinger-Barak 2003)
Dental Considerations
bull timing of treatment for pregnant patientsbull dental radiation exposurebull use of local anestheticsbull prescription of common antibiotics and
analgesicsbull nitrous oxide gas administration
Treatment Timing
bull First Trimesterndash Spontaneous miscarriages naturally occur
more often in 1st trimesterndash Avoid elective treatment that can be delayedndash Offer anticipatory guidance
bull Second Trimesterndash The optimal time for dental treatmentndash Organogenesis complete fetus not largendash Easier to prevent than treat established disease
bull Third Trimesterndash Late in term very uncomfortable (short visits)ndash Position slightly on left side
Timing of Dental Treatment During Pregnancy - From Little and Fallace
First Trimester
bull Plaque controlbull Oral hygiene instructionbull Scaling polishing curettagebull Avoid elective treatment urgent care
only
Timing of Dental Treatment During Pregnancy - From Little and Fallace
Second Trimester
bull Plaque controlbull Oral hygiene instructionbull Scaling polishing curettagebull Routine dental care
Timing of Dental Treatment During Pregnancy - From Little and Fallace
Third Trimester
bull Plaque controlbull Oral hygiene instructionbull Scaling polishing curettagebull Routine dental care (after middle of third
trimester elective care should be avoided)
Use of Radiation on Pregnant Patientbull Dose given and time of gestation are
importantbull doses lt 5-10 rads (cGy) not teratogenicbull fetus is most susceptible to radiation
between the 2nd and 6th week of gestationbull single dental x-ray exposes patient to 001
millirads of radiation In relative terms this amount is 40 times less than daily dose acquired from cosmic radiation Therefore diagnostic radiation should not be withheld during pregnancy
Radiographs during Pregnancy
bull Take as needed with optimal methods for reducing secondary radiation and exposure time
bull Always use a lead apronbull Exposure to fetus (with apron use) is 00001
centiGray(rad)bull Daily cosmic radiation - 0004 centiGray (rad)
Risks of Dental X-Rays
bull X-ray only if necessary (ie root canal therapy trauma)
bull When x-rays are indicated radiation exposure is extremely low
bull Exposure can be limited byndash Lead apron shielding ndash Modern fast film ndash Avoiding retakes
FDA drug classification for pregnancybull Combines risk statements including
congenital anomalies fetal effects perinatal risks and therapeutic risk-benefit ratio
bull Untreated disease or condition may pose more serious risks to both mother and fetus than any theoretical risks from the medication
bull Category A thru D and X
FDA drug classification for pregnancy
bull A = Controlled Studies in women fail to demonstrate a risk to the fetus in the first trimester and the possibility of fetal harm appears remote
FDA drug classification for pregnancy
bull B = Animal studies show no risk or if risk shown in animals controlled
trials in women showed no risk
FDA drug classification for pregnancy
bull C = Studies in animals with adverse effects and no human studies
OR no animal or human studies but benefits of use may outweigh potential harms
FDA drug classification for pregnancy
bull D = There is evidence of human fetal risk but benefits may outweigh risks
FDA drug classification for pregnancy
bull X = Contraindicated
Common Analgesics
bull paracetamol (B)bull Ibuprofen (BD) bull Oxycodone (BD) bull Hydrocodone and codeine
(CD)
avoid in third trimester
Analgesics
bull Paracetamol is the analgesic of choice for all stages of gestation
bull used to treat mild to moderate pain and fevers
bull short term usage is believed to be safebull avoid chronic and large doses of
paracetamol1048715
Analgesics - continuedbull Aspirin is nonteratogenic but may cause
maternal and fetal hemorrhagebull large and chronic doses during last trimester
may result in premature closure of ductus arteriosus fetal hypertension anemia and low birth weight
bull avoid ibuprofen in 3rd trimester because of possible adverse circulatory effects
bull short term use of codeine seems safebull avoid codeine late in gestation because of
possible fetal respiratory depression and withdrawal symptoms
Analgesics to Use During1st and 2nd Trimester
bull Category B (for best)bull Paracetamol Ibuprofenbull Naproxenbull Category C (use with caution)bull Paracetamol with codeine or
hydrocodonebull Paracetamol with oxycodone
Analgesics to Avoid During theThird Trimesterbull Causes delivery problemsbull Aspirin (C 3D)bull Ibuprofen (B3D)bull Naproxen (B3D)bull Causes neonatal respiratory
depression and opioid withdrawalbull Codeine (C3D)bull Hydrocodone (C3D)bull Oxycodone(C3D)
Sedation in Pregnancy
bull SedativesAnxiolytics (eg Diazepam ) are rated D and can cause oral clefts with prolonged exposure
bull Nitrous oxide should not be used in 1st trimester (If used in 2nd and 3rd do not go below 50 O2)
Common Antibioticsbull To treat oral abscess or cellulitis
ndash Penicillin (B) ndash Amoxicillin (B) ndash Cephalexin (B)ndash Erythromycin base (B) (Not estolate as it
cause cholestatic hepatitis)ndash Clindamycin (B)
Antibioticsbull penicillin V and amoxicillin is preferred drug
for mild to moderate infectionsbull widely used for many years with no ill effectsbull no studies show penicillin to be teratogenicbull amoxicillin extensively used without harming
the fetusbull Drug classes1048715 B penicillin cephalosporins erythromycin clindamycin Azithromycin D Tetracycline
Antibiotics To Use During Pregnancy
bull Penicillin Vbull Amoxicillinbull Erythromycin (base form)bull Cephalexin cephalosporinbull Clindamycinbull Metronidazole
Antibiotics to Avoid duringPregnancy
bull Doxycyclinebull Tetracyclinebull Erythromycin (estolate form)bull Vancomycin
The Problem With Tetracycline
bull Accumulates in bones and chelates calcium
bull Inhibits bone growthbull Discolors teeth
Other Antimicrobial Agentsbull OK to usebull Nystatin (B)bull Chlorhexidine rinse (B)bull Use with cautionbull Clotrimazole (C)bull Ketoconazole (C)bull Fluconazole (C)bull Do not usebull Doxycycline (D)
Local Anesthetic Use inPregnancy
bull Class Bbull Lidocaine (Xylocaine)bull Etidocainebull Prilocaine bull Class Cbull Procainebull Bupivicainebull Mepivicaine
Use of Local Anestheticsbull Lidocaine + vasoconstrictor most common
local anesthetic used in dentistrybull extensively used in pregnancy with no proven ill
effectsbull accidental intravascular injections of lidocaine
pass through the placenta but the concentrations are too low to harm fetus
bull prilocaine might cause methemoglobinemia
Ulcer healing drugsCimetidine bull FDA category B Famotidinebull FDA category BRanitidinebull FDA category Bbull not known to be harmful
Ulcer healing drugsOmeprazolebull FDA category BNot known to be
harmful Esomeprazolebull FDA category BLansoprazolebull FDA category BPantoprazolebull Avoid unless potential benefit
outweighs riskmdashfetotoxic in animals
Ulcer healing drugs
Misoprostolbull First second third trimesters Avoidmdash
potent uterine stimulant (has been used to induce abortion) and may be teratogenic
Ulcer healing drugs
Antacidsbull Almunium hydroxideMagnesium
hydroxidemdashFDA category B Calcium carbonatemdashFDA category C
SimetheconemdashFDA category C
Use of Nitrous Oxide Gas
bull used over 150 years bull safety is being debatedbull SHORT TERM exposure do not cause
birth defects or spontaneous abortionbull CHRONIC exposure may result in fetal
loss and infertilitybull literature suggests that nitrous oxide
should be avoided until more conclusive research is available
bull FDA Drug class not yet assigned
Common Preventives
bull Fluoridendash No increased risk during pregnancy
bull Xylitolndash No studies no harm reported
bull Chlorhexidinendash No increased risk during pregnancy
Are topical agents safe
bull Fluoridebull Toothpaste amp mouthrinse
bull Xylitol chewing gum bull Chlorhexidine (11 alcohol)bull No over the counter mouthrinses with
alcohol (Listerine 20 alcohol)
Pre-natal Fluoride
bull Daily 22 mg tablet of sodium fluoride during 3rd through 9th months
bull decreases caries rate in offspringbull Safe and effective
Glenn FB 1982
Is it safe to use mercury restorations
bull No evidence of harmful effect
bull Benefits outweigh risks
bull Canada Germany and New Zealand have some restrictions
bull Determine the best option
Referencesbull Wasylko L Matsui D Dykxhoorn SM Rieder MJ Weinberg
S A Review of Common Dental Treatments During Pregnancy J Canadian Dental Association 64434-439 1998
bull Little JW Donald AF Craig SM Rhodus NL Dental Management of the Medically Compromised Patient - 5th edition Mosby Toronto Pp434-442 1997
bull Livingston HM Dellinger TM Holder R Considerations in the management of the pregnant patient Special Care in Dentistry 185 pp183-188 1998
bull Larimore WL Petrie KA Drug use during pregnacy and lactation Primary Care Clinics in Office Practice 271 35-53 2000
bull Health Canada The Safety of DentalAmalgam Minister Of Supply and Services Canada 1996
REFERENCESbull 1 Weiss G Endocrinology of parturition J Clin
Endocrinol Metab 2000854421-5bull 2 Theunissen IM Parer JT Fluid and electrolytes in
pregnancy Clin Obstet Gynecol 1994373-15bull 3 Duvekot JJ Peeters LLH Renal hemodynamics and
volume homeostasis in pregnancy Obstet Gynecol Surv 199449830-9
bull 4 Barron WM Lindheimer MD Medical disorders during pregnancy 2nd ed St Louis Mosby 1995 p 129
bull 5 Thornburg KL Jacobson SL Giraud GD Morton MJ Hemodynamic changes in pregnancy Semin Perinatol 20002411-4
bull 6 Fiese R Herzog S Issues in dental and surgical management of the pregnant patient Oral Surg Oral Med Oral Pathol 198865292-7
bull 7 Martin C Varner MW Physiologic changes in pregnancysurgical implications Clin Obstet Gynecol 199437241-55
bull 8 Clark SL Cotton DB Lee W Bishop C Hill T Southwick J et al Central hemodynamic assessment of normal term pregnancy Am J Obstet Gynecol 19891611439-42
bull 9 Mabie WC Di Sessa TG Crocker LG Sibai BM Arheart KL A longitudinal study of cardiac output in normal human pregnancy Am J Obstet Gynecol 1994170849-56
bull 10 Clapp JF 3rd Capeless E Cardiovascular function before during and after the first and subsequent pregnancies Am J Cardiol 1997801469-73
bull 11 Duvekot JJ Peeters LL Maternal cardiovascular hemodynamic adaptation to pregnancy Obstet Gynecol Surv 199449(Suppl) S1-14
bull 12 Bhagwat AR Engel PJ Heart disease and pregnancy Cardiol Clin 199513163-78
bull 13 Lanni SM Tillinghast J Silver H Hemodynamic changes and baroreflex gain in the supine hypotensive syndrome Am J Obstet Gynecol 20021871636-41
bull 14 Little JW Falace DA Miller CS Rhodus NL Dental management of the medically compromised patient 6th ed St Louis Mosby 2002 p 303
bull 15 Garcia-Rio F Pino JM Gomez L Alvarez-Sala R Villasante C Villamor J Regulation of breathing and perception of dyspnea in healthy pregnant women Chest 1996110446-53
bull 16 McAuliffe F Kametas N Costello J Rafferty GF Greenough A Nicolaides K Respiratory function in singleton and twin pregnancy BJOG 2002109765-9
bull 17 Clapp JF 3rd Seaward BL Sleamaker RH Hiser J Maternal physiologic adaptations to early human pregnancy Am J Obstet Gynecol 19881591456-60
bull 18 OrsquoDay MP Cardio-respiratory physiological adaptation of pregnancy Semin Perinatol 199721268-75
bull 19 Contreras G Gutierrez M Beroiza T Fantin A Oddo H Villarroel L et al Ventilatory drive and respiratory muscle function in pregnancy Am Rev Respir Dis 1991144837-41
bull 20 Turner M Aziz SR Management of the pregnant oral and maxillofac
bull 21 Sifakis S Pharmakides G Anemia in pregnancy Ann N Y Acad Sci 2000900125-36
bull 22 Branch DW Physiologic adaptations of pregnancy Am J Reprod Immunol 199228120-2
bull 23 Burrows RF Kelton JG Incidentally detected thrombocytopenia in healthy mothers and their infants N Engl J Med 1988319 142-5
bull 24 Hanly JG Antiphospholipid syndrome an overview CMAJ 200324(168)1675-82
bull 25 Heilmann L von Tempelhoff GF Pollow K Antiphospholipid syndrome in obstetrics Clin Appl Thromb Hemost 20039 143-50
bull 26 Sherman P Flaxman SM Nausea and vomiting of pregnancy in an evolutionary perspective Am J Obstet Gynecol 2002 185(Suppl)s190-7
bull 27 Koch KL Gastrointestinal factors in nausea and vomiting of pregnancy Am J Obstet Gynecol 2002185(Suppl)s198-203
bull 28 Koch KL Frissora CL Nausea and vomiting during pregnancy Gastroenterol Clin N Am 200332201-34
bull 29 Baron TH Ramirez B Richter JE Gastrointestinal motility disorders during pregnancy Ann Intern Med 1993118 366-75
bull 30 Richter JE Gastroesophageal reflux disease during pregnancy Gastroenterol Clin N Am 200332235-61
bull 31 Marrero JM Goggin PM de Caestecker JS Pearce JM Maxwell JD Determinants of pregnancy heartburn Br J Obstet Gynaecol 199299731-4
bull 32 Hamaoui E Hamaoui M Nutritional assessment and support during pregnancy Gastroenterol Clin N Am 20033259-121
bull 33 King JC Physiology of pregnancy and nutrient metabolism Am J Clin Nutr 200071(suppl)1218s-25s
bull 34 Casanueva E Pfeffer F Fernandez-Gaxiola AC Gutierrez- Valenzuela V Rothenberg SJ Iron and folate status before pregnancy and anemia during pregnancy Ann Nutr Metab 2003 4760-3
bull 35 Chrsquong CL Morgan M Hainsworth I Kingham JG Prospective study of liver dysfunction in Southwest Wales Gut 200251 876-80
bull 36 Rahman TM Wendon J Severe hepatic dysfunction in pregnancy QJM 200295343-57
bull 37 Knox TA Olans LB Liver disease in pregnancy N Engl J Med 1996335569-76
bull 38 Saftlas AF Olson DR Franks AL Atrash H Pokras R Epidemiology of preeclampsia and eclampsia in the United States 1979e1986 Am J Obstet Gynecol 1990163460-5
bull 39 Walker JJ Pre-eclampsia Lancet 20003561260-5
bull 40 Davidson JM Renal disorders in pregnancy Curr Opin Obstet Gynecol 200113109-14
bull 41 Dafnis E Sabatini S The effect of pregnancy on renal function physiology and pathophysiologyAmJMedSci 1992303184-205
bull 42 Davison JM Shiells EA Philips PR Lindheimer MD Serial evaluation of vasopressin release and thirst in human pregnancy Role of human chorionic gonadotrophin in the osmoregulatory changes of gestation J Clin Invest 198881798-806
bull 43 Glinoer D de Nayer P Bourdoux P Lemone M Robyn C van Steirteghem A et al Regulation of maternal thyroid during pregnancy J Clin Endocrinol Metab 199071276-87
bull 44 Wilson SG Retallack RW Kent JC Worth GK Gutteridge DH Serum free 125-dihydroxyvitamin D and the free 125- dihydroxyvitamin D index during a longitudinal study of human pregnancy and lactation Clin Endocrinol 199032613-22
bull 45 Rasmussen N Frolich A Hornnes PJ Hegedus L Serum ionized calcium and intact parathyroid hormone levels during pregnancy and postpartum Br J Obstet Gynaecol 199097857-9
bull 46 Guyton AC Textbook of medical physiology 8th ed Philadelphia W B Saunders 1991 p 915e28
bull 47 Trainer PJ Corticosteroids and pregnancy Semin Reprod Med 200220375-80
bull 48 Soory M Hormonal factors in periodontal disease Dent Update 200027380-3
bull 49 Hugoson A Gingivitis in pregnant women A longitudinal clinical study Odontol Revy 19712265-84
bull 50 Neville BW Damm DD Allen CM Bouquot JE Oral amp Maxillofacial Pathology 3rd ed Philadelphia W B Saunders 2002 p 329-30 447-9
bull 51 Tilakaratne A Soory M Ranasinghe AW Corea SM Ekanayake SL de Silva M Periodontal disease status during pregnancy and 3 months post-partum in rural population of Sri-Lankan women J Clin Periodontol 200027787-92
bull 52 Laine M Tenovuo J Lehtonen OP Ojanatko-Harri A Vilja P Tuohimaa P Pregnancy e related changes in human whole saliva Arch Oral Biol 198833913-7
bull 53 Yuan K Wing LY Lin MT Pathogenetic roles of angiogenic factors in pyogenic granulomas in pregnancy are modulated by female sex hormones J Periodontol 200273701-8
bull 54 Evans RD Briggs PF Tooth-surface loss related to pregnancyinduced vomiting Prim Dent Care 1994124-6
bull 55 Salvolini E Di Giorgio R Curatola A Mazzanti L Fratto G Biochemical modifications of human whole saliva induced by pregnancy Br J Obstet Gynaec 1998105656-60
bull 56 Mauldin JG Newman RB Preterm birth risk assessment Semin Perinatol 200125215-22
bull 57 Heine RP McGregor JA Goodwin TM Artal R Hayashi RH Robertson PA et al Serial salivary estriol to detect an increased risk of preterm birth Obstet Gynecol 200096490-7
bull 58 Kauh YC Zachian TF Melasma Adv Exp Med Biol 1999455 491-9
bull 59 Wong RC Ellis CN Physiologic skin changes in pregnancy J Am Acad Dermatol 198410929-40
bull 60 Errickson CV Matus NR Skin disorders of pregnancy Am Fam Physician 199449605-10
bull 61 Lopez NJ Smith PC Gutierrez J Periodontal therapy may reduce the risk of preterm low birth weight in women with periodontal disease a randomized controlled trial J Periodontol 200273911-24
bull 62 McGaw T Periodontal disease and preterm delivery of lowbirth- weight infants J Can Dent Assoc 200268165-9
bull 63 Richards AG Dental x-ray protection Dent Clin North Am 1968631-41
bull 64 1990 Recommendations of the International Commission on Radiological Protection Ann ICRP 1991211-201
bull 65 Hall EJ Radiation the two-edged sword cancer risks at high and low doses Cancer J 20006343-50
bull 66 Diethelm L Xu H Diagnostic imaging of the lung during pregnancy Clin Obstet Gynecol 19963936-55
bull 67 Brent RL The effects of embryonic and fetal exposure to x-rays microwaves and ultrasound ClinObstetGynecol 198326484-510
bull 68 National Council on Radiation Protection NCRP report no128 1998 Bethesda Md Author
bull 69 Wasylko L Matsui D Dykxhoorn SM Reider MJ Weinberg S A review of common dental treatments during pregnancy implications for patients and dental personnel J Can Dent Assoc 199864434-9
bull 70 Freeman JP Brand JW Radiation doses of commonly used dental radiographic surveys Oral Surg Oral Med Oral Pathol 199477285-9
bull 71 Kircos LTAngin LL Lorton LOrder ofmagnitude dose reduction in intraoral radiography J Am Dent Assoc 1987114344-7
bull 72 Updegrave WJ Simplified and standardized intraoral radiography with reduced tissue irradiation J Am Dent Assoc 197285861-9
bull 73 Wood RE Harris AM van der Merwe EJ Nortje CJ The leaded apron revisited does it reduce gonadal radiation dose in dental radiology Oral Surg Oral Med Oral Pathol 199171642-6
bull 74 An update on radiographic practices information and recommendations ADA Council on Scientific Affairs J Am Dent Assoc 2001132234-8
bull 75 Rayburn WF Recommending medications during pregnancy an evidence based approach Clin Obstet Gynecol 2002451-5
bull 76 Rathmell JP Viscomi C Ashburn MA Management of nonobstetric pain during pregnancy and lactation Anesth Analg 1997851074-87
bull 77 Teratology society public affairs committee FDA classification of drugs for teratogenic risk Teratology 199449446-7
bull 78 Moore PA Selecting drugs for the pregnant dental patient J Am Dent Assoc 19981291281-6
bull 79 Haas DA An update on analgesics for the management of acute postoperative dental pain J Can Dent Assoc 200268476-82
bull 80 Haas DA Pynn BR Sands TD Drug use for the pregnant or lactating patient Gen Dent 20004854-60
bull 81 Committee on Drugs American Academy of Pediatrics The transfer of drugs and other chemicals into human milk Pediatrics 199493137-50
bull 82 Nielsen GL Sorensen HT Larsen H Pedersen L Risk of adverse birth outcome and miscarriage in pregnant users of nonsteroidal anti-inflammatory drugs population based observational study and case-control study BMJ 2001322266-70
bull 83 Janssen N Genta M The effects of immunosuppressive and anti-inflammatory medications on fertility pregnancy and lactation Arch Intern Med 200016610-9
bull 84 Ostensen M Nonsteroidal anti-inflammatory drugs during pregnancy Scand J Rheumatol Suppl 1998107128-32
bull 85 USPDI -Drug information for the health care professional 22nd ed Greenwood Village CO Micromedex 2002 p 152-79
bull 86 Denson DD Coyle DE Thompson GA Santos D Turner PA Myers JA et al Bupivacaine protein binding in the term parturient effects of lactic acidosis Clin Pharmacol Ther 198435702-9
bull 87 Dillon DE Wagner CL Wiest D Newman RB Drug therapy in the nursing mother Obstet Gynecol Clin North Am 199724 675-96
bull 88 Dashe JS Gilstrap LC Antibiotic use in pregnancy Obstet Gynecol Clin North Am 199724617-29
bull 89 American College of Rheumatology Ad hoc Committee on Clinical Guidelines Guidelines for monitoring drug therapy in rheumatoid arthritis Arthritis Rheum 199639723-31
bull 90 Ng PC The fetal and neonatal hypothalamic-pituitary-adrenal axis Arch Dis Child Fetal Neonatal Ed 200082F250-4
bull 91 Crowley P Antenatal corticosteroidsmdashcurrent thinking BJOG 2003110(Suppl 20)77-8
bull 92 ACOG committee opinion antenatal corticosteroid therapy for fetal maturation Obstet Gynecol 200299871-3
bull 93 Ost L Wettrell G Bjorkhem I Rane A Prednisolone excretion in human milk J Pediatr 19851061008-11
bull 94 Rowland AS Baird DD Shore DL Weinberg CR Savitz DA Wilcox AJ Nitrous oxide and spontaneous abortion in female dental assistants Am J Epidemiol 1995141531-8
bull 95 McGlothlin JD Jensen PA Fischbach TJ Hughes RT Jones JH Control of anesthetic gases in dental operatories Scand J Work Environ Health 199218(Suppl 2)103-5
bull ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY Volume 97 Number 6 Suresh and Radfar 681
bull 96 Rosen MA Nitrous oxide for relief of labor pain a systematic review Am J Obstet Gynecol 2002186(Suppl Nature)S110-6
bull 97 Sands TD Pynn BR Management considerations for the pregnant or nursing emergency patient Ont Dent 199875 17-9
bull 98 Daya S Recurrent spontaneous early pregnancy loss and low dose aspirin Minerva Ginecol 200355441-9
bull 99 Sinclair C Handbook of obstetrical emergencies 1st ed Philadelphia WB Saunders 1996 p 29-39 69
bull 100 Tarsitano BF Rollings RE The pregnant dental patient evaluation and management Gen Dent 199341226-34
bull 101 Livingston MH Dlllinger TM Holder R Consideration in the management of the pregnant patient SCD Special Care in Dentistry 199818183-8
Thank you
- A Review on the principle of Dental Management of the Pregnant patient
- Slide 2
- Questions that a dentist may ask
- Stages of Pregnancy
- Slide 5
- Slide 6
- Physiologic Changes in Pregnancy
- Systemic changes in pregnancy
- FLAT SUPINE POSITIONING
- SUPINE HYPOTENSION SYNDROME (Vena Cava Compression)
- Supine Hypotension Syndrome
- Slide 12
- Supine Hypotension Syndrome
- Prevention of Supine Hypotensive Syndrome
- Treatment of Supine Hypotensive Syndrome
- How should the pregnant woman be positioned
- Slide 17
- Slide 18
- Slide 19
- Slide 20
- Slide 21
- Slide 22
- Slide 23
- Pregnancy Related Oral Health Problems
- Oral Problems in Pregnancy
- Pregnancy Gingivitis Pathophysiology
- Pregnancy Gingivitis
- Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Gum Problems - Pregnancy Granuloma
- Slide 31
- Gum Changes - Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Candidiasis
- Pregnancy Myths
- Other Oral Conditions in Pregnancy
- Changes During Pregnancy that Affect Oral Health
- Saliva changes
- Increased Bacteria
- Slide 40
- Enamel erosion caused by frequent vomiting
- Treatment for Acid Exposure
- Oral Diseases Can Effect Pregnancy
- Periodontal Disease and Preterm Labor
- Periodontal Disease and Low Birth Weight
- Periodontal Disease and Preeclampsia
- Periodontitis and Pre-eclampsia
- Dental Considerations
- Treatment Timing
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Slide 52
- Use of Radiation on Pregnant Patient
- Radiographs during Pregnancy
- Risks of Dental X-Rays
- FDA drug classification for pregnancy
- Slide 57
- FDA drug classification for pregnancy
- Slide 59
- Slide 60
- Slide 61
- Common Analgesics
- Analgesics
- Analgesics - continued
- Analgesics to Use During 1st and 2nd Trimester
- Analgesics to Avoid During the Third Trimester
- Sedation in Pregnancy
- Common Antibiotics
- Antibiotics
- Antibiotics To Use During Pregnancy
- Antibiotics to Avoid during Pregnancy
- The Problem With Tetracycline
- Other Antimicrobial Agents
- Local Anesthetic Use in Pregnancy
- Use of Local Anesthetics
- Ulcer healing drugs
- Slide 77
- Slide 78
- Slide 79
- Use of Nitrous Oxide Gas
- Common Preventives
- Are topical agents safe
- Pre-natal Fluoride
- Is it safe to use mercury restorations
- References
- REFERENCES
- Slide 87
- Slide 88
- Slide 89
- Slide 90
- Slide 91
- Slide 92
- Slide 93
- Slide 94
- Slide 95
- Slide 96
- Slide 97
- Slide 98
- Thank you
-
Gum Problems - Pregnancy Granuloma
Gum Problems - Pregnancy Granuloma
Gum Changes - Pregnancy Granuloma
Pregnancy Granuloma (continued)
Treatment
bull Scaling and root planingbull Excision if it is too large or bleeds too
easilybull May regress spontaneously after
pregnancy
Candidiasis
bullWipes offbullUsually asymptomatic but may burnbullTreatment topical or systemic antifungals
Pregnancy MythsbullldquoA mother loses a tooth for every babyrdquobullNo evidence that aphthous ulcers are any more common in pregnancy
Other Oral Conditions in Pregnancy
bull Dry mouthbull Excessive salivationbull Tooth erosions associated with
severe GERD or hyperemesis
Changes During Pregnancy that Affect Oral Health
bull Hormonal Affects
ndash Increased tooth mobility
ndash Saliva changes
ndash Increased bacteria
ndash Gingival problems
Saliva changesbull Decreased buffers
bull Decreased minerals
bull Decreasing flow first and last trimester
bull Increased flow second trimester
bull More acidic
Increased Bacteriabull Increased acidity
ndash Increase in decay-causing bacteriabull Increased Snacking
ndash Morning sicknesslow blood sugarndash Between-meal snacks
bull Increase in amount and frequency of starchescarbohydrates ndash Crackers are commonly recommendedndash Promotes decay-causing bacteria
Changes During Pregnancy that Affect Oral Healthbull Morning sickness
ndash Difficulty with hygienebull Gingival diseasebull Tooth decay
ndash Vomitingbull Esophogeal Reflux (heartburn)bull Acid exposure
ndash Irritation of the gumsndash Weakening of tooth enamelndash Dental erosion
Enamel erosion caused by frequent vomiting
Treatment for Acid Exposure
bull Do NOT brush immediately after vomiting
bull Rinse ndash Water with baking sodandash Antacidndash Plain water
bull Eat some cheese
Oral Diseases Can Effect Pregnancy
bull Preterm low birth weight (LBW) linked to periodontal disease
bull Thorough calculus (tartar) removal in pregnant women with periodontitis may reduce pre-term births
Periodontal Disease and Preterm LaborbullMaternal periodontal disease is associated with increased risk of preterm laborbullAnaerobic oral gram-negative bacteria cause inflammatory responsebullInflammatory response stimulates prostaglandin and cytokine production to stimulate labor
Periodontal Disease and Low Birth Weight
bull Periodontal disease is associated with low birth weight
bull Evidence is not conclusivebull Biochemical mechanism similar cascade
as in preterm labor leading to placental blood flow restriction and necrosis
Periodontal Disease and Preeclampsia
bull Emerging databull Mechanism unclearbull Proposed mechanism
ndash Periodontal infection leads to inflammatory vascular damage
ndash Triggers cell damage in placenta
Periodontitis and Pre-eclampsia
bull Periodontal disease may be associated with pre-eclampsia (Boggess 2003)
bull PGE2 IL-1 and TNF-α from gingival crevicular fluid were higher in women with preeclampsia compared with healthy matched pregnant women (Oettinger-Barak 2003)
Dental Considerations
bull timing of treatment for pregnant patientsbull dental radiation exposurebull use of local anestheticsbull prescription of common antibiotics and
analgesicsbull nitrous oxide gas administration
Treatment Timing
bull First Trimesterndash Spontaneous miscarriages naturally occur
more often in 1st trimesterndash Avoid elective treatment that can be delayedndash Offer anticipatory guidance
bull Second Trimesterndash The optimal time for dental treatmentndash Organogenesis complete fetus not largendash Easier to prevent than treat established disease
bull Third Trimesterndash Late in term very uncomfortable (short visits)ndash Position slightly on left side
Timing of Dental Treatment During Pregnancy - From Little and Fallace
First Trimester
bull Plaque controlbull Oral hygiene instructionbull Scaling polishing curettagebull Avoid elective treatment urgent care
only
Timing of Dental Treatment During Pregnancy - From Little and Fallace
Second Trimester
bull Plaque controlbull Oral hygiene instructionbull Scaling polishing curettagebull Routine dental care
Timing of Dental Treatment During Pregnancy - From Little and Fallace
Third Trimester
bull Plaque controlbull Oral hygiene instructionbull Scaling polishing curettagebull Routine dental care (after middle of third
trimester elective care should be avoided)
Use of Radiation on Pregnant Patientbull Dose given and time of gestation are
importantbull doses lt 5-10 rads (cGy) not teratogenicbull fetus is most susceptible to radiation
between the 2nd and 6th week of gestationbull single dental x-ray exposes patient to 001
millirads of radiation In relative terms this amount is 40 times less than daily dose acquired from cosmic radiation Therefore diagnostic radiation should not be withheld during pregnancy
Radiographs during Pregnancy
bull Take as needed with optimal methods for reducing secondary radiation and exposure time
bull Always use a lead apronbull Exposure to fetus (with apron use) is 00001
centiGray(rad)bull Daily cosmic radiation - 0004 centiGray (rad)
Risks of Dental X-Rays
bull X-ray only if necessary (ie root canal therapy trauma)
bull When x-rays are indicated radiation exposure is extremely low
bull Exposure can be limited byndash Lead apron shielding ndash Modern fast film ndash Avoiding retakes
FDA drug classification for pregnancybull Combines risk statements including
congenital anomalies fetal effects perinatal risks and therapeutic risk-benefit ratio
bull Untreated disease or condition may pose more serious risks to both mother and fetus than any theoretical risks from the medication
bull Category A thru D and X
FDA drug classification for pregnancy
bull A = Controlled Studies in women fail to demonstrate a risk to the fetus in the first trimester and the possibility of fetal harm appears remote
FDA drug classification for pregnancy
bull B = Animal studies show no risk or if risk shown in animals controlled
trials in women showed no risk
FDA drug classification for pregnancy
bull C = Studies in animals with adverse effects and no human studies
OR no animal or human studies but benefits of use may outweigh potential harms
FDA drug classification for pregnancy
bull D = There is evidence of human fetal risk but benefits may outweigh risks
FDA drug classification for pregnancy
bull X = Contraindicated
Common Analgesics
bull paracetamol (B)bull Ibuprofen (BD) bull Oxycodone (BD) bull Hydrocodone and codeine
(CD)
avoid in third trimester
Analgesics
bull Paracetamol is the analgesic of choice for all stages of gestation
bull used to treat mild to moderate pain and fevers
bull short term usage is believed to be safebull avoid chronic and large doses of
paracetamol1048715
Analgesics - continuedbull Aspirin is nonteratogenic but may cause
maternal and fetal hemorrhagebull large and chronic doses during last trimester
may result in premature closure of ductus arteriosus fetal hypertension anemia and low birth weight
bull avoid ibuprofen in 3rd trimester because of possible adverse circulatory effects
bull short term use of codeine seems safebull avoid codeine late in gestation because of
possible fetal respiratory depression and withdrawal symptoms
Analgesics to Use During1st and 2nd Trimester
bull Category B (for best)bull Paracetamol Ibuprofenbull Naproxenbull Category C (use with caution)bull Paracetamol with codeine or
hydrocodonebull Paracetamol with oxycodone
Analgesics to Avoid During theThird Trimesterbull Causes delivery problemsbull Aspirin (C 3D)bull Ibuprofen (B3D)bull Naproxen (B3D)bull Causes neonatal respiratory
depression and opioid withdrawalbull Codeine (C3D)bull Hydrocodone (C3D)bull Oxycodone(C3D)
Sedation in Pregnancy
bull SedativesAnxiolytics (eg Diazepam ) are rated D and can cause oral clefts with prolonged exposure
bull Nitrous oxide should not be used in 1st trimester (If used in 2nd and 3rd do not go below 50 O2)
Common Antibioticsbull To treat oral abscess or cellulitis
ndash Penicillin (B) ndash Amoxicillin (B) ndash Cephalexin (B)ndash Erythromycin base (B) (Not estolate as it
cause cholestatic hepatitis)ndash Clindamycin (B)
Antibioticsbull penicillin V and amoxicillin is preferred drug
for mild to moderate infectionsbull widely used for many years with no ill effectsbull no studies show penicillin to be teratogenicbull amoxicillin extensively used without harming
the fetusbull Drug classes1048715 B penicillin cephalosporins erythromycin clindamycin Azithromycin D Tetracycline
Antibiotics To Use During Pregnancy
bull Penicillin Vbull Amoxicillinbull Erythromycin (base form)bull Cephalexin cephalosporinbull Clindamycinbull Metronidazole
Antibiotics to Avoid duringPregnancy
bull Doxycyclinebull Tetracyclinebull Erythromycin (estolate form)bull Vancomycin
The Problem With Tetracycline
bull Accumulates in bones and chelates calcium
bull Inhibits bone growthbull Discolors teeth
Other Antimicrobial Agentsbull OK to usebull Nystatin (B)bull Chlorhexidine rinse (B)bull Use with cautionbull Clotrimazole (C)bull Ketoconazole (C)bull Fluconazole (C)bull Do not usebull Doxycycline (D)
Local Anesthetic Use inPregnancy
bull Class Bbull Lidocaine (Xylocaine)bull Etidocainebull Prilocaine bull Class Cbull Procainebull Bupivicainebull Mepivicaine
Use of Local Anestheticsbull Lidocaine + vasoconstrictor most common
local anesthetic used in dentistrybull extensively used in pregnancy with no proven ill
effectsbull accidental intravascular injections of lidocaine
pass through the placenta but the concentrations are too low to harm fetus
bull prilocaine might cause methemoglobinemia
Ulcer healing drugsCimetidine bull FDA category B Famotidinebull FDA category BRanitidinebull FDA category Bbull not known to be harmful
Ulcer healing drugsOmeprazolebull FDA category BNot known to be
harmful Esomeprazolebull FDA category BLansoprazolebull FDA category BPantoprazolebull Avoid unless potential benefit
outweighs riskmdashfetotoxic in animals
Ulcer healing drugs
Misoprostolbull First second third trimesters Avoidmdash
potent uterine stimulant (has been used to induce abortion) and may be teratogenic
Ulcer healing drugs
Antacidsbull Almunium hydroxideMagnesium
hydroxidemdashFDA category B Calcium carbonatemdashFDA category C
SimetheconemdashFDA category C
Use of Nitrous Oxide Gas
bull used over 150 years bull safety is being debatedbull SHORT TERM exposure do not cause
birth defects or spontaneous abortionbull CHRONIC exposure may result in fetal
loss and infertilitybull literature suggests that nitrous oxide
should be avoided until more conclusive research is available
bull FDA Drug class not yet assigned
Common Preventives
bull Fluoridendash No increased risk during pregnancy
bull Xylitolndash No studies no harm reported
bull Chlorhexidinendash No increased risk during pregnancy
Are topical agents safe
bull Fluoridebull Toothpaste amp mouthrinse
bull Xylitol chewing gum bull Chlorhexidine (11 alcohol)bull No over the counter mouthrinses with
alcohol (Listerine 20 alcohol)
Pre-natal Fluoride
bull Daily 22 mg tablet of sodium fluoride during 3rd through 9th months
bull decreases caries rate in offspringbull Safe and effective
Glenn FB 1982
Is it safe to use mercury restorations
bull No evidence of harmful effect
bull Benefits outweigh risks
bull Canada Germany and New Zealand have some restrictions
bull Determine the best option
Referencesbull Wasylko L Matsui D Dykxhoorn SM Rieder MJ Weinberg
S A Review of Common Dental Treatments During Pregnancy J Canadian Dental Association 64434-439 1998
bull Little JW Donald AF Craig SM Rhodus NL Dental Management of the Medically Compromised Patient - 5th edition Mosby Toronto Pp434-442 1997
bull Livingston HM Dellinger TM Holder R Considerations in the management of the pregnant patient Special Care in Dentistry 185 pp183-188 1998
bull Larimore WL Petrie KA Drug use during pregnacy and lactation Primary Care Clinics in Office Practice 271 35-53 2000
bull Health Canada The Safety of DentalAmalgam Minister Of Supply and Services Canada 1996
REFERENCESbull 1 Weiss G Endocrinology of parturition J Clin
Endocrinol Metab 2000854421-5bull 2 Theunissen IM Parer JT Fluid and electrolytes in
pregnancy Clin Obstet Gynecol 1994373-15bull 3 Duvekot JJ Peeters LLH Renal hemodynamics and
volume homeostasis in pregnancy Obstet Gynecol Surv 199449830-9
bull 4 Barron WM Lindheimer MD Medical disorders during pregnancy 2nd ed St Louis Mosby 1995 p 129
bull 5 Thornburg KL Jacobson SL Giraud GD Morton MJ Hemodynamic changes in pregnancy Semin Perinatol 20002411-4
bull 6 Fiese R Herzog S Issues in dental and surgical management of the pregnant patient Oral Surg Oral Med Oral Pathol 198865292-7
bull 7 Martin C Varner MW Physiologic changes in pregnancysurgical implications Clin Obstet Gynecol 199437241-55
bull 8 Clark SL Cotton DB Lee W Bishop C Hill T Southwick J et al Central hemodynamic assessment of normal term pregnancy Am J Obstet Gynecol 19891611439-42
bull 9 Mabie WC Di Sessa TG Crocker LG Sibai BM Arheart KL A longitudinal study of cardiac output in normal human pregnancy Am J Obstet Gynecol 1994170849-56
bull 10 Clapp JF 3rd Capeless E Cardiovascular function before during and after the first and subsequent pregnancies Am J Cardiol 1997801469-73
bull 11 Duvekot JJ Peeters LL Maternal cardiovascular hemodynamic adaptation to pregnancy Obstet Gynecol Surv 199449(Suppl) S1-14
bull 12 Bhagwat AR Engel PJ Heart disease and pregnancy Cardiol Clin 199513163-78
bull 13 Lanni SM Tillinghast J Silver H Hemodynamic changes and baroreflex gain in the supine hypotensive syndrome Am J Obstet Gynecol 20021871636-41
bull 14 Little JW Falace DA Miller CS Rhodus NL Dental management of the medically compromised patient 6th ed St Louis Mosby 2002 p 303
bull 15 Garcia-Rio F Pino JM Gomez L Alvarez-Sala R Villasante C Villamor J Regulation of breathing and perception of dyspnea in healthy pregnant women Chest 1996110446-53
bull 16 McAuliffe F Kametas N Costello J Rafferty GF Greenough A Nicolaides K Respiratory function in singleton and twin pregnancy BJOG 2002109765-9
bull 17 Clapp JF 3rd Seaward BL Sleamaker RH Hiser J Maternal physiologic adaptations to early human pregnancy Am J Obstet Gynecol 19881591456-60
bull 18 OrsquoDay MP Cardio-respiratory physiological adaptation of pregnancy Semin Perinatol 199721268-75
bull 19 Contreras G Gutierrez M Beroiza T Fantin A Oddo H Villarroel L et al Ventilatory drive and respiratory muscle function in pregnancy Am Rev Respir Dis 1991144837-41
bull 20 Turner M Aziz SR Management of the pregnant oral and maxillofac
bull 21 Sifakis S Pharmakides G Anemia in pregnancy Ann N Y Acad Sci 2000900125-36
bull 22 Branch DW Physiologic adaptations of pregnancy Am J Reprod Immunol 199228120-2
bull 23 Burrows RF Kelton JG Incidentally detected thrombocytopenia in healthy mothers and their infants N Engl J Med 1988319 142-5
bull 24 Hanly JG Antiphospholipid syndrome an overview CMAJ 200324(168)1675-82
bull 25 Heilmann L von Tempelhoff GF Pollow K Antiphospholipid syndrome in obstetrics Clin Appl Thromb Hemost 20039 143-50
bull 26 Sherman P Flaxman SM Nausea and vomiting of pregnancy in an evolutionary perspective Am J Obstet Gynecol 2002 185(Suppl)s190-7
bull 27 Koch KL Gastrointestinal factors in nausea and vomiting of pregnancy Am J Obstet Gynecol 2002185(Suppl)s198-203
bull 28 Koch KL Frissora CL Nausea and vomiting during pregnancy Gastroenterol Clin N Am 200332201-34
bull 29 Baron TH Ramirez B Richter JE Gastrointestinal motility disorders during pregnancy Ann Intern Med 1993118 366-75
bull 30 Richter JE Gastroesophageal reflux disease during pregnancy Gastroenterol Clin N Am 200332235-61
bull 31 Marrero JM Goggin PM de Caestecker JS Pearce JM Maxwell JD Determinants of pregnancy heartburn Br J Obstet Gynaecol 199299731-4
bull 32 Hamaoui E Hamaoui M Nutritional assessment and support during pregnancy Gastroenterol Clin N Am 20033259-121
bull 33 King JC Physiology of pregnancy and nutrient metabolism Am J Clin Nutr 200071(suppl)1218s-25s
bull 34 Casanueva E Pfeffer F Fernandez-Gaxiola AC Gutierrez- Valenzuela V Rothenberg SJ Iron and folate status before pregnancy and anemia during pregnancy Ann Nutr Metab 2003 4760-3
bull 35 Chrsquong CL Morgan M Hainsworth I Kingham JG Prospective study of liver dysfunction in Southwest Wales Gut 200251 876-80
bull 36 Rahman TM Wendon J Severe hepatic dysfunction in pregnancy QJM 200295343-57
bull 37 Knox TA Olans LB Liver disease in pregnancy N Engl J Med 1996335569-76
bull 38 Saftlas AF Olson DR Franks AL Atrash H Pokras R Epidemiology of preeclampsia and eclampsia in the United States 1979e1986 Am J Obstet Gynecol 1990163460-5
bull 39 Walker JJ Pre-eclampsia Lancet 20003561260-5
bull 40 Davidson JM Renal disorders in pregnancy Curr Opin Obstet Gynecol 200113109-14
bull 41 Dafnis E Sabatini S The effect of pregnancy on renal function physiology and pathophysiologyAmJMedSci 1992303184-205
bull 42 Davison JM Shiells EA Philips PR Lindheimer MD Serial evaluation of vasopressin release and thirst in human pregnancy Role of human chorionic gonadotrophin in the osmoregulatory changes of gestation J Clin Invest 198881798-806
bull 43 Glinoer D de Nayer P Bourdoux P Lemone M Robyn C van Steirteghem A et al Regulation of maternal thyroid during pregnancy J Clin Endocrinol Metab 199071276-87
bull 44 Wilson SG Retallack RW Kent JC Worth GK Gutteridge DH Serum free 125-dihydroxyvitamin D and the free 125- dihydroxyvitamin D index during a longitudinal study of human pregnancy and lactation Clin Endocrinol 199032613-22
bull 45 Rasmussen N Frolich A Hornnes PJ Hegedus L Serum ionized calcium and intact parathyroid hormone levels during pregnancy and postpartum Br J Obstet Gynaecol 199097857-9
bull 46 Guyton AC Textbook of medical physiology 8th ed Philadelphia W B Saunders 1991 p 915e28
bull 47 Trainer PJ Corticosteroids and pregnancy Semin Reprod Med 200220375-80
bull 48 Soory M Hormonal factors in periodontal disease Dent Update 200027380-3
bull 49 Hugoson A Gingivitis in pregnant women A longitudinal clinical study Odontol Revy 19712265-84
bull 50 Neville BW Damm DD Allen CM Bouquot JE Oral amp Maxillofacial Pathology 3rd ed Philadelphia W B Saunders 2002 p 329-30 447-9
bull 51 Tilakaratne A Soory M Ranasinghe AW Corea SM Ekanayake SL de Silva M Periodontal disease status during pregnancy and 3 months post-partum in rural population of Sri-Lankan women J Clin Periodontol 200027787-92
bull 52 Laine M Tenovuo J Lehtonen OP Ojanatko-Harri A Vilja P Tuohimaa P Pregnancy e related changes in human whole saliva Arch Oral Biol 198833913-7
bull 53 Yuan K Wing LY Lin MT Pathogenetic roles of angiogenic factors in pyogenic granulomas in pregnancy are modulated by female sex hormones J Periodontol 200273701-8
bull 54 Evans RD Briggs PF Tooth-surface loss related to pregnancyinduced vomiting Prim Dent Care 1994124-6
bull 55 Salvolini E Di Giorgio R Curatola A Mazzanti L Fratto G Biochemical modifications of human whole saliva induced by pregnancy Br J Obstet Gynaec 1998105656-60
bull 56 Mauldin JG Newman RB Preterm birth risk assessment Semin Perinatol 200125215-22
bull 57 Heine RP McGregor JA Goodwin TM Artal R Hayashi RH Robertson PA et al Serial salivary estriol to detect an increased risk of preterm birth Obstet Gynecol 200096490-7
bull 58 Kauh YC Zachian TF Melasma Adv Exp Med Biol 1999455 491-9
bull 59 Wong RC Ellis CN Physiologic skin changes in pregnancy J Am Acad Dermatol 198410929-40
bull 60 Errickson CV Matus NR Skin disorders of pregnancy Am Fam Physician 199449605-10
bull 61 Lopez NJ Smith PC Gutierrez J Periodontal therapy may reduce the risk of preterm low birth weight in women with periodontal disease a randomized controlled trial J Periodontol 200273911-24
bull 62 McGaw T Periodontal disease and preterm delivery of lowbirth- weight infants J Can Dent Assoc 200268165-9
bull 63 Richards AG Dental x-ray protection Dent Clin North Am 1968631-41
bull 64 1990 Recommendations of the International Commission on Radiological Protection Ann ICRP 1991211-201
bull 65 Hall EJ Radiation the two-edged sword cancer risks at high and low doses Cancer J 20006343-50
bull 66 Diethelm L Xu H Diagnostic imaging of the lung during pregnancy Clin Obstet Gynecol 19963936-55
bull 67 Brent RL The effects of embryonic and fetal exposure to x-rays microwaves and ultrasound ClinObstetGynecol 198326484-510
bull 68 National Council on Radiation Protection NCRP report no128 1998 Bethesda Md Author
bull 69 Wasylko L Matsui D Dykxhoorn SM Reider MJ Weinberg S A review of common dental treatments during pregnancy implications for patients and dental personnel J Can Dent Assoc 199864434-9
bull 70 Freeman JP Brand JW Radiation doses of commonly used dental radiographic surveys Oral Surg Oral Med Oral Pathol 199477285-9
bull 71 Kircos LTAngin LL Lorton LOrder ofmagnitude dose reduction in intraoral radiography J Am Dent Assoc 1987114344-7
bull 72 Updegrave WJ Simplified and standardized intraoral radiography with reduced tissue irradiation J Am Dent Assoc 197285861-9
bull 73 Wood RE Harris AM van der Merwe EJ Nortje CJ The leaded apron revisited does it reduce gonadal radiation dose in dental radiology Oral Surg Oral Med Oral Pathol 199171642-6
bull 74 An update on radiographic practices information and recommendations ADA Council on Scientific Affairs J Am Dent Assoc 2001132234-8
bull 75 Rayburn WF Recommending medications during pregnancy an evidence based approach Clin Obstet Gynecol 2002451-5
bull 76 Rathmell JP Viscomi C Ashburn MA Management of nonobstetric pain during pregnancy and lactation Anesth Analg 1997851074-87
bull 77 Teratology society public affairs committee FDA classification of drugs for teratogenic risk Teratology 199449446-7
bull 78 Moore PA Selecting drugs for the pregnant dental patient J Am Dent Assoc 19981291281-6
bull 79 Haas DA An update on analgesics for the management of acute postoperative dental pain J Can Dent Assoc 200268476-82
bull 80 Haas DA Pynn BR Sands TD Drug use for the pregnant or lactating patient Gen Dent 20004854-60
bull 81 Committee on Drugs American Academy of Pediatrics The transfer of drugs and other chemicals into human milk Pediatrics 199493137-50
bull 82 Nielsen GL Sorensen HT Larsen H Pedersen L Risk of adverse birth outcome and miscarriage in pregnant users of nonsteroidal anti-inflammatory drugs population based observational study and case-control study BMJ 2001322266-70
bull 83 Janssen N Genta M The effects of immunosuppressive and anti-inflammatory medications on fertility pregnancy and lactation Arch Intern Med 200016610-9
bull 84 Ostensen M Nonsteroidal anti-inflammatory drugs during pregnancy Scand J Rheumatol Suppl 1998107128-32
bull 85 USPDI -Drug information for the health care professional 22nd ed Greenwood Village CO Micromedex 2002 p 152-79
bull 86 Denson DD Coyle DE Thompson GA Santos D Turner PA Myers JA et al Bupivacaine protein binding in the term parturient effects of lactic acidosis Clin Pharmacol Ther 198435702-9
bull 87 Dillon DE Wagner CL Wiest D Newman RB Drug therapy in the nursing mother Obstet Gynecol Clin North Am 199724 675-96
bull 88 Dashe JS Gilstrap LC Antibiotic use in pregnancy Obstet Gynecol Clin North Am 199724617-29
bull 89 American College of Rheumatology Ad hoc Committee on Clinical Guidelines Guidelines for monitoring drug therapy in rheumatoid arthritis Arthritis Rheum 199639723-31
bull 90 Ng PC The fetal and neonatal hypothalamic-pituitary-adrenal axis Arch Dis Child Fetal Neonatal Ed 200082F250-4
bull 91 Crowley P Antenatal corticosteroidsmdashcurrent thinking BJOG 2003110(Suppl 20)77-8
bull 92 ACOG committee opinion antenatal corticosteroid therapy for fetal maturation Obstet Gynecol 200299871-3
bull 93 Ost L Wettrell G Bjorkhem I Rane A Prednisolone excretion in human milk J Pediatr 19851061008-11
bull 94 Rowland AS Baird DD Shore DL Weinberg CR Savitz DA Wilcox AJ Nitrous oxide and spontaneous abortion in female dental assistants Am J Epidemiol 1995141531-8
bull 95 McGlothlin JD Jensen PA Fischbach TJ Hughes RT Jones JH Control of anesthetic gases in dental operatories Scand J Work Environ Health 199218(Suppl 2)103-5
bull ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY Volume 97 Number 6 Suresh and Radfar 681
bull 96 Rosen MA Nitrous oxide for relief of labor pain a systematic review Am J Obstet Gynecol 2002186(Suppl Nature)S110-6
bull 97 Sands TD Pynn BR Management considerations for the pregnant or nursing emergency patient Ont Dent 199875 17-9
bull 98 Daya S Recurrent spontaneous early pregnancy loss and low dose aspirin Minerva Ginecol 200355441-9
bull 99 Sinclair C Handbook of obstetrical emergencies 1st ed Philadelphia WB Saunders 1996 p 29-39 69
bull 100 Tarsitano BF Rollings RE The pregnant dental patient evaluation and management Gen Dent 199341226-34
bull 101 Livingston MH Dlllinger TM Holder R Consideration in the management of the pregnant patient SCD Special Care in Dentistry 199818183-8
Thank you
- A Review on the principle of Dental Management of the Pregnant patient
- Slide 2
- Questions that a dentist may ask
- Stages of Pregnancy
- Slide 5
- Slide 6
- Physiologic Changes in Pregnancy
- Systemic changes in pregnancy
- FLAT SUPINE POSITIONING
- SUPINE HYPOTENSION SYNDROME (Vena Cava Compression)
- Supine Hypotension Syndrome
- Slide 12
- Supine Hypotension Syndrome
- Prevention of Supine Hypotensive Syndrome
- Treatment of Supine Hypotensive Syndrome
- How should the pregnant woman be positioned
- Slide 17
- Slide 18
- Slide 19
- Slide 20
- Slide 21
- Slide 22
- Slide 23
- Pregnancy Related Oral Health Problems
- Oral Problems in Pregnancy
- Pregnancy Gingivitis Pathophysiology
- Pregnancy Gingivitis
- Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Gum Problems - Pregnancy Granuloma
- Slide 31
- Gum Changes - Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Candidiasis
- Pregnancy Myths
- Other Oral Conditions in Pregnancy
- Changes During Pregnancy that Affect Oral Health
- Saliva changes
- Increased Bacteria
- Slide 40
- Enamel erosion caused by frequent vomiting
- Treatment for Acid Exposure
- Oral Diseases Can Effect Pregnancy
- Periodontal Disease and Preterm Labor
- Periodontal Disease and Low Birth Weight
- Periodontal Disease and Preeclampsia
- Periodontitis and Pre-eclampsia
- Dental Considerations
- Treatment Timing
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Slide 52
- Use of Radiation on Pregnant Patient
- Radiographs during Pregnancy
- Risks of Dental X-Rays
- FDA drug classification for pregnancy
- Slide 57
- FDA drug classification for pregnancy
- Slide 59
- Slide 60
- Slide 61
- Common Analgesics
- Analgesics
- Analgesics - continued
- Analgesics to Use During 1st and 2nd Trimester
- Analgesics to Avoid During the Third Trimester
- Sedation in Pregnancy
- Common Antibiotics
- Antibiotics
- Antibiotics To Use During Pregnancy
- Antibiotics to Avoid during Pregnancy
- The Problem With Tetracycline
- Other Antimicrobial Agents
- Local Anesthetic Use in Pregnancy
- Use of Local Anesthetics
- Ulcer healing drugs
- Slide 77
- Slide 78
- Slide 79
- Use of Nitrous Oxide Gas
- Common Preventives
- Are topical agents safe
- Pre-natal Fluoride
- Is it safe to use mercury restorations
- References
- REFERENCES
- Slide 87
- Slide 88
- Slide 89
- Slide 90
- Slide 91
- Slide 92
- Slide 93
- Slide 94
- Slide 95
- Slide 96
- Slide 97
- Slide 98
- Thank you
-
Gum Problems - Pregnancy Granuloma
Gum Changes - Pregnancy Granuloma
Pregnancy Granuloma (continued)
Treatment
bull Scaling and root planingbull Excision if it is too large or bleeds too
easilybull May regress spontaneously after
pregnancy
Candidiasis
bullWipes offbullUsually asymptomatic but may burnbullTreatment topical or systemic antifungals
Pregnancy MythsbullldquoA mother loses a tooth for every babyrdquobullNo evidence that aphthous ulcers are any more common in pregnancy
Other Oral Conditions in Pregnancy
bull Dry mouthbull Excessive salivationbull Tooth erosions associated with
severe GERD or hyperemesis
Changes During Pregnancy that Affect Oral Health
bull Hormonal Affects
ndash Increased tooth mobility
ndash Saliva changes
ndash Increased bacteria
ndash Gingival problems
Saliva changesbull Decreased buffers
bull Decreased minerals
bull Decreasing flow first and last trimester
bull Increased flow second trimester
bull More acidic
Increased Bacteriabull Increased acidity
ndash Increase in decay-causing bacteriabull Increased Snacking
ndash Morning sicknesslow blood sugarndash Between-meal snacks
bull Increase in amount and frequency of starchescarbohydrates ndash Crackers are commonly recommendedndash Promotes decay-causing bacteria
Changes During Pregnancy that Affect Oral Healthbull Morning sickness
ndash Difficulty with hygienebull Gingival diseasebull Tooth decay
ndash Vomitingbull Esophogeal Reflux (heartburn)bull Acid exposure
ndash Irritation of the gumsndash Weakening of tooth enamelndash Dental erosion
Enamel erosion caused by frequent vomiting
Treatment for Acid Exposure
bull Do NOT brush immediately after vomiting
bull Rinse ndash Water with baking sodandash Antacidndash Plain water
bull Eat some cheese
Oral Diseases Can Effect Pregnancy
bull Preterm low birth weight (LBW) linked to periodontal disease
bull Thorough calculus (tartar) removal in pregnant women with periodontitis may reduce pre-term births
Periodontal Disease and Preterm LaborbullMaternal periodontal disease is associated with increased risk of preterm laborbullAnaerobic oral gram-negative bacteria cause inflammatory responsebullInflammatory response stimulates prostaglandin and cytokine production to stimulate labor
Periodontal Disease and Low Birth Weight
bull Periodontal disease is associated with low birth weight
bull Evidence is not conclusivebull Biochemical mechanism similar cascade
as in preterm labor leading to placental blood flow restriction and necrosis
Periodontal Disease and Preeclampsia
bull Emerging databull Mechanism unclearbull Proposed mechanism
ndash Periodontal infection leads to inflammatory vascular damage
ndash Triggers cell damage in placenta
Periodontitis and Pre-eclampsia
bull Periodontal disease may be associated with pre-eclampsia (Boggess 2003)
bull PGE2 IL-1 and TNF-α from gingival crevicular fluid were higher in women with preeclampsia compared with healthy matched pregnant women (Oettinger-Barak 2003)
Dental Considerations
bull timing of treatment for pregnant patientsbull dental radiation exposurebull use of local anestheticsbull prescription of common antibiotics and
analgesicsbull nitrous oxide gas administration
Treatment Timing
bull First Trimesterndash Spontaneous miscarriages naturally occur
more often in 1st trimesterndash Avoid elective treatment that can be delayedndash Offer anticipatory guidance
bull Second Trimesterndash The optimal time for dental treatmentndash Organogenesis complete fetus not largendash Easier to prevent than treat established disease
bull Third Trimesterndash Late in term very uncomfortable (short visits)ndash Position slightly on left side
Timing of Dental Treatment During Pregnancy - From Little and Fallace
First Trimester
bull Plaque controlbull Oral hygiene instructionbull Scaling polishing curettagebull Avoid elective treatment urgent care
only
Timing of Dental Treatment During Pregnancy - From Little and Fallace
Second Trimester
bull Plaque controlbull Oral hygiene instructionbull Scaling polishing curettagebull Routine dental care
Timing of Dental Treatment During Pregnancy - From Little and Fallace
Third Trimester
bull Plaque controlbull Oral hygiene instructionbull Scaling polishing curettagebull Routine dental care (after middle of third
trimester elective care should be avoided)
Use of Radiation on Pregnant Patientbull Dose given and time of gestation are
importantbull doses lt 5-10 rads (cGy) not teratogenicbull fetus is most susceptible to radiation
between the 2nd and 6th week of gestationbull single dental x-ray exposes patient to 001
millirads of radiation In relative terms this amount is 40 times less than daily dose acquired from cosmic radiation Therefore diagnostic radiation should not be withheld during pregnancy
Radiographs during Pregnancy
bull Take as needed with optimal methods for reducing secondary radiation and exposure time
bull Always use a lead apronbull Exposure to fetus (with apron use) is 00001
centiGray(rad)bull Daily cosmic radiation - 0004 centiGray (rad)
Risks of Dental X-Rays
bull X-ray only if necessary (ie root canal therapy trauma)
bull When x-rays are indicated radiation exposure is extremely low
bull Exposure can be limited byndash Lead apron shielding ndash Modern fast film ndash Avoiding retakes
FDA drug classification for pregnancybull Combines risk statements including
congenital anomalies fetal effects perinatal risks and therapeutic risk-benefit ratio
bull Untreated disease or condition may pose more serious risks to both mother and fetus than any theoretical risks from the medication
bull Category A thru D and X
FDA drug classification for pregnancy
bull A = Controlled Studies in women fail to demonstrate a risk to the fetus in the first trimester and the possibility of fetal harm appears remote
FDA drug classification for pregnancy
bull B = Animal studies show no risk or if risk shown in animals controlled
trials in women showed no risk
FDA drug classification for pregnancy
bull C = Studies in animals with adverse effects and no human studies
OR no animal or human studies but benefits of use may outweigh potential harms
FDA drug classification for pregnancy
bull D = There is evidence of human fetal risk but benefits may outweigh risks
FDA drug classification for pregnancy
bull X = Contraindicated
Common Analgesics
bull paracetamol (B)bull Ibuprofen (BD) bull Oxycodone (BD) bull Hydrocodone and codeine
(CD)
avoid in third trimester
Analgesics
bull Paracetamol is the analgesic of choice for all stages of gestation
bull used to treat mild to moderate pain and fevers
bull short term usage is believed to be safebull avoid chronic and large doses of
paracetamol1048715
Analgesics - continuedbull Aspirin is nonteratogenic but may cause
maternal and fetal hemorrhagebull large and chronic doses during last trimester
may result in premature closure of ductus arteriosus fetal hypertension anemia and low birth weight
bull avoid ibuprofen in 3rd trimester because of possible adverse circulatory effects
bull short term use of codeine seems safebull avoid codeine late in gestation because of
possible fetal respiratory depression and withdrawal symptoms
Analgesics to Use During1st and 2nd Trimester
bull Category B (for best)bull Paracetamol Ibuprofenbull Naproxenbull Category C (use with caution)bull Paracetamol with codeine or
hydrocodonebull Paracetamol with oxycodone
Analgesics to Avoid During theThird Trimesterbull Causes delivery problemsbull Aspirin (C 3D)bull Ibuprofen (B3D)bull Naproxen (B3D)bull Causes neonatal respiratory
depression and opioid withdrawalbull Codeine (C3D)bull Hydrocodone (C3D)bull Oxycodone(C3D)
Sedation in Pregnancy
bull SedativesAnxiolytics (eg Diazepam ) are rated D and can cause oral clefts with prolonged exposure
bull Nitrous oxide should not be used in 1st trimester (If used in 2nd and 3rd do not go below 50 O2)
Common Antibioticsbull To treat oral abscess or cellulitis
ndash Penicillin (B) ndash Amoxicillin (B) ndash Cephalexin (B)ndash Erythromycin base (B) (Not estolate as it
cause cholestatic hepatitis)ndash Clindamycin (B)
Antibioticsbull penicillin V and amoxicillin is preferred drug
for mild to moderate infectionsbull widely used for many years with no ill effectsbull no studies show penicillin to be teratogenicbull amoxicillin extensively used without harming
the fetusbull Drug classes1048715 B penicillin cephalosporins erythromycin clindamycin Azithromycin D Tetracycline
Antibiotics To Use During Pregnancy
bull Penicillin Vbull Amoxicillinbull Erythromycin (base form)bull Cephalexin cephalosporinbull Clindamycinbull Metronidazole
Antibiotics to Avoid duringPregnancy
bull Doxycyclinebull Tetracyclinebull Erythromycin (estolate form)bull Vancomycin
The Problem With Tetracycline
bull Accumulates in bones and chelates calcium
bull Inhibits bone growthbull Discolors teeth
Other Antimicrobial Agentsbull OK to usebull Nystatin (B)bull Chlorhexidine rinse (B)bull Use with cautionbull Clotrimazole (C)bull Ketoconazole (C)bull Fluconazole (C)bull Do not usebull Doxycycline (D)
Local Anesthetic Use inPregnancy
bull Class Bbull Lidocaine (Xylocaine)bull Etidocainebull Prilocaine bull Class Cbull Procainebull Bupivicainebull Mepivicaine
Use of Local Anestheticsbull Lidocaine + vasoconstrictor most common
local anesthetic used in dentistrybull extensively used in pregnancy with no proven ill
effectsbull accidental intravascular injections of lidocaine
pass through the placenta but the concentrations are too low to harm fetus
bull prilocaine might cause methemoglobinemia
Ulcer healing drugsCimetidine bull FDA category B Famotidinebull FDA category BRanitidinebull FDA category Bbull not known to be harmful
Ulcer healing drugsOmeprazolebull FDA category BNot known to be
harmful Esomeprazolebull FDA category BLansoprazolebull FDA category BPantoprazolebull Avoid unless potential benefit
outweighs riskmdashfetotoxic in animals
Ulcer healing drugs
Misoprostolbull First second third trimesters Avoidmdash
potent uterine stimulant (has been used to induce abortion) and may be teratogenic
Ulcer healing drugs
Antacidsbull Almunium hydroxideMagnesium
hydroxidemdashFDA category B Calcium carbonatemdashFDA category C
SimetheconemdashFDA category C
Use of Nitrous Oxide Gas
bull used over 150 years bull safety is being debatedbull SHORT TERM exposure do not cause
birth defects or spontaneous abortionbull CHRONIC exposure may result in fetal
loss and infertilitybull literature suggests that nitrous oxide
should be avoided until more conclusive research is available
bull FDA Drug class not yet assigned
Common Preventives
bull Fluoridendash No increased risk during pregnancy
bull Xylitolndash No studies no harm reported
bull Chlorhexidinendash No increased risk during pregnancy
Are topical agents safe
bull Fluoridebull Toothpaste amp mouthrinse
bull Xylitol chewing gum bull Chlorhexidine (11 alcohol)bull No over the counter mouthrinses with
alcohol (Listerine 20 alcohol)
Pre-natal Fluoride
bull Daily 22 mg tablet of sodium fluoride during 3rd through 9th months
bull decreases caries rate in offspringbull Safe and effective
Glenn FB 1982
Is it safe to use mercury restorations
bull No evidence of harmful effect
bull Benefits outweigh risks
bull Canada Germany and New Zealand have some restrictions
bull Determine the best option
Referencesbull Wasylko L Matsui D Dykxhoorn SM Rieder MJ Weinberg
S A Review of Common Dental Treatments During Pregnancy J Canadian Dental Association 64434-439 1998
bull Little JW Donald AF Craig SM Rhodus NL Dental Management of the Medically Compromised Patient - 5th edition Mosby Toronto Pp434-442 1997
bull Livingston HM Dellinger TM Holder R Considerations in the management of the pregnant patient Special Care in Dentistry 185 pp183-188 1998
bull Larimore WL Petrie KA Drug use during pregnacy and lactation Primary Care Clinics in Office Practice 271 35-53 2000
bull Health Canada The Safety of DentalAmalgam Minister Of Supply and Services Canada 1996
REFERENCESbull 1 Weiss G Endocrinology of parturition J Clin
Endocrinol Metab 2000854421-5bull 2 Theunissen IM Parer JT Fluid and electrolytes in
pregnancy Clin Obstet Gynecol 1994373-15bull 3 Duvekot JJ Peeters LLH Renal hemodynamics and
volume homeostasis in pregnancy Obstet Gynecol Surv 199449830-9
bull 4 Barron WM Lindheimer MD Medical disorders during pregnancy 2nd ed St Louis Mosby 1995 p 129
bull 5 Thornburg KL Jacobson SL Giraud GD Morton MJ Hemodynamic changes in pregnancy Semin Perinatol 20002411-4
bull 6 Fiese R Herzog S Issues in dental and surgical management of the pregnant patient Oral Surg Oral Med Oral Pathol 198865292-7
bull 7 Martin C Varner MW Physiologic changes in pregnancysurgical implications Clin Obstet Gynecol 199437241-55
bull 8 Clark SL Cotton DB Lee W Bishop C Hill T Southwick J et al Central hemodynamic assessment of normal term pregnancy Am J Obstet Gynecol 19891611439-42
bull 9 Mabie WC Di Sessa TG Crocker LG Sibai BM Arheart KL A longitudinal study of cardiac output in normal human pregnancy Am J Obstet Gynecol 1994170849-56
bull 10 Clapp JF 3rd Capeless E Cardiovascular function before during and after the first and subsequent pregnancies Am J Cardiol 1997801469-73
bull 11 Duvekot JJ Peeters LL Maternal cardiovascular hemodynamic adaptation to pregnancy Obstet Gynecol Surv 199449(Suppl) S1-14
bull 12 Bhagwat AR Engel PJ Heart disease and pregnancy Cardiol Clin 199513163-78
bull 13 Lanni SM Tillinghast J Silver H Hemodynamic changes and baroreflex gain in the supine hypotensive syndrome Am J Obstet Gynecol 20021871636-41
bull 14 Little JW Falace DA Miller CS Rhodus NL Dental management of the medically compromised patient 6th ed St Louis Mosby 2002 p 303
bull 15 Garcia-Rio F Pino JM Gomez L Alvarez-Sala R Villasante C Villamor J Regulation of breathing and perception of dyspnea in healthy pregnant women Chest 1996110446-53
bull 16 McAuliffe F Kametas N Costello J Rafferty GF Greenough A Nicolaides K Respiratory function in singleton and twin pregnancy BJOG 2002109765-9
bull 17 Clapp JF 3rd Seaward BL Sleamaker RH Hiser J Maternal physiologic adaptations to early human pregnancy Am J Obstet Gynecol 19881591456-60
bull 18 OrsquoDay MP Cardio-respiratory physiological adaptation of pregnancy Semin Perinatol 199721268-75
bull 19 Contreras G Gutierrez M Beroiza T Fantin A Oddo H Villarroel L et al Ventilatory drive and respiratory muscle function in pregnancy Am Rev Respir Dis 1991144837-41
bull 20 Turner M Aziz SR Management of the pregnant oral and maxillofac
bull 21 Sifakis S Pharmakides G Anemia in pregnancy Ann N Y Acad Sci 2000900125-36
bull 22 Branch DW Physiologic adaptations of pregnancy Am J Reprod Immunol 199228120-2
bull 23 Burrows RF Kelton JG Incidentally detected thrombocytopenia in healthy mothers and their infants N Engl J Med 1988319 142-5
bull 24 Hanly JG Antiphospholipid syndrome an overview CMAJ 200324(168)1675-82
bull 25 Heilmann L von Tempelhoff GF Pollow K Antiphospholipid syndrome in obstetrics Clin Appl Thromb Hemost 20039 143-50
bull 26 Sherman P Flaxman SM Nausea and vomiting of pregnancy in an evolutionary perspective Am J Obstet Gynecol 2002 185(Suppl)s190-7
bull 27 Koch KL Gastrointestinal factors in nausea and vomiting of pregnancy Am J Obstet Gynecol 2002185(Suppl)s198-203
bull 28 Koch KL Frissora CL Nausea and vomiting during pregnancy Gastroenterol Clin N Am 200332201-34
bull 29 Baron TH Ramirez B Richter JE Gastrointestinal motility disorders during pregnancy Ann Intern Med 1993118 366-75
bull 30 Richter JE Gastroesophageal reflux disease during pregnancy Gastroenterol Clin N Am 200332235-61
bull 31 Marrero JM Goggin PM de Caestecker JS Pearce JM Maxwell JD Determinants of pregnancy heartburn Br J Obstet Gynaecol 199299731-4
bull 32 Hamaoui E Hamaoui M Nutritional assessment and support during pregnancy Gastroenterol Clin N Am 20033259-121
bull 33 King JC Physiology of pregnancy and nutrient metabolism Am J Clin Nutr 200071(suppl)1218s-25s
bull 34 Casanueva E Pfeffer F Fernandez-Gaxiola AC Gutierrez- Valenzuela V Rothenberg SJ Iron and folate status before pregnancy and anemia during pregnancy Ann Nutr Metab 2003 4760-3
bull 35 Chrsquong CL Morgan M Hainsworth I Kingham JG Prospective study of liver dysfunction in Southwest Wales Gut 200251 876-80
bull 36 Rahman TM Wendon J Severe hepatic dysfunction in pregnancy QJM 200295343-57
bull 37 Knox TA Olans LB Liver disease in pregnancy N Engl J Med 1996335569-76
bull 38 Saftlas AF Olson DR Franks AL Atrash H Pokras R Epidemiology of preeclampsia and eclampsia in the United States 1979e1986 Am J Obstet Gynecol 1990163460-5
bull 39 Walker JJ Pre-eclampsia Lancet 20003561260-5
bull 40 Davidson JM Renal disorders in pregnancy Curr Opin Obstet Gynecol 200113109-14
bull 41 Dafnis E Sabatini S The effect of pregnancy on renal function physiology and pathophysiologyAmJMedSci 1992303184-205
bull 42 Davison JM Shiells EA Philips PR Lindheimer MD Serial evaluation of vasopressin release and thirst in human pregnancy Role of human chorionic gonadotrophin in the osmoregulatory changes of gestation J Clin Invest 198881798-806
bull 43 Glinoer D de Nayer P Bourdoux P Lemone M Robyn C van Steirteghem A et al Regulation of maternal thyroid during pregnancy J Clin Endocrinol Metab 199071276-87
bull 44 Wilson SG Retallack RW Kent JC Worth GK Gutteridge DH Serum free 125-dihydroxyvitamin D and the free 125- dihydroxyvitamin D index during a longitudinal study of human pregnancy and lactation Clin Endocrinol 199032613-22
bull 45 Rasmussen N Frolich A Hornnes PJ Hegedus L Serum ionized calcium and intact parathyroid hormone levels during pregnancy and postpartum Br J Obstet Gynaecol 199097857-9
bull 46 Guyton AC Textbook of medical physiology 8th ed Philadelphia W B Saunders 1991 p 915e28
bull 47 Trainer PJ Corticosteroids and pregnancy Semin Reprod Med 200220375-80
bull 48 Soory M Hormonal factors in periodontal disease Dent Update 200027380-3
bull 49 Hugoson A Gingivitis in pregnant women A longitudinal clinical study Odontol Revy 19712265-84
bull 50 Neville BW Damm DD Allen CM Bouquot JE Oral amp Maxillofacial Pathology 3rd ed Philadelphia W B Saunders 2002 p 329-30 447-9
bull 51 Tilakaratne A Soory M Ranasinghe AW Corea SM Ekanayake SL de Silva M Periodontal disease status during pregnancy and 3 months post-partum in rural population of Sri-Lankan women J Clin Periodontol 200027787-92
bull 52 Laine M Tenovuo J Lehtonen OP Ojanatko-Harri A Vilja P Tuohimaa P Pregnancy e related changes in human whole saliva Arch Oral Biol 198833913-7
bull 53 Yuan K Wing LY Lin MT Pathogenetic roles of angiogenic factors in pyogenic granulomas in pregnancy are modulated by female sex hormones J Periodontol 200273701-8
bull 54 Evans RD Briggs PF Tooth-surface loss related to pregnancyinduced vomiting Prim Dent Care 1994124-6
bull 55 Salvolini E Di Giorgio R Curatola A Mazzanti L Fratto G Biochemical modifications of human whole saliva induced by pregnancy Br J Obstet Gynaec 1998105656-60
bull 56 Mauldin JG Newman RB Preterm birth risk assessment Semin Perinatol 200125215-22
bull 57 Heine RP McGregor JA Goodwin TM Artal R Hayashi RH Robertson PA et al Serial salivary estriol to detect an increased risk of preterm birth Obstet Gynecol 200096490-7
bull 58 Kauh YC Zachian TF Melasma Adv Exp Med Biol 1999455 491-9
bull 59 Wong RC Ellis CN Physiologic skin changes in pregnancy J Am Acad Dermatol 198410929-40
bull 60 Errickson CV Matus NR Skin disorders of pregnancy Am Fam Physician 199449605-10
bull 61 Lopez NJ Smith PC Gutierrez J Periodontal therapy may reduce the risk of preterm low birth weight in women with periodontal disease a randomized controlled trial J Periodontol 200273911-24
bull 62 McGaw T Periodontal disease and preterm delivery of lowbirth- weight infants J Can Dent Assoc 200268165-9
bull 63 Richards AG Dental x-ray protection Dent Clin North Am 1968631-41
bull 64 1990 Recommendations of the International Commission on Radiological Protection Ann ICRP 1991211-201
bull 65 Hall EJ Radiation the two-edged sword cancer risks at high and low doses Cancer J 20006343-50
bull 66 Diethelm L Xu H Diagnostic imaging of the lung during pregnancy Clin Obstet Gynecol 19963936-55
bull 67 Brent RL The effects of embryonic and fetal exposure to x-rays microwaves and ultrasound ClinObstetGynecol 198326484-510
bull 68 National Council on Radiation Protection NCRP report no128 1998 Bethesda Md Author
bull 69 Wasylko L Matsui D Dykxhoorn SM Reider MJ Weinberg S A review of common dental treatments during pregnancy implications for patients and dental personnel J Can Dent Assoc 199864434-9
bull 70 Freeman JP Brand JW Radiation doses of commonly used dental radiographic surveys Oral Surg Oral Med Oral Pathol 199477285-9
bull 71 Kircos LTAngin LL Lorton LOrder ofmagnitude dose reduction in intraoral radiography J Am Dent Assoc 1987114344-7
bull 72 Updegrave WJ Simplified and standardized intraoral radiography with reduced tissue irradiation J Am Dent Assoc 197285861-9
bull 73 Wood RE Harris AM van der Merwe EJ Nortje CJ The leaded apron revisited does it reduce gonadal radiation dose in dental radiology Oral Surg Oral Med Oral Pathol 199171642-6
bull 74 An update on radiographic practices information and recommendations ADA Council on Scientific Affairs J Am Dent Assoc 2001132234-8
bull 75 Rayburn WF Recommending medications during pregnancy an evidence based approach Clin Obstet Gynecol 2002451-5
bull 76 Rathmell JP Viscomi C Ashburn MA Management of nonobstetric pain during pregnancy and lactation Anesth Analg 1997851074-87
bull 77 Teratology society public affairs committee FDA classification of drugs for teratogenic risk Teratology 199449446-7
bull 78 Moore PA Selecting drugs for the pregnant dental patient J Am Dent Assoc 19981291281-6
bull 79 Haas DA An update on analgesics for the management of acute postoperative dental pain J Can Dent Assoc 200268476-82
bull 80 Haas DA Pynn BR Sands TD Drug use for the pregnant or lactating patient Gen Dent 20004854-60
bull 81 Committee on Drugs American Academy of Pediatrics The transfer of drugs and other chemicals into human milk Pediatrics 199493137-50
bull 82 Nielsen GL Sorensen HT Larsen H Pedersen L Risk of adverse birth outcome and miscarriage in pregnant users of nonsteroidal anti-inflammatory drugs population based observational study and case-control study BMJ 2001322266-70
bull 83 Janssen N Genta M The effects of immunosuppressive and anti-inflammatory medications on fertility pregnancy and lactation Arch Intern Med 200016610-9
bull 84 Ostensen M Nonsteroidal anti-inflammatory drugs during pregnancy Scand J Rheumatol Suppl 1998107128-32
bull 85 USPDI -Drug information for the health care professional 22nd ed Greenwood Village CO Micromedex 2002 p 152-79
bull 86 Denson DD Coyle DE Thompson GA Santos D Turner PA Myers JA et al Bupivacaine protein binding in the term parturient effects of lactic acidosis Clin Pharmacol Ther 198435702-9
bull 87 Dillon DE Wagner CL Wiest D Newman RB Drug therapy in the nursing mother Obstet Gynecol Clin North Am 199724 675-96
bull 88 Dashe JS Gilstrap LC Antibiotic use in pregnancy Obstet Gynecol Clin North Am 199724617-29
bull 89 American College of Rheumatology Ad hoc Committee on Clinical Guidelines Guidelines for monitoring drug therapy in rheumatoid arthritis Arthritis Rheum 199639723-31
bull 90 Ng PC The fetal and neonatal hypothalamic-pituitary-adrenal axis Arch Dis Child Fetal Neonatal Ed 200082F250-4
bull 91 Crowley P Antenatal corticosteroidsmdashcurrent thinking BJOG 2003110(Suppl 20)77-8
bull 92 ACOG committee opinion antenatal corticosteroid therapy for fetal maturation Obstet Gynecol 200299871-3
bull 93 Ost L Wettrell G Bjorkhem I Rane A Prednisolone excretion in human milk J Pediatr 19851061008-11
bull 94 Rowland AS Baird DD Shore DL Weinberg CR Savitz DA Wilcox AJ Nitrous oxide and spontaneous abortion in female dental assistants Am J Epidemiol 1995141531-8
bull 95 McGlothlin JD Jensen PA Fischbach TJ Hughes RT Jones JH Control of anesthetic gases in dental operatories Scand J Work Environ Health 199218(Suppl 2)103-5
bull ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY Volume 97 Number 6 Suresh and Radfar 681
bull 96 Rosen MA Nitrous oxide for relief of labor pain a systematic review Am J Obstet Gynecol 2002186(Suppl Nature)S110-6
bull 97 Sands TD Pynn BR Management considerations for the pregnant or nursing emergency patient Ont Dent 199875 17-9
bull 98 Daya S Recurrent spontaneous early pregnancy loss and low dose aspirin Minerva Ginecol 200355441-9
bull 99 Sinclair C Handbook of obstetrical emergencies 1st ed Philadelphia WB Saunders 1996 p 29-39 69
bull 100 Tarsitano BF Rollings RE The pregnant dental patient evaluation and management Gen Dent 199341226-34
bull 101 Livingston MH Dlllinger TM Holder R Consideration in the management of the pregnant patient SCD Special Care in Dentistry 199818183-8
Thank you
- A Review on the principle of Dental Management of the Pregnant patient
- Slide 2
- Questions that a dentist may ask
- Stages of Pregnancy
- Slide 5
- Slide 6
- Physiologic Changes in Pregnancy
- Systemic changes in pregnancy
- FLAT SUPINE POSITIONING
- SUPINE HYPOTENSION SYNDROME (Vena Cava Compression)
- Supine Hypotension Syndrome
- Slide 12
- Supine Hypotension Syndrome
- Prevention of Supine Hypotensive Syndrome
- Treatment of Supine Hypotensive Syndrome
- How should the pregnant woman be positioned
- Slide 17
- Slide 18
- Slide 19
- Slide 20
- Slide 21
- Slide 22
- Slide 23
- Pregnancy Related Oral Health Problems
- Oral Problems in Pregnancy
- Pregnancy Gingivitis Pathophysiology
- Pregnancy Gingivitis
- Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Gum Problems - Pregnancy Granuloma
- Slide 31
- Gum Changes - Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Candidiasis
- Pregnancy Myths
- Other Oral Conditions in Pregnancy
- Changes During Pregnancy that Affect Oral Health
- Saliva changes
- Increased Bacteria
- Slide 40
- Enamel erosion caused by frequent vomiting
- Treatment for Acid Exposure
- Oral Diseases Can Effect Pregnancy
- Periodontal Disease and Preterm Labor
- Periodontal Disease and Low Birth Weight
- Periodontal Disease and Preeclampsia
- Periodontitis and Pre-eclampsia
- Dental Considerations
- Treatment Timing
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Slide 52
- Use of Radiation on Pregnant Patient
- Radiographs during Pregnancy
- Risks of Dental X-Rays
- FDA drug classification for pregnancy
- Slide 57
- FDA drug classification for pregnancy
- Slide 59
- Slide 60
- Slide 61
- Common Analgesics
- Analgesics
- Analgesics - continued
- Analgesics to Use During 1st and 2nd Trimester
- Analgesics to Avoid During the Third Trimester
- Sedation in Pregnancy
- Common Antibiotics
- Antibiotics
- Antibiotics To Use During Pregnancy
- Antibiotics to Avoid during Pregnancy
- The Problem With Tetracycline
- Other Antimicrobial Agents
- Local Anesthetic Use in Pregnancy
- Use of Local Anesthetics
- Ulcer healing drugs
- Slide 77
- Slide 78
- Slide 79
- Use of Nitrous Oxide Gas
- Common Preventives
- Are topical agents safe
- Pre-natal Fluoride
- Is it safe to use mercury restorations
- References
- REFERENCES
- Slide 87
- Slide 88
- Slide 89
- Slide 90
- Slide 91
- Slide 92
- Slide 93
- Slide 94
- Slide 95
- Slide 96
- Slide 97
- Slide 98
- Thank you
-
Gum Changes - Pregnancy Granuloma
Pregnancy Granuloma (continued)
Treatment
bull Scaling and root planingbull Excision if it is too large or bleeds too
easilybull May regress spontaneously after
pregnancy
Candidiasis
bullWipes offbullUsually asymptomatic but may burnbullTreatment topical or systemic antifungals
Pregnancy MythsbullldquoA mother loses a tooth for every babyrdquobullNo evidence that aphthous ulcers are any more common in pregnancy
Other Oral Conditions in Pregnancy
bull Dry mouthbull Excessive salivationbull Tooth erosions associated with
severe GERD or hyperemesis
Changes During Pregnancy that Affect Oral Health
bull Hormonal Affects
ndash Increased tooth mobility
ndash Saliva changes
ndash Increased bacteria
ndash Gingival problems
Saliva changesbull Decreased buffers
bull Decreased minerals
bull Decreasing flow first and last trimester
bull Increased flow second trimester
bull More acidic
Increased Bacteriabull Increased acidity
ndash Increase in decay-causing bacteriabull Increased Snacking
ndash Morning sicknesslow blood sugarndash Between-meal snacks
bull Increase in amount and frequency of starchescarbohydrates ndash Crackers are commonly recommendedndash Promotes decay-causing bacteria
Changes During Pregnancy that Affect Oral Healthbull Morning sickness
ndash Difficulty with hygienebull Gingival diseasebull Tooth decay
ndash Vomitingbull Esophogeal Reflux (heartburn)bull Acid exposure
ndash Irritation of the gumsndash Weakening of tooth enamelndash Dental erosion
Enamel erosion caused by frequent vomiting
Treatment for Acid Exposure
bull Do NOT brush immediately after vomiting
bull Rinse ndash Water with baking sodandash Antacidndash Plain water
bull Eat some cheese
Oral Diseases Can Effect Pregnancy
bull Preterm low birth weight (LBW) linked to periodontal disease
bull Thorough calculus (tartar) removal in pregnant women with periodontitis may reduce pre-term births
Periodontal Disease and Preterm LaborbullMaternal periodontal disease is associated with increased risk of preterm laborbullAnaerobic oral gram-negative bacteria cause inflammatory responsebullInflammatory response stimulates prostaglandin and cytokine production to stimulate labor
Periodontal Disease and Low Birth Weight
bull Periodontal disease is associated with low birth weight
bull Evidence is not conclusivebull Biochemical mechanism similar cascade
as in preterm labor leading to placental blood flow restriction and necrosis
Periodontal Disease and Preeclampsia
bull Emerging databull Mechanism unclearbull Proposed mechanism
ndash Periodontal infection leads to inflammatory vascular damage
ndash Triggers cell damage in placenta
Periodontitis and Pre-eclampsia
bull Periodontal disease may be associated with pre-eclampsia (Boggess 2003)
bull PGE2 IL-1 and TNF-α from gingival crevicular fluid were higher in women with preeclampsia compared with healthy matched pregnant women (Oettinger-Barak 2003)
Dental Considerations
bull timing of treatment for pregnant patientsbull dental radiation exposurebull use of local anestheticsbull prescription of common antibiotics and
analgesicsbull nitrous oxide gas administration
Treatment Timing
bull First Trimesterndash Spontaneous miscarriages naturally occur
more often in 1st trimesterndash Avoid elective treatment that can be delayedndash Offer anticipatory guidance
bull Second Trimesterndash The optimal time for dental treatmentndash Organogenesis complete fetus not largendash Easier to prevent than treat established disease
bull Third Trimesterndash Late in term very uncomfortable (short visits)ndash Position slightly on left side
Timing of Dental Treatment During Pregnancy - From Little and Fallace
First Trimester
bull Plaque controlbull Oral hygiene instructionbull Scaling polishing curettagebull Avoid elective treatment urgent care
only
Timing of Dental Treatment During Pregnancy - From Little and Fallace
Second Trimester
bull Plaque controlbull Oral hygiene instructionbull Scaling polishing curettagebull Routine dental care
Timing of Dental Treatment During Pregnancy - From Little and Fallace
Third Trimester
bull Plaque controlbull Oral hygiene instructionbull Scaling polishing curettagebull Routine dental care (after middle of third
trimester elective care should be avoided)
Use of Radiation on Pregnant Patientbull Dose given and time of gestation are
importantbull doses lt 5-10 rads (cGy) not teratogenicbull fetus is most susceptible to radiation
between the 2nd and 6th week of gestationbull single dental x-ray exposes patient to 001
millirads of radiation In relative terms this amount is 40 times less than daily dose acquired from cosmic radiation Therefore diagnostic radiation should not be withheld during pregnancy
Radiographs during Pregnancy
bull Take as needed with optimal methods for reducing secondary radiation and exposure time
bull Always use a lead apronbull Exposure to fetus (with apron use) is 00001
centiGray(rad)bull Daily cosmic radiation - 0004 centiGray (rad)
Risks of Dental X-Rays
bull X-ray only if necessary (ie root canal therapy trauma)
bull When x-rays are indicated radiation exposure is extremely low
bull Exposure can be limited byndash Lead apron shielding ndash Modern fast film ndash Avoiding retakes
FDA drug classification for pregnancybull Combines risk statements including
congenital anomalies fetal effects perinatal risks and therapeutic risk-benefit ratio
bull Untreated disease or condition may pose more serious risks to both mother and fetus than any theoretical risks from the medication
bull Category A thru D and X
FDA drug classification for pregnancy
bull A = Controlled Studies in women fail to demonstrate a risk to the fetus in the first trimester and the possibility of fetal harm appears remote
FDA drug classification for pregnancy
bull B = Animal studies show no risk or if risk shown in animals controlled
trials in women showed no risk
FDA drug classification for pregnancy
bull C = Studies in animals with adverse effects and no human studies
OR no animal or human studies but benefits of use may outweigh potential harms
FDA drug classification for pregnancy
bull D = There is evidence of human fetal risk but benefits may outweigh risks
FDA drug classification for pregnancy
bull X = Contraindicated
Common Analgesics
bull paracetamol (B)bull Ibuprofen (BD) bull Oxycodone (BD) bull Hydrocodone and codeine
(CD)
avoid in third trimester
Analgesics
bull Paracetamol is the analgesic of choice for all stages of gestation
bull used to treat mild to moderate pain and fevers
bull short term usage is believed to be safebull avoid chronic and large doses of
paracetamol1048715
Analgesics - continuedbull Aspirin is nonteratogenic but may cause
maternal and fetal hemorrhagebull large and chronic doses during last trimester
may result in premature closure of ductus arteriosus fetal hypertension anemia and low birth weight
bull avoid ibuprofen in 3rd trimester because of possible adverse circulatory effects
bull short term use of codeine seems safebull avoid codeine late in gestation because of
possible fetal respiratory depression and withdrawal symptoms
Analgesics to Use During1st and 2nd Trimester
bull Category B (for best)bull Paracetamol Ibuprofenbull Naproxenbull Category C (use with caution)bull Paracetamol with codeine or
hydrocodonebull Paracetamol with oxycodone
Analgesics to Avoid During theThird Trimesterbull Causes delivery problemsbull Aspirin (C 3D)bull Ibuprofen (B3D)bull Naproxen (B3D)bull Causes neonatal respiratory
depression and opioid withdrawalbull Codeine (C3D)bull Hydrocodone (C3D)bull Oxycodone(C3D)
Sedation in Pregnancy
bull SedativesAnxiolytics (eg Diazepam ) are rated D and can cause oral clefts with prolonged exposure
bull Nitrous oxide should not be used in 1st trimester (If used in 2nd and 3rd do not go below 50 O2)
Common Antibioticsbull To treat oral abscess or cellulitis
ndash Penicillin (B) ndash Amoxicillin (B) ndash Cephalexin (B)ndash Erythromycin base (B) (Not estolate as it
cause cholestatic hepatitis)ndash Clindamycin (B)
Antibioticsbull penicillin V and amoxicillin is preferred drug
for mild to moderate infectionsbull widely used for many years with no ill effectsbull no studies show penicillin to be teratogenicbull amoxicillin extensively used without harming
the fetusbull Drug classes1048715 B penicillin cephalosporins erythromycin clindamycin Azithromycin D Tetracycline
Antibiotics To Use During Pregnancy
bull Penicillin Vbull Amoxicillinbull Erythromycin (base form)bull Cephalexin cephalosporinbull Clindamycinbull Metronidazole
Antibiotics to Avoid duringPregnancy
bull Doxycyclinebull Tetracyclinebull Erythromycin (estolate form)bull Vancomycin
The Problem With Tetracycline
bull Accumulates in bones and chelates calcium
bull Inhibits bone growthbull Discolors teeth
Other Antimicrobial Agentsbull OK to usebull Nystatin (B)bull Chlorhexidine rinse (B)bull Use with cautionbull Clotrimazole (C)bull Ketoconazole (C)bull Fluconazole (C)bull Do not usebull Doxycycline (D)
Local Anesthetic Use inPregnancy
bull Class Bbull Lidocaine (Xylocaine)bull Etidocainebull Prilocaine bull Class Cbull Procainebull Bupivicainebull Mepivicaine
Use of Local Anestheticsbull Lidocaine + vasoconstrictor most common
local anesthetic used in dentistrybull extensively used in pregnancy with no proven ill
effectsbull accidental intravascular injections of lidocaine
pass through the placenta but the concentrations are too low to harm fetus
bull prilocaine might cause methemoglobinemia
Ulcer healing drugsCimetidine bull FDA category B Famotidinebull FDA category BRanitidinebull FDA category Bbull not known to be harmful
Ulcer healing drugsOmeprazolebull FDA category BNot known to be
harmful Esomeprazolebull FDA category BLansoprazolebull FDA category BPantoprazolebull Avoid unless potential benefit
outweighs riskmdashfetotoxic in animals
Ulcer healing drugs
Misoprostolbull First second third trimesters Avoidmdash
potent uterine stimulant (has been used to induce abortion) and may be teratogenic
Ulcer healing drugs
Antacidsbull Almunium hydroxideMagnesium
hydroxidemdashFDA category B Calcium carbonatemdashFDA category C
SimetheconemdashFDA category C
Use of Nitrous Oxide Gas
bull used over 150 years bull safety is being debatedbull SHORT TERM exposure do not cause
birth defects or spontaneous abortionbull CHRONIC exposure may result in fetal
loss and infertilitybull literature suggests that nitrous oxide
should be avoided until more conclusive research is available
bull FDA Drug class not yet assigned
Common Preventives
bull Fluoridendash No increased risk during pregnancy
bull Xylitolndash No studies no harm reported
bull Chlorhexidinendash No increased risk during pregnancy
Are topical agents safe
bull Fluoridebull Toothpaste amp mouthrinse
bull Xylitol chewing gum bull Chlorhexidine (11 alcohol)bull No over the counter mouthrinses with
alcohol (Listerine 20 alcohol)
Pre-natal Fluoride
bull Daily 22 mg tablet of sodium fluoride during 3rd through 9th months
bull decreases caries rate in offspringbull Safe and effective
Glenn FB 1982
Is it safe to use mercury restorations
bull No evidence of harmful effect
bull Benefits outweigh risks
bull Canada Germany and New Zealand have some restrictions
bull Determine the best option
Referencesbull Wasylko L Matsui D Dykxhoorn SM Rieder MJ Weinberg
S A Review of Common Dental Treatments During Pregnancy J Canadian Dental Association 64434-439 1998
bull Little JW Donald AF Craig SM Rhodus NL Dental Management of the Medically Compromised Patient - 5th edition Mosby Toronto Pp434-442 1997
bull Livingston HM Dellinger TM Holder R Considerations in the management of the pregnant patient Special Care in Dentistry 185 pp183-188 1998
bull Larimore WL Petrie KA Drug use during pregnacy and lactation Primary Care Clinics in Office Practice 271 35-53 2000
bull Health Canada The Safety of DentalAmalgam Minister Of Supply and Services Canada 1996
REFERENCESbull 1 Weiss G Endocrinology of parturition J Clin
Endocrinol Metab 2000854421-5bull 2 Theunissen IM Parer JT Fluid and electrolytes in
pregnancy Clin Obstet Gynecol 1994373-15bull 3 Duvekot JJ Peeters LLH Renal hemodynamics and
volume homeostasis in pregnancy Obstet Gynecol Surv 199449830-9
bull 4 Barron WM Lindheimer MD Medical disorders during pregnancy 2nd ed St Louis Mosby 1995 p 129
bull 5 Thornburg KL Jacobson SL Giraud GD Morton MJ Hemodynamic changes in pregnancy Semin Perinatol 20002411-4
bull 6 Fiese R Herzog S Issues in dental and surgical management of the pregnant patient Oral Surg Oral Med Oral Pathol 198865292-7
bull 7 Martin C Varner MW Physiologic changes in pregnancysurgical implications Clin Obstet Gynecol 199437241-55
bull 8 Clark SL Cotton DB Lee W Bishop C Hill T Southwick J et al Central hemodynamic assessment of normal term pregnancy Am J Obstet Gynecol 19891611439-42
bull 9 Mabie WC Di Sessa TG Crocker LG Sibai BM Arheart KL A longitudinal study of cardiac output in normal human pregnancy Am J Obstet Gynecol 1994170849-56
bull 10 Clapp JF 3rd Capeless E Cardiovascular function before during and after the first and subsequent pregnancies Am J Cardiol 1997801469-73
bull 11 Duvekot JJ Peeters LL Maternal cardiovascular hemodynamic adaptation to pregnancy Obstet Gynecol Surv 199449(Suppl) S1-14
bull 12 Bhagwat AR Engel PJ Heart disease and pregnancy Cardiol Clin 199513163-78
bull 13 Lanni SM Tillinghast J Silver H Hemodynamic changes and baroreflex gain in the supine hypotensive syndrome Am J Obstet Gynecol 20021871636-41
bull 14 Little JW Falace DA Miller CS Rhodus NL Dental management of the medically compromised patient 6th ed St Louis Mosby 2002 p 303
bull 15 Garcia-Rio F Pino JM Gomez L Alvarez-Sala R Villasante C Villamor J Regulation of breathing and perception of dyspnea in healthy pregnant women Chest 1996110446-53
bull 16 McAuliffe F Kametas N Costello J Rafferty GF Greenough A Nicolaides K Respiratory function in singleton and twin pregnancy BJOG 2002109765-9
bull 17 Clapp JF 3rd Seaward BL Sleamaker RH Hiser J Maternal physiologic adaptations to early human pregnancy Am J Obstet Gynecol 19881591456-60
bull 18 OrsquoDay MP Cardio-respiratory physiological adaptation of pregnancy Semin Perinatol 199721268-75
bull 19 Contreras G Gutierrez M Beroiza T Fantin A Oddo H Villarroel L et al Ventilatory drive and respiratory muscle function in pregnancy Am Rev Respir Dis 1991144837-41
bull 20 Turner M Aziz SR Management of the pregnant oral and maxillofac
bull 21 Sifakis S Pharmakides G Anemia in pregnancy Ann N Y Acad Sci 2000900125-36
bull 22 Branch DW Physiologic adaptations of pregnancy Am J Reprod Immunol 199228120-2
bull 23 Burrows RF Kelton JG Incidentally detected thrombocytopenia in healthy mothers and their infants N Engl J Med 1988319 142-5
bull 24 Hanly JG Antiphospholipid syndrome an overview CMAJ 200324(168)1675-82
bull 25 Heilmann L von Tempelhoff GF Pollow K Antiphospholipid syndrome in obstetrics Clin Appl Thromb Hemost 20039 143-50
bull 26 Sherman P Flaxman SM Nausea and vomiting of pregnancy in an evolutionary perspective Am J Obstet Gynecol 2002 185(Suppl)s190-7
bull 27 Koch KL Gastrointestinal factors in nausea and vomiting of pregnancy Am J Obstet Gynecol 2002185(Suppl)s198-203
bull 28 Koch KL Frissora CL Nausea and vomiting during pregnancy Gastroenterol Clin N Am 200332201-34
bull 29 Baron TH Ramirez B Richter JE Gastrointestinal motility disorders during pregnancy Ann Intern Med 1993118 366-75
bull 30 Richter JE Gastroesophageal reflux disease during pregnancy Gastroenterol Clin N Am 200332235-61
bull 31 Marrero JM Goggin PM de Caestecker JS Pearce JM Maxwell JD Determinants of pregnancy heartburn Br J Obstet Gynaecol 199299731-4
bull 32 Hamaoui E Hamaoui M Nutritional assessment and support during pregnancy Gastroenterol Clin N Am 20033259-121
bull 33 King JC Physiology of pregnancy and nutrient metabolism Am J Clin Nutr 200071(suppl)1218s-25s
bull 34 Casanueva E Pfeffer F Fernandez-Gaxiola AC Gutierrez- Valenzuela V Rothenberg SJ Iron and folate status before pregnancy and anemia during pregnancy Ann Nutr Metab 2003 4760-3
bull 35 Chrsquong CL Morgan M Hainsworth I Kingham JG Prospective study of liver dysfunction in Southwest Wales Gut 200251 876-80
bull 36 Rahman TM Wendon J Severe hepatic dysfunction in pregnancy QJM 200295343-57
bull 37 Knox TA Olans LB Liver disease in pregnancy N Engl J Med 1996335569-76
bull 38 Saftlas AF Olson DR Franks AL Atrash H Pokras R Epidemiology of preeclampsia and eclampsia in the United States 1979e1986 Am J Obstet Gynecol 1990163460-5
bull 39 Walker JJ Pre-eclampsia Lancet 20003561260-5
bull 40 Davidson JM Renal disorders in pregnancy Curr Opin Obstet Gynecol 200113109-14
bull 41 Dafnis E Sabatini S The effect of pregnancy on renal function physiology and pathophysiologyAmJMedSci 1992303184-205
bull 42 Davison JM Shiells EA Philips PR Lindheimer MD Serial evaluation of vasopressin release and thirst in human pregnancy Role of human chorionic gonadotrophin in the osmoregulatory changes of gestation J Clin Invest 198881798-806
bull 43 Glinoer D de Nayer P Bourdoux P Lemone M Robyn C van Steirteghem A et al Regulation of maternal thyroid during pregnancy J Clin Endocrinol Metab 199071276-87
bull 44 Wilson SG Retallack RW Kent JC Worth GK Gutteridge DH Serum free 125-dihydroxyvitamin D and the free 125- dihydroxyvitamin D index during a longitudinal study of human pregnancy and lactation Clin Endocrinol 199032613-22
bull 45 Rasmussen N Frolich A Hornnes PJ Hegedus L Serum ionized calcium and intact parathyroid hormone levels during pregnancy and postpartum Br J Obstet Gynaecol 199097857-9
bull 46 Guyton AC Textbook of medical physiology 8th ed Philadelphia W B Saunders 1991 p 915e28
bull 47 Trainer PJ Corticosteroids and pregnancy Semin Reprod Med 200220375-80
bull 48 Soory M Hormonal factors in periodontal disease Dent Update 200027380-3
bull 49 Hugoson A Gingivitis in pregnant women A longitudinal clinical study Odontol Revy 19712265-84
bull 50 Neville BW Damm DD Allen CM Bouquot JE Oral amp Maxillofacial Pathology 3rd ed Philadelphia W B Saunders 2002 p 329-30 447-9
bull 51 Tilakaratne A Soory M Ranasinghe AW Corea SM Ekanayake SL de Silva M Periodontal disease status during pregnancy and 3 months post-partum in rural population of Sri-Lankan women J Clin Periodontol 200027787-92
bull 52 Laine M Tenovuo J Lehtonen OP Ojanatko-Harri A Vilja P Tuohimaa P Pregnancy e related changes in human whole saliva Arch Oral Biol 198833913-7
bull 53 Yuan K Wing LY Lin MT Pathogenetic roles of angiogenic factors in pyogenic granulomas in pregnancy are modulated by female sex hormones J Periodontol 200273701-8
bull 54 Evans RD Briggs PF Tooth-surface loss related to pregnancyinduced vomiting Prim Dent Care 1994124-6
bull 55 Salvolini E Di Giorgio R Curatola A Mazzanti L Fratto G Biochemical modifications of human whole saliva induced by pregnancy Br J Obstet Gynaec 1998105656-60
bull 56 Mauldin JG Newman RB Preterm birth risk assessment Semin Perinatol 200125215-22
bull 57 Heine RP McGregor JA Goodwin TM Artal R Hayashi RH Robertson PA et al Serial salivary estriol to detect an increased risk of preterm birth Obstet Gynecol 200096490-7
bull 58 Kauh YC Zachian TF Melasma Adv Exp Med Biol 1999455 491-9
bull 59 Wong RC Ellis CN Physiologic skin changes in pregnancy J Am Acad Dermatol 198410929-40
bull 60 Errickson CV Matus NR Skin disorders of pregnancy Am Fam Physician 199449605-10
bull 61 Lopez NJ Smith PC Gutierrez J Periodontal therapy may reduce the risk of preterm low birth weight in women with periodontal disease a randomized controlled trial J Periodontol 200273911-24
bull 62 McGaw T Periodontal disease and preterm delivery of lowbirth- weight infants J Can Dent Assoc 200268165-9
bull 63 Richards AG Dental x-ray protection Dent Clin North Am 1968631-41
bull 64 1990 Recommendations of the International Commission on Radiological Protection Ann ICRP 1991211-201
bull 65 Hall EJ Radiation the two-edged sword cancer risks at high and low doses Cancer J 20006343-50
bull 66 Diethelm L Xu H Diagnostic imaging of the lung during pregnancy Clin Obstet Gynecol 19963936-55
bull 67 Brent RL The effects of embryonic and fetal exposure to x-rays microwaves and ultrasound ClinObstetGynecol 198326484-510
bull 68 National Council on Radiation Protection NCRP report no128 1998 Bethesda Md Author
bull 69 Wasylko L Matsui D Dykxhoorn SM Reider MJ Weinberg S A review of common dental treatments during pregnancy implications for patients and dental personnel J Can Dent Assoc 199864434-9
bull 70 Freeman JP Brand JW Radiation doses of commonly used dental radiographic surveys Oral Surg Oral Med Oral Pathol 199477285-9
bull 71 Kircos LTAngin LL Lorton LOrder ofmagnitude dose reduction in intraoral radiography J Am Dent Assoc 1987114344-7
bull 72 Updegrave WJ Simplified and standardized intraoral radiography with reduced tissue irradiation J Am Dent Assoc 197285861-9
bull 73 Wood RE Harris AM van der Merwe EJ Nortje CJ The leaded apron revisited does it reduce gonadal radiation dose in dental radiology Oral Surg Oral Med Oral Pathol 199171642-6
bull 74 An update on radiographic practices information and recommendations ADA Council on Scientific Affairs J Am Dent Assoc 2001132234-8
bull 75 Rayburn WF Recommending medications during pregnancy an evidence based approach Clin Obstet Gynecol 2002451-5
bull 76 Rathmell JP Viscomi C Ashburn MA Management of nonobstetric pain during pregnancy and lactation Anesth Analg 1997851074-87
bull 77 Teratology society public affairs committee FDA classification of drugs for teratogenic risk Teratology 199449446-7
bull 78 Moore PA Selecting drugs for the pregnant dental patient J Am Dent Assoc 19981291281-6
bull 79 Haas DA An update on analgesics for the management of acute postoperative dental pain J Can Dent Assoc 200268476-82
bull 80 Haas DA Pynn BR Sands TD Drug use for the pregnant or lactating patient Gen Dent 20004854-60
bull 81 Committee on Drugs American Academy of Pediatrics The transfer of drugs and other chemicals into human milk Pediatrics 199493137-50
bull 82 Nielsen GL Sorensen HT Larsen H Pedersen L Risk of adverse birth outcome and miscarriage in pregnant users of nonsteroidal anti-inflammatory drugs population based observational study and case-control study BMJ 2001322266-70
bull 83 Janssen N Genta M The effects of immunosuppressive and anti-inflammatory medications on fertility pregnancy and lactation Arch Intern Med 200016610-9
bull 84 Ostensen M Nonsteroidal anti-inflammatory drugs during pregnancy Scand J Rheumatol Suppl 1998107128-32
bull 85 USPDI -Drug information for the health care professional 22nd ed Greenwood Village CO Micromedex 2002 p 152-79
bull 86 Denson DD Coyle DE Thompson GA Santos D Turner PA Myers JA et al Bupivacaine protein binding in the term parturient effects of lactic acidosis Clin Pharmacol Ther 198435702-9
bull 87 Dillon DE Wagner CL Wiest D Newman RB Drug therapy in the nursing mother Obstet Gynecol Clin North Am 199724 675-96
bull 88 Dashe JS Gilstrap LC Antibiotic use in pregnancy Obstet Gynecol Clin North Am 199724617-29
bull 89 American College of Rheumatology Ad hoc Committee on Clinical Guidelines Guidelines for monitoring drug therapy in rheumatoid arthritis Arthritis Rheum 199639723-31
bull 90 Ng PC The fetal and neonatal hypothalamic-pituitary-adrenal axis Arch Dis Child Fetal Neonatal Ed 200082F250-4
bull 91 Crowley P Antenatal corticosteroidsmdashcurrent thinking BJOG 2003110(Suppl 20)77-8
bull 92 ACOG committee opinion antenatal corticosteroid therapy for fetal maturation Obstet Gynecol 200299871-3
bull 93 Ost L Wettrell G Bjorkhem I Rane A Prednisolone excretion in human milk J Pediatr 19851061008-11
bull 94 Rowland AS Baird DD Shore DL Weinberg CR Savitz DA Wilcox AJ Nitrous oxide and spontaneous abortion in female dental assistants Am J Epidemiol 1995141531-8
bull 95 McGlothlin JD Jensen PA Fischbach TJ Hughes RT Jones JH Control of anesthetic gases in dental operatories Scand J Work Environ Health 199218(Suppl 2)103-5
bull ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY Volume 97 Number 6 Suresh and Radfar 681
bull 96 Rosen MA Nitrous oxide for relief of labor pain a systematic review Am J Obstet Gynecol 2002186(Suppl Nature)S110-6
bull 97 Sands TD Pynn BR Management considerations for the pregnant or nursing emergency patient Ont Dent 199875 17-9
bull 98 Daya S Recurrent spontaneous early pregnancy loss and low dose aspirin Minerva Ginecol 200355441-9
bull 99 Sinclair C Handbook of obstetrical emergencies 1st ed Philadelphia WB Saunders 1996 p 29-39 69
bull 100 Tarsitano BF Rollings RE The pregnant dental patient evaluation and management Gen Dent 199341226-34
bull 101 Livingston MH Dlllinger TM Holder R Consideration in the management of the pregnant patient SCD Special Care in Dentistry 199818183-8
Thank you
- A Review on the principle of Dental Management of the Pregnant patient
- Slide 2
- Questions that a dentist may ask
- Stages of Pregnancy
- Slide 5
- Slide 6
- Physiologic Changes in Pregnancy
- Systemic changes in pregnancy
- FLAT SUPINE POSITIONING
- SUPINE HYPOTENSION SYNDROME (Vena Cava Compression)
- Supine Hypotension Syndrome
- Slide 12
- Supine Hypotension Syndrome
- Prevention of Supine Hypotensive Syndrome
- Treatment of Supine Hypotensive Syndrome
- How should the pregnant woman be positioned
- Slide 17
- Slide 18
- Slide 19
- Slide 20
- Slide 21
- Slide 22
- Slide 23
- Pregnancy Related Oral Health Problems
- Oral Problems in Pregnancy
- Pregnancy Gingivitis Pathophysiology
- Pregnancy Gingivitis
- Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Gum Problems - Pregnancy Granuloma
- Slide 31
- Gum Changes - Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Candidiasis
- Pregnancy Myths
- Other Oral Conditions in Pregnancy
- Changes During Pregnancy that Affect Oral Health
- Saliva changes
- Increased Bacteria
- Slide 40
- Enamel erosion caused by frequent vomiting
- Treatment for Acid Exposure
- Oral Diseases Can Effect Pregnancy
- Periodontal Disease and Preterm Labor
- Periodontal Disease and Low Birth Weight
- Periodontal Disease and Preeclampsia
- Periodontitis and Pre-eclampsia
- Dental Considerations
- Treatment Timing
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Slide 52
- Use of Radiation on Pregnant Patient
- Radiographs during Pregnancy
- Risks of Dental X-Rays
- FDA drug classification for pregnancy
- Slide 57
- FDA drug classification for pregnancy
- Slide 59
- Slide 60
- Slide 61
- Common Analgesics
- Analgesics
- Analgesics - continued
- Analgesics to Use During 1st and 2nd Trimester
- Analgesics to Avoid During the Third Trimester
- Sedation in Pregnancy
- Common Antibiotics
- Antibiotics
- Antibiotics To Use During Pregnancy
- Antibiotics to Avoid during Pregnancy
- The Problem With Tetracycline
- Other Antimicrobial Agents
- Local Anesthetic Use in Pregnancy
- Use of Local Anesthetics
- Ulcer healing drugs
- Slide 77
- Slide 78
- Slide 79
- Use of Nitrous Oxide Gas
- Common Preventives
- Are topical agents safe
- Pre-natal Fluoride
- Is it safe to use mercury restorations
- References
- REFERENCES
- Slide 87
- Slide 88
- Slide 89
- Slide 90
- Slide 91
- Slide 92
- Slide 93
- Slide 94
- Slide 95
- Slide 96
- Slide 97
- Slide 98
- Thank you
-
Pregnancy Granuloma (continued)
Treatment
bull Scaling and root planingbull Excision if it is too large or bleeds too
easilybull May regress spontaneously after
pregnancy
Candidiasis
bullWipes offbullUsually asymptomatic but may burnbullTreatment topical or systemic antifungals
Pregnancy MythsbullldquoA mother loses a tooth for every babyrdquobullNo evidence that aphthous ulcers are any more common in pregnancy
Other Oral Conditions in Pregnancy
bull Dry mouthbull Excessive salivationbull Tooth erosions associated with
severe GERD or hyperemesis
Changes During Pregnancy that Affect Oral Health
bull Hormonal Affects
ndash Increased tooth mobility
ndash Saliva changes
ndash Increased bacteria
ndash Gingival problems
Saliva changesbull Decreased buffers
bull Decreased minerals
bull Decreasing flow first and last trimester
bull Increased flow second trimester
bull More acidic
Increased Bacteriabull Increased acidity
ndash Increase in decay-causing bacteriabull Increased Snacking
ndash Morning sicknesslow blood sugarndash Between-meal snacks
bull Increase in amount and frequency of starchescarbohydrates ndash Crackers are commonly recommendedndash Promotes decay-causing bacteria
Changes During Pregnancy that Affect Oral Healthbull Morning sickness
ndash Difficulty with hygienebull Gingival diseasebull Tooth decay
ndash Vomitingbull Esophogeal Reflux (heartburn)bull Acid exposure
ndash Irritation of the gumsndash Weakening of tooth enamelndash Dental erosion
Enamel erosion caused by frequent vomiting
Treatment for Acid Exposure
bull Do NOT brush immediately after vomiting
bull Rinse ndash Water with baking sodandash Antacidndash Plain water
bull Eat some cheese
Oral Diseases Can Effect Pregnancy
bull Preterm low birth weight (LBW) linked to periodontal disease
bull Thorough calculus (tartar) removal in pregnant women with periodontitis may reduce pre-term births
Periodontal Disease and Preterm LaborbullMaternal periodontal disease is associated with increased risk of preterm laborbullAnaerobic oral gram-negative bacteria cause inflammatory responsebullInflammatory response stimulates prostaglandin and cytokine production to stimulate labor
Periodontal Disease and Low Birth Weight
bull Periodontal disease is associated with low birth weight
bull Evidence is not conclusivebull Biochemical mechanism similar cascade
as in preterm labor leading to placental blood flow restriction and necrosis
Periodontal Disease and Preeclampsia
bull Emerging databull Mechanism unclearbull Proposed mechanism
ndash Periodontal infection leads to inflammatory vascular damage
ndash Triggers cell damage in placenta
Periodontitis and Pre-eclampsia
bull Periodontal disease may be associated with pre-eclampsia (Boggess 2003)
bull PGE2 IL-1 and TNF-α from gingival crevicular fluid were higher in women with preeclampsia compared with healthy matched pregnant women (Oettinger-Barak 2003)
Dental Considerations
bull timing of treatment for pregnant patientsbull dental radiation exposurebull use of local anestheticsbull prescription of common antibiotics and
analgesicsbull nitrous oxide gas administration
Treatment Timing
bull First Trimesterndash Spontaneous miscarriages naturally occur
more often in 1st trimesterndash Avoid elective treatment that can be delayedndash Offer anticipatory guidance
bull Second Trimesterndash The optimal time for dental treatmentndash Organogenesis complete fetus not largendash Easier to prevent than treat established disease
bull Third Trimesterndash Late in term very uncomfortable (short visits)ndash Position slightly on left side
Timing of Dental Treatment During Pregnancy - From Little and Fallace
First Trimester
bull Plaque controlbull Oral hygiene instructionbull Scaling polishing curettagebull Avoid elective treatment urgent care
only
Timing of Dental Treatment During Pregnancy - From Little and Fallace
Second Trimester
bull Plaque controlbull Oral hygiene instructionbull Scaling polishing curettagebull Routine dental care
Timing of Dental Treatment During Pregnancy - From Little and Fallace
Third Trimester
bull Plaque controlbull Oral hygiene instructionbull Scaling polishing curettagebull Routine dental care (after middle of third
trimester elective care should be avoided)
Use of Radiation on Pregnant Patientbull Dose given and time of gestation are
importantbull doses lt 5-10 rads (cGy) not teratogenicbull fetus is most susceptible to radiation
between the 2nd and 6th week of gestationbull single dental x-ray exposes patient to 001
millirads of radiation In relative terms this amount is 40 times less than daily dose acquired from cosmic radiation Therefore diagnostic radiation should not be withheld during pregnancy
Radiographs during Pregnancy
bull Take as needed with optimal methods for reducing secondary radiation and exposure time
bull Always use a lead apronbull Exposure to fetus (with apron use) is 00001
centiGray(rad)bull Daily cosmic radiation - 0004 centiGray (rad)
Risks of Dental X-Rays
bull X-ray only if necessary (ie root canal therapy trauma)
bull When x-rays are indicated radiation exposure is extremely low
bull Exposure can be limited byndash Lead apron shielding ndash Modern fast film ndash Avoiding retakes
FDA drug classification for pregnancybull Combines risk statements including
congenital anomalies fetal effects perinatal risks and therapeutic risk-benefit ratio
bull Untreated disease or condition may pose more serious risks to both mother and fetus than any theoretical risks from the medication
bull Category A thru D and X
FDA drug classification for pregnancy
bull A = Controlled Studies in women fail to demonstrate a risk to the fetus in the first trimester and the possibility of fetal harm appears remote
FDA drug classification for pregnancy
bull B = Animal studies show no risk or if risk shown in animals controlled
trials in women showed no risk
FDA drug classification for pregnancy
bull C = Studies in animals with adverse effects and no human studies
OR no animal or human studies but benefits of use may outweigh potential harms
FDA drug classification for pregnancy
bull D = There is evidence of human fetal risk but benefits may outweigh risks
FDA drug classification for pregnancy
bull X = Contraindicated
Common Analgesics
bull paracetamol (B)bull Ibuprofen (BD) bull Oxycodone (BD) bull Hydrocodone and codeine
(CD)
avoid in third trimester
Analgesics
bull Paracetamol is the analgesic of choice for all stages of gestation
bull used to treat mild to moderate pain and fevers
bull short term usage is believed to be safebull avoid chronic and large doses of
paracetamol1048715
Analgesics - continuedbull Aspirin is nonteratogenic but may cause
maternal and fetal hemorrhagebull large and chronic doses during last trimester
may result in premature closure of ductus arteriosus fetal hypertension anemia and low birth weight
bull avoid ibuprofen in 3rd trimester because of possible adverse circulatory effects
bull short term use of codeine seems safebull avoid codeine late in gestation because of
possible fetal respiratory depression and withdrawal symptoms
Analgesics to Use During1st and 2nd Trimester
bull Category B (for best)bull Paracetamol Ibuprofenbull Naproxenbull Category C (use with caution)bull Paracetamol with codeine or
hydrocodonebull Paracetamol with oxycodone
Analgesics to Avoid During theThird Trimesterbull Causes delivery problemsbull Aspirin (C 3D)bull Ibuprofen (B3D)bull Naproxen (B3D)bull Causes neonatal respiratory
depression and opioid withdrawalbull Codeine (C3D)bull Hydrocodone (C3D)bull Oxycodone(C3D)
Sedation in Pregnancy
bull SedativesAnxiolytics (eg Diazepam ) are rated D and can cause oral clefts with prolonged exposure
bull Nitrous oxide should not be used in 1st trimester (If used in 2nd and 3rd do not go below 50 O2)
Common Antibioticsbull To treat oral abscess or cellulitis
ndash Penicillin (B) ndash Amoxicillin (B) ndash Cephalexin (B)ndash Erythromycin base (B) (Not estolate as it
cause cholestatic hepatitis)ndash Clindamycin (B)
Antibioticsbull penicillin V and amoxicillin is preferred drug
for mild to moderate infectionsbull widely used for many years with no ill effectsbull no studies show penicillin to be teratogenicbull amoxicillin extensively used without harming
the fetusbull Drug classes1048715 B penicillin cephalosporins erythromycin clindamycin Azithromycin D Tetracycline
Antibiotics To Use During Pregnancy
bull Penicillin Vbull Amoxicillinbull Erythromycin (base form)bull Cephalexin cephalosporinbull Clindamycinbull Metronidazole
Antibiotics to Avoid duringPregnancy
bull Doxycyclinebull Tetracyclinebull Erythromycin (estolate form)bull Vancomycin
The Problem With Tetracycline
bull Accumulates in bones and chelates calcium
bull Inhibits bone growthbull Discolors teeth
Other Antimicrobial Agentsbull OK to usebull Nystatin (B)bull Chlorhexidine rinse (B)bull Use with cautionbull Clotrimazole (C)bull Ketoconazole (C)bull Fluconazole (C)bull Do not usebull Doxycycline (D)
Local Anesthetic Use inPregnancy
bull Class Bbull Lidocaine (Xylocaine)bull Etidocainebull Prilocaine bull Class Cbull Procainebull Bupivicainebull Mepivicaine
Use of Local Anestheticsbull Lidocaine + vasoconstrictor most common
local anesthetic used in dentistrybull extensively used in pregnancy with no proven ill
effectsbull accidental intravascular injections of lidocaine
pass through the placenta but the concentrations are too low to harm fetus
bull prilocaine might cause methemoglobinemia
Ulcer healing drugsCimetidine bull FDA category B Famotidinebull FDA category BRanitidinebull FDA category Bbull not known to be harmful
Ulcer healing drugsOmeprazolebull FDA category BNot known to be
harmful Esomeprazolebull FDA category BLansoprazolebull FDA category BPantoprazolebull Avoid unless potential benefit
outweighs riskmdashfetotoxic in animals
Ulcer healing drugs
Misoprostolbull First second third trimesters Avoidmdash
potent uterine stimulant (has been used to induce abortion) and may be teratogenic
Ulcer healing drugs
Antacidsbull Almunium hydroxideMagnesium
hydroxidemdashFDA category B Calcium carbonatemdashFDA category C
SimetheconemdashFDA category C
Use of Nitrous Oxide Gas
bull used over 150 years bull safety is being debatedbull SHORT TERM exposure do not cause
birth defects or spontaneous abortionbull CHRONIC exposure may result in fetal
loss and infertilitybull literature suggests that nitrous oxide
should be avoided until more conclusive research is available
bull FDA Drug class not yet assigned
Common Preventives
bull Fluoridendash No increased risk during pregnancy
bull Xylitolndash No studies no harm reported
bull Chlorhexidinendash No increased risk during pregnancy
Are topical agents safe
bull Fluoridebull Toothpaste amp mouthrinse
bull Xylitol chewing gum bull Chlorhexidine (11 alcohol)bull No over the counter mouthrinses with
alcohol (Listerine 20 alcohol)
Pre-natal Fluoride
bull Daily 22 mg tablet of sodium fluoride during 3rd through 9th months
bull decreases caries rate in offspringbull Safe and effective
Glenn FB 1982
Is it safe to use mercury restorations
bull No evidence of harmful effect
bull Benefits outweigh risks
bull Canada Germany and New Zealand have some restrictions
bull Determine the best option
Referencesbull Wasylko L Matsui D Dykxhoorn SM Rieder MJ Weinberg
S A Review of Common Dental Treatments During Pregnancy J Canadian Dental Association 64434-439 1998
bull Little JW Donald AF Craig SM Rhodus NL Dental Management of the Medically Compromised Patient - 5th edition Mosby Toronto Pp434-442 1997
bull Livingston HM Dellinger TM Holder R Considerations in the management of the pregnant patient Special Care in Dentistry 185 pp183-188 1998
bull Larimore WL Petrie KA Drug use during pregnacy and lactation Primary Care Clinics in Office Practice 271 35-53 2000
bull Health Canada The Safety of DentalAmalgam Minister Of Supply and Services Canada 1996
REFERENCESbull 1 Weiss G Endocrinology of parturition J Clin
Endocrinol Metab 2000854421-5bull 2 Theunissen IM Parer JT Fluid and electrolytes in
pregnancy Clin Obstet Gynecol 1994373-15bull 3 Duvekot JJ Peeters LLH Renal hemodynamics and
volume homeostasis in pregnancy Obstet Gynecol Surv 199449830-9
bull 4 Barron WM Lindheimer MD Medical disorders during pregnancy 2nd ed St Louis Mosby 1995 p 129
bull 5 Thornburg KL Jacobson SL Giraud GD Morton MJ Hemodynamic changes in pregnancy Semin Perinatol 20002411-4
bull 6 Fiese R Herzog S Issues in dental and surgical management of the pregnant patient Oral Surg Oral Med Oral Pathol 198865292-7
bull 7 Martin C Varner MW Physiologic changes in pregnancysurgical implications Clin Obstet Gynecol 199437241-55
bull 8 Clark SL Cotton DB Lee W Bishop C Hill T Southwick J et al Central hemodynamic assessment of normal term pregnancy Am J Obstet Gynecol 19891611439-42
bull 9 Mabie WC Di Sessa TG Crocker LG Sibai BM Arheart KL A longitudinal study of cardiac output in normal human pregnancy Am J Obstet Gynecol 1994170849-56
bull 10 Clapp JF 3rd Capeless E Cardiovascular function before during and after the first and subsequent pregnancies Am J Cardiol 1997801469-73
bull 11 Duvekot JJ Peeters LL Maternal cardiovascular hemodynamic adaptation to pregnancy Obstet Gynecol Surv 199449(Suppl) S1-14
bull 12 Bhagwat AR Engel PJ Heart disease and pregnancy Cardiol Clin 199513163-78
bull 13 Lanni SM Tillinghast J Silver H Hemodynamic changes and baroreflex gain in the supine hypotensive syndrome Am J Obstet Gynecol 20021871636-41
bull 14 Little JW Falace DA Miller CS Rhodus NL Dental management of the medically compromised patient 6th ed St Louis Mosby 2002 p 303
bull 15 Garcia-Rio F Pino JM Gomez L Alvarez-Sala R Villasante C Villamor J Regulation of breathing and perception of dyspnea in healthy pregnant women Chest 1996110446-53
bull 16 McAuliffe F Kametas N Costello J Rafferty GF Greenough A Nicolaides K Respiratory function in singleton and twin pregnancy BJOG 2002109765-9
bull 17 Clapp JF 3rd Seaward BL Sleamaker RH Hiser J Maternal physiologic adaptations to early human pregnancy Am J Obstet Gynecol 19881591456-60
bull 18 OrsquoDay MP Cardio-respiratory physiological adaptation of pregnancy Semin Perinatol 199721268-75
bull 19 Contreras G Gutierrez M Beroiza T Fantin A Oddo H Villarroel L et al Ventilatory drive and respiratory muscle function in pregnancy Am Rev Respir Dis 1991144837-41
bull 20 Turner M Aziz SR Management of the pregnant oral and maxillofac
bull 21 Sifakis S Pharmakides G Anemia in pregnancy Ann N Y Acad Sci 2000900125-36
bull 22 Branch DW Physiologic adaptations of pregnancy Am J Reprod Immunol 199228120-2
bull 23 Burrows RF Kelton JG Incidentally detected thrombocytopenia in healthy mothers and their infants N Engl J Med 1988319 142-5
bull 24 Hanly JG Antiphospholipid syndrome an overview CMAJ 200324(168)1675-82
bull 25 Heilmann L von Tempelhoff GF Pollow K Antiphospholipid syndrome in obstetrics Clin Appl Thromb Hemost 20039 143-50
bull 26 Sherman P Flaxman SM Nausea and vomiting of pregnancy in an evolutionary perspective Am J Obstet Gynecol 2002 185(Suppl)s190-7
bull 27 Koch KL Gastrointestinal factors in nausea and vomiting of pregnancy Am J Obstet Gynecol 2002185(Suppl)s198-203
bull 28 Koch KL Frissora CL Nausea and vomiting during pregnancy Gastroenterol Clin N Am 200332201-34
bull 29 Baron TH Ramirez B Richter JE Gastrointestinal motility disorders during pregnancy Ann Intern Med 1993118 366-75
bull 30 Richter JE Gastroesophageal reflux disease during pregnancy Gastroenterol Clin N Am 200332235-61
bull 31 Marrero JM Goggin PM de Caestecker JS Pearce JM Maxwell JD Determinants of pregnancy heartburn Br J Obstet Gynaecol 199299731-4
bull 32 Hamaoui E Hamaoui M Nutritional assessment and support during pregnancy Gastroenterol Clin N Am 20033259-121
bull 33 King JC Physiology of pregnancy and nutrient metabolism Am J Clin Nutr 200071(suppl)1218s-25s
bull 34 Casanueva E Pfeffer F Fernandez-Gaxiola AC Gutierrez- Valenzuela V Rothenberg SJ Iron and folate status before pregnancy and anemia during pregnancy Ann Nutr Metab 2003 4760-3
bull 35 Chrsquong CL Morgan M Hainsworth I Kingham JG Prospective study of liver dysfunction in Southwest Wales Gut 200251 876-80
bull 36 Rahman TM Wendon J Severe hepatic dysfunction in pregnancy QJM 200295343-57
bull 37 Knox TA Olans LB Liver disease in pregnancy N Engl J Med 1996335569-76
bull 38 Saftlas AF Olson DR Franks AL Atrash H Pokras R Epidemiology of preeclampsia and eclampsia in the United States 1979e1986 Am J Obstet Gynecol 1990163460-5
bull 39 Walker JJ Pre-eclampsia Lancet 20003561260-5
bull 40 Davidson JM Renal disorders in pregnancy Curr Opin Obstet Gynecol 200113109-14
bull 41 Dafnis E Sabatini S The effect of pregnancy on renal function physiology and pathophysiologyAmJMedSci 1992303184-205
bull 42 Davison JM Shiells EA Philips PR Lindheimer MD Serial evaluation of vasopressin release and thirst in human pregnancy Role of human chorionic gonadotrophin in the osmoregulatory changes of gestation J Clin Invest 198881798-806
bull 43 Glinoer D de Nayer P Bourdoux P Lemone M Robyn C van Steirteghem A et al Regulation of maternal thyroid during pregnancy J Clin Endocrinol Metab 199071276-87
bull 44 Wilson SG Retallack RW Kent JC Worth GK Gutteridge DH Serum free 125-dihydroxyvitamin D and the free 125- dihydroxyvitamin D index during a longitudinal study of human pregnancy and lactation Clin Endocrinol 199032613-22
bull 45 Rasmussen N Frolich A Hornnes PJ Hegedus L Serum ionized calcium and intact parathyroid hormone levels during pregnancy and postpartum Br J Obstet Gynaecol 199097857-9
bull 46 Guyton AC Textbook of medical physiology 8th ed Philadelphia W B Saunders 1991 p 915e28
bull 47 Trainer PJ Corticosteroids and pregnancy Semin Reprod Med 200220375-80
bull 48 Soory M Hormonal factors in periodontal disease Dent Update 200027380-3
bull 49 Hugoson A Gingivitis in pregnant women A longitudinal clinical study Odontol Revy 19712265-84
bull 50 Neville BW Damm DD Allen CM Bouquot JE Oral amp Maxillofacial Pathology 3rd ed Philadelphia W B Saunders 2002 p 329-30 447-9
bull 51 Tilakaratne A Soory M Ranasinghe AW Corea SM Ekanayake SL de Silva M Periodontal disease status during pregnancy and 3 months post-partum in rural population of Sri-Lankan women J Clin Periodontol 200027787-92
bull 52 Laine M Tenovuo J Lehtonen OP Ojanatko-Harri A Vilja P Tuohimaa P Pregnancy e related changes in human whole saliva Arch Oral Biol 198833913-7
bull 53 Yuan K Wing LY Lin MT Pathogenetic roles of angiogenic factors in pyogenic granulomas in pregnancy are modulated by female sex hormones J Periodontol 200273701-8
bull 54 Evans RD Briggs PF Tooth-surface loss related to pregnancyinduced vomiting Prim Dent Care 1994124-6
bull 55 Salvolini E Di Giorgio R Curatola A Mazzanti L Fratto G Biochemical modifications of human whole saliva induced by pregnancy Br J Obstet Gynaec 1998105656-60
bull 56 Mauldin JG Newman RB Preterm birth risk assessment Semin Perinatol 200125215-22
bull 57 Heine RP McGregor JA Goodwin TM Artal R Hayashi RH Robertson PA et al Serial salivary estriol to detect an increased risk of preterm birth Obstet Gynecol 200096490-7
bull 58 Kauh YC Zachian TF Melasma Adv Exp Med Biol 1999455 491-9
bull 59 Wong RC Ellis CN Physiologic skin changes in pregnancy J Am Acad Dermatol 198410929-40
bull 60 Errickson CV Matus NR Skin disorders of pregnancy Am Fam Physician 199449605-10
bull 61 Lopez NJ Smith PC Gutierrez J Periodontal therapy may reduce the risk of preterm low birth weight in women with periodontal disease a randomized controlled trial J Periodontol 200273911-24
bull 62 McGaw T Periodontal disease and preterm delivery of lowbirth- weight infants J Can Dent Assoc 200268165-9
bull 63 Richards AG Dental x-ray protection Dent Clin North Am 1968631-41
bull 64 1990 Recommendations of the International Commission on Radiological Protection Ann ICRP 1991211-201
bull 65 Hall EJ Radiation the two-edged sword cancer risks at high and low doses Cancer J 20006343-50
bull 66 Diethelm L Xu H Diagnostic imaging of the lung during pregnancy Clin Obstet Gynecol 19963936-55
bull 67 Brent RL The effects of embryonic and fetal exposure to x-rays microwaves and ultrasound ClinObstetGynecol 198326484-510
bull 68 National Council on Radiation Protection NCRP report no128 1998 Bethesda Md Author
bull 69 Wasylko L Matsui D Dykxhoorn SM Reider MJ Weinberg S A review of common dental treatments during pregnancy implications for patients and dental personnel J Can Dent Assoc 199864434-9
bull 70 Freeman JP Brand JW Radiation doses of commonly used dental radiographic surveys Oral Surg Oral Med Oral Pathol 199477285-9
bull 71 Kircos LTAngin LL Lorton LOrder ofmagnitude dose reduction in intraoral radiography J Am Dent Assoc 1987114344-7
bull 72 Updegrave WJ Simplified and standardized intraoral radiography with reduced tissue irradiation J Am Dent Assoc 197285861-9
bull 73 Wood RE Harris AM van der Merwe EJ Nortje CJ The leaded apron revisited does it reduce gonadal radiation dose in dental radiology Oral Surg Oral Med Oral Pathol 199171642-6
bull 74 An update on radiographic practices information and recommendations ADA Council on Scientific Affairs J Am Dent Assoc 2001132234-8
bull 75 Rayburn WF Recommending medications during pregnancy an evidence based approach Clin Obstet Gynecol 2002451-5
bull 76 Rathmell JP Viscomi C Ashburn MA Management of nonobstetric pain during pregnancy and lactation Anesth Analg 1997851074-87
bull 77 Teratology society public affairs committee FDA classification of drugs for teratogenic risk Teratology 199449446-7
bull 78 Moore PA Selecting drugs for the pregnant dental patient J Am Dent Assoc 19981291281-6
bull 79 Haas DA An update on analgesics for the management of acute postoperative dental pain J Can Dent Assoc 200268476-82
bull 80 Haas DA Pynn BR Sands TD Drug use for the pregnant or lactating patient Gen Dent 20004854-60
bull 81 Committee on Drugs American Academy of Pediatrics The transfer of drugs and other chemicals into human milk Pediatrics 199493137-50
bull 82 Nielsen GL Sorensen HT Larsen H Pedersen L Risk of adverse birth outcome and miscarriage in pregnant users of nonsteroidal anti-inflammatory drugs population based observational study and case-control study BMJ 2001322266-70
bull 83 Janssen N Genta M The effects of immunosuppressive and anti-inflammatory medications on fertility pregnancy and lactation Arch Intern Med 200016610-9
bull 84 Ostensen M Nonsteroidal anti-inflammatory drugs during pregnancy Scand J Rheumatol Suppl 1998107128-32
bull 85 USPDI -Drug information for the health care professional 22nd ed Greenwood Village CO Micromedex 2002 p 152-79
bull 86 Denson DD Coyle DE Thompson GA Santos D Turner PA Myers JA et al Bupivacaine protein binding in the term parturient effects of lactic acidosis Clin Pharmacol Ther 198435702-9
bull 87 Dillon DE Wagner CL Wiest D Newman RB Drug therapy in the nursing mother Obstet Gynecol Clin North Am 199724 675-96
bull 88 Dashe JS Gilstrap LC Antibiotic use in pregnancy Obstet Gynecol Clin North Am 199724617-29
bull 89 American College of Rheumatology Ad hoc Committee on Clinical Guidelines Guidelines for monitoring drug therapy in rheumatoid arthritis Arthritis Rheum 199639723-31
bull 90 Ng PC The fetal and neonatal hypothalamic-pituitary-adrenal axis Arch Dis Child Fetal Neonatal Ed 200082F250-4
bull 91 Crowley P Antenatal corticosteroidsmdashcurrent thinking BJOG 2003110(Suppl 20)77-8
bull 92 ACOG committee opinion antenatal corticosteroid therapy for fetal maturation Obstet Gynecol 200299871-3
bull 93 Ost L Wettrell G Bjorkhem I Rane A Prednisolone excretion in human milk J Pediatr 19851061008-11
bull 94 Rowland AS Baird DD Shore DL Weinberg CR Savitz DA Wilcox AJ Nitrous oxide and spontaneous abortion in female dental assistants Am J Epidemiol 1995141531-8
bull 95 McGlothlin JD Jensen PA Fischbach TJ Hughes RT Jones JH Control of anesthetic gases in dental operatories Scand J Work Environ Health 199218(Suppl 2)103-5
bull ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY Volume 97 Number 6 Suresh and Radfar 681
bull 96 Rosen MA Nitrous oxide for relief of labor pain a systematic review Am J Obstet Gynecol 2002186(Suppl Nature)S110-6
bull 97 Sands TD Pynn BR Management considerations for the pregnant or nursing emergency patient Ont Dent 199875 17-9
bull 98 Daya S Recurrent spontaneous early pregnancy loss and low dose aspirin Minerva Ginecol 200355441-9
bull 99 Sinclair C Handbook of obstetrical emergencies 1st ed Philadelphia WB Saunders 1996 p 29-39 69
bull 100 Tarsitano BF Rollings RE The pregnant dental patient evaluation and management Gen Dent 199341226-34
bull 101 Livingston MH Dlllinger TM Holder R Consideration in the management of the pregnant patient SCD Special Care in Dentistry 199818183-8
Thank you
- A Review on the principle of Dental Management of the Pregnant patient
- Slide 2
- Questions that a dentist may ask
- Stages of Pregnancy
- Slide 5
- Slide 6
- Physiologic Changes in Pregnancy
- Systemic changes in pregnancy
- FLAT SUPINE POSITIONING
- SUPINE HYPOTENSION SYNDROME (Vena Cava Compression)
- Supine Hypotension Syndrome
- Slide 12
- Supine Hypotension Syndrome
- Prevention of Supine Hypotensive Syndrome
- Treatment of Supine Hypotensive Syndrome
- How should the pregnant woman be positioned
- Slide 17
- Slide 18
- Slide 19
- Slide 20
- Slide 21
- Slide 22
- Slide 23
- Pregnancy Related Oral Health Problems
- Oral Problems in Pregnancy
- Pregnancy Gingivitis Pathophysiology
- Pregnancy Gingivitis
- Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Gum Problems - Pregnancy Granuloma
- Slide 31
- Gum Changes - Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Candidiasis
- Pregnancy Myths
- Other Oral Conditions in Pregnancy
- Changes During Pregnancy that Affect Oral Health
- Saliva changes
- Increased Bacteria
- Slide 40
- Enamel erosion caused by frequent vomiting
- Treatment for Acid Exposure
- Oral Diseases Can Effect Pregnancy
- Periodontal Disease and Preterm Labor
- Periodontal Disease and Low Birth Weight
- Periodontal Disease and Preeclampsia
- Periodontitis and Pre-eclampsia
- Dental Considerations
- Treatment Timing
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Slide 52
- Use of Radiation on Pregnant Patient
- Radiographs during Pregnancy
- Risks of Dental X-Rays
- FDA drug classification for pregnancy
- Slide 57
- FDA drug classification for pregnancy
- Slide 59
- Slide 60
- Slide 61
- Common Analgesics
- Analgesics
- Analgesics - continued
- Analgesics to Use During 1st and 2nd Trimester
- Analgesics to Avoid During the Third Trimester
- Sedation in Pregnancy
- Common Antibiotics
- Antibiotics
- Antibiotics To Use During Pregnancy
- Antibiotics to Avoid during Pregnancy
- The Problem With Tetracycline
- Other Antimicrobial Agents
- Local Anesthetic Use in Pregnancy
- Use of Local Anesthetics
- Ulcer healing drugs
- Slide 77
- Slide 78
- Slide 79
- Use of Nitrous Oxide Gas
- Common Preventives
- Are topical agents safe
- Pre-natal Fluoride
- Is it safe to use mercury restorations
- References
- REFERENCES
- Slide 87
- Slide 88
- Slide 89
- Slide 90
- Slide 91
- Slide 92
- Slide 93
- Slide 94
- Slide 95
- Slide 96
- Slide 97
- Slide 98
- Thank you
-
Candidiasis
bullWipes offbullUsually asymptomatic but may burnbullTreatment topical or systemic antifungals
Pregnancy MythsbullldquoA mother loses a tooth for every babyrdquobullNo evidence that aphthous ulcers are any more common in pregnancy
Other Oral Conditions in Pregnancy
bull Dry mouthbull Excessive salivationbull Tooth erosions associated with
severe GERD or hyperemesis
Changes During Pregnancy that Affect Oral Health
bull Hormonal Affects
ndash Increased tooth mobility
ndash Saliva changes
ndash Increased bacteria
ndash Gingival problems
Saliva changesbull Decreased buffers
bull Decreased minerals
bull Decreasing flow first and last trimester
bull Increased flow second trimester
bull More acidic
Increased Bacteriabull Increased acidity
ndash Increase in decay-causing bacteriabull Increased Snacking
ndash Morning sicknesslow blood sugarndash Between-meal snacks
bull Increase in amount and frequency of starchescarbohydrates ndash Crackers are commonly recommendedndash Promotes decay-causing bacteria
Changes During Pregnancy that Affect Oral Healthbull Morning sickness
ndash Difficulty with hygienebull Gingival diseasebull Tooth decay
ndash Vomitingbull Esophogeal Reflux (heartburn)bull Acid exposure
ndash Irritation of the gumsndash Weakening of tooth enamelndash Dental erosion
Enamel erosion caused by frequent vomiting
Treatment for Acid Exposure
bull Do NOT brush immediately after vomiting
bull Rinse ndash Water with baking sodandash Antacidndash Plain water
bull Eat some cheese
Oral Diseases Can Effect Pregnancy
bull Preterm low birth weight (LBW) linked to periodontal disease
bull Thorough calculus (tartar) removal in pregnant women with periodontitis may reduce pre-term births
Periodontal Disease and Preterm LaborbullMaternal periodontal disease is associated with increased risk of preterm laborbullAnaerobic oral gram-negative bacteria cause inflammatory responsebullInflammatory response stimulates prostaglandin and cytokine production to stimulate labor
Periodontal Disease and Low Birth Weight
bull Periodontal disease is associated with low birth weight
bull Evidence is not conclusivebull Biochemical mechanism similar cascade
as in preterm labor leading to placental blood flow restriction and necrosis
Periodontal Disease and Preeclampsia
bull Emerging databull Mechanism unclearbull Proposed mechanism
ndash Periodontal infection leads to inflammatory vascular damage
ndash Triggers cell damage in placenta
Periodontitis and Pre-eclampsia
bull Periodontal disease may be associated with pre-eclampsia (Boggess 2003)
bull PGE2 IL-1 and TNF-α from gingival crevicular fluid were higher in women with preeclampsia compared with healthy matched pregnant women (Oettinger-Barak 2003)
Dental Considerations
bull timing of treatment for pregnant patientsbull dental radiation exposurebull use of local anestheticsbull prescription of common antibiotics and
analgesicsbull nitrous oxide gas administration
Treatment Timing
bull First Trimesterndash Spontaneous miscarriages naturally occur
more often in 1st trimesterndash Avoid elective treatment that can be delayedndash Offer anticipatory guidance
bull Second Trimesterndash The optimal time for dental treatmentndash Organogenesis complete fetus not largendash Easier to prevent than treat established disease
bull Third Trimesterndash Late in term very uncomfortable (short visits)ndash Position slightly on left side
Timing of Dental Treatment During Pregnancy - From Little and Fallace
First Trimester
bull Plaque controlbull Oral hygiene instructionbull Scaling polishing curettagebull Avoid elective treatment urgent care
only
Timing of Dental Treatment During Pregnancy - From Little and Fallace
Second Trimester
bull Plaque controlbull Oral hygiene instructionbull Scaling polishing curettagebull Routine dental care
Timing of Dental Treatment During Pregnancy - From Little and Fallace
Third Trimester
bull Plaque controlbull Oral hygiene instructionbull Scaling polishing curettagebull Routine dental care (after middle of third
trimester elective care should be avoided)
Use of Radiation on Pregnant Patientbull Dose given and time of gestation are
importantbull doses lt 5-10 rads (cGy) not teratogenicbull fetus is most susceptible to radiation
between the 2nd and 6th week of gestationbull single dental x-ray exposes patient to 001
millirads of radiation In relative terms this amount is 40 times less than daily dose acquired from cosmic radiation Therefore diagnostic radiation should not be withheld during pregnancy
Radiographs during Pregnancy
bull Take as needed with optimal methods for reducing secondary radiation and exposure time
bull Always use a lead apronbull Exposure to fetus (with apron use) is 00001
centiGray(rad)bull Daily cosmic radiation - 0004 centiGray (rad)
Risks of Dental X-Rays
bull X-ray only if necessary (ie root canal therapy trauma)
bull When x-rays are indicated radiation exposure is extremely low
bull Exposure can be limited byndash Lead apron shielding ndash Modern fast film ndash Avoiding retakes
FDA drug classification for pregnancybull Combines risk statements including
congenital anomalies fetal effects perinatal risks and therapeutic risk-benefit ratio
bull Untreated disease or condition may pose more serious risks to both mother and fetus than any theoretical risks from the medication
bull Category A thru D and X
FDA drug classification for pregnancy
bull A = Controlled Studies in women fail to demonstrate a risk to the fetus in the first trimester and the possibility of fetal harm appears remote
FDA drug classification for pregnancy
bull B = Animal studies show no risk or if risk shown in animals controlled
trials in women showed no risk
FDA drug classification for pregnancy
bull C = Studies in animals with adverse effects and no human studies
OR no animal or human studies but benefits of use may outweigh potential harms
FDA drug classification for pregnancy
bull D = There is evidence of human fetal risk but benefits may outweigh risks
FDA drug classification for pregnancy
bull X = Contraindicated
Common Analgesics
bull paracetamol (B)bull Ibuprofen (BD) bull Oxycodone (BD) bull Hydrocodone and codeine
(CD)
avoid in third trimester
Analgesics
bull Paracetamol is the analgesic of choice for all stages of gestation
bull used to treat mild to moderate pain and fevers
bull short term usage is believed to be safebull avoid chronic and large doses of
paracetamol1048715
Analgesics - continuedbull Aspirin is nonteratogenic but may cause
maternal and fetal hemorrhagebull large and chronic doses during last trimester
may result in premature closure of ductus arteriosus fetal hypertension anemia and low birth weight
bull avoid ibuprofen in 3rd trimester because of possible adverse circulatory effects
bull short term use of codeine seems safebull avoid codeine late in gestation because of
possible fetal respiratory depression and withdrawal symptoms
Analgesics to Use During1st and 2nd Trimester
bull Category B (for best)bull Paracetamol Ibuprofenbull Naproxenbull Category C (use with caution)bull Paracetamol with codeine or
hydrocodonebull Paracetamol with oxycodone
Analgesics to Avoid During theThird Trimesterbull Causes delivery problemsbull Aspirin (C 3D)bull Ibuprofen (B3D)bull Naproxen (B3D)bull Causes neonatal respiratory
depression and opioid withdrawalbull Codeine (C3D)bull Hydrocodone (C3D)bull Oxycodone(C3D)
Sedation in Pregnancy
bull SedativesAnxiolytics (eg Diazepam ) are rated D and can cause oral clefts with prolonged exposure
bull Nitrous oxide should not be used in 1st trimester (If used in 2nd and 3rd do not go below 50 O2)
Common Antibioticsbull To treat oral abscess or cellulitis
ndash Penicillin (B) ndash Amoxicillin (B) ndash Cephalexin (B)ndash Erythromycin base (B) (Not estolate as it
cause cholestatic hepatitis)ndash Clindamycin (B)
Antibioticsbull penicillin V and amoxicillin is preferred drug
for mild to moderate infectionsbull widely used for many years with no ill effectsbull no studies show penicillin to be teratogenicbull amoxicillin extensively used without harming
the fetusbull Drug classes1048715 B penicillin cephalosporins erythromycin clindamycin Azithromycin D Tetracycline
Antibiotics To Use During Pregnancy
bull Penicillin Vbull Amoxicillinbull Erythromycin (base form)bull Cephalexin cephalosporinbull Clindamycinbull Metronidazole
Antibiotics to Avoid duringPregnancy
bull Doxycyclinebull Tetracyclinebull Erythromycin (estolate form)bull Vancomycin
The Problem With Tetracycline
bull Accumulates in bones and chelates calcium
bull Inhibits bone growthbull Discolors teeth
Other Antimicrobial Agentsbull OK to usebull Nystatin (B)bull Chlorhexidine rinse (B)bull Use with cautionbull Clotrimazole (C)bull Ketoconazole (C)bull Fluconazole (C)bull Do not usebull Doxycycline (D)
Local Anesthetic Use inPregnancy
bull Class Bbull Lidocaine (Xylocaine)bull Etidocainebull Prilocaine bull Class Cbull Procainebull Bupivicainebull Mepivicaine
Use of Local Anestheticsbull Lidocaine + vasoconstrictor most common
local anesthetic used in dentistrybull extensively used in pregnancy with no proven ill
effectsbull accidental intravascular injections of lidocaine
pass through the placenta but the concentrations are too low to harm fetus
bull prilocaine might cause methemoglobinemia
Ulcer healing drugsCimetidine bull FDA category B Famotidinebull FDA category BRanitidinebull FDA category Bbull not known to be harmful
Ulcer healing drugsOmeprazolebull FDA category BNot known to be
harmful Esomeprazolebull FDA category BLansoprazolebull FDA category BPantoprazolebull Avoid unless potential benefit
outweighs riskmdashfetotoxic in animals
Ulcer healing drugs
Misoprostolbull First second third trimesters Avoidmdash
potent uterine stimulant (has been used to induce abortion) and may be teratogenic
Ulcer healing drugs
Antacidsbull Almunium hydroxideMagnesium
hydroxidemdashFDA category B Calcium carbonatemdashFDA category C
SimetheconemdashFDA category C
Use of Nitrous Oxide Gas
bull used over 150 years bull safety is being debatedbull SHORT TERM exposure do not cause
birth defects or spontaneous abortionbull CHRONIC exposure may result in fetal
loss and infertilitybull literature suggests that nitrous oxide
should be avoided until more conclusive research is available
bull FDA Drug class not yet assigned
Common Preventives
bull Fluoridendash No increased risk during pregnancy
bull Xylitolndash No studies no harm reported
bull Chlorhexidinendash No increased risk during pregnancy
Are topical agents safe
bull Fluoridebull Toothpaste amp mouthrinse
bull Xylitol chewing gum bull Chlorhexidine (11 alcohol)bull No over the counter mouthrinses with
alcohol (Listerine 20 alcohol)
Pre-natal Fluoride
bull Daily 22 mg tablet of sodium fluoride during 3rd through 9th months
bull decreases caries rate in offspringbull Safe and effective
Glenn FB 1982
Is it safe to use mercury restorations
bull No evidence of harmful effect
bull Benefits outweigh risks
bull Canada Germany and New Zealand have some restrictions
bull Determine the best option
Referencesbull Wasylko L Matsui D Dykxhoorn SM Rieder MJ Weinberg
S A Review of Common Dental Treatments During Pregnancy J Canadian Dental Association 64434-439 1998
bull Little JW Donald AF Craig SM Rhodus NL Dental Management of the Medically Compromised Patient - 5th edition Mosby Toronto Pp434-442 1997
bull Livingston HM Dellinger TM Holder R Considerations in the management of the pregnant patient Special Care in Dentistry 185 pp183-188 1998
bull Larimore WL Petrie KA Drug use during pregnacy and lactation Primary Care Clinics in Office Practice 271 35-53 2000
bull Health Canada The Safety of DentalAmalgam Minister Of Supply and Services Canada 1996
REFERENCESbull 1 Weiss G Endocrinology of parturition J Clin
Endocrinol Metab 2000854421-5bull 2 Theunissen IM Parer JT Fluid and electrolytes in
pregnancy Clin Obstet Gynecol 1994373-15bull 3 Duvekot JJ Peeters LLH Renal hemodynamics and
volume homeostasis in pregnancy Obstet Gynecol Surv 199449830-9
bull 4 Barron WM Lindheimer MD Medical disorders during pregnancy 2nd ed St Louis Mosby 1995 p 129
bull 5 Thornburg KL Jacobson SL Giraud GD Morton MJ Hemodynamic changes in pregnancy Semin Perinatol 20002411-4
bull 6 Fiese R Herzog S Issues in dental and surgical management of the pregnant patient Oral Surg Oral Med Oral Pathol 198865292-7
bull 7 Martin C Varner MW Physiologic changes in pregnancysurgical implications Clin Obstet Gynecol 199437241-55
bull 8 Clark SL Cotton DB Lee W Bishop C Hill T Southwick J et al Central hemodynamic assessment of normal term pregnancy Am J Obstet Gynecol 19891611439-42
bull 9 Mabie WC Di Sessa TG Crocker LG Sibai BM Arheart KL A longitudinal study of cardiac output in normal human pregnancy Am J Obstet Gynecol 1994170849-56
bull 10 Clapp JF 3rd Capeless E Cardiovascular function before during and after the first and subsequent pregnancies Am J Cardiol 1997801469-73
bull 11 Duvekot JJ Peeters LL Maternal cardiovascular hemodynamic adaptation to pregnancy Obstet Gynecol Surv 199449(Suppl) S1-14
bull 12 Bhagwat AR Engel PJ Heart disease and pregnancy Cardiol Clin 199513163-78
bull 13 Lanni SM Tillinghast J Silver H Hemodynamic changes and baroreflex gain in the supine hypotensive syndrome Am J Obstet Gynecol 20021871636-41
bull 14 Little JW Falace DA Miller CS Rhodus NL Dental management of the medically compromised patient 6th ed St Louis Mosby 2002 p 303
bull 15 Garcia-Rio F Pino JM Gomez L Alvarez-Sala R Villasante C Villamor J Regulation of breathing and perception of dyspnea in healthy pregnant women Chest 1996110446-53
bull 16 McAuliffe F Kametas N Costello J Rafferty GF Greenough A Nicolaides K Respiratory function in singleton and twin pregnancy BJOG 2002109765-9
bull 17 Clapp JF 3rd Seaward BL Sleamaker RH Hiser J Maternal physiologic adaptations to early human pregnancy Am J Obstet Gynecol 19881591456-60
bull 18 OrsquoDay MP Cardio-respiratory physiological adaptation of pregnancy Semin Perinatol 199721268-75
bull 19 Contreras G Gutierrez M Beroiza T Fantin A Oddo H Villarroel L et al Ventilatory drive and respiratory muscle function in pregnancy Am Rev Respir Dis 1991144837-41
bull 20 Turner M Aziz SR Management of the pregnant oral and maxillofac
bull 21 Sifakis S Pharmakides G Anemia in pregnancy Ann N Y Acad Sci 2000900125-36
bull 22 Branch DW Physiologic adaptations of pregnancy Am J Reprod Immunol 199228120-2
bull 23 Burrows RF Kelton JG Incidentally detected thrombocytopenia in healthy mothers and their infants N Engl J Med 1988319 142-5
bull 24 Hanly JG Antiphospholipid syndrome an overview CMAJ 200324(168)1675-82
bull 25 Heilmann L von Tempelhoff GF Pollow K Antiphospholipid syndrome in obstetrics Clin Appl Thromb Hemost 20039 143-50
bull 26 Sherman P Flaxman SM Nausea and vomiting of pregnancy in an evolutionary perspective Am J Obstet Gynecol 2002 185(Suppl)s190-7
bull 27 Koch KL Gastrointestinal factors in nausea and vomiting of pregnancy Am J Obstet Gynecol 2002185(Suppl)s198-203
bull 28 Koch KL Frissora CL Nausea and vomiting during pregnancy Gastroenterol Clin N Am 200332201-34
bull 29 Baron TH Ramirez B Richter JE Gastrointestinal motility disorders during pregnancy Ann Intern Med 1993118 366-75
bull 30 Richter JE Gastroesophageal reflux disease during pregnancy Gastroenterol Clin N Am 200332235-61
bull 31 Marrero JM Goggin PM de Caestecker JS Pearce JM Maxwell JD Determinants of pregnancy heartburn Br J Obstet Gynaecol 199299731-4
bull 32 Hamaoui E Hamaoui M Nutritional assessment and support during pregnancy Gastroenterol Clin N Am 20033259-121
bull 33 King JC Physiology of pregnancy and nutrient metabolism Am J Clin Nutr 200071(suppl)1218s-25s
bull 34 Casanueva E Pfeffer F Fernandez-Gaxiola AC Gutierrez- Valenzuela V Rothenberg SJ Iron and folate status before pregnancy and anemia during pregnancy Ann Nutr Metab 2003 4760-3
bull 35 Chrsquong CL Morgan M Hainsworth I Kingham JG Prospective study of liver dysfunction in Southwest Wales Gut 200251 876-80
bull 36 Rahman TM Wendon J Severe hepatic dysfunction in pregnancy QJM 200295343-57
bull 37 Knox TA Olans LB Liver disease in pregnancy N Engl J Med 1996335569-76
bull 38 Saftlas AF Olson DR Franks AL Atrash H Pokras R Epidemiology of preeclampsia and eclampsia in the United States 1979e1986 Am J Obstet Gynecol 1990163460-5
bull 39 Walker JJ Pre-eclampsia Lancet 20003561260-5
bull 40 Davidson JM Renal disorders in pregnancy Curr Opin Obstet Gynecol 200113109-14
bull 41 Dafnis E Sabatini S The effect of pregnancy on renal function physiology and pathophysiologyAmJMedSci 1992303184-205
bull 42 Davison JM Shiells EA Philips PR Lindheimer MD Serial evaluation of vasopressin release and thirst in human pregnancy Role of human chorionic gonadotrophin in the osmoregulatory changes of gestation J Clin Invest 198881798-806
bull 43 Glinoer D de Nayer P Bourdoux P Lemone M Robyn C van Steirteghem A et al Regulation of maternal thyroid during pregnancy J Clin Endocrinol Metab 199071276-87
bull 44 Wilson SG Retallack RW Kent JC Worth GK Gutteridge DH Serum free 125-dihydroxyvitamin D and the free 125- dihydroxyvitamin D index during a longitudinal study of human pregnancy and lactation Clin Endocrinol 199032613-22
bull 45 Rasmussen N Frolich A Hornnes PJ Hegedus L Serum ionized calcium and intact parathyroid hormone levels during pregnancy and postpartum Br J Obstet Gynaecol 199097857-9
bull 46 Guyton AC Textbook of medical physiology 8th ed Philadelphia W B Saunders 1991 p 915e28
bull 47 Trainer PJ Corticosteroids and pregnancy Semin Reprod Med 200220375-80
bull 48 Soory M Hormonal factors in periodontal disease Dent Update 200027380-3
bull 49 Hugoson A Gingivitis in pregnant women A longitudinal clinical study Odontol Revy 19712265-84
bull 50 Neville BW Damm DD Allen CM Bouquot JE Oral amp Maxillofacial Pathology 3rd ed Philadelphia W B Saunders 2002 p 329-30 447-9
bull 51 Tilakaratne A Soory M Ranasinghe AW Corea SM Ekanayake SL de Silva M Periodontal disease status during pregnancy and 3 months post-partum in rural population of Sri-Lankan women J Clin Periodontol 200027787-92
bull 52 Laine M Tenovuo J Lehtonen OP Ojanatko-Harri A Vilja P Tuohimaa P Pregnancy e related changes in human whole saliva Arch Oral Biol 198833913-7
bull 53 Yuan K Wing LY Lin MT Pathogenetic roles of angiogenic factors in pyogenic granulomas in pregnancy are modulated by female sex hormones J Periodontol 200273701-8
bull 54 Evans RD Briggs PF Tooth-surface loss related to pregnancyinduced vomiting Prim Dent Care 1994124-6
bull 55 Salvolini E Di Giorgio R Curatola A Mazzanti L Fratto G Biochemical modifications of human whole saliva induced by pregnancy Br J Obstet Gynaec 1998105656-60
bull 56 Mauldin JG Newman RB Preterm birth risk assessment Semin Perinatol 200125215-22
bull 57 Heine RP McGregor JA Goodwin TM Artal R Hayashi RH Robertson PA et al Serial salivary estriol to detect an increased risk of preterm birth Obstet Gynecol 200096490-7
bull 58 Kauh YC Zachian TF Melasma Adv Exp Med Biol 1999455 491-9
bull 59 Wong RC Ellis CN Physiologic skin changes in pregnancy J Am Acad Dermatol 198410929-40
bull 60 Errickson CV Matus NR Skin disorders of pregnancy Am Fam Physician 199449605-10
bull 61 Lopez NJ Smith PC Gutierrez J Periodontal therapy may reduce the risk of preterm low birth weight in women with periodontal disease a randomized controlled trial J Periodontol 200273911-24
bull 62 McGaw T Periodontal disease and preterm delivery of lowbirth- weight infants J Can Dent Assoc 200268165-9
bull 63 Richards AG Dental x-ray protection Dent Clin North Am 1968631-41
bull 64 1990 Recommendations of the International Commission on Radiological Protection Ann ICRP 1991211-201
bull 65 Hall EJ Radiation the two-edged sword cancer risks at high and low doses Cancer J 20006343-50
bull 66 Diethelm L Xu H Diagnostic imaging of the lung during pregnancy Clin Obstet Gynecol 19963936-55
bull 67 Brent RL The effects of embryonic and fetal exposure to x-rays microwaves and ultrasound ClinObstetGynecol 198326484-510
bull 68 National Council on Radiation Protection NCRP report no128 1998 Bethesda Md Author
bull 69 Wasylko L Matsui D Dykxhoorn SM Reider MJ Weinberg S A review of common dental treatments during pregnancy implications for patients and dental personnel J Can Dent Assoc 199864434-9
bull 70 Freeman JP Brand JW Radiation doses of commonly used dental radiographic surveys Oral Surg Oral Med Oral Pathol 199477285-9
bull 71 Kircos LTAngin LL Lorton LOrder ofmagnitude dose reduction in intraoral radiography J Am Dent Assoc 1987114344-7
bull 72 Updegrave WJ Simplified and standardized intraoral radiography with reduced tissue irradiation J Am Dent Assoc 197285861-9
bull 73 Wood RE Harris AM van der Merwe EJ Nortje CJ The leaded apron revisited does it reduce gonadal radiation dose in dental radiology Oral Surg Oral Med Oral Pathol 199171642-6
bull 74 An update on radiographic practices information and recommendations ADA Council on Scientific Affairs J Am Dent Assoc 2001132234-8
bull 75 Rayburn WF Recommending medications during pregnancy an evidence based approach Clin Obstet Gynecol 2002451-5
bull 76 Rathmell JP Viscomi C Ashburn MA Management of nonobstetric pain during pregnancy and lactation Anesth Analg 1997851074-87
bull 77 Teratology society public affairs committee FDA classification of drugs for teratogenic risk Teratology 199449446-7
bull 78 Moore PA Selecting drugs for the pregnant dental patient J Am Dent Assoc 19981291281-6
bull 79 Haas DA An update on analgesics for the management of acute postoperative dental pain J Can Dent Assoc 200268476-82
bull 80 Haas DA Pynn BR Sands TD Drug use for the pregnant or lactating patient Gen Dent 20004854-60
bull 81 Committee on Drugs American Academy of Pediatrics The transfer of drugs and other chemicals into human milk Pediatrics 199493137-50
bull 82 Nielsen GL Sorensen HT Larsen H Pedersen L Risk of adverse birth outcome and miscarriage in pregnant users of nonsteroidal anti-inflammatory drugs population based observational study and case-control study BMJ 2001322266-70
bull 83 Janssen N Genta M The effects of immunosuppressive and anti-inflammatory medications on fertility pregnancy and lactation Arch Intern Med 200016610-9
bull 84 Ostensen M Nonsteroidal anti-inflammatory drugs during pregnancy Scand J Rheumatol Suppl 1998107128-32
bull 85 USPDI -Drug information for the health care professional 22nd ed Greenwood Village CO Micromedex 2002 p 152-79
bull 86 Denson DD Coyle DE Thompson GA Santos D Turner PA Myers JA et al Bupivacaine protein binding in the term parturient effects of lactic acidosis Clin Pharmacol Ther 198435702-9
bull 87 Dillon DE Wagner CL Wiest D Newman RB Drug therapy in the nursing mother Obstet Gynecol Clin North Am 199724 675-96
bull 88 Dashe JS Gilstrap LC Antibiotic use in pregnancy Obstet Gynecol Clin North Am 199724617-29
bull 89 American College of Rheumatology Ad hoc Committee on Clinical Guidelines Guidelines for monitoring drug therapy in rheumatoid arthritis Arthritis Rheum 199639723-31
bull 90 Ng PC The fetal and neonatal hypothalamic-pituitary-adrenal axis Arch Dis Child Fetal Neonatal Ed 200082F250-4
bull 91 Crowley P Antenatal corticosteroidsmdashcurrent thinking BJOG 2003110(Suppl 20)77-8
bull 92 ACOG committee opinion antenatal corticosteroid therapy for fetal maturation Obstet Gynecol 200299871-3
bull 93 Ost L Wettrell G Bjorkhem I Rane A Prednisolone excretion in human milk J Pediatr 19851061008-11
bull 94 Rowland AS Baird DD Shore DL Weinberg CR Savitz DA Wilcox AJ Nitrous oxide and spontaneous abortion in female dental assistants Am J Epidemiol 1995141531-8
bull 95 McGlothlin JD Jensen PA Fischbach TJ Hughes RT Jones JH Control of anesthetic gases in dental operatories Scand J Work Environ Health 199218(Suppl 2)103-5
bull ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY Volume 97 Number 6 Suresh and Radfar 681
bull 96 Rosen MA Nitrous oxide for relief of labor pain a systematic review Am J Obstet Gynecol 2002186(Suppl Nature)S110-6
bull 97 Sands TD Pynn BR Management considerations for the pregnant or nursing emergency patient Ont Dent 199875 17-9
bull 98 Daya S Recurrent spontaneous early pregnancy loss and low dose aspirin Minerva Ginecol 200355441-9
bull 99 Sinclair C Handbook of obstetrical emergencies 1st ed Philadelphia WB Saunders 1996 p 29-39 69
bull 100 Tarsitano BF Rollings RE The pregnant dental patient evaluation and management Gen Dent 199341226-34
bull 101 Livingston MH Dlllinger TM Holder R Consideration in the management of the pregnant patient SCD Special Care in Dentistry 199818183-8
Thank you
- A Review on the principle of Dental Management of the Pregnant patient
- Slide 2
- Questions that a dentist may ask
- Stages of Pregnancy
- Slide 5
- Slide 6
- Physiologic Changes in Pregnancy
- Systemic changes in pregnancy
- FLAT SUPINE POSITIONING
- SUPINE HYPOTENSION SYNDROME (Vena Cava Compression)
- Supine Hypotension Syndrome
- Slide 12
- Supine Hypotension Syndrome
- Prevention of Supine Hypotensive Syndrome
- Treatment of Supine Hypotensive Syndrome
- How should the pregnant woman be positioned
- Slide 17
- Slide 18
- Slide 19
- Slide 20
- Slide 21
- Slide 22
- Slide 23
- Pregnancy Related Oral Health Problems
- Oral Problems in Pregnancy
- Pregnancy Gingivitis Pathophysiology
- Pregnancy Gingivitis
- Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Gum Problems - Pregnancy Granuloma
- Slide 31
- Gum Changes - Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Candidiasis
- Pregnancy Myths
- Other Oral Conditions in Pregnancy
- Changes During Pregnancy that Affect Oral Health
- Saliva changes
- Increased Bacteria
- Slide 40
- Enamel erosion caused by frequent vomiting
- Treatment for Acid Exposure
- Oral Diseases Can Effect Pregnancy
- Periodontal Disease and Preterm Labor
- Periodontal Disease and Low Birth Weight
- Periodontal Disease and Preeclampsia
- Periodontitis and Pre-eclampsia
- Dental Considerations
- Treatment Timing
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Slide 52
- Use of Radiation on Pregnant Patient
- Radiographs during Pregnancy
- Risks of Dental X-Rays
- FDA drug classification for pregnancy
- Slide 57
- FDA drug classification for pregnancy
- Slide 59
- Slide 60
- Slide 61
- Common Analgesics
- Analgesics
- Analgesics - continued
- Analgesics to Use During 1st and 2nd Trimester
- Analgesics to Avoid During the Third Trimester
- Sedation in Pregnancy
- Common Antibiotics
- Antibiotics
- Antibiotics To Use During Pregnancy
- Antibiotics to Avoid during Pregnancy
- The Problem With Tetracycline
- Other Antimicrobial Agents
- Local Anesthetic Use in Pregnancy
- Use of Local Anesthetics
- Ulcer healing drugs
- Slide 77
- Slide 78
- Slide 79
- Use of Nitrous Oxide Gas
- Common Preventives
- Are topical agents safe
- Pre-natal Fluoride
- Is it safe to use mercury restorations
- References
- REFERENCES
- Slide 87
- Slide 88
- Slide 89
- Slide 90
- Slide 91
- Slide 92
- Slide 93
- Slide 94
- Slide 95
- Slide 96
- Slide 97
- Slide 98
- Thank you
-
Pregnancy MythsbullldquoA mother loses a tooth for every babyrdquobullNo evidence that aphthous ulcers are any more common in pregnancy
Other Oral Conditions in Pregnancy
bull Dry mouthbull Excessive salivationbull Tooth erosions associated with
severe GERD or hyperemesis
Changes During Pregnancy that Affect Oral Health
bull Hormonal Affects
ndash Increased tooth mobility
ndash Saliva changes
ndash Increased bacteria
ndash Gingival problems
Saliva changesbull Decreased buffers
bull Decreased minerals
bull Decreasing flow first and last trimester
bull Increased flow second trimester
bull More acidic
Increased Bacteriabull Increased acidity
ndash Increase in decay-causing bacteriabull Increased Snacking
ndash Morning sicknesslow blood sugarndash Between-meal snacks
bull Increase in amount and frequency of starchescarbohydrates ndash Crackers are commonly recommendedndash Promotes decay-causing bacteria
Changes During Pregnancy that Affect Oral Healthbull Morning sickness
ndash Difficulty with hygienebull Gingival diseasebull Tooth decay
ndash Vomitingbull Esophogeal Reflux (heartburn)bull Acid exposure
ndash Irritation of the gumsndash Weakening of tooth enamelndash Dental erosion
Enamel erosion caused by frequent vomiting
Treatment for Acid Exposure
bull Do NOT brush immediately after vomiting
bull Rinse ndash Water with baking sodandash Antacidndash Plain water
bull Eat some cheese
Oral Diseases Can Effect Pregnancy
bull Preterm low birth weight (LBW) linked to periodontal disease
bull Thorough calculus (tartar) removal in pregnant women with periodontitis may reduce pre-term births
Periodontal Disease and Preterm LaborbullMaternal periodontal disease is associated with increased risk of preterm laborbullAnaerobic oral gram-negative bacteria cause inflammatory responsebullInflammatory response stimulates prostaglandin and cytokine production to stimulate labor
Periodontal Disease and Low Birth Weight
bull Periodontal disease is associated with low birth weight
bull Evidence is not conclusivebull Biochemical mechanism similar cascade
as in preterm labor leading to placental blood flow restriction and necrosis
Periodontal Disease and Preeclampsia
bull Emerging databull Mechanism unclearbull Proposed mechanism
ndash Periodontal infection leads to inflammatory vascular damage
ndash Triggers cell damage in placenta
Periodontitis and Pre-eclampsia
bull Periodontal disease may be associated with pre-eclampsia (Boggess 2003)
bull PGE2 IL-1 and TNF-α from gingival crevicular fluid were higher in women with preeclampsia compared with healthy matched pregnant women (Oettinger-Barak 2003)
Dental Considerations
bull timing of treatment for pregnant patientsbull dental radiation exposurebull use of local anestheticsbull prescription of common antibiotics and
analgesicsbull nitrous oxide gas administration
Treatment Timing
bull First Trimesterndash Spontaneous miscarriages naturally occur
more often in 1st trimesterndash Avoid elective treatment that can be delayedndash Offer anticipatory guidance
bull Second Trimesterndash The optimal time for dental treatmentndash Organogenesis complete fetus not largendash Easier to prevent than treat established disease
bull Third Trimesterndash Late in term very uncomfortable (short visits)ndash Position slightly on left side
Timing of Dental Treatment During Pregnancy - From Little and Fallace
First Trimester
bull Plaque controlbull Oral hygiene instructionbull Scaling polishing curettagebull Avoid elective treatment urgent care
only
Timing of Dental Treatment During Pregnancy - From Little and Fallace
Second Trimester
bull Plaque controlbull Oral hygiene instructionbull Scaling polishing curettagebull Routine dental care
Timing of Dental Treatment During Pregnancy - From Little and Fallace
Third Trimester
bull Plaque controlbull Oral hygiene instructionbull Scaling polishing curettagebull Routine dental care (after middle of third
trimester elective care should be avoided)
Use of Radiation on Pregnant Patientbull Dose given and time of gestation are
importantbull doses lt 5-10 rads (cGy) not teratogenicbull fetus is most susceptible to radiation
between the 2nd and 6th week of gestationbull single dental x-ray exposes patient to 001
millirads of radiation In relative terms this amount is 40 times less than daily dose acquired from cosmic radiation Therefore diagnostic radiation should not be withheld during pregnancy
Radiographs during Pregnancy
bull Take as needed with optimal methods for reducing secondary radiation and exposure time
bull Always use a lead apronbull Exposure to fetus (with apron use) is 00001
centiGray(rad)bull Daily cosmic radiation - 0004 centiGray (rad)
Risks of Dental X-Rays
bull X-ray only if necessary (ie root canal therapy trauma)
bull When x-rays are indicated radiation exposure is extremely low
bull Exposure can be limited byndash Lead apron shielding ndash Modern fast film ndash Avoiding retakes
FDA drug classification for pregnancybull Combines risk statements including
congenital anomalies fetal effects perinatal risks and therapeutic risk-benefit ratio
bull Untreated disease or condition may pose more serious risks to both mother and fetus than any theoretical risks from the medication
bull Category A thru D and X
FDA drug classification for pregnancy
bull A = Controlled Studies in women fail to demonstrate a risk to the fetus in the first trimester and the possibility of fetal harm appears remote
FDA drug classification for pregnancy
bull B = Animal studies show no risk or if risk shown in animals controlled
trials in women showed no risk
FDA drug classification for pregnancy
bull C = Studies in animals with adverse effects and no human studies
OR no animal or human studies but benefits of use may outweigh potential harms
FDA drug classification for pregnancy
bull D = There is evidence of human fetal risk but benefits may outweigh risks
FDA drug classification for pregnancy
bull X = Contraindicated
Common Analgesics
bull paracetamol (B)bull Ibuprofen (BD) bull Oxycodone (BD) bull Hydrocodone and codeine
(CD)
avoid in third trimester
Analgesics
bull Paracetamol is the analgesic of choice for all stages of gestation
bull used to treat mild to moderate pain and fevers
bull short term usage is believed to be safebull avoid chronic and large doses of
paracetamol1048715
Analgesics - continuedbull Aspirin is nonteratogenic but may cause
maternal and fetal hemorrhagebull large and chronic doses during last trimester
may result in premature closure of ductus arteriosus fetal hypertension anemia and low birth weight
bull avoid ibuprofen in 3rd trimester because of possible adverse circulatory effects
bull short term use of codeine seems safebull avoid codeine late in gestation because of
possible fetal respiratory depression and withdrawal symptoms
Analgesics to Use During1st and 2nd Trimester
bull Category B (for best)bull Paracetamol Ibuprofenbull Naproxenbull Category C (use with caution)bull Paracetamol with codeine or
hydrocodonebull Paracetamol with oxycodone
Analgesics to Avoid During theThird Trimesterbull Causes delivery problemsbull Aspirin (C 3D)bull Ibuprofen (B3D)bull Naproxen (B3D)bull Causes neonatal respiratory
depression and opioid withdrawalbull Codeine (C3D)bull Hydrocodone (C3D)bull Oxycodone(C3D)
Sedation in Pregnancy
bull SedativesAnxiolytics (eg Diazepam ) are rated D and can cause oral clefts with prolonged exposure
bull Nitrous oxide should not be used in 1st trimester (If used in 2nd and 3rd do not go below 50 O2)
Common Antibioticsbull To treat oral abscess or cellulitis
ndash Penicillin (B) ndash Amoxicillin (B) ndash Cephalexin (B)ndash Erythromycin base (B) (Not estolate as it
cause cholestatic hepatitis)ndash Clindamycin (B)
Antibioticsbull penicillin V and amoxicillin is preferred drug
for mild to moderate infectionsbull widely used for many years with no ill effectsbull no studies show penicillin to be teratogenicbull amoxicillin extensively used without harming
the fetusbull Drug classes1048715 B penicillin cephalosporins erythromycin clindamycin Azithromycin D Tetracycline
Antibiotics To Use During Pregnancy
bull Penicillin Vbull Amoxicillinbull Erythromycin (base form)bull Cephalexin cephalosporinbull Clindamycinbull Metronidazole
Antibiotics to Avoid duringPregnancy
bull Doxycyclinebull Tetracyclinebull Erythromycin (estolate form)bull Vancomycin
The Problem With Tetracycline
bull Accumulates in bones and chelates calcium
bull Inhibits bone growthbull Discolors teeth
Other Antimicrobial Agentsbull OK to usebull Nystatin (B)bull Chlorhexidine rinse (B)bull Use with cautionbull Clotrimazole (C)bull Ketoconazole (C)bull Fluconazole (C)bull Do not usebull Doxycycline (D)
Local Anesthetic Use inPregnancy
bull Class Bbull Lidocaine (Xylocaine)bull Etidocainebull Prilocaine bull Class Cbull Procainebull Bupivicainebull Mepivicaine
Use of Local Anestheticsbull Lidocaine + vasoconstrictor most common
local anesthetic used in dentistrybull extensively used in pregnancy with no proven ill
effectsbull accidental intravascular injections of lidocaine
pass through the placenta but the concentrations are too low to harm fetus
bull prilocaine might cause methemoglobinemia
Ulcer healing drugsCimetidine bull FDA category B Famotidinebull FDA category BRanitidinebull FDA category Bbull not known to be harmful
Ulcer healing drugsOmeprazolebull FDA category BNot known to be
harmful Esomeprazolebull FDA category BLansoprazolebull FDA category BPantoprazolebull Avoid unless potential benefit
outweighs riskmdashfetotoxic in animals
Ulcer healing drugs
Misoprostolbull First second third trimesters Avoidmdash
potent uterine stimulant (has been used to induce abortion) and may be teratogenic
Ulcer healing drugs
Antacidsbull Almunium hydroxideMagnesium
hydroxidemdashFDA category B Calcium carbonatemdashFDA category C
SimetheconemdashFDA category C
Use of Nitrous Oxide Gas
bull used over 150 years bull safety is being debatedbull SHORT TERM exposure do not cause
birth defects or spontaneous abortionbull CHRONIC exposure may result in fetal
loss and infertilitybull literature suggests that nitrous oxide
should be avoided until more conclusive research is available
bull FDA Drug class not yet assigned
Common Preventives
bull Fluoridendash No increased risk during pregnancy
bull Xylitolndash No studies no harm reported
bull Chlorhexidinendash No increased risk during pregnancy
Are topical agents safe
bull Fluoridebull Toothpaste amp mouthrinse
bull Xylitol chewing gum bull Chlorhexidine (11 alcohol)bull No over the counter mouthrinses with
alcohol (Listerine 20 alcohol)
Pre-natal Fluoride
bull Daily 22 mg tablet of sodium fluoride during 3rd through 9th months
bull decreases caries rate in offspringbull Safe and effective
Glenn FB 1982
Is it safe to use mercury restorations
bull No evidence of harmful effect
bull Benefits outweigh risks
bull Canada Germany and New Zealand have some restrictions
bull Determine the best option
Referencesbull Wasylko L Matsui D Dykxhoorn SM Rieder MJ Weinberg
S A Review of Common Dental Treatments During Pregnancy J Canadian Dental Association 64434-439 1998
bull Little JW Donald AF Craig SM Rhodus NL Dental Management of the Medically Compromised Patient - 5th edition Mosby Toronto Pp434-442 1997
bull Livingston HM Dellinger TM Holder R Considerations in the management of the pregnant patient Special Care in Dentistry 185 pp183-188 1998
bull Larimore WL Petrie KA Drug use during pregnacy and lactation Primary Care Clinics in Office Practice 271 35-53 2000
bull Health Canada The Safety of DentalAmalgam Minister Of Supply and Services Canada 1996
REFERENCESbull 1 Weiss G Endocrinology of parturition J Clin
Endocrinol Metab 2000854421-5bull 2 Theunissen IM Parer JT Fluid and electrolytes in
pregnancy Clin Obstet Gynecol 1994373-15bull 3 Duvekot JJ Peeters LLH Renal hemodynamics and
volume homeostasis in pregnancy Obstet Gynecol Surv 199449830-9
bull 4 Barron WM Lindheimer MD Medical disorders during pregnancy 2nd ed St Louis Mosby 1995 p 129
bull 5 Thornburg KL Jacobson SL Giraud GD Morton MJ Hemodynamic changes in pregnancy Semin Perinatol 20002411-4
bull 6 Fiese R Herzog S Issues in dental and surgical management of the pregnant patient Oral Surg Oral Med Oral Pathol 198865292-7
bull 7 Martin C Varner MW Physiologic changes in pregnancysurgical implications Clin Obstet Gynecol 199437241-55
bull 8 Clark SL Cotton DB Lee W Bishop C Hill T Southwick J et al Central hemodynamic assessment of normal term pregnancy Am J Obstet Gynecol 19891611439-42
bull 9 Mabie WC Di Sessa TG Crocker LG Sibai BM Arheart KL A longitudinal study of cardiac output in normal human pregnancy Am J Obstet Gynecol 1994170849-56
bull 10 Clapp JF 3rd Capeless E Cardiovascular function before during and after the first and subsequent pregnancies Am J Cardiol 1997801469-73
bull 11 Duvekot JJ Peeters LL Maternal cardiovascular hemodynamic adaptation to pregnancy Obstet Gynecol Surv 199449(Suppl) S1-14
bull 12 Bhagwat AR Engel PJ Heart disease and pregnancy Cardiol Clin 199513163-78
bull 13 Lanni SM Tillinghast J Silver H Hemodynamic changes and baroreflex gain in the supine hypotensive syndrome Am J Obstet Gynecol 20021871636-41
bull 14 Little JW Falace DA Miller CS Rhodus NL Dental management of the medically compromised patient 6th ed St Louis Mosby 2002 p 303
bull 15 Garcia-Rio F Pino JM Gomez L Alvarez-Sala R Villasante C Villamor J Regulation of breathing and perception of dyspnea in healthy pregnant women Chest 1996110446-53
bull 16 McAuliffe F Kametas N Costello J Rafferty GF Greenough A Nicolaides K Respiratory function in singleton and twin pregnancy BJOG 2002109765-9
bull 17 Clapp JF 3rd Seaward BL Sleamaker RH Hiser J Maternal physiologic adaptations to early human pregnancy Am J Obstet Gynecol 19881591456-60
bull 18 OrsquoDay MP Cardio-respiratory physiological adaptation of pregnancy Semin Perinatol 199721268-75
bull 19 Contreras G Gutierrez M Beroiza T Fantin A Oddo H Villarroel L et al Ventilatory drive and respiratory muscle function in pregnancy Am Rev Respir Dis 1991144837-41
bull 20 Turner M Aziz SR Management of the pregnant oral and maxillofac
bull 21 Sifakis S Pharmakides G Anemia in pregnancy Ann N Y Acad Sci 2000900125-36
bull 22 Branch DW Physiologic adaptations of pregnancy Am J Reprod Immunol 199228120-2
bull 23 Burrows RF Kelton JG Incidentally detected thrombocytopenia in healthy mothers and their infants N Engl J Med 1988319 142-5
bull 24 Hanly JG Antiphospholipid syndrome an overview CMAJ 200324(168)1675-82
bull 25 Heilmann L von Tempelhoff GF Pollow K Antiphospholipid syndrome in obstetrics Clin Appl Thromb Hemost 20039 143-50
bull 26 Sherman P Flaxman SM Nausea and vomiting of pregnancy in an evolutionary perspective Am J Obstet Gynecol 2002 185(Suppl)s190-7
bull 27 Koch KL Gastrointestinal factors in nausea and vomiting of pregnancy Am J Obstet Gynecol 2002185(Suppl)s198-203
bull 28 Koch KL Frissora CL Nausea and vomiting during pregnancy Gastroenterol Clin N Am 200332201-34
bull 29 Baron TH Ramirez B Richter JE Gastrointestinal motility disorders during pregnancy Ann Intern Med 1993118 366-75
bull 30 Richter JE Gastroesophageal reflux disease during pregnancy Gastroenterol Clin N Am 200332235-61
bull 31 Marrero JM Goggin PM de Caestecker JS Pearce JM Maxwell JD Determinants of pregnancy heartburn Br J Obstet Gynaecol 199299731-4
bull 32 Hamaoui E Hamaoui M Nutritional assessment and support during pregnancy Gastroenterol Clin N Am 20033259-121
bull 33 King JC Physiology of pregnancy and nutrient metabolism Am J Clin Nutr 200071(suppl)1218s-25s
bull 34 Casanueva E Pfeffer F Fernandez-Gaxiola AC Gutierrez- Valenzuela V Rothenberg SJ Iron and folate status before pregnancy and anemia during pregnancy Ann Nutr Metab 2003 4760-3
bull 35 Chrsquong CL Morgan M Hainsworth I Kingham JG Prospective study of liver dysfunction in Southwest Wales Gut 200251 876-80
bull 36 Rahman TM Wendon J Severe hepatic dysfunction in pregnancy QJM 200295343-57
bull 37 Knox TA Olans LB Liver disease in pregnancy N Engl J Med 1996335569-76
bull 38 Saftlas AF Olson DR Franks AL Atrash H Pokras R Epidemiology of preeclampsia and eclampsia in the United States 1979e1986 Am J Obstet Gynecol 1990163460-5
bull 39 Walker JJ Pre-eclampsia Lancet 20003561260-5
bull 40 Davidson JM Renal disorders in pregnancy Curr Opin Obstet Gynecol 200113109-14
bull 41 Dafnis E Sabatini S The effect of pregnancy on renal function physiology and pathophysiologyAmJMedSci 1992303184-205
bull 42 Davison JM Shiells EA Philips PR Lindheimer MD Serial evaluation of vasopressin release and thirst in human pregnancy Role of human chorionic gonadotrophin in the osmoregulatory changes of gestation J Clin Invest 198881798-806
bull 43 Glinoer D de Nayer P Bourdoux P Lemone M Robyn C van Steirteghem A et al Regulation of maternal thyroid during pregnancy J Clin Endocrinol Metab 199071276-87
bull 44 Wilson SG Retallack RW Kent JC Worth GK Gutteridge DH Serum free 125-dihydroxyvitamin D and the free 125- dihydroxyvitamin D index during a longitudinal study of human pregnancy and lactation Clin Endocrinol 199032613-22
bull 45 Rasmussen N Frolich A Hornnes PJ Hegedus L Serum ionized calcium and intact parathyroid hormone levels during pregnancy and postpartum Br J Obstet Gynaecol 199097857-9
bull 46 Guyton AC Textbook of medical physiology 8th ed Philadelphia W B Saunders 1991 p 915e28
bull 47 Trainer PJ Corticosteroids and pregnancy Semin Reprod Med 200220375-80
bull 48 Soory M Hormonal factors in periodontal disease Dent Update 200027380-3
bull 49 Hugoson A Gingivitis in pregnant women A longitudinal clinical study Odontol Revy 19712265-84
bull 50 Neville BW Damm DD Allen CM Bouquot JE Oral amp Maxillofacial Pathology 3rd ed Philadelphia W B Saunders 2002 p 329-30 447-9
bull 51 Tilakaratne A Soory M Ranasinghe AW Corea SM Ekanayake SL de Silva M Periodontal disease status during pregnancy and 3 months post-partum in rural population of Sri-Lankan women J Clin Periodontol 200027787-92
bull 52 Laine M Tenovuo J Lehtonen OP Ojanatko-Harri A Vilja P Tuohimaa P Pregnancy e related changes in human whole saliva Arch Oral Biol 198833913-7
bull 53 Yuan K Wing LY Lin MT Pathogenetic roles of angiogenic factors in pyogenic granulomas in pregnancy are modulated by female sex hormones J Periodontol 200273701-8
bull 54 Evans RD Briggs PF Tooth-surface loss related to pregnancyinduced vomiting Prim Dent Care 1994124-6
bull 55 Salvolini E Di Giorgio R Curatola A Mazzanti L Fratto G Biochemical modifications of human whole saliva induced by pregnancy Br J Obstet Gynaec 1998105656-60
bull 56 Mauldin JG Newman RB Preterm birth risk assessment Semin Perinatol 200125215-22
bull 57 Heine RP McGregor JA Goodwin TM Artal R Hayashi RH Robertson PA et al Serial salivary estriol to detect an increased risk of preterm birth Obstet Gynecol 200096490-7
bull 58 Kauh YC Zachian TF Melasma Adv Exp Med Biol 1999455 491-9
bull 59 Wong RC Ellis CN Physiologic skin changes in pregnancy J Am Acad Dermatol 198410929-40
bull 60 Errickson CV Matus NR Skin disorders of pregnancy Am Fam Physician 199449605-10
bull 61 Lopez NJ Smith PC Gutierrez J Periodontal therapy may reduce the risk of preterm low birth weight in women with periodontal disease a randomized controlled trial J Periodontol 200273911-24
bull 62 McGaw T Periodontal disease and preterm delivery of lowbirth- weight infants J Can Dent Assoc 200268165-9
bull 63 Richards AG Dental x-ray protection Dent Clin North Am 1968631-41
bull 64 1990 Recommendations of the International Commission on Radiological Protection Ann ICRP 1991211-201
bull 65 Hall EJ Radiation the two-edged sword cancer risks at high and low doses Cancer J 20006343-50
bull 66 Diethelm L Xu H Diagnostic imaging of the lung during pregnancy Clin Obstet Gynecol 19963936-55
bull 67 Brent RL The effects of embryonic and fetal exposure to x-rays microwaves and ultrasound ClinObstetGynecol 198326484-510
bull 68 National Council on Radiation Protection NCRP report no128 1998 Bethesda Md Author
bull 69 Wasylko L Matsui D Dykxhoorn SM Reider MJ Weinberg S A review of common dental treatments during pregnancy implications for patients and dental personnel J Can Dent Assoc 199864434-9
bull 70 Freeman JP Brand JW Radiation doses of commonly used dental radiographic surveys Oral Surg Oral Med Oral Pathol 199477285-9
bull 71 Kircos LTAngin LL Lorton LOrder ofmagnitude dose reduction in intraoral radiography J Am Dent Assoc 1987114344-7
bull 72 Updegrave WJ Simplified and standardized intraoral radiography with reduced tissue irradiation J Am Dent Assoc 197285861-9
bull 73 Wood RE Harris AM van der Merwe EJ Nortje CJ The leaded apron revisited does it reduce gonadal radiation dose in dental radiology Oral Surg Oral Med Oral Pathol 199171642-6
bull 74 An update on radiographic practices information and recommendations ADA Council on Scientific Affairs J Am Dent Assoc 2001132234-8
bull 75 Rayburn WF Recommending medications during pregnancy an evidence based approach Clin Obstet Gynecol 2002451-5
bull 76 Rathmell JP Viscomi C Ashburn MA Management of nonobstetric pain during pregnancy and lactation Anesth Analg 1997851074-87
bull 77 Teratology society public affairs committee FDA classification of drugs for teratogenic risk Teratology 199449446-7
bull 78 Moore PA Selecting drugs for the pregnant dental patient J Am Dent Assoc 19981291281-6
bull 79 Haas DA An update on analgesics for the management of acute postoperative dental pain J Can Dent Assoc 200268476-82
bull 80 Haas DA Pynn BR Sands TD Drug use for the pregnant or lactating patient Gen Dent 20004854-60
bull 81 Committee on Drugs American Academy of Pediatrics The transfer of drugs and other chemicals into human milk Pediatrics 199493137-50
bull 82 Nielsen GL Sorensen HT Larsen H Pedersen L Risk of adverse birth outcome and miscarriage in pregnant users of nonsteroidal anti-inflammatory drugs population based observational study and case-control study BMJ 2001322266-70
bull 83 Janssen N Genta M The effects of immunosuppressive and anti-inflammatory medications on fertility pregnancy and lactation Arch Intern Med 200016610-9
bull 84 Ostensen M Nonsteroidal anti-inflammatory drugs during pregnancy Scand J Rheumatol Suppl 1998107128-32
bull 85 USPDI -Drug information for the health care professional 22nd ed Greenwood Village CO Micromedex 2002 p 152-79
bull 86 Denson DD Coyle DE Thompson GA Santos D Turner PA Myers JA et al Bupivacaine protein binding in the term parturient effects of lactic acidosis Clin Pharmacol Ther 198435702-9
bull 87 Dillon DE Wagner CL Wiest D Newman RB Drug therapy in the nursing mother Obstet Gynecol Clin North Am 199724 675-96
bull 88 Dashe JS Gilstrap LC Antibiotic use in pregnancy Obstet Gynecol Clin North Am 199724617-29
bull 89 American College of Rheumatology Ad hoc Committee on Clinical Guidelines Guidelines for monitoring drug therapy in rheumatoid arthritis Arthritis Rheum 199639723-31
bull 90 Ng PC The fetal and neonatal hypothalamic-pituitary-adrenal axis Arch Dis Child Fetal Neonatal Ed 200082F250-4
bull 91 Crowley P Antenatal corticosteroidsmdashcurrent thinking BJOG 2003110(Suppl 20)77-8
bull 92 ACOG committee opinion antenatal corticosteroid therapy for fetal maturation Obstet Gynecol 200299871-3
bull 93 Ost L Wettrell G Bjorkhem I Rane A Prednisolone excretion in human milk J Pediatr 19851061008-11
bull 94 Rowland AS Baird DD Shore DL Weinberg CR Savitz DA Wilcox AJ Nitrous oxide and spontaneous abortion in female dental assistants Am J Epidemiol 1995141531-8
bull 95 McGlothlin JD Jensen PA Fischbach TJ Hughes RT Jones JH Control of anesthetic gases in dental operatories Scand J Work Environ Health 199218(Suppl 2)103-5
bull ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY Volume 97 Number 6 Suresh and Radfar 681
bull 96 Rosen MA Nitrous oxide for relief of labor pain a systematic review Am J Obstet Gynecol 2002186(Suppl Nature)S110-6
bull 97 Sands TD Pynn BR Management considerations for the pregnant or nursing emergency patient Ont Dent 199875 17-9
bull 98 Daya S Recurrent spontaneous early pregnancy loss and low dose aspirin Minerva Ginecol 200355441-9
bull 99 Sinclair C Handbook of obstetrical emergencies 1st ed Philadelphia WB Saunders 1996 p 29-39 69
bull 100 Tarsitano BF Rollings RE The pregnant dental patient evaluation and management Gen Dent 199341226-34
bull 101 Livingston MH Dlllinger TM Holder R Consideration in the management of the pregnant patient SCD Special Care in Dentistry 199818183-8
Thank you
- A Review on the principle of Dental Management of the Pregnant patient
- Slide 2
- Questions that a dentist may ask
- Stages of Pregnancy
- Slide 5
- Slide 6
- Physiologic Changes in Pregnancy
- Systemic changes in pregnancy
- FLAT SUPINE POSITIONING
- SUPINE HYPOTENSION SYNDROME (Vena Cava Compression)
- Supine Hypotension Syndrome
- Slide 12
- Supine Hypotension Syndrome
- Prevention of Supine Hypotensive Syndrome
- Treatment of Supine Hypotensive Syndrome
- How should the pregnant woman be positioned
- Slide 17
- Slide 18
- Slide 19
- Slide 20
- Slide 21
- Slide 22
- Slide 23
- Pregnancy Related Oral Health Problems
- Oral Problems in Pregnancy
- Pregnancy Gingivitis Pathophysiology
- Pregnancy Gingivitis
- Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Gum Problems - Pregnancy Granuloma
- Slide 31
- Gum Changes - Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Candidiasis
- Pregnancy Myths
- Other Oral Conditions in Pregnancy
- Changes During Pregnancy that Affect Oral Health
- Saliva changes
- Increased Bacteria
- Slide 40
- Enamel erosion caused by frequent vomiting
- Treatment for Acid Exposure
- Oral Diseases Can Effect Pregnancy
- Periodontal Disease and Preterm Labor
- Periodontal Disease and Low Birth Weight
- Periodontal Disease and Preeclampsia
- Periodontitis and Pre-eclampsia
- Dental Considerations
- Treatment Timing
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Slide 52
- Use of Radiation on Pregnant Patient
- Radiographs during Pregnancy
- Risks of Dental X-Rays
- FDA drug classification for pregnancy
- Slide 57
- FDA drug classification for pregnancy
- Slide 59
- Slide 60
- Slide 61
- Common Analgesics
- Analgesics
- Analgesics - continued
- Analgesics to Use During 1st and 2nd Trimester
- Analgesics to Avoid During the Third Trimester
- Sedation in Pregnancy
- Common Antibiotics
- Antibiotics
- Antibiotics To Use During Pregnancy
- Antibiotics to Avoid during Pregnancy
- The Problem With Tetracycline
- Other Antimicrobial Agents
- Local Anesthetic Use in Pregnancy
- Use of Local Anesthetics
- Ulcer healing drugs
- Slide 77
- Slide 78
- Slide 79
- Use of Nitrous Oxide Gas
- Common Preventives
- Are topical agents safe
- Pre-natal Fluoride
- Is it safe to use mercury restorations
- References
- REFERENCES
- Slide 87
- Slide 88
- Slide 89
- Slide 90
- Slide 91
- Slide 92
- Slide 93
- Slide 94
- Slide 95
- Slide 96
- Slide 97
- Slide 98
- Thank you
-
Other Oral Conditions in Pregnancy
bull Dry mouthbull Excessive salivationbull Tooth erosions associated with
severe GERD or hyperemesis
Changes During Pregnancy that Affect Oral Health
bull Hormonal Affects
ndash Increased tooth mobility
ndash Saliva changes
ndash Increased bacteria
ndash Gingival problems
Saliva changesbull Decreased buffers
bull Decreased minerals
bull Decreasing flow first and last trimester
bull Increased flow second trimester
bull More acidic
Increased Bacteriabull Increased acidity
ndash Increase in decay-causing bacteriabull Increased Snacking
ndash Morning sicknesslow blood sugarndash Between-meal snacks
bull Increase in amount and frequency of starchescarbohydrates ndash Crackers are commonly recommendedndash Promotes decay-causing bacteria
Changes During Pregnancy that Affect Oral Healthbull Morning sickness
ndash Difficulty with hygienebull Gingival diseasebull Tooth decay
ndash Vomitingbull Esophogeal Reflux (heartburn)bull Acid exposure
ndash Irritation of the gumsndash Weakening of tooth enamelndash Dental erosion
Enamel erosion caused by frequent vomiting
Treatment for Acid Exposure
bull Do NOT brush immediately after vomiting
bull Rinse ndash Water with baking sodandash Antacidndash Plain water
bull Eat some cheese
Oral Diseases Can Effect Pregnancy
bull Preterm low birth weight (LBW) linked to periodontal disease
bull Thorough calculus (tartar) removal in pregnant women with periodontitis may reduce pre-term births
Periodontal Disease and Preterm LaborbullMaternal periodontal disease is associated with increased risk of preterm laborbullAnaerobic oral gram-negative bacteria cause inflammatory responsebullInflammatory response stimulates prostaglandin and cytokine production to stimulate labor
Periodontal Disease and Low Birth Weight
bull Periodontal disease is associated with low birth weight
bull Evidence is not conclusivebull Biochemical mechanism similar cascade
as in preterm labor leading to placental blood flow restriction and necrosis
Periodontal Disease and Preeclampsia
bull Emerging databull Mechanism unclearbull Proposed mechanism
ndash Periodontal infection leads to inflammatory vascular damage
ndash Triggers cell damage in placenta
Periodontitis and Pre-eclampsia
bull Periodontal disease may be associated with pre-eclampsia (Boggess 2003)
bull PGE2 IL-1 and TNF-α from gingival crevicular fluid were higher in women with preeclampsia compared with healthy matched pregnant women (Oettinger-Barak 2003)
Dental Considerations
bull timing of treatment for pregnant patientsbull dental radiation exposurebull use of local anestheticsbull prescription of common antibiotics and
analgesicsbull nitrous oxide gas administration
Treatment Timing
bull First Trimesterndash Spontaneous miscarriages naturally occur
more often in 1st trimesterndash Avoid elective treatment that can be delayedndash Offer anticipatory guidance
bull Second Trimesterndash The optimal time for dental treatmentndash Organogenesis complete fetus not largendash Easier to prevent than treat established disease
bull Third Trimesterndash Late in term very uncomfortable (short visits)ndash Position slightly on left side
Timing of Dental Treatment During Pregnancy - From Little and Fallace
First Trimester
bull Plaque controlbull Oral hygiene instructionbull Scaling polishing curettagebull Avoid elective treatment urgent care
only
Timing of Dental Treatment During Pregnancy - From Little and Fallace
Second Trimester
bull Plaque controlbull Oral hygiene instructionbull Scaling polishing curettagebull Routine dental care
Timing of Dental Treatment During Pregnancy - From Little and Fallace
Third Trimester
bull Plaque controlbull Oral hygiene instructionbull Scaling polishing curettagebull Routine dental care (after middle of third
trimester elective care should be avoided)
Use of Radiation on Pregnant Patientbull Dose given and time of gestation are
importantbull doses lt 5-10 rads (cGy) not teratogenicbull fetus is most susceptible to radiation
between the 2nd and 6th week of gestationbull single dental x-ray exposes patient to 001
millirads of radiation In relative terms this amount is 40 times less than daily dose acquired from cosmic radiation Therefore diagnostic radiation should not be withheld during pregnancy
Radiographs during Pregnancy
bull Take as needed with optimal methods for reducing secondary radiation and exposure time
bull Always use a lead apronbull Exposure to fetus (with apron use) is 00001
centiGray(rad)bull Daily cosmic radiation - 0004 centiGray (rad)
Risks of Dental X-Rays
bull X-ray only if necessary (ie root canal therapy trauma)
bull When x-rays are indicated radiation exposure is extremely low
bull Exposure can be limited byndash Lead apron shielding ndash Modern fast film ndash Avoiding retakes
FDA drug classification for pregnancybull Combines risk statements including
congenital anomalies fetal effects perinatal risks and therapeutic risk-benefit ratio
bull Untreated disease or condition may pose more serious risks to both mother and fetus than any theoretical risks from the medication
bull Category A thru D and X
FDA drug classification for pregnancy
bull A = Controlled Studies in women fail to demonstrate a risk to the fetus in the first trimester and the possibility of fetal harm appears remote
FDA drug classification for pregnancy
bull B = Animal studies show no risk or if risk shown in animals controlled
trials in women showed no risk
FDA drug classification for pregnancy
bull C = Studies in animals with adverse effects and no human studies
OR no animal or human studies but benefits of use may outweigh potential harms
FDA drug classification for pregnancy
bull D = There is evidence of human fetal risk but benefits may outweigh risks
FDA drug classification for pregnancy
bull X = Contraindicated
Common Analgesics
bull paracetamol (B)bull Ibuprofen (BD) bull Oxycodone (BD) bull Hydrocodone and codeine
(CD)
avoid in third trimester
Analgesics
bull Paracetamol is the analgesic of choice for all stages of gestation
bull used to treat mild to moderate pain and fevers
bull short term usage is believed to be safebull avoid chronic and large doses of
paracetamol1048715
Analgesics - continuedbull Aspirin is nonteratogenic but may cause
maternal and fetal hemorrhagebull large and chronic doses during last trimester
may result in premature closure of ductus arteriosus fetal hypertension anemia and low birth weight
bull avoid ibuprofen in 3rd trimester because of possible adverse circulatory effects
bull short term use of codeine seems safebull avoid codeine late in gestation because of
possible fetal respiratory depression and withdrawal symptoms
Analgesics to Use During1st and 2nd Trimester
bull Category B (for best)bull Paracetamol Ibuprofenbull Naproxenbull Category C (use with caution)bull Paracetamol with codeine or
hydrocodonebull Paracetamol with oxycodone
Analgesics to Avoid During theThird Trimesterbull Causes delivery problemsbull Aspirin (C 3D)bull Ibuprofen (B3D)bull Naproxen (B3D)bull Causes neonatal respiratory
depression and opioid withdrawalbull Codeine (C3D)bull Hydrocodone (C3D)bull Oxycodone(C3D)
Sedation in Pregnancy
bull SedativesAnxiolytics (eg Diazepam ) are rated D and can cause oral clefts with prolonged exposure
bull Nitrous oxide should not be used in 1st trimester (If used in 2nd and 3rd do not go below 50 O2)
Common Antibioticsbull To treat oral abscess or cellulitis
ndash Penicillin (B) ndash Amoxicillin (B) ndash Cephalexin (B)ndash Erythromycin base (B) (Not estolate as it
cause cholestatic hepatitis)ndash Clindamycin (B)
Antibioticsbull penicillin V and amoxicillin is preferred drug
for mild to moderate infectionsbull widely used for many years with no ill effectsbull no studies show penicillin to be teratogenicbull amoxicillin extensively used without harming
the fetusbull Drug classes1048715 B penicillin cephalosporins erythromycin clindamycin Azithromycin D Tetracycline
Antibiotics To Use During Pregnancy
bull Penicillin Vbull Amoxicillinbull Erythromycin (base form)bull Cephalexin cephalosporinbull Clindamycinbull Metronidazole
Antibiotics to Avoid duringPregnancy
bull Doxycyclinebull Tetracyclinebull Erythromycin (estolate form)bull Vancomycin
The Problem With Tetracycline
bull Accumulates in bones and chelates calcium
bull Inhibits bone growthbull Discolors teeth
Other Antimicrobial Agentsbull OK to usebull Nystatin (B)bull Chlorhexidine rinse (B)bull Use with cautionbull Clotrimazole (C)bull Ketoconazole (C)bull Fluconazole (C)bull Do not usebull Doxycycline (D)
Local Anesthetic Use inPregnancy
bull Class Bbull Lidocaine (Xylocaine)bull Etidocainebull Prilocaine bull Class Cbull Procainebull Bupivicainebull Mepivicaine
Use of Local Anestheticsbull Lidocaine + vasoconstrictor most common
local anesthetic used in dentistrybull extensively used in pregnancy with no proven ill
effectsbull accidental intravascular injections of lidocaine
pass through the placenta but the concentrations are too low to harm fetus
bull prilocaine might cause methemoglobinemia
Ulcer healing drugsCimetidine bull FDA category B Famotidinebull FDA category BRanitidinebull FDA category Bbull not known to be harmful
Ulcer healing drugsOmeprazolebull FDA category BNot known to be
harmful Esomeprazolebull FDA category BLansoprazolebull FDA category BPantoprazolebull Avoid unless potential benefit
outweighs riskmdashfetotoxic in animals
Ulcer healing drugs
Misoprostolbull First second third trimesters Avoidmdash
potent uterine stimulant (has been used to induce abortion) and may be teratogenic
Ulcer healing drugs
Antacidsbull Almunium hydroxideMagnesium
hydroxidemdashFDA category B Calcium carbonatemdashFDA category C
SimetheconemdashFDA category C
Use of Nitrous Oxide Gas
bull used over 150 years bull safety is being debatedbull SHORT TERM exposure do not cause
birth defects or spontaneous abortionbull CHRONIC exposure may result in fetal
loss and infertilitybull literature suggests that nitrous oxide
should be avoided until more conclusive research is available
bull FDA Drug class not yet assigned
Common Preventives
bull Fluoridendash No increased risk during pregnancy
bull Xylitolndash No studies no harm reported
bull Chlorhexidinendash No increased risk during pregnancy
Are topical agents safe
bull Fluoridebull Toothpaste amp mouthrinse
bull Xylitol chewing gum bull Chlorhexidine (11 alcohol)bull No over the counter mouthrinses with
alcohol (Listerine 20 alcohol)
Pre-natal Fluoride
bull Daily 22 mg tablet of sodium fluoride during 3rd through 9th months
bull decreases caries rate in offspringbull Safe and effective
Glenn FB 1982
Is it safe to use mercury restorations
bull No evidence of harmful effect
bull Benefits outweigh risks
bull Canada Germany and New Zealand have some restrictions
bull Determine the best option
Referencesbull Wasylko L Matsui D Dykxhoorn SM Rieder MJ Weinberg
S A Review of Common Dental Treatments During Pregnancy J Canadian Dental Association 64434-439 1998
bull Little JW Donald AF Craig SM Rhodus NL Dental Management of the Medically Compromised Patient - 5th edition Mosby Toronto Pp434-442 1997
bull Livingston HM Dellinger TM Holder R Considerations in the management of the pregnant patient Special Care in Dentistry 185 pp183-188 1998
bull Larimore WL Petrie KA Drug use during pregnacy and lactation Primary Care Clinics in Office Practice 271 35-53 2000
bull Health Canada The Safety of DentalAmalgam Minister Of Supply and Services Canada 1996
REFERENCESbull 1 Weiss G Endocrinology of parturition J Clin
Endocrinol Metab 2000854421-5bull 2 Theunissen IM Parer JT Fluid and electrolytes in
pregnancy Clin Obstet Gynecol 1994373-15bull 3 Duvekot JJ Peeters LLH Renal hemodynamics and
volume homeostasis in pregnancy Obstet Gynecol Surv 199449830-9
bull 4 Barron WM Lindheimer MD Medical disorders during pregnancy 2nd ed St Louis Mosby 1995 p 129
bull 5 Thornburg KL Jacobson SL Giraud GD Morton MJ Hemodynamic changes in pregnancy Semin Perinatol 20002411-4
bull 6 Fiese R Herzog S Issues in dental and surgical management of the pregnant patient Oral Surg Oral Med Oral Pathol 198865292-7
bull 7 Martin C Varner MW Physiologic changes in pregnancysurgical implications Clin Obstet Gynecol 199437241-55
bull 8 Clark SL Cotton DB Lee W Bishop C Hill T Southwick J et al Central hemodynamic assessment of normal term pregnancy Am J Obstet Gynecol 19891611439-42
bull 9 Mabie WC Di Sessa TG Crocker LG Sibai BM Arheart KL A longitudinal study of cardiac output in normal human pregnancy Am J Obstet Gynecol 1994170849-56
bull 10 Clapp JF 3rd Capeless E Cardiovascular function before during and after the first and subsequent pregnancies Am J Cardiol 1997801469-73
bull 11 Duvekot JJ Peeters LL Maternal cardiovascular hemodynamic adaptation to pregnancy Obstet Gynecol Surv 199449(Suppl) S1-14
bull 12 Bhagwat AR Engel PJ Heart disease and pregnancy Cardiol Clin 199513163-78
bull 13 Lanni SM Tillinghast J Silver H Hemodynamic changes and baroreflex gain in the supine hypotensive syndrome Am J Obstet Gynecol 20021871636-41
bull 14 Little JW Falace DA Miller CS Rhodus NL Dental management of the medically compromised patient 6th ed St Louis Mosby 2002 p 303
bull 15 Garcia-Rio F Pino JM Gomez L Alvarez-Sala R Villasante C Villamor J Regulation of breathing and perception of dyspnea in healthy pregnant women Chest 1996110446-53
bull 16 McAuliffe F Kametas N Costello J Rafferty GF Greenough A Nicolaides K Respiratory function in singleton and twin pregnancy BJOG 2002109765-9
bull 17 Clapp JF 3rd Seaward BL Sleamaker RH Hiser J Maternal physiologic adaptations to early human pregnancy Am J Obstet Gynecol 19881591456-60
bull 18 OrsquoDay MP Cardio-respiratory physiological adaptation of pregnancy Semin Perinatol 199721268-75
bull 19 Contreras G Gutierrez M Beroiza T Fantin A Oddo H Villarroel L et al Ventilatory drive and respiratory muscle function in pregnancy Am Rev Respir Dis 1991144837-41
bull 20 Turner M Aziz SR Management of the pregnant oral and maxillofac
bull 21 Sifakis S Pharmakides G Anemia in pregnancy Ann N Y Acad Sci 2000900125-36
bull 22 Branch DW Physiologic adaptations of pregnancy Am J Reprod Immunol 199228120-2
bull 23 Burrows RF Kelton JG Incidentally detected thrombocytopenia in healthy mothers and their infants N Engl J Med 1988319 142-5
bull 24 Hanly JG Antiphospholipid syndrome an overview CMAJ 200324(168)1675-82
bull 25 Heilmann L von Tempelhoff GF Pollow K Antiphospholipid syndrome in obstetrics Clin Appl Thromb Hemost 20039 143-50
bull 26 Sherman P Flaxman SM Nausea and vomiting of pregnancy in an evolutionary perspective Am J Obstet Gynecol 2002 185(Suppl)s190-7
bull 27 Koch KL Gastrointestinal factors in nausea and vomiting of pregnancy Am J Obstet Gynecol 2002185(Suppl)s198-203
bull 28 Koch KL Frissora CL Nausea and vomiting during pregnancy Gastroenterol Clin N Am 200332201-34
bull 29 Baron TH Ramirez B Richter JE Gastrointestinal motility disorders during pregnancy Ann Intern Med 1993118 366-75
bull 30 Richter JE Gastroesophageal reflux disease during pregnancy Gastroenterol Clin N Am 200332235-61
bull 31 Marrero JM Goggin PM de Caestecker JS Pearce JM Maxwell JD Determinants of pregnancy heartburn Br J Obstet Gynaecol 199299731-4
bull 32 Hamaoui E Hamaoui M Nutritional assessment and support during pregnancy Gastroenterol Clin N Am 20033259-121
bull 33 King JC Physiology of pregnancy and nutrient metabolism Am J Clin Nutr 200071(suppl)1218s-25s
bull 34 Casanueva E Pfeffer F Fernandez-Gaxiola AC Gutierrez- Valenzuela V Rothenberg SJ Iron and folate status before pregnancy and anemia during pregnancy Ann Nutr Metab 2003 4760-3
bull 35 Chrsquong CL Morgan M Hainsworth I Kingham JG Prospective study of liver dysfunction in Southwest Wales Gut 200251 876-80
bull 36 Rahman TM Wendon J Severe hepatic dysfunction in pregnancy QJM 200295343-57
bull 37 Knox TA Olans LB Liver disease in pregnancy N Engl J Med 1996335569-76
bull 38 Saftlas AF Olson DR Franks AL Atrash H Pokras R Epidemiology of preeclampsia and eclampsia in the United States 1979e1986 Am J Obstet Gynecol 1990163460-5
bull 39 Walker JJ Pre-eclampsia Lancet 20003561260-5
bull 40 Davidson JM Renal disorders in pregnancy Curr Opin Obstet Gynecol 200113109-14
bull 41 Dafnis E Sabatini S The effect of pregnancy on renal function physiology and pathophysiologyAmJMedSci 1992303184-205
bull 42 Davison JM Shiells EA Philips PR Lindheimer MD Serial evaluation of vasopressin release and thirst in human pregnancy Role of human chorionic gonadotrophin in the osmoregulatory changes of gestation J Clin Invest 198881798-806
bull 43 Glinoer D de Nayer P Bourdoux P Lemone M Robyn C van Steirteghem A et al Regulation of maternal thyroid during pregnancy J Clin Endocrinol Metab 199071276-87
bull 44 Wilson SG Retallack RW Kent JC Worth GK Gutteridge DH Serum free 125-dihydroxyvitamin D and the free 125- dihydroxyvitamin D index during a longitudinal study of human pregnancy and lactation Clin Endocrinol 199032613-22
bull 45 Rasmussen N Frolich A Hornnes PJ Hegedus L Serum ionized calcium and intact parathyroid hormone levels during pregnancy and postpartum Br J Obstet Gynaecol 199097857-9
bull 46 Guyton AC Textbook of medical physiology 8th ed Philadelphia W B Saunders 1991 p 915e28
bull 47 Trainer PJ Corticosteroids and pregnancy Semin Reprod Med 200220375-80
bull 48 Soory M Hormonal factors in periodontal disease Dent Update 200027380-3
bull 49 Hugoson A Gingivitis in pregnant women A longitudinal clinical study Odontol Revy 19712265-84
bull 50 Neville BW Damm DD Allen CM Bouquot JE Oral amp Maxillofacial Pathology 3rd ed Philadelphia W B Saunders 2002 p 329-30 447-9
bull 51 Tilakaratne A Soory M Ranasinghe AW Corea SM Ekanayake SL de Silva M Periodontal disease status during pregnancy and 3 months post-partum in rural population of Sri-Lankan women J Clin Periodontol 200027787-92
bull 52 Laine M Tenovuo J Lehtonen OP Ojanatko-Harri A Vilja P Tuohimaa P Pregnancy e related changes in human whole saliva Arch Oral Biol 198833913-7
bull 53 Yuan K Wing LY Lin MT Pathogenetic roles of angiogenic factors in pyogenic granulomas in pregnancy are modulated by female sex hormones J Periodontol 200273701-8
bull 54 Evans RD Briggs PF Tooth-surface loss related to pregnancyinduced vomiting Prim Dent Care 1994124-6
bull 55 Salvolini E Di Giorgio R Curatola A Mazzanti L Fratto G Biochemical modifications of human whole saliva induced by pregnancy Br J Obstet Gynaec 1998105656-60
bull 56 Mauldin JG Newman RB Preterm birth risk assessment Semin Perinatol 200125215-22
bull 57 Heine RP McGregor JA Goodwin TM Artal R Hayashi RH Robertson PA et al Serial salivary estriol to detect an increased risk of preterm birth Obstet Gynecol 200096490-7
bull 58 Kauh YC Zachian TF Melasma Adv Exp Med Biol 1999455 491-9
bull 59 Wong RC Ellis CN Physiologic skin changes in pregnancy J Am Acad Dermatol 198410929-40
bull 60 Errickson CV Matus NR Skin disorders of pregnancy Am Fam Physician 199449605-10
bull 61 Lopez NJ Smith PC Gutierrez J Periodontal therapy may reduce the risk of preterm low birth weight in women with periodontal disease a randomized controlled trial J Periodontol 200273911-24
bull 62 McGaw T Periodontal disease and preterm delivery of lowbirth- weight infants J Can Dent Assoc 200268165-9
bull 63 Richards AG Dental x-ray protection Dent Clin North Am 1968631-41
bull 64 1990 Recommendations of the International Commission on Radiological Protection Ann ICRP 1991211-201
bull 65 Hall EJ Radiation the two-edged sword cancer risks at high and low doses Cancer J 20006343-50
bull 66 Diethelm L Xu H Diagnostic imaging of the lung during pregnancy Clin Obstet Gynecol 19963936-55
bull 67 Brent RL The effects of embryonic and fetal exposure to x-rays microwaves and ultrasound ClinObstetGynecol 198326484-510
bull 68 National Council on Radiation Protection NCRP report no128 1998 Bethesda Md Author
bull 69 Wasylko L Matsui D Dykxhoorn SM Reider MJ Weinberg S A review of common dental treatments during pregnancy implications for patients and dental personnel J Can Dent Assoc 199864434-9
bull 70 Freeman JP Brand JW Radiation doses of commonly used dental radiographic surveys Oral Surg Oral Med Oral Pathol 199477285-9
bull 71 Kircos LTAngin LL Lorton LOrder ofmagnitude dose reduction in intraoral radiography J Am Dent Assoc 1987114344-7
bull 72 Updegrave WJ Simplified and standardized intraoral radiography with reduced tissue irradiation J Am Dent Assoc 197285861-9
bull 73 Wood RE Harris AM van der Merwe EJ Nortje CJ The leaded apron revisited does it reduce gonadal radiation dose in dental radiology Oral Surg Oral Med Oral Pathol 199171642-6
bull 74 An update on radiographic practices information and recommendations ADA Council on Scientific Affairs J Am Dent Assoc 2001132234-8
bull 75 Rayburn WF Recommending medications during pregnancy an evidence based approach Clin Obstet Gynecol 2002451-5
bull 76 Rathmell JP Viscomi C Ashburn MA Management of nonobstetric pain during pregnancy and lactation Anesth Analg 1997851074-87
bull 77 Teratology society public affairs committee FDA classification of drugs for teratogenic risk Teratology 199449446-7
bull 78 Moore PA Selecting drugs for the pregnant dental patient J Am Dent Assoc 19981291281-6
bull 79 Haas DA An update on analgesics for the management of acute postoperative dental pain J Can Dent Assoc 200268476-82
bull 80 Haas DA Pynn BR Sands TD Drug use for the pregnant or lactating patient Gen Dent 20004854-60
bull 81 Committee on Drugs American Academy of Pediatrics The transfer of drugs and other chemicals into human milk Pediatrics 199493137-50
bull 82 Nielsen GL Sorensen HT Larsen H Pedersen L Risk of adverse birth outcome and miscarriage in pregnant users of nonsteroidal anti-inflammatory drugs population based observational study and case-control study BMJ 2001322266-70
bull 83 Janssen N Genta M The effects of immunosuppressive and anti-inflammatory medications on fertility pregnancy and lactation Arch Intern Med 200016610-9
bull 84 Ostensen M Nonsteroidal anti-inflammatory drugs during pregnancy Scand J Rheumatol Suppl 1998107128-32
bull 85 USPDI -Drug information for the health care professional 22nd ed Greenwood Village CO Micromedex 2002 p 152-79
bull 86 Denson DD Coyle DE Thompson GA Santos D Turner PA Myers JA et al Bupivacaine protein binding in the term parturient effects of lactic acidosis Clin Pharmacol Ther 198435702-9
bull 87 Dillon DE Wagner CL Wiest D Newman RB Drug therapy in the nursing mother Obstet Gynecol Clin North Am 199724 675-96
bull 88 Dashe JS Gilstrap LC Antibiotic use in pregnancy Obstet Gynecol Clin North Am 199724617-29
bull 89 American College of Rheumatology Ad hoc Committee on Clinical Guidelines Guidelines for monitoring drug therapy in rheumatoid arthritis Arthritis Rheum 199639723-31
bull 90 Ng PC The fetal and neonatal hypothalamic-pituitary-adrenal axis Arch Dis Child Fetal Neonatal Ed 200082F250-4
bull 91 Crowley P Antenatal corticosteroidsmdashcurrent thinking BJOG 2003110(Suppl 20)77-8
bull 92 ACOG committee opinion antenatal corticosteroid therapy for fetal maturation Obstet Gynecol 200299871-3
bull 93 Ost L Wettrell G Bjorkhem I Rane A Prednisolone excretion in human milk J Pediatr 19851061008-11
bull 94 Rowland AS Baird DD Shore DL Weinberg CR Savitz DA Wilcox AJ Nitrous oxide and spontaneous abortion in female dental assistants Am J Epidemiol 1995141531-8
bull 95 McGlothlin JD Jensen PA Fischbach TJ Hughes RT Jones JH Control of anesthetic gases in dental operatories Scand J Work Environ Health 199218(Suppl 2)103-5
bull ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY Volume 97 Number 6 Suresh and Radfar 681
bull 96 Rosen MA Nitrous oxide for relief of labor pain a systematic review Am J Obstet Gynecol 2002186(Suppl Nature)S110-6
bull 97 Sands TD Pynn BR Management considerations for the pregnant or nursing emergency patient Ont Dent 199875 17-9
bull 98 Daya S Recurrent spontaneous early pregnancy loss and low dose aspirin Minerva Ginecol 200355441-9
bull 99 Sinclair C Handbook of obstetrical emergencies 1st ed Philadelphia WB Saunders 1996 p 29-39 69
bull 100 Tarsitano BF Rollings RE The pregnant dental patient evaluation and management Gen Dent 199341226-34
bull 101 Livingston MH Dlllinger TM Holder R Consideration in the management of the pregnant patient SCD Special Care in Dentistry 199818183-8
Thank you
- A Review on the principle of Dental Management of the Pregnant patient
- Slide 2
- Questions that a dentist may ask
- Stages of Pregnancy
- Slide 5
- Slide 6
- Physiologic Changes in Pregnancy
- Systemic changes in pregnancy
- FLAT SUPINE POSITIONING
- SUPINE HYPOTENSION SYNDROME (Vena Cava Compression)
- Supine Hypotension Syndrome
- Slide 12
- Supine Hypotension Syndrome
- Prevention of Supine Hypotensive Syndrome
- Treatment of Supine Hypotensive Syndrome
- How should the pregnant woman be positioned
- Slide 17
- Slide 18
- Slide 19
- Slide 20
- Slide 21
- Slide 22
- Slide 23
- Pregnancy Related Oral Health Problems
- Oral Problems in Pregnancy
- Pregnancy Gingivitis Pathophysiology
- Pregnancy Gingivitis
- Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Gum Problems - Pregnancy Granuloma
- Slide 31
- Gum Changes - Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Candidiasis
- Pregnancy Myths
- Other Oral Conditions in Pregnancy
- Changes During Pregnancy that Affect Oral Health
- Saliva changes
- Increased Bacteria
- Slide 40
- Enamel erosion caused by frequent vomiting
- Treatment for Acid Exposure
- Oral Diseases Can Effect Pregnancy
- Periodontal Disease and Preterm Labor
- Periodontal Disease and Low Birth Weight
- Periodontal Disease and Preeclampsia
- Periodontitis and Pre-eclampsia
- Dental Considerations
- Treatment Timing
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Slide 52
- Use of Radiation on Pregnant Patient
- Radiographs during Pregnancy
- Risks of Dental X-Rays
- FDA drug classification for pregnancy
- Slide 57
- FDA drug classification for pregnancy
- Slide 59
- Slide 60
- Slide 61
- Common Analgesics
- Analgesics
- Analgesics - continued
- Analgesics to Use During 1st and 2nd Trimester
- Analgesics to Avoid During the Third Trimester
- Sedation in Pregnancy
- Common Antibiotics
- Antibiotics
- Antibiotics To Use During Pregnancy
- Antibiotics to Avoid during Pregnancy
- The Problem With Tetracycline
- Other Antimicrobial Agents
- Local Anesthetic Use in Pregnancy
- Use of Local Anesthetics
- Ulcer healing drugs
- Slide 77
- Slide 78
- Slide 79
- Use of Nitrous Oxide Gas
- Common Preventives
- Are topical agents safe
- Pre-natal Fluoride
- Is it safe to use mercury restorations
- References
- REFERENCES
- Slide 87
- Slide 88
- Slide 89
- Slide 90
- Slide 91
- Slide 92
- Slide 93
- Slide 94
- Slide 95
- Slide 96
- Slide 97
- Slide 98
- Thank you
-
Changes During Pregnancy that Affect Oral Health
bull Hormonal Affects
ndash Increased tooth mobility
ndash Saliva changes
ndash Increased bacteria
ndash Gingival problems
Saliva changesbull Decreased buffers
bull Decreased minerals
bull Decreasing flow first and last trimester
bull Increased flow second trimester
bull More acidic
Increased Bacteriabull Increased acidity
ndash Increase in decay-causing bacteriabull Increased Snacking
ndash Morning sicknesslow blood sugarndash Between-meal snacks
bull Increase in amount and frequency of starchescarbohydrates ndash Crackers are commonly recommendedndash Promotes decay-causing bacteria
Changes During Pregnancy that Affect Oral Healthbull Morning sickness
ndash Difficulty with hygienebull Gingival diseasebull Tooth decay
ndash Vomitingbull Esophogeal Reflux (heartburn)bull Acid exposure
ndash Irritation of the gumsndash Weakening of tooth enamelndash Dental erosion
Enamel erosion caused by frequent vomiting
Treatment for Acid Exposure
bull Do NOT brush immediately after vomiting
bull Rinse ndash Water with baking sodandash Antacidndash Plain water
bull Eat some cheese
Oral Diseases Can Effect Pregnancy
bull Preterm low birth weight (LBW) linked to periodontal disease
bull Thorough calculus (tartar) removal in pregnant women with periodontitis may reduce pre-term births
Periodontal Disease and Preterm LaborbullMaternal periodontal disease is associated with increased risk of preterm laborbullAnaerobic oral gram-negative bacteria cause inflammatory responsebullInflammatory response stimulates prostaglandin and cytokine production to stimulate labor
Periodontal Disease and Low Birth Weight
bull Periodontal disease is associated with low birth weight
bull Evidence is not conclusivebull Biochemical mechanism similar cascade
as in preterm labor leading to placental blood flow restriction and necrosis
Periodontal Disease and Preeclampsia
bull Emerging databull Mechanism unclearbull Proposed mechanism
ndash Periodontal infection leads to inflammatory vascular damage
ndash Triggers cell damage in placenta
Periodontitis and Pre-eclampsia
bull Periodontal disease may be associated with pre-eclampsia (Boggess 2003)
bull PGE2 IL-1 and TNF-α from gingival crevicular fluid were higher in women with preeclampsia compared with healthy matched pregnant women (Oettinger-Barak 2003)
Dental Considerations
bull timing of treatment for pregnant patientsbull dental radiation exposurebull use of local anestheticsbull prescription of common antibiotics and
analgesicsbull nitrous oxide gas administration
Treatment Timing
bull First Trimesterndash Spontaneous miscarriages naturally occur
more often in 1st trimesterndash Avoid elective treatment that can be delayedndash Offer anticipatory guidance
bull Second Trimesterndash The optimal time for dental treatmentndash Organogenesis complete fetus not largendash Easier to prevent than treat established disease
bull Third Trimesterndash Late in term very uncomfortable (short visits)ndash Position slightly on left side
Timing of Dental Treatment During Pregnancy - From Little and Fallace
First Trimester
bull Plaque controlbull Oral hygiene instructionbull Scaling polishing curettagebull Avoid elective treatment urgent care
only
Timing of Dental Treatment During Pregnancy - From Little and Fallace
Second Trimester
bull Plaque controlbull Oral hygiene instructionbull Scaling polishing curettagebull Routine dental care
Timing of Dental Treatment During Pregnancy - From Little and Fallace
Third Trimester
bull Plaque controlbull Oral hygiene instructionbull Scaling polishing curettagebull Routine dental care (after middle of third
trimester elective care should be avoided)
Use of Radiation on Pregnant Patientbull Dose given and time of gestation are
importantbull doses lt 5-10 rads (cGy) not teratogenicbull fetus is most susceptible to radiation
between the 2nd and 6th week of gestationbull single dental x-ray exposes patient to 001
millirads of radiation In relative terms this amount is 40 times less than daily dose acquired from cosmic radiation Therefore diagnostic radiation should not be withheld during pregnancy
Radiographs during Pregnancy
bull Take as needed with optimal methods for reducing secondary radiation and exposure time
bull Always use a lead apronbull Exposure to fetus (with apron use) is 00001
centiGray(rad)bull Daily cosmic radiation - 0004 centiGray (rad)
Risks of Dental X-Rays
bull X-ray only if necessary (ie root canal therapy trauma)
bull When x-rays are indicated radiation exposure is extremely low
bull Exposure can be limited byndash Lead apron shielding ndash Modern fast film ndash Avoiding retakes
FDA drug classification for pregnancybull Combines risk statements including
congenital anomalies fetal effects perinatal risks and therapeutic risk-benefit ratio
bull Untreated disease or condition may pose more serious risks to both mother and fetus than any theoretical risks from the medication
bull Category A thru D and X
FDA drug classification for pregnancy
bull A = Controlled Studies in women fail to demonstrate a risk to the fetus in the first trimester and the possibility of fetal harm appears remote
FDA drug classification for pregnancy
bull B = Animal studies show no risk or if risk shown in animals controlled
trials in women showed no risk
FDA drug classification for pregnancy
bull C = Studies in animals with adverse effects and no human studies
OR no animal or human studies but benefits of use may outweigh potential harms
FDA drug classification for pregnancy
bull D = There is evidence of human fetal risk but benefits may outweigh risks
FDA drug classification for pregnancy
bull X = Contraindicated
Common Analgesics
bull paracetamol (B)bull Ibuprofen (BD) bull Oxycodone (BD) bull Hydrocodone and codeine
(CD)
avoid in third trimester
Analgesics
bull Paracetamol is the analgesic of choice for all stages of gestation
bull used to treat mild to moderate pain and fevers
bull short term usage is believed to be safebull avoid chronic and large doses of
paracetamol1048715
Analgesics - continuedbull Aspirin is nonteratogenic but may cause
maternal and fetal hemorrhagebull large and chronic doses during last trimester
may result in premature closure of ductus arteriosus fetal hypertension anemia and low birth weight
bull avoid ibuprofen in 3rd trimester because of possible adverse circulatory effects
bull short term use of codeine seems safebull avoid codeine late in gestation because of
possible fetal respiratory depression and withdrawal symptoms
Analgesics to Use During1st and 2nd Trimester
bull Category B (for best)bull Paracetamol Ibuprofenbull Naproxenbull Category C (use with caution)bull Paracetamol with codeine or
hydrocodonebull Paracetamol with oxycodone
Analgesics to Avoid During theThird Trimesterbull Causes delivery problemsbull Aspirin (C 3D)bull Ibuprofen (B3D)bull Naproxen (B3D)bull Causes neonatal respiratory
depression and opioid withdrawalbull Codeine (C3D)bull Hydrocodone (C3D)bull Oxycodone(C3D)
Sedation in Pregnancy
bull SedativesAnxiolytics (eg Diazepam ) are rated D and can cause oral clefts with prolonged exposure
bull Nitrous oxide should not be used in 1st trimester (If used in 2nd and 3rd do not go below 50 O2)
Common Antibioticsbull To treat oral abscess or cellulitis
ndash Penicillin (B) ndash Amoxicillin (B) ndash Cephalexin (B)ndash Erythromycin base (B) (Not estolate as it
cause cholestatic hepatitis)ndash Clindamycin (B)
Antibioticsbull penicillin V and amoxicillin is preferred drug
for mild to moderate infectionsbull widely used for many years with no ill effectsbull no studies show penicillin to be teratogenicbull amoxicillin extensively used without harming
the fetusbull Drug classes1048715 B penicillin cephalosporins erythromycin clindamycin Azithromycin D Tetracycline
Antibiotics To Use During Pregnancy
bull Penicillin Vbull Amoxicillinbull Erythromycin (base form)bull Cephalexin cephalosporinbull Clindamycinbull Metronidazole
Antibiotics to Avoid duringPregnancy
bull Doxycyclinebull Tetracyclinebull Erythromycin (estolate form)bull Vancomycin
The Problem With Tetracycline
bull Accumulates in bones and chelates calcium
bull Inhibits bone growthbull Discolors teeth
Other Antimicrobial Agentsbull OK to usebull Nystatin (B)bull Chlorhexidine rinse (B)bull Use with cautionbull Clotrimazole (C)bull Ketoconazole (C)bull Fluconazole (C)bull Do not usebull Doxycycline (D)
Local Anesthetic Use inPregnancy
bull Class Bbull Lidocaine (Xylocaine)bull Etidocainebull Prilocaine bull Class Cbull Procainebull Bupivicainebull Mepivicaine
Use of Local Anestheticsbull Lidocaine + vasoconstrictor most common
local anesthetic used in dentistrybull extensively used in pregnancy with no proven ill
effectsbull accidental intravascular injections of lidocaine
pass through the placenta but the concentrations are too low to harm fetus
bull prilocaine might cause methemoglobinemia
Ulcer healing drugsCimetidine bull FDA category B Famotidinebull FDA category BRanitidinebull FDA category Bbull not known to be harmful
Ulcer healing drugsOmeprazolebull FDA category BNot known to be
harmful Esomeprazolebull FDA category BLansoprazolebull FDA category BPantoprazolebull Avoid unless potential benefit
outweighs riskmdashfetotoxic in animals
Ulcer healing drugs
Misoprostolbull First second third trimesters Avoidmdash
potent uterine stimulant (has been used to induce abortion) and may be teratogenic
Ulcer healing drugs
Antacidsbull Almunium hydroxideMagnesium
hydroxidemdashFDA category B Calcium carbonatemdashFDA category C
SimetheconemdashFDA category C
Use of Nitrous Oxide Gas
bull used over 150 years bull safety is being debatedbull SHORT TERM exposure do not cause
birth defects or spontaneous abortionbull CHRONIC exposure may result in fetal
loss and infertilitybull literature suggests that nitrous oxide
should be avoided until more conclusive research is available
bull FDA Drug class not yet assigned
Common Preventives
bull Fluoridendash No increased risk during pregnancy
bull Xylitolndash No studies no harm reported
bull Chlorhexidinendash No increased risk during pregnancy
Are topical agents safe
bull Fluoridebull Toothpaste amp mouthrinse
bull Xylitol chewing gum bull Chlorhexidine (11 alcohol)bull No over the counter mouthrinses with
alcohol (Listerine 20 alcohol)
Pre-natal Fluoride
bull Daily 22 mg tablet of sodium fluoride during 3rd through 9th months
bull decreases caries rate in offspringbull Safe and effective
Glenn FB 1982
Is it safe to use mercury restorations
bull No evidence of harmful effect
bull Benefits outweigh risks
bull Canada Germany and New Zealand have some restrictions
bull Determine the best option
Referencesbull Wasylko L Matsui D Dykxhoorn SM Rieder MJ Weinberg
S A Review of Common Dental Treatments During Pregnancy J Canadian Dental Association 64434-439 1998
bull Little JW Donald AF Craig SM Rhodus NL Dental Management of the Medically Compromised Patient - 5th edition Mosby Toronto Pp434-442 1997
bull Livingston HM Dellinger TM Holder R Considerations in the management of the pregnant patient Special Care in Dentistry 185 pp183-188 1998
bull Larimore WL Petrie KA Drug use during pregnacy and lactation Primary Care Clinics in Office Practice 271 35-53 2000
bull Health Canada The Safety of DentalAmalgam Minister Of Supply and Services Canada 1996
REFERENCESbull 1 Weiss G Endocrinology of parturition J Clin
Endocrinol Metab 2000854421-5bull 2 Theunissen IM Parer JT Fluid and electrolytes in
pregnancy Clin Obstet Gynecol 1994373-15bull 3 Duvekot JJ Peeters LLH Renal hemodynamics and
volume homeostasis in pregnancy Obstet Gynecol Surv 199449830-9
bull 4 Barron WM Lindheimer MD Medical disorders during pregnancy 2nd ed St Louis Mosby 1995 p 129
bull 5 Thornburg KL Jacobson SL Giraud GD Morton MJ Hemodynamic changes in pregnancy Semin Perinatol 20002411-4
bull 6 Fiese R Herzog S Issues in dental and surgical management of the pregnant patient Oral Surg Oral Med Oral Pathol 198865292-7
bull 7 Martin C Varner MW Physiologic changes in pregnancysurgical implications Clin Obstet Gynecol 199437241-55
bull 8 Clark SL Cotton DB Lee W Bishop C Hill T Southwick J et al Central hemodynamic assessment of normal term pregnancy Am J Obstet Gynecol 19891611439-42
bull 9 Mabie WC Di Sessa TG Crocker LG Sibai BM Arheart KL A longitudinal study of cardiac output in normal human pregnancy Am J Obstet Gynecol 1994170849-56
bull 10 Clapp JF 3rd Capeless E Cardiovascular function before during and after the first and subsequent pregnancies Am J Cardiol 1997801469-73
bull 11 Duvekot JJ Peeters LL Maternal cardiovascular hemodynamic adaptation to pregnancy Obstet Gynecol Surv 199449(Suppl) S1-14
bull 12 Bhagwat AR Engel PJ Heart disease and pregnancy Cardiol Clin 199513163-78
bull 13 Lanni SM Tillinghast J Silver H Hemodynamic changes and baroreflex gain in the supine hypotensive syndrome Am J Obstet Gynecol 20021871636-41
bull 14 Little JW Falace DA Miller CS Rhodus NL Dental management of the medically compromised patient 6th ed St Louis Mosby 2002 p 303
bull 15 Garcia-Rio F Pino JM Gomez L Alvarez-Sala R Villasante C Villamor J Regulation of breathing and perception of dyspnea in healthy pregnant women Chest 1996110446-53
bull 16 McAuliffe F Kametas N Costello J Rafferty GF Greenough A Nicolaides K Respiratory function in singleton and twin pregnancy BJOG 2002109765-9
bull 17 Clapp JF 3rd Seaward BL Sleamaker RH Hiser J Maternal physiologic adaptations to early human pregnancy Am J Obstet Gynecol 19881591456-60
bull 18 OrsquoDay MP Cardio-respiratory physiological adaptation of pregnancy Semin Perinatol 199721268-75
bull 19 Contreras G Gutierrez M Beroiza T Fantin A Oddo H Villarroel L et al Ventilatory drive and respiratory muscle function in pregnancy Am Rev Respir Dis 1991144837-41
bull 20 Turner M Aziz SR Management of the pregnant oral and maxillofac
bull 21 Sifakis S Pharmakides G Anemia in pregnancy Ann N Y Acad Sci 2000900125-36
bull 22 Branch DW Physiologic adaptations of pregnancy Am J Reprod Immunol 199228120-2
bull 23 Burrows RF Kelton JG Incidentally detected thrombocytopenia in healthy mothers and their infants N Engl J Med 1988319 142-5
bull 24 Hanly JG Antiphospholipid syndrome an overview CMAJ 200324(168)1675-82
bull 25 Heilmann L von Tempelhoff GF Pollow K Antiphospholipid syndrome in obstetrics Clin Appl Thromb Hemost 20039 143-50
bull 26 Sherman P Flaxman SM Nausea and vomiting of pregnancy in an evolutionary perspective Am J Obstet Gynecol 2002 185(Suppl)s190-7
bull 27 Koch KL Gastrointestinal factors in nausea and vomiting of pregnancy Am J Obstet Gynecol 2002185(Suppl)s198-203
bull 28 Koch KL Frissora CL Nausea and vomiting during pregnancy Gastroenterol Clin N Am 200332201-34
bull 29 Baron TH Ramirez B Richter JE Gastrointestinal motility disorders during pregnancy Ann Intern Med 1993118 366-75
bull 30 Richter JE Gastroesophageal reflux disease during pregnancy Gastroenterol Clin N Am 200332235-61
bull 31 Marrero JM Goggin PM de Caestecker JS Pearce JM Maxwell JD Determinants of pregnancy heartburn Br J Obstet Gynaecol 199299731-4
bull 32 Hamaoui E Hamaoui M Nutritional assessment and support during pregnancy Gastroenterol Clin N Am 20033259-121
bull 33 King JC Physiology of pregnancy and nutrient metabolism Am J Clin Nutr 200071(suppl)1218s-25s
bull 34 Casanueva E Pfeffer F Fernandez-Gaxiola AC Gutierrez- Valenzuela V Rothenberg SJ Iron and folate status before pregnancy and anemia during pregnancy Ann Nutr Metab 2003 4760-3
bull 35 Chrsquong CL Morgan M Hainsworth I Kingham JG Prospective study of liver dysfunction in Southwest Wales Gut 200251 876-80
bull 36 Rahman TM Wendon J Severe hepatic dysfunction in pregnancy QJM 200295343-57
bull 37 Knox TA Olans LB Liver disease in pregnancy N Engl J Med 1996335569-76
bull 38 Saftlas AF Olson DR Franks AL Atrash H Pokras R Epidemiology of preeclampsia and eclampsia in the United States 1979e1986 Am J Obstet Gynecol 1990163460-5
bull 39 Walker JJ Pre-eclampsia Lancet 20003561260-5
bull 40 Davidson JM Renal disorders in pregnancy Curr Opin Obstet Gynecol 200113109-14
bull 41 Dafnis E Sabatini S The effect of pregnancy on renal function physiology and pathophysiologyAmJMedSci 1992303184-205
bull 42 Davison JM Shiells EA Philips PR Lindheimer MD Serial evaluation of vasopressin release and thirst in human pregnancy Role of human chorionic gonadotrophin in the osmoregulatory changes of gestation J Clin Invest 198881798-806
bull 43 Glinoer D de Nayer P Bourdoux P Lemone M Robyn C van Steirteghem A et al Regulation of maternal thyroid during pregnancy J Clin Endocrinol Metab 199071276-87
bull 44 Wilson SG Retallack RW Kent JC Worth GK Gutteridge DH Serum free 125-dihydroxyvitamin D and the free 125- dihydroxyvitamin D index during a longitudinal study of human pregnancy and lactation Clin Endocrinol 199032613-22
bull 45 Rasmussen N Frolich A Hornnes PJ Hegedus L Serum ionized calcium and intact parathyroid hormone levels during pregnancy and postpartum Br J Obstet Gynaecol 199097857-9
bull 46 Guyton AC Textbook of medical physiology 8th ed Philadelphia W B Saunders 1991 p 915e28
bull 47 Trainer PJ Corticosteroids and pregnancy Semin Reprod Med 200220375-80
bull 48 Soory M Hormonal factors in periodontal disease Dent Update 200027380-3
bull 49 Hugoson A Gingivitis in pregnant women A longitudinal clinical study Odontol Revy 19712265-84
bull 50 Neville BW Damm DD Allen CM Bouquot JE Oral amp Maxillofacial Pathology 3rd ed Philadelphia W B Saunders 2002 p 329-30 447-9
bull 51 Tilakaratne A Soory M Ranasinghe AW Corea SM Ekanayake SL de Silva M Periodontal disease status during pregnancy and 3 months post-partum in rural population of Sri-Lankan women J Clin Periodontol 200027787-92
bull 52 Laine M Tenovuo J Lehtonen OP Ojanatko-Harri A Vilja P Tuohimaa P Pregnancy e related changes in human whole saliva Arch Oral Biol 198833913-7
bull 53 Yuan K Wing LY Lin MT Pathogenetic roles of angiogenic factors in pyogenic granulomas in pregnancy are modulated by female sex hormones J Periodontol 200273701-8
bull 54 Evans RD Briggs PF Tooth-surface loss related to pregnancyinduced vomiting Prim Dent Care 1994124-6
bull 55 Salvolini E Di Giorgio R Curatola A Mazzanti L Fratto G Biochemical modifications of human whole saliva induced by pregnancy Br J Obstet Gynaec 1998105656-60
bull 56 Mauldin JG Newman RB Preterm birth risk assessment Semin Perinatol 200125215-22
bull 57 Heine RP McGregor JA Goodwin TM Artal R Hayashi RH Robertson PA et al Serial salivary estriol to detect an increased risk of preterm birth Obstet Gynecol 200096490-7
bull 58 Kauh YC Zachian TF Melasma Adv Exp Med Biol 1999455 491-9
bull 59 Wong RC Ellis CN Physiologic skin changes in pregnancy J Am Acad Dermatol 198410929-40
bull 60 Errickson CV Matus NR Skin disorders of pregnancy Am Fam Physician 199449605-10
bull 61 Lopez NJ Smith PC Gutierrez J Periodontal therapy may reduce the risk of preterm low birth weight in women with periodontal disease a randomized controlled trial J Periodontol 200273911-24
bull 62 McGaw T Periodontal disease and preterm delivery of lowbirth- weight infants J Can Dent Assoc 200268165-9
bull 63 Richards AG Dental x-ray protection Dent Clin North Am 1968631-41
bull 64 1990 Recommendations of the International Commission on Radiological Protection Ann ICRP 1991211-201
bull 65 Hall EJ Radiation the two-edged sword cancer risks at high and low doses Cancer J 20006343-50
bull 66 Diethelm L Xu H Diagnostic imaging of the lung during pregnancy Clin Obstet Gynecol 19963936-55
bull 67 Brent RL The effects of embryonic and fetal exposure to x-rays microwaves and ultrasound ClinObstetGynecol 198326484-510
bull 68 National Council on Radiation Protection NCRP report no128 1998 Bethesda Md Author
bull 69 Wasylko L Matsui D Dykxhoorn SM Reider MJ Weinberg S A review of common dental treatments during pregnancy implications for patients and dental personnel J Can Dent Assoc 199864434-9
bull 70 Freeman JP Brand JW Radiation doses of commonly used dental radiographic surveys Oral Surg Oral Med Oral Pathol 199477285-9
bull 71 Kircos LTAngin LL Lorton LOrder ofmagnitude dose reduction in intraoral radiography J Am Dent Assoc 1987114344-7
bull 72 Updegrave WJ Simplified and standardized intraoral radiography with reduced tissue irradiation J Am Dent Assoc 197285861-9
bull 73 Wood RE Harris AM van der Merwe EJ Nortje CJ The leaded apron revisited does it reduce gonadal radiation dose in dental radiology Oral Surg Oral Med Oral Pathol 199171642-6
bull 74 An update on radiographic practices information and recommendations ADA Council on Scientific Affairs J Am Dent Assoc 2001132234-8
bull 75 Rayburn WF Recommending medications during pregnancy an evidence based approach Clin Obstet Gynecol 2002451-5
bull 76 Rathmell JP Viscomi C Ashburn MA Management of nonobstetric pain during pregnancy and lactation Anesth Analg 1997851074-87
bull 77 Teratology society public affairs committee FDA classification of drugs for teratogenic risk Teratology 199449446-7
bull 78 Moore PA Selecting drugs for the pregnant dental patient J Am Dent Assoc 19981291281-6
bull 79 Haas DA An update on analgesics for the management of acute postoperative dental pain J Can Dent Assoc 200268476-82
bull 80 Haas DA Pynn BR Sands TD Drug use for the pregnant or lactating patient Gen Dent 20004854-60
bull 81 Committee on Drugs American Academy of Pediatrics The transfer of drugs and other chemicals into human milk Pediatrics 199493137-50
bull 82 Nielsen GL Sorensen HT Larsen H Pedersen L Risk of adverse birth outcome and miscarriage in pregnant users of nonsteroidal anti-inflammatory drugs population based observational study and case-control study BMJ 2001322266-70
bull 83 Janssen N Genta M The effects of immunosuppressive and anti-inflammatory medications on fertility pregnancy and lactation Arch Intern Med 200016610-9
bull 84 Ostensen M Nonsteroidal anti-inflammatory drugs during pregnancy Scand J Rheumatol Suppl 1998107128-32
bull 85 USPDI -Drug information for the health care professional 22nd ed Greenwood Village CO Micromedex 2002 p 152-79
bull 86 Denson DD Coyle DE Thompson GA Santos D Turner PA Myers JA et al Bupivacaine protein binding in the term parturient effects of lactic acidosis Clin Pharmacol Ther 198435702-9
bull 87 Dillon DE Wagner CL Wiest D Newman RB Drug therapy in the nursing mother Obstet Gynecol Clin North Am 199724 675-96
bull 88 Dashe JS Gilstrap LC Antibiotic use in pregnancy Obstet Gynecol Clin North Am 199724617-29
bull 89 American College of Rheumatology Ad hoc Committee on Clinical Guidelines Guidelines for monitoring drug therapy in rheumatoid arthritis Arthritis Rheum 199639723-31
bull 90 Ng PC The fetal and neonatal hypothalamic-pituitary-adrenal axis Arch Dis Child Fetal Neonatal Ed 200082F250-4
bull 91 Crowley P Antenatal corticosteroidsmdashcurrent thinking BJOG 2003110(Suppl 20)77-8
bull 92 ACOG committee opinion antenatal corticosteroid therapy for fetal maturation Obstet Gynecol 200299871-3
bull 93 Ost L Wettrell G Bjorkhem I Rane A Prednisolone excretion in human milk J Pediatr 19851061008-11
bull 94 Rowland AS Baird DD Shore DL Weinberg CR Savitz DA Wilcox AJ Nitrous oxide and spontaneous abortion in female dental assistants Am J Epidemiol 1995141531-8
bull 95 McGlothlin JD Jensen PA Fischbach TJ Hughes RT Jones JH Control of anesthetic gases in dental operatories Scand J Work Environ Health 199218(Suppl 2)103-5
bull ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY Volume 97 Number 6 Suresh and Radfar 681
bull 96 Rosen MA Nitrous oxide for relief of labor pain a systematic review Am J Obstet Gynecol 2002186(Suppl Nature)S110-6
bull 97 Sands TD Pynn BR Management considerations for the pregnant or nursing emergency patient Ont Dent 199875 17-9
bull 98 Daya S Recurrent spontaneous early pregnancy loss and low dose aspirin Minerva Ginecol 200355441-9
bull 99 Sinclair C Handbook of obstetrical emergencies 1st ed Philadelphia WB Saunders 1996 p 29-39 69
bull 100 Tarsitano BF Rollings RE The pregnant dental patient evaluation and management Gen Dent 199341226-34
bull 101 Livingston MH Dlllinger TM Holder R Consideration in the management of the pregnant patient SCD Special Care in Dentistry 199818183-8
Thank you
- A Review on the principle of Dental Management of the Pregnant patient
- Slide 2
- Questions that a dentist may ask
- Stages of Pregnancy
- Slide 5
- Slide 6
- Physiologic Changes in Pregnancy
- Systemic changes in pregnancy
- FLAT SUPINE POSITIONING
- SUPINE HYPOTENSION SYNDROME (Vena Cava Compression)
- Supine Hypotension Syndrome
- Slide 12
- Supine Hypotension Syndrome
- Prevention of Supine Hypotensive Syndrome
- Treatment of Supine Hypotensive Syndrome
- How should the pregnant woman be positioned
- Slide 17
- Slide 18
- Slide 19
- Slide 20
- Slide 21
- Slide 22
- Slide 23
- Pregnancy Related Oral Health Problems
- Oral Problems in Pregnancy
- Pregnancy Gingivitis Pathophysiology
- Pregnancy Gingivitis
- Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Gum Problems - Pregnancy Granuloma
- Slide 31
- Gum Changes - Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Candidiasis
- Pregnancy Myths
- Other Oral Conditions in Pregnancy
- Changes During Pregnancy that Affect Oral Health
- Saliva changes
- Increased Bacteria
- Slide 40
- Enamel erosion caused by frequent vomiting
- Treatment for Acid Exposure
- Oral Diseases Can Effect Pregnancy
- Periodontal Disease and Preterm Labor
- Periodontal Disease and Low Birth Weight
- Periodontal Disease and Preeclampsia
- Periodontitis and Pre-eclampsia
- Dental Considerations
- Treatment Timing
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Slide 52
- Use of Radiation on Pregnant Patient
- Radiographs during Pregnancy
- Risks of Dental X-Rays
- FDA drug classification for pregnancy
- Slide 57
- FDA drug classification for pregnancy
- Slide 59
- Slide 60
- Slide 61
- Common Analgesics
- Analgesics
- Analgesics - continued
- Analgesics to Use During 1st and 2nd Trimester
- Analgesics to Avoid During the Third Trimester
- Sedation in Pregnancy
- Common Antibiotics
- Antibiotics
- Antibiotics To Use During Pregnancy
- Antibiotics to Avoid during Pregnancy
- The Problem With Tetracycline
- Other Antimicrobial Agents
- Local Anesthetic Use in Pregnancy
- Use of Local Anesthetics
- Ulcer healing drugs
- Slide 77
- Slide 78
- Slide 79
- Use of Nitrous Oxide Gas
- Common Preventives
- Are topical agents safe
- Pre-natal Fluoride
- Is it safe to use mercury restorations
- References
- REFERENCES
- Slide 87
- Slide 88
- Slide 89
- Slide 90
- Slide 91
- Slide 92
- Slide 93
- Slide 94
- Slide 95
- Slide 96
- Slide 97
- Slide 98
- Thank you
-
Saliva changesbull Decreased buffers
bull Decreased minerals
bull Decreasing flow first and last trimester
bull Increased flow second trimester
bull More acidic
Increased Bacteriabull Increased acidity
ndash Increase in decay-causing bacteriabull Increased Snacking
ndash Morning sicknesslow blood sugarndash Between-meal snacks
bull Increase in amount and frequency of starchescarbohydrates ndash Crackers are commonly recommendedndash Promotes decay-causing bacteria
Changes During Pregnancy that Affect Oral Healthbull Morning sickness
ndash Difficulty with hygienebull Gingival diseasebull Tooth decay
ndash Vomitingbull Esophogeal Reflux (heartburn)bull Acid exposure
ndash Irritation of the gumsndash Weakening of tooth enamelndash Dental erosion
Enamel erosion caused by frequent vomiting
Treatment for Acid Exposure
bull Do NOT brush immediately after vomiting
bull Rinse ndash Water with baking sodandash Antacidndash Plain water
bull Eat some cheese
Oral Diseases Can Effect Pregnancy
bull Preterm low birth weight (LBW) linked to periodontal disease
bull Thorough calculus (tartar) removal in pregnant women with periodontitis may reduce pre-term births
Periodontal Disease and Preterm LaborbullMaternal periodontal disease is associated with increased risk of preterm laborbullAnaerobic oral gram-negative bacteria cause inflammatory responsebullInflammatory response stimulates prostaglandin and cytokine production to stimulate labor
Periodontal Disease and Low Birth Weight
bull Periodontal disease is associated with low birth weight
bull Evidence is not conclusivebull Biochemical mechanism similar cascade
as in preterm labor leading to placental blood flow restriction and necrosis
Periodontal Disease and Preeclampsia
bull Emerging databull Mechanism unclearbull Proposed mechanism
ndash Periodontal infection leads to inflammatory vascular damage
ndash Triggers cell damage in placenta
Periodontitis and Pre-eclampsia
bull Periodontal disease may be associated with pre-eclampsia (Boggess 2003)
bull PGE2 IL-1 and TNF-α from gingival crevicular fluid were higher in women with preeclampsia compared with healthy matched pregnant women (Oettinger-Barak 2003)
Dental Considerations
bull timing of treatment for pregnant patientsbull dental radiation exposurebull use of local anestheticsbull prescription of common antibiotics and
analgesicsbull nitrous oxide gas administration
Treatment Timing
bull First Trimesterndash Spontaneous miscarriages naturally occur
more often in 1st trimesterndash Avoid elective treatment that can be delayedndash Offer anticipatory guidance
bull Second Trimesterndash The optimal time for dental treatmentndash Organogenesis complete fetus not largendash Easier to prevent than treat established disease
bull Third Trimesterndash Late in term very uncomfortable (short visits)ndash Position slightly on left side
Timing of Dental Treatment During Pregnancy - From Little and Fallace
First Trimester
bull Plaque controlbull Oral hygiene instructionbull Scaling polishing curettagebull Avoid elective treatment urgent care
only
Timing of Dental Treatment During Pregnancy - From Little and Fallace
Second Trimester
bull Plaque controlbull Oral hygiene instructionbull Scaling polishing curettagebull Routine dental care
Timing of Dental Treatment During Pregnancy - From Little and Fallace
Third Trimester
bull Plaque controlbull Oral hygiene instructionbull Scaling polishing curettagebull Routine dental care (after middle of third
trimester elective care should be avoided)
Use of Radiation on Pregnant Patientbull Dose given and time of gestation are
importantbull doses lt 5-10 rads (cGy) not teratogenicbull fetus is most susceptible to radiation
between the 2nd and 6th week of gestationbull single dental x-ray exposes patient to 001
millirads of radiation In relative terms this amount is 40 times less than daily dose acquired from cosmic radiation Therefore diagnostic radiation should not be withheld during pregnancy
Radiographs during Pregnancy
bull Take as needed with optimal methods for reducing secondary radiation and exposure time
bull Always use a lead apronbull Exposure to fetus (with apron use) is 00001
centiGray(rad)bull Daily cosmic radiation - 0004 centiGray (rad)
Risks of Dental X-Rays
bull X-ray only if necessary (ie root canal therapy trauma)
bull When x-rays are indicated radiation exposure is extremely low
bull Exposure can be limited byndash Lead apron shielding ndash Modern fast film ndash Avoiding retakes
FDA drug classification for pregnancybull Combines risk statements including
congenital anomalies fetal effects perinatal risks and therapeutic risk-benefit ratio
bull Untreated disease or condition may pose more serious risks to both mother and fetus than any theoretical risks from the medication
bull Category A thru D and X
FDA drug classification for pregnancy
bull A = Controlled Studies in women fail to demonstrate a risk to the fetus in the first trimester and the possibility of fetal harm appears remote
FDA drug classification for pregnancy
bull B = Animal studies show no risk or if risk shown in animals controlled
trials in women showed no risk
FDA drug classification for pregnancy
bull C = Studies in animals with adverse effects and no human studies
OR no animal or human studies but benefits of use may outweigh potential harms
FDA drug classification for pregnancy
bull D = There is evidence of human fetal risk but benefits may outweigh risks
FDA drug classification for pregnancy
bull X = Contraindicated
Common Analgesics
bull paracetamol (B)bull Ibuprofen (BD) bull Oxycodone (BD) bull Hydrocodone and codeine
(CD)
avoid in third trimester
Analgesics
bull Paracetamol is the analgesic of choice for all stages of gestation
bull used to treat mild to moderate pain and fevers
bull short term usage is believed to be safebull avoid chronic and large doses of
paracetamol1048715
Analgesics - continuedbull Aspirin is nonteratogenic but may cause
maternal and fetal hemorrhagebull large and chronic doses during last trimester
may result in premature closure of ductus arteriosus fetal hypertension anemia and low birth weight
bull avoid ibuprofen in 3rd trimester because of possible adverse circulatory effects
bull short term use of codeine seems safebull avoid codeine late in gestation because of
possible fetal respiratory depression and withdrawal symptoms
Analgesics to Use During1st and 2nd Trimester
bull Category B (for best)bull Paracetamol Ibuprofenbull Naproxenbull Category C (use with caution)bull Paracetamol with codeine or
hydrocodonebull Paracetamol with oxycodone
Analgesics to Avoid During theThird Trimesterbull Causes delivery problemsbull Aspirin (C 3D)bull Ibuprofen (B3D)bull Naproxen (B3D)bull Causes neonatal respiratory
depression and opioid withdrawalbull Codeine (C3D)bull Hydrocodone (C3D)bull Oxycodone(C3D)
Sedation in Pregnancy
bull SedativesAnxiolytics (eg Diazepam ) are rated D and can cause oral clefts with prolonged exposure
bull Nitrous oxide should not be used in 1st trimester (If used in 2nd and 3rd do not go below 50 O2)
Common Antibioticsbull To treat oral abscess or cellulitis
ndash Penicillin (B) ndash Amoxicillin (B) ndash Cephalexin (B)ndash Erythromycin base (B) (Not estolate as it
cause cholestatic hepatitis)ndash Clindamycin (B)
Antibioticsbull penicillin V and amoxicillin is preferred drug
for mild to moderate infectionsbull widely used for many years with no ill effectsbull no studies show penicillin to be teratogenicbull amoxicillin extensively used without harming
the fetusbull Drug classes1048715 B penicillin cephalosporins erythromycin clindamycin Azithromycin D Tetracycline
Antibiotics To Use During Pregnancy
bull Penicillin Vbull Amoxicillinbull Erythromycin (base form)bull Cephalexin cephalosporinbull Clindamycinbull Metronidazole
Antibiotics to Avoid duringPregnancy
bull Doxycyclinebull Tetracyclinebull Erythromycin (estolate form)bull Vancomycin
The Problem With Tetracycline
bull Accumulates in bones and chelates calcium
bull Inhibits bone growthbull Discolors teeth
Other Antimicrobial Agentsbull OK to usebull Nystatin (B)bull Chlorhexidine rinse (B)bull Use with cautionbull Clotrimazole (C)bull Ketoconazole (C)bull Fluconazole (C)bull Do not usebull Doxycycline (D)
Local Anesthetic Use inPregnancy
bull Class Bbull Lidocaine (Xylocaine)bull Etidocainebull Prilocaine bull Class Cbull Procainebull Bupivicainebull Mepivicaine
Use of Local Anestheticsbull Lidocaine + vasoconstrictor most common
local anesthetic used in dentistrybull extensively used in pregnancy with no proven ill
effectsbull accidental intravascular injections of lidocaine
pass through the placenta but the concentrations are too low to harm fetus
bull prilocaine might cause methemoglobinemia
Ulcer healing drugsCimetidine bull FDA category B Famotidinebull FDA category BRanitidinebull FDA category Bbull not known to be harmful
Ulcer healing drugsOmeprazolebull FDA category BNot known to be
harmful Esomeprazolebull FDA category BLansoprazolebull FDA category BPantoprazolebull Avoid unless potential benefit
outweighs riskmdashfetotoxic in animals
Ulcer healing drugs
Misoprostolbull First second third trimesters Avoidmdash
potent uterine stimulant (has been used to induce abortion) and may be teratogenic
Ulcer healing drugs
Antacidsbull Almunium hydroxideMagnesium
hydroxidemdashFDA category B Calcium carbonatemdashFDA category C
SimetheconemdashFDA category C
Use of Nitrous Oxide Gas
bull used over 150 years bull safety is being debatedbull SHORT TERM exposure do not cause
birth defects or spontaneous abortionbull CHRONIC exposure may result in fetal
loss and infertilitybull literature suggests that nitrous oxide
should be avoided until more conclusive research is available
bull FDA Drug class not yet assigned
Common Preventives
bull Fluoridendash No increased risk during pregnancy
bull Xylitolndash No studies no harm reported
bull Chlorhexidinendash No increased risk during pregnancy
Are topical agents safe
bull Fluoridebull Toothpaste amp mouthrinse
bull Xylitol chewing gum bull Chlorhexidine (11 alcohol)bull No over the counter mouthrinses with
alcohol (Listerine 20 alcohol)
Pre-natal Fluoride
bull Daily 22 mg tablet of sodium fluoride during 3rd through 9th months
bull decreases caries rate in offspringbull Safe and effective
Glenn FB 1982
Is it safe to use mercury restorations
bull No evidence of harmful effect
bull Benefits outweigh risks
bull Canada Germany and New Zealand have some restrictions
bull Determine the best option
Referencesbull Wasylko L Matsui D Dykxhoorn SM Rieder MJ Weinberg
S A Review of Common Dental Treatments During Pregnancy J Canadian Dental Association 64434-439 1998
bull Little JW Donald AF Craig SM Rhodus NL Dental Management of the Medically Compromised Patient - 5th edition Mosby Toronto Pp434-442 1997
bull Livingston HM Dellinger TM Holder R Considerations in the management of the pregnant patient Special Care in Dentistry 185 pp183-188 1998
bull Larimore WL Petrie KA Drug use during pregnacy and lactation Primary Care Clinics in Office Practice 271 35-53 2000
bull Health Canada The Safety of DentalAmalgam Minister Of Supply and Services Canada 1996
REFERENCESbull 1 Weiss G Endocrinology of parturition J Clin
Endocrinol Metab 2000854421-5bull 2 Theunissen IM Parer JT Fluid and electrolytes in
pregnancy Clin Obstet Gynecol 1994373-15bull 3 Duvekot JJ Peeters LLH Renal hemodynamics and
volume homeostasis in pregnancy Obstet Gynecol Surv 199449830-9
bull 4 Barron WM Lindheimer MD Medical disorders during pregnancy 2nd ed St Louis Mosby 1995 p 129
bull 5 Thornburg KL Jacobson SL Giraud GD Morton MJ Hemodynamic changes in pregnancy Semin Perinatol 20002411-4
bull 6 Fiese R Herzog S Issues in dental and surgical management of the pregnant patient Oral Surg Oral Med Oral Pathol 198865292-7
bull 7 Martin C Varner MW Physiologic changes in pregnancysurgical implications Clin Obstet Gynecol 199437241-55
bull 8 Clark SL Cotton DB Lee W Bishop C Hill T Southwick J et al Central hemodynamic assessment of normal term pregnancy Am J Obstet Gynecol 19891611439-42
bull 9 Mabie WC Di Sessa TG Crocker LG Sibai BM Arheart KL A longitudinal study of cardiac output in normal human pregnancy Am J Obstet Gynecol 1994170849-56
bull 10 Clapp JF 3rd Capeless E Cardiovascular function before during and after the first and subsequent pregnancies Am J Cardiol 1997801469-73
bull 11 Duvekot JJ Peeters LL Maternal cardiovascular hemodynamic adaptation to pregnancy Obstet Gynecol Surv 199449(Suppl) S1-14
bull 12 Bhagwat AR Engel PJ Heart disease and pregnancy Cardiol Clin 199513163-78
bull 13 Lanni SM Tillinghast J Silver H Hemodynamic changes and baroreflex gain in the supine hypotensive syndrome Am J Obstet Gynecol 20021871636-41
bull 14 Little JW Falace DA Miller CS Rhodus NL Dental management of the medically compromised patient 6th ed St Louis Mosby 2002 p 303
bull 15 Garcia-Rio F Pino JM Gomez L Alvarez-Sala R Villasante C Villamor J Regulation of breathing and perception of dyspnea in healthy pregnant women Chest 1996110446-53
bull 16 McAuliffe F Kametas N Costello J Rafferty GF Greenough A Nicolaides K Respiratory function in singleton and twin pregnancy BJOG 2002109765-9
bull 17 Clapp JF 3rd Seaward BL Sleamaker RH Hiser J Maternal physiologic adaptations to early human pregnancy Am J Obstet Gynecol 19881591456-60
bull 18 OrsquoDay MP Cardio-respiratory physiological adaptation of pregnancy Semin Perinatol 199721268-75
bull 19 Contreras G Gutierrez M Beroiza T Fantin A Oddo H Villarroel L et al Ventilatory drive and respiratory muscle function in pregnancy Am Rev Respir Dis 1991144837-41
bull 20 Turner M Aziz SR Management of the pregnant oral and maxillofac
bull 21 Sifakis S Pharmakides G Anemia in pregnancy Ann N Y Acad Sci 2000900125-36
bull 22 Branch DW Physiologic adaptations of pregnancy Am J Reprod Immunol 199228120-2
bull 23 Burrows RF Kelton JG Incidentally detected thrombocytopenia in healthy mothers and their infants N Engl J Med 1988319 142-5
bull 24 Hanly JG Antiphospholipid syndrome an overview CMAJ 200324(168)1675-82
bull 25 Heilmann L von Tempelhoff GF Pollow K Antiphospholipid syndrome in obstetrics Clin Appl Thromb Hemost 20039 143-50
bull 26 Sherman P Flaxman SM Nausea and vomiting of pregnancy in an evolutionary perspective Am J Obstet Gynecol 2002 185(Suppl)s190-7
bull 27 Koch KL Gastrointestinal factors in nausea and vomiting of pregnancy Am J Obstet Gynecol 2002185(Suppl)s198-203
bull 28 Koch KL Frissora CL Nausea and vomiting during pregnancy Gastroenterol Clin N Am 200332201-34
bull 29 Baron TH Ramirez B Richter JE Gastrointestinal motility disorders during pregnancy Ann Intern Med 1993118 366-75
bull 30 Richter JE Gastroesophageal reflux disease during pregnancy Gastroenterol Clin N Am 200332235-61
bull 31 Marrero JM Goggin PM de Caestecker JS Pearce JM Maxwell JD Determinants of pregnancy heartburn Br J Obstet Gynaecol 199299731-4
bull 32 Hamaoui E Hamaoui M Nutritional assessment and support during pregnancy Gastroenterol Clin N Am 20033259-121
bull 33 King JC Physiology of pregnancy and nutrient metabolism Am J Clin Nutr 200071(suppl)1218s-25s
bull 34 Casanueva E Pfeffer F Fernandez-Gaxiola AC Gutierrez- Valenzuela V Rothenberg SJ Iron and folate status before pregnancy and anemia during pregnancy Ann Nutr Metab 2003 4760-3
bull 35 Chrsquong CL Morgan M Hainsworth I Kingham JG Prospective study of liver dysfunction in Southwest Wales Gut 200251 876-80
bull 36 Rahman TM Wendon J Severe hepatic dysfunction in pregnancy QJM 200295343-57
bull 37 Knox TA Olans LB Liver disease in pregnancy N Engl J Med 1996335569-76
bull 38 Saftlas AF Olson DR Franks AL Atrash H Pokras R Epidemiology of preeclampsia and eclampsia in the United States 1979e1986 Am J Obstet Gynecol 1990163460-5
bull 39 Walker JJ Pre-eclampsia Lancet 20003561260-5
bull 40 Davidson JM Renal disorders in pregnancy Curr Opin Obstet Gynecol 200113109-14
bull 41 Dafnis E Sabatini S The effect of pregnancy on renal function physiology and pathophysiologyAmJMedSci 1992303184-205
bull 42 Davison JM Shiells EA Philips PR Lindheimer MD Serial evaluation of vasopressin release and thirst in human pregnancy Role of human chorionic gonadotrophin in the osmoregulatory changes of gestation J Clin Invest 198881798-806
bull 43 Glinoer D de Nayer P Bourdoux P Lemone M Robyn C van Steirteghem A et al Regulation of maternal thyroid during pregnancy J Clin Endocrinol Metab 199071276-87
bull 44 Wilson SG Retallack RW Kent JC Worth GK Gutteridge DH Serum free 125-dihydroxyvitamin D and the free 125- dihydroxyvitamin D index during a longitudinal study of human pregnancy and lactation Clin Endocrinol 199032613-22
bull 45 Rasmussen N Frolich A Hornnes PJ Hegedus L Serum ionized calcium and intact parathyroid hormone levels during pregnancy and postpartum Br J Obstet Gynaecol 199097857-9
bull 46 Guyton AC Textbook of medical physiology 8th ed Philadelphia W B Saunders 1991 p 915e28
bull 47 Trainer PJ Corticosteroids and pregnancy Semin Reprod Med 200220375-80
bull 48 Soory M Hormonal factors in periodontal disease Dent Update 200027380-3
bull 49 Hugoson A Gingivitis in pregnant women A longitudinal clinical study Odontol Revy 19712265-84
bull 50 Neville BW Damm DD Allen CM Bouquot JE Oral amp Maxillofacial Pathology 3rd ed Philadelphia W B Saunders 2002 p 329-30 447-9
bull 51 Tilakaratne A Soory M Ranasinghe AW Corea SM Ekanayake SL de Silva M Periodontal disease status during pregnancy and 3 months post-partum in rural population of Sri-Lankan women J Clin Periodontol 200027787-92
bull 52 Laine M Tenovuo J Lehtonen OP Ojanatko-Harri A Vilja P Tuohimaa P Pregnancy e related changes in human whole saliva Arch Oral Biol 198833913-7
bull 53 Yuan K Wing LY Lin MT Pathogenetic roles of angiogenic factors in pyogenic granulomas in pregnancy are modulated by female sex hormones J Periodontol 200273701-8
bull 54 Evans RD Briggs PF Tooth-surface loss related to pregnancyinduced vomiting Prim Dent Care 1994124-6
bull 55 Salvolini E Di Giorgio R Curatola A Mazzanti L Fratto G Biochemical modifications of human whole saliva induced by pregnancy Br J Obstet Gynaec 1998105656-60
bull 56 Mauldin JG Newman RB Preterm birth risk assessment Semin Perinatol 200125215-22
bull 57 Heine RP McGregor JA Goodwin TM Artal R Hayashi RH Robertson PA et al Serial salivary estriol to detect an increased risk of preterm birth Obstet Gynecol 200096490-7
bull 58 Kauh YC Zachian TF Melasma Adv Exp Med Biol 1999455 491-9
bull 59 Wong RC Ellis CN Physiologic skin changes in pregnancy J Am Acad Dermatol 198410929-40
bull 60 Errickson CV Matus NR Skin disorders of pregnancy Am Fam Physician 199449605-10
bull 61 Lopez NJ Smith PC Gutierrez J Periodontal therapy may reduce the risk of preterm low birth weight in women with periodontal disease a randomized controlled trial J Periodontol 200273911-24
bull 62 McGaw T Periodontal disease and preterm delivery of lowbirth- weight infants J Can Dent Assoc 200268165-9
bull 63 Richards AG Dental x-ray protection Dent Clin North Am 1968631-41
bull 64 1990 Recommendations of the International Commission on Radiological Protection Ann ICRP 1991211-201
bull 65 Hall EJ Radiation the two-edged sword cancer risks at high and low doses Cancer J 20006343-50
bull 66 Diethelm L Xu H Diagnostic imaging of the lung during pregnancy Clin Obstet Gynecol 19963936-55
bull 67 Brent RL The effects of embryonic and fetal exposure to x-rays microwaves and ultrasound ClinObstetGynecol 198326484-510
bull 68 National Council on Radiation Protection NCRP report no128 1998 Bethesda Md Author
bull 69 Wasylko L Matsui D Dykxhoorn SM Reider MJ Weinberg S A review of common dental treatments during pregnancy implications for patients and dental personnel J Can Dent Assoc 199864434-9
bull 70 Freeman JP Brand JW Radiation doses of commonly used dental radiographic surveys Oral Surg Oral Med Oral Pathol 199477285-9
bull 71 Kircos LTAngin LL Lorton LOrder ofmagnitude dose reduction in intraoral radiography J Am Dent Assoc 1987114344-7
bull 72 Updegrave WJ Simplified and standardized intraoral radiography with reduced tissue irradiation J Am Dent Assoc 197285861-9
bull 73 Wood RE Harris AM van der Merwe EJ Nortje CJ The leaded apron revisited does it reduce gonadal radiation dose in dental radiology Oral Surg Oral Med Oral Pathol 199171642-6
bull 74 An update on radiographic practices information and recommendations ADA Council on Scientific Affairs J Am Dent Assoc 2001132234-8
bull 75 Rayburn WF Recommending medications during pregnancy an evidence based approach Clin Obstet Gynecol 2002451-5
bull 76 Rathmell JP Viscomi C Ashburn MA Management of nonobstetric pain during pregnancy and lactation Anesth Analg 1997851074-87
bull 77 Teratology society public affairs committee FDA classification of drugs for teratogenic risk Teratology 199449446-7
bull 78 Moore PA Selecting drugs for the pregnant dental patient J Am Dent Assoc 19981291281-6
bull 79 Haas DA An update on analgesics for the management of acute postoperative dental pain J Can Dent Assoc 200268476-82
bull 80 Haas DA Pynn BR Sands TD Drug use for the pregnant or lactating patient Gen Dent 20004854-60
bull 81 Committee on Drugs American Academy of Pediatrics The transfer of drugs and other chemicals into human milk Pediatrics 199493137-50
bull 82 Nielsen GL Sorensen HT Larsen H Pedersen L Risk of adverse birth outcome and miscarriage in pregnant users of nonsteroidal anti-inflammatory drugs population based observational study and case-control study BMJ 2001322266-70
bull 83 Janssen N Genta M The effects of immunosuppressive and anti-inflammatory medications on fertility pregnancy and lactation Arch Intern Med 200016610-9
bull 84 Ostensen M Nonsteroidal anti-inflammatory drugs during pregnancy Scand J Rheumatol Suppl 1998107128-32
bull 85 USPDI -Drug information for the health care professional 22nd ed Greenwood Village CO Micromedex 2002 p 152-79
bull 86 Denson DD Coyle DE Thompson GA Santos D Turner PA Myers JA et al Bupivacaine protein binding in the term parturient effects of lactic acidosis Clin Pharmacol Ther 198435702-9
bull 87 Dillon DE Wagner CL Wiest D Newman RB Drug therapy in the nursing mother Obstet Gynecol Clin North Am 199724 675-96
bull 88 Dashe JS Gilstrap LC Antibiotic use in pregnancy Obstet Gynecol Clin North Am 199724617-29
bull 89 American College of Rheumatology Ad hoc Committee on Clinical Guidelines Guidelines for monitoring drug therapy in rheumatoid arthritis Arthritis Rheum 199639723-31
bull 90 Ng PC The fetal and neonatal hypothalamic-pituitary-adrenal axis Arch Dis Child Fetal Neonatal Ed 200082F250-4
bull 91 Crowley P Antenatal corticosteroidsmdashcurrent thinking BJOG 2003110(Suppl 20)77-8
bull 92 ACOG committee opinion antenatal corticosteroid therapy for fetal maturation Obstet Gynecol 200299871-3
bull 93 Ost L Wettrell G Bjorkhem I Rane A Prednisolone excretion in human milk J Pediatr 19851061008-11
bull 94 Rowland AS Baird DD Shore DL Weinberg CR Savitz DA Wilcox AJ Nitrous oxide and spontaneous abortion in female dental assistants Am J Epidemiol 1995141531-8
bull 95 McGlothlin JD Jensen PA Fischbach TJ Hughes RT Jones JH Control of anesthetic gases in dental operatories Scand J Work Environ Health 199218(Suppl 2)103-5
bull ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY Volume 97 Number 6 Suresh and Radfar 681
bull 96 Rosen MA Nitrous oxide for relief of labor pain a systematic review Am J Obstet Gynecol 2002186(Suppl Nature)S110-6
bull 97 Sands TD Pynn BR Management considerations for the pregnant or nursing emergency patient Ont Dent 199875 17-9
bull 98 Daya S Recurrent spontaneous early pregnancy loss and low dose aspirin Minerva Ginecol 200355441-9
bull 99 Sinclair C Handbook of obstetrical emergencies 1st ed Philadelphia WB Saunders 1996 p 29-39 69
bull 100 Tarsitano BF Rollings RE The pregnant dental patient evaluation and management Gen Dent 199341226-34
bull 101 Livingston MH Dlllinger TM Holder R Consideration in the management of the pregnant patient SCD Special Care in Dentistry 199818183-8
Thank you
- A Review on the principle of Dental Management of the Pregnant patient
- Slide 2
- Questions that a dentist may ask
- Stages of Pregnancy
- Slide 5
- Slide 6
- Physiologic Changes in Pregnancy
- Systemic changes in pregnancy
- FLAT SUPINE POSITIONING
- SUPINE HYPOTENSION SYNDROME (Vena Cava Compression)
- Supine Hypotension Syndrome
- Slide 12
- Supine Hypotension Syndrome
- Prevention of Supine Hypotensive Syndrome
- Treatment of Supine Hypotensive Syndrome
- How should the pregnant woman be positioned
- Slide 17
- Slide 18
- Slide 19
- Slide 20
- Slide 21
- Slide 22
- Slide 23
- Pregnancy Related Oral Health Problems
- Oral Problems in Pregnancy
- Pregnancy Gingivitis Pathophysiology
- Pregnancy Gingivitis
- Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Gum Problems - Pregnancy Granuloma
- Slide 31
- Gum Changes - Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Candidiasis
- Pregnancy Myths
- Other Oral Conditions in Pregnancy
- Changes During Pregnancy that Affect Oral Health
- Saliva changes
- Increased Bacteria
- Slide 40
- Enamel erosion caused by frequent vomiting
- Treatment for Acid Exposure
- Oral Diseases Can Effect Pregnancy
- Periodontal Disease and Preterm Labor
- Periodontal Disease and Low Birth Weight
- Periodontal Disease and Preeclampsia
- Periodontitis and Pre-eclampsia
- Dental Considerations
- Treatment Timing
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Slide 52
- Use of Radiation on Pregnant Patient
- Radiographs during Pregnancy
- Risks of Dental X-Rays
- FDA drug classification for pregnancy
- Slide 57
- FDA drug classification for pregnancy
- Slide 59
- Slide 60
- Slide 61
- Common Analgesics
- Analgesics
- Analgesics - continued
- Analgesics to Use During 1st and 2nd Trimester
- Analgesics to Avoid During the Third Trimester
- Sedation in Pregnancy
- Common Antibiotics
- Antibiotics
- Antibiotics To Use During Pregnancy
- Antibiotics to Avoid during Pregnancy
- The Problem With Tetracycline
- Other Antimicrobial Agents
- Local Anesthetic Use in Pregnancy
- Use of Local Anesthetics
- Ulcer healing drugs
- Slide 77
- Slide 78
- Slide 79
- Use of Nitrous Oxide Gas
- Common Preventives
- Are topical agents safe
- Pre-natal Fluoride
- Is it safe to use mercury restorations
- References
- REFERENCES
- Slide 87
- Slide 88
- Slide 89
- Slide 90
- Slide 91
- Slide 92
- Slide 93
- Slide 94
- Slide 95
- Slide 96
- Slide 97
- Slide 98
- Thank you
-
Increased Bacteriabull Increased acidity
ndash Increase in decay-causing bacteriabull Increased Snacking
ndash Morning sicknesslow blood sugarndash Between-meal snacks
bull Increase in amount and frequency of starchescarbohydrates ndash Crackers are commonly recommendedndash Promotes decay-causing bacteria
Changes During Pregnancy that Affect Oral Healthbull Morning sickness
ndash Difficulty with hygienebull Gingival diseasebull Tooth decay
ndash Vomitingbull Esophogeal Reflux (heartburn)bull Acid exposure
ndash Irritation of the gumsndash Weakening of tooth enamelndash Dental erosion
Enamel erosion caused by frequent vomiting
Treatment for Acid Exposure
bull Do NOT brush immediately after vomiting
bull Rinse ndash Water with baking sodandash Antacidndash Plain water
bull Eat some cheese
Oral Diseases Can Effect Pregnancy
bull Preterm low birth weight (LBW) linked to periodontal disease
bull Thorough calculus (tartar) removal in pregnant women with periodontitis may reduce pre-term births
Periodontal Disease and Preterm LaborbullMaternal periodontal disease is associated with increased risk of preterm laborbullAnaerobic oral gram-negative bacteria cause inflammatory responsebullInflammatory response stimulates prostaglandin and cytokine production to stimulate labor
Periodontal Disease and Low Birth Weight
bull Periodontal disease is associated with low birth weight
bull Evidence is not conclusivebull Biochemical mechanism similar cascade
as in preterm labor leading to placental blood flow restriction and necrosis
Periodontal Disease and Preeclampsia
bull Emerging databull Mechanism unclearbull Proposed mechanism
ndash Periodontal infection leads to inflammatory vascular damage
ndash Triggers cell damage in placenta
Periodontitis and Pre-eclampsia
bull Periodontal disease may be associated with pre-eclampsia (Boggess 2003)
bull PGE2 IL-1 and TNF-α from gingival crevicular fluid were higher in women with preeclampsia compared with healthy matched pregnant women (Oettinger-Barak 2003)
Dental Considerations
bull timing of treatment for pregnant patientsbull dental radiation exposurebull use of local anestheticsbull prescription of common antibiotics and
analgesicsbull nitrous oxide gas administration
Treatment Timing
bull First Trimesterndash Spontaneous miscarriages naturally occur
more often in 1st trimesterndash Avoid elective treatment that can be delayedndash Offer anticipatory guidance
bull Second Trimesterndash The optimal time for dental treatmentndash Organogenesis complete fetus not largendash Easier to prevent than treat established disease
bull Third Trimesterndash Late in term very uncomfortable (short visits)ndash Position slightly on left side
Timing of Dental Treatment During Pregnancy - From Little and Fallace
First Trimester
bull Plaque controlbull Oral hygiene instructionbull Scaling polishing curettagebull Avoid elective treatment urgent care
only
Timing of Dental Treatment During Pregnancy - From Little and Fallace
Second Trimester
bull Plaque controlbull Oral hygiene instructionbull Scaling polishing curettagebull Routine dental care
Timing of Dental Treatment During Pregnancy - From Little and Fallace
Third Trimester
bull Plaque controlbull Oral hygiene instructionbull Scaling polishing curettagebull Routine dental care (after middle of third
trimester elective care should be avoided)
Use of Radiation on Pregnant Patientbull Dose given and time of gestation are
importantbull doses lt 5-10 rads (cGy) not teratogenicbull fetus is most susceptible to radiation
between the 2nd and 6th week of gestationbull single dental x-ray exposes patient to 001
millirads of radiation In relative terms this amount is 40 times less than daily dose acquired from cosmic radiation Therefore diagnostic radiation should not be withheld during pregnancy
Radiographs during Pregnancy
bull Take as needed with optimal methods for reducing secondary radiation and exposure time
bull Always use a lead apronbull Exposure to fetus (with apron use) is 00001
centiGray(rad)bull Daily cosmic radiation - 0004 centiGray (rad)
Risks of Dental X-Rays
bull X-ray only if necessary (ie root canal therapy trauma)
bull When x-rays are indicated radiation exposure is extremely low
bull Exposure can be limited byndash Lead apron shielding ndash Modern fast film ndash Avoiding retakes
FDA drug classification for pregnancybull Combines risk statements including
congenital anomalies fetal effects perinatal risks and therapeutic risk-benefit ratio
bull Untreated disease or condition may pose more serious risks to both mother and fetus than any theoretical risks from the medication
bull Category A thru D and X
FDA drug classification for pregnancy
bull A = Controlled Studies in women fail to demonstrate a risk to the fetus in the first trimester and the possibility of fetal harm appears remote
FDA drug classification for pregnancy
bull B = Animal studies show no risk or if risk shown in animals controlled
trials in women showed no risk
FDA drug classification for pregnancy
bull C = Studies in animals with adverse effects and no human studies
OR no animal or human studies but benefits of use may outweigh potential harms
FDA drug classification for pregnancy
bull D = There is evidence of human fetal risk but benefits may outweigh risks
FDA drug classification for pregnancy
bull X = Contraindicated
Common Analgesics
bull paracetamol (B)bull Ibuprofen (BD) bull Oxycodone (BD) bull Hydrocodone and codeine
(CD)
avoid in third trimester
Analgesics
bull Paracetamol is the analgesic of choice for all stages of gestation
bull used to treat mild to moderate pain and fevers
bull short term usage is believed to be safebull avoid chronic and large doses of
paracetamol1048715
Analgesics - continuedbull Aspirin is nonteratogenic but may cause
maternal and fetal hemorrhagebull large and chronic doses during last trimester
may result in premature closure of ductus arteriosus fetal hypertension anemia and low birth weight
bull avoid ibuprofen in 3rd trimester because of possible adverse circulatory effects
bull short term use of codeine seems safebull avoid codeine late in gestation because of
possible fetal respiratory depression and withdrawal symptoms
Analgesics to Use During1st and 2nd Trimester
bull Category B (for best)bull Paracetamol Ibuprofenbull Naproxenbull Category C (use with caution)bull Paracetamol with codeine or
hydrocodonebull Paracetamol with oxycodone
Analgesics to Avoid During theThird Trimesterbull Causes delivery problemsbull Aspirin (C 3D)bull Ibuprofen (B3D)bull Naproxen (B3D)bull Causes neonatal respiratory
depression and opioid withdrawalbull Codeine (C3D)bull Hydrocodone (C3D)bull Oxycodone(C3D)
Sedation in Pregnancy
bull SedativesAnxiolytics (eg Diazepam ) are rated D and can cause oral clefts with prolonged exposure
bull Nitrous oxide should not be used in 1st trimester (If used in 2nd and 3rd do not go below 50 O2)
Common Antibioticsbull To treat oral abscess or cellulitis
ndash Penicillin (B) ndash Amoxicillin (B) ndash Cephalexin (B)ndash Erythromycin base (B) (Not estolate as it
cause cholestatic hepatitis)ndash Clindamycin (B)
Antibioticsbull penicillin V and amoxicillin is preferred drug
for mild to moderate infectionsbull widely used for many years with no ill effectsbull no studies show penicillin to be teratogenicbull amoxicillin extensively used without harming
the fetusbull Drug classes1048715 B penicillin cephalosporins erythromycin clindamycin Azithromycin D Tetracycline
Antibiotics To Use During Pregnancy
bull Penicillin Vbull Amoxicillinbull Erythromycin (base form)bull Cephalexin cephalosporinbull Clindamycinbull Metronidazole
Antibiotics to Avoid duringPregnancy
bull Doxycyclinebull Tetracyclinebull Erythromycin (estolate form)bull Vancomycin
The Problem With Tetracycline
bull Accumulates in bones and chelates calcium
bull Inhibits bone growthbull Discolors teeth
Other Antimicrobial Agentsbull OK to usebull Nystatin (B)bull Chlorhexidine rinse (B)bull Use with cautionbull Clotrimazole (C)bull Ketoconazole (C)bull Fluconazole (C)bull Do not usebull Doxycycline (D)
Local Anesthetic Use inPregnancy
bull Class Bbull Lidocaine (Xylocaine)bull Etidocainebull Prilocaine bull Class Cbull Procainebull Bupivicainebull Mepivicaine
Use of Local Anestheticsbull Lidocaine + vasoconstrictor most common
local anesthetic used in dentistrybull extensively used in pregnancy with no proven ill
effectsbull accidental intravascular injections of lidocaine
pass through the placenta but the concentrations are too low to harm fetus
bull prilocaine might cause methemoglobinemia
Ulcer healing drugsCimetidine bull FDA category B Famotidinebull FDA category BRanitidinebull FDA category Bbull not known to be harmful
Ulcer healing drugsOmeprazolebull FDA category BNot known to be
harmful Esomeprazolebull FDA category BLansoprazolebull FDA category BPantoprazolebull Avoid unless potential benefit
outweighs riskmdashfetotoxic in animals
Ulcer healing drugs
Misoprostolbull First second third trimesters Avoidmdash
potent uterine stimulant (has been used to induce abortion) and may be teratogenic
Ulcer healing drugs
Antacidsbull Almunium hydroxideMagnesium
hydroxidemdashFDA category B Calcium carbonatemdashFDA category C
SimetheconemdashFDA category C
Use of Nitrous Oxide Gas
bull used over 150 years bull safety is being debatedbull SHORT TERM exposure do not cause
birth defects or spontaneous abortionbull CHRONIC exposure may result in fetal
loss and infertilitybull literature suggests that nitrous oxide
should be avoided until more conclusive research is available
bull FDA Drug class not yet assigned
Common Preventives
bull Fluoridendash No increased risk during pregnancy
bull Xylitolndash No studies no harm reported
bull Chlorhexidinendash No increased risk during pregnancy
Are topical agents safe
bull Fluoridebull Toothpaste amp mouthrinse
bull Xylitol chewing gum bull Chlorhexidine (11 alcohol)bull No over the counter mouthrinses with
alcohol (Listerine 20 alcohol)
Pre-natal Fluoride
bull Daily 22 mg tablet of sodium fluoride during 3rd through 9th months
bull decreases caries rate in offspringbull Safe and effective
Glenn FB 1982
Is it safe to use mercury restorations
bull No evidence of harmful effect
bull Benefits outweigh risks
bull Canada Germany and New Zealand have some restrictions
bull Determine the best option
Referencesbull Wasylko L Matsui D Dykxhoorn SM Rieder MJ Weinberg
S A Review of Common Dental Treatments During Pregnancy J Canadian Dental Association 64434-439 1998
bull Little JW Donald AF Craig SM Rhodus NL Dental Management of the Medically Compromised Patient - 5th edition Mosby Toronto Pp434-442 1997
bull Livingston HM Dellinger TM Holder R Considerations in the management of the pregnant patient Special Care in Dentistry 185 pp183-188 1998
bull Larimore WL Petrie KA Drug use during pregnacy and lactation Primary Care Clinics in Office Practice 271 35-53 2000
bull Health Canada The Safety of DentalAmalgam Minister Of Supply and Services Canada 1996
REFERENCESbull 1 Weiss G Endocrinology of parturition J Clin
Endocrinol Metab 2000854421-5bull 2 Theunissen IM Parer JT Fluid and electrolytes in
pregnancy Clin Obstet Gynecol 1994373-15bull 3 Duvekot JJ Peeters LLH Renal hemodynamics and
volume homeostasis in pregnancy Obstet Gynecol Surv 199449830-9
bull 4 Barron WM Lindheimer MD Medical disorders during pregnancy 2nd ed St Louis Mosby 1995 p 129
bull 5 Thornburg KL Jacobson SL Giraud GD Morton MJ Hemodynamic changes in pregnancy Semin Perinatol 20002411-4
bull 6 Fiese R Herzog S Issues in dental and surgical management of the pregnant patient Oral Surg Oral Med Oral Pathol 198865292-7
bull 7 Martin C Varner MW Physiologic changes in pregnancysurgical implications Clin Obstet Gynecol 199437241-55
bull 8 Clark SL Cotton DB Lee W Bishop C Hill T Southwick J et al Central hemodynamic assessment of normal term pregnancy Am J Obstet Gynecol 19891611439-42
bull 9 Mabie WC Di Sessa TG Crocker LG Sibai BM Arheart KL A longitudinal study of cardiac output in normal human pregnancy Am J Obstet Gynecol 1994170849-56
bull 10 Clapp JF 3rd Capeless E Cardiovascular function before during and after the first and subsequent pregnancies Am J Cardiol 1997801469-73
bull 11 Duvekot JJ Peeters LL Maternal cardiovascular hemodynamic adaptation to pregnancy Obstet Gynecol Surv 199449(Suppl) S1-14
bull 12 Bhagwat AR Engel PJ Heart disease and pregnancy Cardiol Clin 199513163-78
bull 13 Lanni SM Tillinghast J Silver H Hemodynamic changes and baroreflex gain in the supine hypotensive syndrome Am J Obstet Gynecol 20021871636-41
bull 14 Little JW Falace DA Miller CS Rhodus NL Dental management of the medically compromised patient 6th ed St Louis Mosby 2002 p 303
bull 15 Garcia-Rio F Pino JM Gomez L Alvarez-Sala R Villasante C Villamor J Regulation of breathing and perception of dyspnea in healthy pregnant women Chest 1996110446-53
bull 16 McAuliffe F Kametas N Costello J Rafferty GF Greenough A Nicolaides K Respiratory function in singleton and twin pregnancy BJOG 2002109765-9
bull 17 Clapp JF 3rd Seaward BL Sleamaker RH Hiser J Maternal physiologic adaptations to early human pregnancy Am J Obstet Gynecol 19881591456-60
bull 18 OrsquoDay MP Cardio-respiratory physiological adaptation of pregnancy Semin Perinatol 199721268-75
bull 19 Contreras G Gutierrez M Beroiza T Fantin A Oddo H Villarroel L et al Ventilatory drive and respiratory muscle function in pregnancy Am Rev Respir Dis 1991144837-41
bull 20 Turner M Aziz SR Management of the pregnant oral and maxillofac
bull 21 Sifakis S Pharmakides G Anemia in pregnancy Ann N Y Acad Sci 2000900125-36
bull 22 Branch DW Physiologic adaptations of pregnancy Am J Reprod Immunol 199228120-2
bull 23 Burrows RF Kelton JG Incidentally detected thrombocytopenia in healthy mothers and their infants N Engl J Med 1988319 142-5
bull 24 Hanly JG Antiphospholipid syndrome an overview CMAJ 200324(168)1675-82
bull 25 Heilmann L von Tempelhoff GF Pollow K Antiphospholipid syndrome in obstetrics Clin Appl Thromb Hemost 20039 143-50
bull 26 Sherman P Flaxman SM Nausea and vomiting of pregnancy in an evolutionary perspective Am J Obstet Gynecol 2002 185(Suppl)s190-7
bull 27 Koch KL Gastrointestinal factors in nausea and vomiting of pregnancy Am J Obstet Gynecol 2002185(Suppl)s198-203
bull 28 Koch KL Frissora CL Nausea and vomiting during pregnancy Gastroenterol Clin N Am 200332201-34
bull 29 Baron TH Ramirez B Richter JE Gastrointestinal motility disorders during pregnancy Ann Intern Med 1993118 366-75
bull 30 Richter JE Gastroesophageal reflux disease during pregnancy Gastroenterol Clin N Am 200332235-61
bull 31 Marrero JM Goggin PM de Caestecker JS Pearce JM Maxwell JD Determinants of pregnancy heartburn Br J Obstet Gynaecol 199299731-4
bull 32 Hamaoui E Hamaoui M Nutritional assessment and support during pregnancy Gastroenterol Clin N Am 20033259-121
bull 33 King JC Physiology of pregnancy and nutrient metabolism Am J Clin Nutr 200071(suppl)1218s-25s
bull 34 Casanueva E Pfeffer F Fernandez-Gaxiola AC Gutierrez- Valenzuela V Rothenberg SJ Iron and folate status before pregnancy and anemia during pregnancy Ann Nutr Metab 2003 4760-3
bull 35 Chrsquong CL Morgan M Hainsworth I Kingham JG Prospective study of liver dysfunction in Southwest Wales Gut 200251 876-80
bull 36 Rahman TM Wendon J Severe hepatic dysfunction in pregnancy QJM 200295343-57
bull 37 Knox TA Olans LB Liver disease in pregnancy N Engl J Med 1996335569-76
bull 38 Saftlas AF Olson DR Franks AL Atrash H Pokras R Epidemiology of preeclampsia and eclampsia in the United States 1979e1986 Am J Obstet Gynecol 1990163460-5
bull 39 Walker JJ Pre-eclampsia Lancet 20003561260-5
bull 40 Davidson JM Renal disorders in pregnancy Curr Opin Obstet Gynecol 200113109-14
bull 41 Dafnis E Sabatini S The effect of pregnancy on renal function physiology and pathophysiologyAmJMedSci 1992303184-205
bull 42 Davison JM Shiells EA Philips PR Lindheimer MD Serial evaluation of vasopressin release and thirst in human pregnancy Role of human chorionic gonadotrophin in the osmoregulatory changes of gestation J Clin Invest 198881798-806
bull 43 Glinoer D de Nayer P Bourdoux P Lemone M Robyn C van Steirteghem A et al Regulation of maternal thyroid during pregnancy J Clin Endocrinol Metab 199071276-87
bull 44 Wilson SG Retallack RW Kent JC Worth GK Gutteridge DH Serum free 125-dihydroxyvitamin D and the free 125- dihydroxyvitamin D index during a longitudinal study of human pregnancy and lactation Clin Endocrinol 199032613-22
bull 45 Rasmussen N Frolich A Hornnes PJ Hegedus L Serum ionized calcium and intact parathyroid hormone levels during pregnancy and postpartum Br J Obstet Gynaecol 199097857-9
bull 46 Guyton AC Textbook of medical physiology 8th ed Philadelphia W B Saunders 1991 p 915e28
bull 47 Trainer PJ Corticosteroids and pregnancy Semin Reprod Med 200220375-80
bull 48 Soory M Hormonal factors in periodontal disease Dent Update 200027380-3
bull 49 Hugoson A Gingivitis in pregnant women A longitudinal clinical study Odontol Revy 19712265-84
bull 50 Neville BW Damm DD Allen CM Bouquot JE Oral amp Maxillofacial Pathology 3rd ed Philadelphia W B Saunders 2002 p 329-30 447-9
bull 51 Tilakaratne A Soory M Ranasinghe AW Corea SM Ekanayake SL de Silva M Periodontal disease status during pregnancy and 3 months post-partum in rural population of Sri-Lankan women J Clin Periodontol 200027787-92
bull 52 Laine M Tenovuo J Lehtonen OP Ojanatko-Harri A Vilja P Tuohimaa P Pregnancy e related changes in human whole saliva Arch Oral Biol 198833913-7
bull 53 Yuan K Wing LY Lin MT Pathogenetic roles of angiogenic factors in pyogenic granulomas in pregnancy are modulated by female sex hormones J Periodontol 200273701-8
bull 54 Evans RD Briggs PF Tooth-surface loss related to pregnancyinduced vomiting Prim Dent Care 1994124-6
bull 55 Salvolini E Di Giorgio R Curatola A Mazzanti L Fratto G Biochemical modifications of human whole saliva induced by pregnancy Br J Obstet Gynaec 1998105656-60
bull 56 Mauldin JG Newman RB Preterm birth risk assessment Semin Perinatol 200125215-22
bull 57 Heine RP McGregor JA Goodwin TM Artal R Hayashi RH Robertson PA et al Serial salivary estriol to detect an increased risk of preterm birth Obstet Gynecol 200096490-7
bull 58 Kauh YC Zachian TF Melasma Adv Exp Med Biol 1999455 491-9
bull 59 Wong RC Ellis CN Physiologic skin changes in pregnancy J Am Acad Dermatol 198410929-40
bull 60 Errickson CV Matus NR Skin disorders of pregnancy Am Fam Physician 199449605-10
bull 61 Lopez NJ Smith PC Gutierrez J Periodontal therapy may reduce the risk of preterm low birth weight in women with periodontal disease a randomized controlled trial J Periodontol 200273911-24
bull 62 McGaw T Periodontal disease and preterm delivery of lowbirth- weight infants J Can Dent Assoc 200268165-9
bull 63 Richards AG Dental x-ray protection Dent Clin North Am 1968631-41
bull 64 1990 Recommendations of the International Commission on Radiological Protection Ann ICRP 1991211-201
bull 65 Hall EJ Radiation the two-edged sword cancer risks at high and low doses Cancer J 20006343-50
bull 66 Diethelm L Xu H Diagnostic imaging of the lung during pregnancy Clin Obstet Gynecol 19963936-55
bull 67 Brent RL The effects of embryonic and fetal exposure to x-rays microwaves and ultrasound ClinObstetGynecol 198326484-510
bull 68 National Council on Radiation Protection NCRP report no128 1998 Bethesda Md Author
bull 69 Wasylko L Matsui D Dykxhoorn SM Reider MJ Weinberg S A review of common dental treatments during pregnancy implications for patients and dental personnel J Can Dent Assoc 199864434-9
bull 70 Freeman JP Brand JW Radiation doses of commonly used dental radiographic surveys Oral Surg Oral Med Oral Pathol 199477285-9
bull 71 Kircos LTAngin LL Lorton LOrder ofmagnitude dose reduction in intraoral radiography J Am Dent Assoc 1987114344-7
bull 72 Updegrave WJ Simplified and standardized intraoral radiography with reduced tissue irradiation J Am Dent Assoc 197285861-9
bull 73 Wood RE Harris AM van der Merwe EJ Nortje CJ The leaded apron revisited does it reduce gonadal radiation dose in dental radiology Oral Surg Oral Med Oral Pathol 199171642-6
bull 74 An update on radiographic practices information and recommendations ADA Council on Scientific Affairs J Am Dent Assoc 2001132234-8
bull 75 Rayburn WF Recommending medications during pregnancy an evidence based approach Clin Obstet Gynecol 2002451-5
bull 76 Rathmell JP Viscomi C Ashburn MA Management of nonobstetric pain during pregnancy and lactation Anesth Analg 1997851074-87
bull 77 Teratology society public affairs committee FDA classification of drugs for teratogenic risk Teratology 199449446-7
bull 78 Moore PA Selecting drugs for the pregnant dental patient J Am Dent Assoc 19981291281-6
bull 79 Haas DA An update on analgesics for the management of acute postoperative dental pain J Can Dent Assoc 200268476-82
bull 80 Haas DA Pynn BR Sands TD Drug use for the pregnant or lactating patient Gen Dent 20004854-60
bull 81 Committee on Drugs American Academy of Pediatrics The transfer of drugs and other chemicals into human milk Pediatrics 199493137-50
bull 82 Nielsen GL Sorensen HT Larsen H Pedersen L Risk of adverse birth outcome and miscarriage in pregnant users of nonsteroidal anti-inflammatory drugs population based observational study and case-control study BMJ 2001322266-70
bull 83 Janssen N Genta M The effects of immunosuppressive and anti-inflammatory medications on fertility pregnancy and lactation Arch Intern Med 200016610-9
bull 84 Ostensen M Nonsteroidal anti-inflammatory drugs during pregnancy Scand J Rheumatol Suppl 1998107128-32
bull 85 USPDI -Drug information for the health care professional 22nd ed Greenwood Village CO Micromedex 2002 p 152-79
bull 86 Denson DD Coyle DE Thompson GA Santos D Turner PA Myers JA et al Bupivacaine protein binding in the term parturient effects of lactic acidosis Clin Pharmacol Ther 198435702-9
bull 87 Dillon DE Wagner CL Wiest D Newman RB Drug therapy in the nursing mother Obstet Gynecol Clin North Am 199724 675-96
bull 88 Dashe JS Gilstrap LC Antibiotic use in pregnancy Obstet Gynecol Clin North Am 199724617-29
bull 89 American College of Rheumatology Ad hoc Committee on Clinical Guidelines Guidelines for monitoring drug therapy in rheumatoid arthritis Arthritis Rheum 199639723-31
bull 90 Ng PC The fetal and neonatal hypothalamic-pituitary-adrenal axis Arch Dis Child Fetal Neonatal Ed 200082F250-4
bull 91 Crowley P Antenatal corticosteroidsmdashcurrent thinking BJOG 2003110(Suppl 20)77-8
bull 92 ACOG committee opinion antenatal corticosteroid therapy for fetal maturation Obstet Gynecol 200299871-3
bull 93 Ost L Wettrell G Bjorkhem I Rane A Prednisolone excretion in human milk J Pediatr 19851061008-11
bull 94 Rowland AS Baird DD Shore DL Weinberg CR Savitz DA Wilcox AJ Nitrous oxide and spontaneous abortion in female dental assistants Am J Epidemiol 1995141531-8
bull 95 McGlothlin JD Jensen PA Fischbach TJ Hughes RT Jones JH Control of anesthetic gases in dental operatories Scand J Work Environ Health 199218(Suppl 2)103-5
bull ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY Volume 97 Number 6 Suresh and Radfar 681
bull 96 Rosen MA Nitrous oxide for relief of labor pain a systematic review Am J Obstet Gynecol 2002186(Suppl Nature)S110-6
bull 97 Sands TD Pynn BR Management considerations for the pregnant or nursing emergency patient Ont Dent 199875 17-9
bull 98 Daya S Recurrent spontaneous early pregnancy loss and low dose aspirin Minerva Ginecol 200355441-9
bull 99 Sinclair C Handbook of obstetrical emergencies 1st ed Philadelphia WB Saunders 1996 p 29-39 69
bull 100 Tarsitano BF Rollings RE The pregnant dental patient evaluation and management Gen Dent 199341226-34
bull 101 Livingston MH Dlllinger TM Holder R Consideration in the management of the pregnant patient SCD Special Care in Dentistry 199818183-8
Thank you
- A Review on the principle of Dental Management of the Pregnant patient
- Slide 2
- Questions that a dentist may ask
- Stages of Pregnancy
- Slide 5
- Slide 6
- Physiologic Changes in Pregnancy
- Systemic changes in pregnancy
- FLAT SUPINE POSITIONING
- SUPINE HYPOTENSION SYNDROME (Vena Cava Compression)
- Supine Hypotension Syndrome
- Slide 12
- Supine Hypotension Syndrome
- Prevention of Supine Hypotensive Syndrome
- Treatment of Supine Hypotensive Syndrome
- How should the pregnant woman be positioned
- Slide 17
- Slide 18
- Slide 19
- Slide 20
- Slide 21
- Slide 22
- Slide 23
- Pregnancy Related Oral Health Problems
- Oral Problems in Pregnancy
- Pregnancy Gingivitis Pathophysiology
- Pregnancy Gingivitis
- Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Gum Problems - Pregnancy Granuloma
- Slide 31
- Gum Changes - Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Candidiasis
- Pregnancy Myths
- Other Oral Conditions in Pregnancy
- Changes During Pregnancy that Affect Oral Health
- Saliva changes
- Increased Bacteria
- Slide 40
- Enamel erosion caused by frequent vomiting
- Treatment for Acid Exposure
- Oral Diseases Can Effect Pregnancy
- Periodontal Disease and Preterm Labor
- Periodontal Disease and Low Birth Weight
- Periodontal Disease and Preeclampsia
- Periodontitis and Pre-eclampsia
- Dental Considerations
- Treatment Timing
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Slide 52
- Use of Radiation on Pregnant Patient
- Radiographs during Pregnancy
- Risks of Dental X-Rays
- FDA drug classification for pregnancy
- Slide 57
- FDA drug classification for pregnancy
- Slide 59
- Slide 60
- Slide 61
- Common Analgesics
- Analgesics
- Analgesics - continued
- Analgesics to Use During 1st and 2nd Trimester
- Analgesics to Avoid During the Third Trimester
- Sedation in Pregnancy
- Common Antibiotics
- Antibiotics
- Antibiotics To Use During Pregnancy
- Antibiotics to Avoid during Pregnancy
- The Problem With Tetracycline
- Other Antimicrobial Agents
- Local Anesthetic Use in Pregnancy
- Use of Local Anesthetics
- Ulcer healing drugs
- Slide 77
- Slide 78
- Slide 79
- Use of Nitrous Oxide Gas
- Common Preventives
- Are topical agents safe
- Pre-natal Fluoride
- Is it safe to use mercury restorations
- References
- REFERENCES
- Slide 87
- Slide 88
- Slide 89
- Slide 90
- Slide 91
- Slide 92
- Slide 93
- Slide 94
- Slide 95
- Slide 96
- Slide 97
- Slide 98
- Thank you
-
Changes During Pregnancy that Affect Oral Healthbull Morning sickness
ndash Difficulty with hygienebull Gingival diseasebull Tooth decay
ndash Vomitingbull Esophogeal Reflux (heartburn)bull Acid exposure
ndash Irritation of the gumsndash Weakening of tooth enamelndash Dental erosion
Enamel erosion caused by frequent vomiting
Treatment for Acid Exposure
bull Do NOT brush immediately after vomiting
bull Rinse ndash Water with baking sodandash Antacidndash Plain water
bull Eat some cheese
Oral Diseases Can Effect Pregnancy
bull Preterm low birth weight (LBW) linked to periodontal disease
bull Thorough calculus (tartar) removal in pregnant women with periodontitis may reduce pre-term births
Periodontal Disease and Preterm LaborbullMaternal periodontal disease is associated with increased risk of preterm laborbullAnaerobic oral gram-negative bacteria cause inflammatory responsebullInflammatory response stimulates prostaglandin and cytokine production to stimulate labor
Periodontal Disease and Low Birth Weight
bull Periodontal disease is associated with low birth weight
bull Evidence is not conclusivebull Biochemical mechanism similar cascade
as in preterm labor leading to placental blood flow restriction and necrosis
Periodontal Disease and Preeclampsia
bull Emerging databull Mechanism unclearbull Proposed mechanism
ndash Periodontal infection leads to inflammatory vascular damage
ndash Triggers cell damage in placenta
Periodontitis and Pre-eclampsia
bull Periodontal disease may be associated with pre-eclampsia (Boggess 2003)
bull PGE2 IL-1 and TNF-α from gingival crevicular fluid were higher in women with preeclampsia compared with healthy matched pregnant women (Oettinger-Barak 2003)
Dental Considerations
bull timing of treatment for pregnant patientsbull dental radiation exposurebull use of local anestheticsbull prescription of common antibiotics and
analgesicsbull nitrous oxide gas administration
Treatment Timing
bull First Trimesterndash Spontaneous miscarriages naturally occur
more often in 1st trimesterndash Avoid elective treatment that can be delayedndash Offer anticipatory guidance
bull Second Trimesterndash The optimal time for dental treatmentndash Organogenesis complete fetus not largendash Easier to prevent than treat established disease
bull Third Trimesterndash Late in term very uncomfortable (short visits)ndash Position slightly on left side
Timing of Dental Treatment During Pregnancy - From Little and Fallace
First Trimester
bull Plaque controlbull Oral hygiene instructionbull Scaling polishing curettagebull Avoid elective treatment urgent care
only
Timing of Dental Treatment During Pregnancy - From Little and Fallace
Second Trimester
bull Plaque controlbull Oral hygiene instructionbull Scaling polishing curettagebull Routine dental care
Timing of Dental Treatment During Pregnancy - From Little and Fallace
Third Trimester
bull Plaque controlbull Oral hygiene instructionbull Scaling polishing curettagebull Routine dental care (after middle of third
trimester elective care should be avoided)
Use of Radiation on Pregnant Patientbull Dose given and time of gestation are
importantbull doses lt 5-10 rads (cGy) not teratogenicbull fetus is most susceptible to radiation
between the 2nd and 6th week of gestationbull single dental x-ray exposes patient to 001
millirads of radiation In relative terms this amount is 40 times less than daily dose acquired from cosmic radiation Therefore diagnostic radiation should not be withheld during pregnancy
Radiographs during Pregnancy
bull Take as needed with optimal methods for reducing secondary radiation and exposure time
bull Always use a lead apronbull Exposure to fetus (with apron use) is 00001
centiGray(rad)bull Daily cosmic radiation - 0004 centiGray (rad)
Risks of Dental X-Rays
bull X-ray only if necessary (ie root canal therapy trauma)
bull When x-rays are indicated radiation exposure is extremely low
bull Exposure can be limited byndash Lead apron shielding ndash Modern fast film ndash Avoiding retakes
FDA drug classification for pregnancybull Combines risk statements including
congenital anomalies fetal effects perinatal risks and therapeutic risk-benefit ratio
bull Untreated disease or condition may pose more serious risks to both mother and fetus than any theoretical risks from the medication
bull Category A thru D and X
FDA drug classification for pregnancy
bull A = Controlled Studies in women fail to demonstrate a risk to the fetus in the first trimester and the possibility of fetal harm appears remote
FDA drug classification for pregnancy
bull B = Animal studies show no risk or if risk shown in animals controlled
trials in women showed no risk
FDA drug classification for pregnancy
bull C = Studies in animals with adverse effects and no human studies
OR no animal or human studies but benefits of use may outweigh potential harms
FDA drug classification for pregnancy
bull D = There is evidence of human fetal risk but benefits may outweigh risks
FDA drug classification for pregnancy
bull X = Contraindicated
Common Analgesics
bull paracetamol (B)bull Ibuprofen (BD) bull Oxycodone (BD) bull Hydrocodone and codeine
(CD)
avoid in third trimester
Analgesics
bull Paracetamol is the analgesic of choice for all stages of gestation
bull used to treat mild to moderate pain and fevers
bull short term usage is believed to be safebull avoid chronic and large doses of
paracetamol1048715
Analgesics - continuedbull Aspirin is nonteratogenic but may cause
maternal and fetal hemorrhagebull large and chronic doses during last trimester
may result in premature closure of ductus arteriosus fetal hypertension anemia and low birth weight
bull avoid ibuprofen in 3rd trimester because of possible adverse circulatory effects
bull short term use of codeine seems safebull avoid codeine late in gestation because of
possible fetal respiratory depression and withdrawal symptoms
Analgesics to Use During1st and 2nd Trimester
bull Category B (for best)bull Paracetamol Ibuprofenbull Naproxenbull Category C (use with caution)bull Paracetamol with codeine or
hydrocodonebull Paracetamol with oxycodone
Analgesics to Avoid During theThird Trimesterbull Causes delivery problemsbull Aspirin (C 3D)bull Ibuprofen (B3D)bull Naproxen (B3D)bull Causes neonatal respiratory
depression and opioid withdrawalbull Codeine (C3D)bull Hydrocodone (C3D)bull Oxycodone(C3D)
Sedation in Pregnancy
bull SedativesAnxiolytics (eg Diazepam ) are rated D and can cause oral clefts with prolonged exposure
bull Nitrous oxide should not be used in 1st trimester (If used in 2nd and 3rd do not go below 50 O2)
Common Antibioticsbull To treat oral abscess or cellulitis
ndash Penicillin (B) ndash Amoxicillin (B) ndash Cephalexin (B)ndash Erythromycin base (B) (Not estolate as it
cause cholestatic hepatitis)ndash Clindamycin (B)
Antibioticsbull penicillin V and amoxicillin is preferred drug
for mild to moderate infectionsbull widely used for many years with no ill effectsbull no studies show penicillin to be teratogenicbull amoxicillin extensively used without harming
the fetusbull Drug classes1048715 B penicillin cephalosporins erythromycin clindamycin Azithromycin D Tetracycline
Antibiotics To Use During Pregnancy
bull Penicillin Vbull Amoxicillinbull Erythromycin (base form)bull Cephalexin cephalosporinbull Clindamycinbull Metronidazole
Antibiotics to Avoid duringPregnancy
bull Doxycyclinebull Tetracyclinebull Erythromycin (estolate form)bull Vancomycin
The Problem With Tetracycline
bull Accumulates in bones and chelates calcium
bull Inhibits bone growthbull Discolors teeth
Other Antimicrobial Agentsbull OK to usebull Nystatin (B)bull Chlorhexidine rinse (B)bull Use with cautionbull Clotrimazole (C)bull Ketoconazole (C)bull Fluconazole (C)bull Do not usebull Doxycycline (D)
Local Anesthetic Use inPregnancy
bull Class Bbull Lidocaine (Xylocaine)bull Etidocainebull Prilocaine bull Class Cbull Procainebull Bupivicainebull Mepivicaine
Use of Local Anestheticsbull Lidocaine + vasoconstrictor most common
local anesthetic used in dentistrybull extensively used in pregnancy with no proven ill
effectsbull accidental intravascular injections of lidocaine
pass through the placenta but the concentrations are too low to harm fetus
bull prilocaine might cause methemoglobinemia
Ulcer healing drugsCimetidine bull FDA category B Famotidinebull FDA category BRanitidinebull FDA category Bbull not known to be harmful
Ulcer healing drugsOmeprazolebull FDA category BNot known to be
harmful Esomeprazolebull FDA category BLansoprazolebull FDA category BPantoprazolebull Avoid unless potential benefit
outweighs riskmdashfetotoxic in animals
Ulcer healing drugs
Misoprostolbull First second third trimesters Avoidmdash
potent uterine stimulant (has been used to induce abortion) and may be teratogenic
Ulcer healing drugs
Antacidsbull Almunium hydroxideMagnesium
hydroxidemdashFDA category B Calcium carbonatemdashFDA category C
SimetheconemdashFDA category C
Use of Nitrous Oxide Gas
bull used over 150 years bull safety is being debatedbull SHORT TERM exposure do not cause
birth defects or spontaneous abortionbull CHRONIC exposure may result in fetal
loss and infertilitybull literature suggests that nitrous oxide
should be avoided until more conclusive research is available
bull FDA Drug class not yet assigned
Common Preventives
bull Fluoridendash No increased risk during pregnancy
bull Xylitolndash No studies no harm reported
bull Chlorhexidinendash No increased risk during pregnancy
Are topical agents safe
bull Fluoridebull Toothpaste amp mouthrinse
bull Xylitol chewing gum bull Chlorhexidine (11 alcohol)bull No over the counter mouthrinses with
alcohol (Listerine 20 alcohol)
Pre-natal Fluoride
bull Daily 22 mg tablet of sodium fluoride during 3rd through 9th months
bull decreases caries rate in offspringbull Safe and effective
Glenn FB 1982
Is it safe to use mercury restorations
bull No evidence of harmful effect
bull Benefits outweigh risks
bull Canada Germany and New Zealand have some restrictions
bull Determine the best option
Referencesbull Wasylko L Matsui D Dykxhoorn SM Rieder MJ Weinberg
S A Review of Common Dental Treatments During Pregnancy J Canadian Dental Association 64434-439 1998
bull Little JW Donald AF Craig SM Rhodus NL Dental Management of the Medically Compromised Patient - 5th edition Mosby Toronto Pp434-442 1997
bull Livingston HM Dellinger TM Holder R Considerations in the management of the pregnant patient Special Care in Dentistry 185 pp183-188 1998
bull Larimore WL Petrie KA Drug use during pregnacy and lactation Primary Care Clinics in Office Practice 271 35-53 2000
bull Health Canada The Safety of DentalAmalgam Minister Of Supply and Services Canada 1996
REFERENCESbull 1 Weiss G Endocrinology of parturition J Clin
Endocrinol Metab 2000854421-5bull 2 Theunissen IM Parer JT Fluid and electrolytes in
pregnancy Clin Obstet Gynecol 1994373-15bull 3 Duvekot JJ Peeters LLH Renal hemodynamics and
volume homeostasis in pregnancy Obstet Gynecol Surv 199449830-9
bull 4 Barron WM Lindheimer MD Medical disorders during pregnancy 2nd ed St Louis Mosby 1995 p 129
bull 5 Thornburg KL Jacobson SL Giraud GD Morton MJ Hemodynamic changes in pregnancy Semin Perinatol 20002411-4
bull 6 Fiese R Herzog S Issues in dental and surgical management of the pregnant patient Oral Surg Oral Med Oral Pathol 198865292-7
bull 7 Martin C Varner MW Physiologic changes in pregnancysurgical implications Clin Obstet Gynecol 199437241-55
bull 8 Clark SL Cotton DB Lee W Bishop C Hill T Southwick J et al Central hemodynamic assessment of normal term pregnancy Am J Obstet Gynecol 19891611439-42
bull 9 Mabie WC Di Sessa TG Crocker LG Sibai BM Arheart KL A longitudinal study of cardiac output in normal human pregnancy Am J Obstet Gynecol 1994170849-56
bull 10 Clapp JF 3rd Capeless E Cardiovascular function before during and after the first and subsequent pregnancies Am J Cardiol 1997801469-73
bull 11 Duvekot JJ Peeters LL Maternal cardiovascular hemodynamic adaptation to pregnancy Obstet Gynecol Surv 199449(Suppl) S1-14
bull 12 Bhagwat AR Engel PJ Heart disease and pregnancy Cardiol Clin 199513163-78
bull 13 Lanni SM Tillinghast J Silver H Hemodynamic changes and baroreflex gain in the supine hypotensive syndrome Am J Obstet Gynecol 20021871636-41
bull 14 Little JW Falace DA Miller CS Rhodus NL Dental management of the medically compromised patient 6th ed St Louis Mosby 2002 p 303
bull 15 Garcia-Rio F Pino JM Gomez L Alvarez-Sala R Villasante C Villamor J Regulation of breathing and perception of dyspnea in healthy pregnant women Chest 1996110446-53
bull 16 McAuliffe F Kametas N Costello J Rafferty GF Greenough A Nicolaides K Respiratory function in singleton and twin pregnancy BJOG 2002109765-9
bull 17 Clapp JF 3rd Seaward BL Sleamaker RH Hiser J Maternal physiologic adaptations to early human pregnancy Am J Obstet Gynecol 19881591456-60
bull 18 OrsquoDay MP Cardio-respiratory physiological adaptation of pregnancy Semin Perinatol 199721268-75
bull 19 Contreras G Gutierrez M Beroiza T Fantin A Oddo H Villarroel L et al Ventilatory drive and respiratory muscle function in pregnancy Am Rev Respir Dis 1991144837-41
bull 20 Turner M Aziz SR Management of the pregnant oral and maxillofac
bull 21 Sifakis S Pharmakides G Anemia in pregnancy Ann N Y Acad Sci 2000900125-36
bull 22 Branch DW Physiologic adaptations of pregnancy Am J Reprod Immunol 199228120-2
bull 23 Burrows RF Kelton JG Incidentally detected thrombocytopenia in healthy mothers and their infants N Engl J Med 1988319 142-5
bull 24 Hanly JG Antiphospholipid syndrome an overview CMAJ 200324(168)1675-82
bull 25 Heilmann L von Tempelhoff GF Pollow K Antiphospholipid syndrome in obstetrics Clin Appl Thromb Hemost 20039 143-50
bull 26 Sherman P Flaxman SM Nausea and vomiting of pregnancy in an evolutionary perspective Am J Obstet Gynecol 2002 185(Suppl)s190-7
bull 27 Koch KL Gastrointestinal factors in nausea and vomiting of pregnancy Am J Obstet Gynecol 2002185(Suppl)s198-203
bull 28 Koch KL Frissora CL Nausea and vomiting during pregnancy Gastroenterol Clin N Am 200332201-34
bull 29 Baron TH Ramirez B Richter JE Gastrointestinal motility disorders during pregnancy Ann Intern Med 1993118 366-75
bull 30 Richter JE Gastroesophageal reflux disease during pregnancy Gastroenterol Clin N Am 200332235-61
bull 31 Marrero JM Goggin PM de Caestecker JS Pearce JM Maxwell JD Determinants of pregnancy heartburn Br J Obstet Gynaecol 199299731-4
bull 32 Hamaoui E Hamaoui M Nutritional assessment and support during pregnancy Gastroenterol Clin N Am 20033259-121
bull 33 King JC Physiology of pregnancy and nutrient metabolism Am J Clin Nutr 200071(suppl)1218s-25s
bull 34 Casanueva E Pfeffer F Fernandez-Gaxiola AC Gutierrez- Valenzuela V Rothenberg SJ Iron and folate status before pregnancy and anemia during pregnancy Ann Nutr Metab 2003 4760-3
bull 35 Chrsquong CL Morgan M Hainsworth I Kingham JG Prospective study of liver dysfunction in Southwest Wales Gut 200251 876-80
bull 36 Rahman TM Wendon J Severe hepatic dysfunction in pregnancy QJM 200295343-57
bull 37 Knox TA Olans LB Liver disease in pregnancy N Engl J Med 1996335569-76
bull 38 Saftlas AF Olson DR Franks AL Atrash H Pokras R Epidemiology of preeclampsia and eclampsia in the United States 1979e1986 Am J Obstet Gynecol 1990163460-5
bull 39 Walker JJ Pre-eclampsia Lancet 20003561260-5
bull 40 Davidson JM Renal disorders in pregnancy Curr Opin Obstet Gynecol 200113109-14
bull 41 Dafnis E Sabatini S The effect of pregnancy on renal function physiology and pathophysiologyAmJMedSci 1992303184-205
bull 42 Davison JM Shiells EA Philips PR Lindheimer MD Serial evaluation of vasopressin release and thirst in human pregnancy Role of human chorionic gonadotrophin in the osmoregulatory changes of gestation J Clin Invest 198881798-806
bull 43 Glinoer D de Nayer P Bourdoux P Lemone M Robyn C van Steirteghem A et al Regulation of maternal thyroid during pregnancy J Clin Endocrinol Metab 199071276-87
bull 44 Wilson SG Retallack RW Kent JC Worth GK Gutteridge DH Serum free 125-dihydroxyvitamin D and the free 125- dihydroxyvitamin D index during a longitudinal study of human pregnancy and lactation Clin Endocrinol 199032613-22
bull 45 Rasmussen N Frolich A Hornnes PJ Hegedus L Serum ionized calcium and intact parathyroid hormone levels during pregnancy and postpartum Br J Obstet Gynaecol 199097857-9
bull 46 Guyton AC Textbook of medical physiology 8th ed Philadelphia W B Saunders 1991 p 915e28
bull 47 Trainer PJ Corticosteroids and pregnancy Semin Reprod Med 200220375-80
bull 48 Soory M Hormonal factors in periodontal disease Dent Update 200027380-3
bull 49 Hugoson A Gingivitis in pregnant women A longitudinal clinical study Odontol Revy 19712265-84
bull 50 Neville BW Damm DD Allen CM Bouquot JE Oral amp Maxillofacial Pathology 3rd ed Philadelphia W B Saunders 2002 p 329-30 447-9
bull 51 Tilakaratne A Soory M Ranasinghe AW Corea SM Ekanayake SL de Silva M Periodontal disease status during pregnancy and 3 months post-partum in rural population of Sri-Lankan women J Clin Periodontol 200027787-92
bull 52 Laine M Tenovuo J Lehtonen OP Ojanatko-Harri A Vilja P Tuohimaa P Pregnancy e related changes in human whole saliva Arch Oral Biol 198833913-7
bull 53 Yuan K Wing LY Lin MT Pathogenetic roles of angiogenic factors in pyogenic granulomas in pregnancy are modulated by female sex hormones J Periodontol 200273701-8
bull 54 Evans RD Briggs PF Tooth-surface loss related to pregnancyinduced vomiting Prim Dent Care 1994124-6
bull 55 Salvolini E Di Giorgio R Curatola A Mazzanti L Fratto G Biochemical modifications of human whole saliva induced by pregnancy Br J Obstet Gynaec 1998105656-60
bull 56 Mauldin JG Newman RB Preterm birth risk assessment Semin Perinatol 200125215-22
bull 57 Heine RP McGregor JA Goodwin TM Artal R Hayashi RH Robertson PA et al Serial salivary estriol to detect an increased risk of preterm birth Obstet Gynecol 200096490-7
bull 58 Kauh YC Zachian TF Melasma Adv Exp Med Biol 1999455 491-9
bull 59 Wong RC Ellis CN Physiologic skin changes in pregnancy J Am Acad Dermatol 198410929-40
bull 60 Errickson CV Matus NR Skin disorders of pregnancy Am Fam Physician 199449605-10
bull 61 Lopez NJ Smith PC Gutierrez J Periodontal therapy may reduce the risk of preterm low birth weight in women with periodontal disease a randomized controlled trial J Periodontol 200273911-24
bull 62 McGaw T Periodontal disease and preterm delivery of lowbirth- weight infants J Can Dent Assoc 200268165-9
bull 63 Richards AG Dental x-ray protection Dent Clin North Am 1968631-41
bull 64 1990 Recommendations of the International Commission on Radiological Protection Ann ICRP 1991211-201
bull 65 Hall EJ Radiation the two-edged sword cancer risks at high and low doses Cancer J 20006343-50
bull 66 Diethelm L Xu H Diagnostic imaging of the lung during pregnancy Clin Obstet Gynecol 19963936-55
bull 67 Brent RL The effects of embryonic and fetal exposure to x-rays microwaves and ultrasound ClinObstetGynecol 198326484-510
bull 68 National Council on Radiation Protection NCRP report no128 1998 Bethesda Md Author
bull 69 Wasylko L Matsui D Dykxhoorn SM Reider MJ Weinberg S A review of common dental treatments during pregnancy implications for patients and dental personnel J Can Dent Assoc 199864434-9
bull 70 Freeman JP Brand JW Radiation doses of commonly used dental radiographic surveys Oral Surg Oral Med Oral Pathol 199477285-9
bull 71 Kircos LTAngin LL Lorton LOrder ofmagnitude dose reduction in intraoral radiography J Am Dent Assoc 1987114344-7
bull 72 Updegrave WJ Simplified and standardized intraoral radiography with reduced tissue irradiation J Am Dent Assoc 197285861-9
bull 73 Wood RE Harris AM van der Merwe EJ Nortje CJ The leaded apron revisited does it reduce gonadal radiation dose in dental radiology Oral Surg Oral Med Oral Pathol 199171642-6
bull 74 An update on radiographic practices information and recommendations ADA Council on Scientific Affairs J Am Dent Assoc 2001132234-8
bull 75 Rayburn WF Recommending medications during pregnancy an evidence based approach Clin Obstet Gynecol 2002451-5
bull 76 Rathmell JP Viscomi C Ashburn MA Management of nonobstetric pain during pregnancy and lactation Anesth Analg 1997851074-87
bull 77 Teratology society public affairs committee FDA classification of drugs for teratogenic risk Teratology 199449446-7
bull 78 Moore PA Selecting drugs for the pregnant dental patient J Am Dent Assoc 19981291281-6
bull 79 Haas DA An update on analgesics for the management of acute postoperative dental pain J Can Dent Assoc 200268476-82
bull 80 Haas DA Pynn BR Sands TD Drug use for the pregnant or lactating patient Gen Dent 20004854-60
bull 81 Committee on Drugs American Academy of Pediatrics The transfer of drugs and other chemicals into human milk Pediatrics 199493137-50
bull 82 Nielsen GL Sorensen HT Larsen H Pedersen L Risk of adverse birth outcome and miscarriage in pregnant users of nonsteroidal anti-inflammatory drugs population based observational study and case-control study BMJ 2001322266-70
bull 83 Janssen N Genta M The effects of immunosuppressive and anti-inflammatory medications on fertility pregnancy and lactation Arch Intern Med 200016610-9
bull 84 Ostensen M Nonsteroidal anti-inflammatory drugs during pregnancy Scand J Rheumatol Suppl 1998107128-32
bull 85 USPDI -Drug information for the health care professional 22nd ed Greenwood Village CO Micromedex 2002 p 152-79
bull 86 Denson DD Coyle DE Thompson GA Santos D Turner PA Myers JA et al Bupivacaine protein binding in the term parturient effects of lactic acidosis Clin Pharmacol Ther 198435702-9
bull 87 Dillon DE Wagner CL Wiest D Newman RB Drug therapy in the nursing mother Obstet Gynecol Clin North Am 199724 675-96
bull 88 Dashe JS Gilstrap LC Antibiotic use in pregnancy Obstet Gynecol Clin North Am 199724617-29
bull 89 American College of Rheumatology Ad hoc Committee on Clinical Guidelines Guidelines for monitoring drug therapy in rheumatoid arthritis Arthritis Rheum 199639723-31
bull 90 Ng PC The fetal and neonatal hypothalamic-pituitary-adrenal axis Arch Dis Child Fetal Neonatal Ed 200082F250-4
bull 91 Crowley P Antenatal corticosteroidsmdashcurrent thinking BJOG 2003110(Suppl 20)77-8
bull 92 ACOG committee opinion antenatal corticosteroid therapy for fetal maturation Obstet Gynecol 200299871-3
bull 93 Ost L Wettrell G Bjorkhem I Rane A Prednisolone excretion in human milk J Pediatr 19851061008-11
bull 94 Rowland AS Baird DD Shore DL Weinberg CR Savitz DA Wilcox AJ Nitrous oxide and spontaneous abortion in female dental assistants Am J Epidemiol 1995141531-8
bull 95 McGlothlin JD Jensen PA Fischbach TJ Hughes RT Jones JH Control of anesthetic gases in dental operatories Scand J Work Environ Health 199218(Suppl 2)103-5
bull ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY Volume 97 Number 6 Suresh and Radfar 681
bull 96 Rosen MA Nitrous oxide for relief of labor pain a systematic review Am J Obstet Gynecol 2002186(Suppl Nature)S110-6
bull 97 Sands TD Pynn BR Management considerations for the pregnant or nursing emergency patient Ont Dent 199875 17-9
bull 98 Daya S Recurrent spontaneous early pregnancy loss and low dose aspirin Minerva Ginecol 200355441-9
bull 99 Sinclair C Handbook of obstetrical emergencies 1st ed Philadelphia WB Saunders 1996 p 29-39 69
bull 100 Tarsitano BF Rollings RE The pregnant dental patient evaluation and management Gen Dent 199341226-34
bull 101 Livingston MH Dlllinger TM Holder R Consideration in the management of the pregnant patient SCD Special Care in Dentistry 199818183-8
Thank you
- A Review on the principle of Dental Management of the Pregnant patient
- Slide 2
- Questions that a dentist may ask
- Stages of Pregnancy
- Slide 5
- Slide 6
- Physiologic Changes in Pregnancy
- Systemic changes in pregnancy
- FLAT SUPINE POSITIONING
- SUPINE HYPOTENSION SYNDROME (Vena Cava Compression)
- Supine Hypotension Syndrome
- Slide 12
- Supine Hypotension Syndrome
- Prevention of Supine Hypotensive Syndrome
- Treatment of Supine Hypotensive Syndrome
- How should the pregnant woman be positioned
- Slide 17
- Slide 18
- Slide 19
- Slide 20
- Slide 21
- Slide 22
- Slide 23
- Pregnancy Related Oral Health Problems
- Oral Problems in Pregnancy
- Pregnancy Gingivitis Pathophysiology
- Pregnancy Gingivitis
- Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Gum Problems - Pregnancy Granuloma
- Slide 31
- Gum Changes - Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Candidiasis
- Pregnancy Myths
- Other Oral Conditions in Pregnancy
- Changes During Pregnancy that Affect Oral Health
- Saliva changes
- Increased Bacteria
- Slide 40
- Enamel erosion caused by frequent vomiting
- Treatment for Acid Exposure
- Oral Diseases Can Effect Pregnancy
- Periodontal Disease and Preterm Labor
- Periodontal Disease and Low Birth Weight
- Periodontal Disease and Preeclampsia
- Periodontitis and Pre-eclampsia
- Dental Considerations
- Treatment Timing
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Slide 52
- Use of Radiation on Pregnant Patient
- Radiographs during Pregnancy
- Risks of Dental X-Rays
- FDA drug classification for pregnancy
- Slide 57
- FDA drug classification for pregnancy
- Slide 59
- Slide 60
- Slide 61
- Common Analgesics
- Analgesics
- Analgesics - continued
- Analgesics to Use During 1st and 2nd Trimester
- Analgesics to Avoid During the Third Trimester
- Sedation in Pregnancy
- Common Antibiotics
- Antibiotics
- Antibiotics To Use During Pregnancy
- Antibiotics to Avoid during Pregnancy
- The Problem With Tetracycline
- Other Antimicrobial Agents
- Local Anesthetic Use in Pregnancy
- Use of Local Anesthetics
- Ulcer healing drugs
- Slide 77
- Slide 78
- Slide 79
- Use of Nitrous Oxide Gas
- Common Preventives
- Are topical agents safe
- Pre-natal Fluoride
- Is it safe to use mercury restorations
- References
- REFERENCES
- Slide 87
- Slide 88
- Slide 89
- Slide 90
- Slide 91
- Slide 92
- Slide 93
- Slide 94
- Slide 95
- Slide 96
- Slide 97
- Slide 98
- Thank you
-
Enamel erosion caused by frequent vomiting
Treatment for Acid Exposure
bull Do NOT brush immediately after vomiting
bull Rinse ndash Water with baking sodandash Antacidndash Plain water
bull Eat some cheese
Oral Diseases Can Effect Pregnancy
bull Preterm low birth weight (LBW) linked to periodontal disease
bull Thorough calculus (tartar) removal in pregnant women with periodontitis may reduce pre-term births
Periodontal Disease and Preterm LaborbullMaternal periodontal disease is associated with increased risk of preterm laborbullAnaerobic oral gram-negative bacteria cause inflammatory responsebullInflammatory response stimulates prostaglandin and cytokine production to stimulate labor
Periodontal Disease and Low Birth Weight
bull Periodontal disease is associated with low birth weight
bull Evidence is not conclusivebull Biochemical mechanism similar cascade
as in preterm labor leading to placental blood flow restriction and necrosis
Periodontal Disease and Preeclampsia
bull Emerging databull Mechanism unclearbull Proposed mechanism
ndash Periodontal infection leads to inflammatory vascular damage
ndash Triggers cell damage in placenta
Periodontitis and Pre-eclampsia
bull Periodontal disease may be associated with pre-eclampsia (Boggess 2003)
bull PGE2 IL-1 and TNF-α from gingival crevicular fluid were higher in women with preeclampsia compared with healthy matched pregnant women (Oettinger-Barak 2003)
Dental Considerations
bull timing of treatment for pregnant patientsbull dental radiation exposurebull use of local anestheticsbull prescription of common antibiotics and
analgesicsbull nitrous oxide gas administration
Treatment Timing
bull First Trimesterndash Spontaneous miscarriages naturally occur
more often in 1st trimesterndash Avoid elective treatment that can be delayedndash Offer anticipatory guidance
bull Second Trimesterndash The optimal time for dental treatmentndash Organogenesis complete fetus not largendash Easier to prevent than treat established disease
bull Third Trimesterndash Late in term very uncomfortable (short visits)ndash Position slightly on left side
Timing of Dental Treatment During Pregnancy - From Little and Fallace
First Trimester
bull Plaque controlbull Oral hygiene instructionbull Scaling polishing curettagebull Avoid elective treatment urgent care
only
Timing of Dental Treatment During Pregnancy - From Little and Fallace
Second Trimester
bull Plaque controlbull Oral hygiene instructionbull Scaling polishing curettagebull Routine dental care
Timing of Dental Treatment During Pregnancy - From Little and Fallace
Third Trimester
bull Plaque controlbull Oral hygiene instructionbull Scaling polishing curettagebull Routine dental care (after middle of third
trimester elective care should be avoided)
Use of Radiation on Pregnant Patientbull Dose given and time of gestation are
importantbull doses lt 5-10 rads (cGy) not teratogenicbull fetus is most susceptible to radiation
between the 2nd and 6th week of gestationbull single dental x-ray exposes patient to 001
millirads of radiation In relative terms this amount is 40 times less than daily dose acquired from cosmic radiation Therefore diagnostic radiation should not be withheld during pregnancy
Radiographs during Pregnancy
bull Take as needed with optimal methods for reducing secondary radiation and exposure time
bull Always use a lead apronbull Exposure to fetus (with apron use) is 00001
centiGray(rad)bull Daily cosmic radiation - 0004 centiGray (rad)
Risks of Dental X-Rays
bull X-ray only if necessary (ie root canal therapy trauma)
bull When x-rays are indicated radiation exposure is extremely low
bull Exposure can be limited byndash Lead apron shielding ndash Modern fast film ndash Avoiding retakes
FDA drug classification for pregnancybull Combines risk statements including
congenital anomalies fetal effects perinatal risks and therapeutic risk-benefit ratio
bull Untreated disease or condition may pose more serious risks to both mother and fetus than any theoretical risks from the medication
bull Category A thru D and X
FDA drug classification for pregnancy
bull A = Controlled Studies in women fail to demonstrate a risk to the fetus in the first trimester and the possibility of fetal harm appears remote
FDA drug classification for pregnancy
bull B = Animal studies show no risk or if risk shown in animals controlled
trials in women showed no risk
FDA drug classification for pregnancy
bull C = Studies in animals with adverse effects and no human studies
OR no animal or human studies but benefits of use may outweigh potential harms
FDA drug classification for pregnancy
bull D = There is evidence of human fetal risk but benefits may outweigh risks
FDA drug classification for pregnancy
bull X = Contraindicated
Common Analgesics
bull paracetamol (B)bull Ibuprofen (BD) bull Oxycodone (BD) bull Hydrocodone and codeine
(CD)
avoid in third trimester
Analgesics
bull Paracetamol is the analgesic of choice for all stages of gestation
bull used to treat mild to moderate pain and fevers
bull short term usage is believed to be safebull avoid chronic and large doses of
paracetamol1048715
Analgesics - continuedbull Aspirin is nonteratogenic but may cause
maternal and fetal hemorrhagebull large and chronic doses during last trimester
may result in premature closure of ductus arteriosus fetal hypertension anemia and low birth weight
bull avoid ibuprofen in 3rd trimester because of possible adverse circulatory effects
bull short term use of codeine seems safebull avoid codeine late in gestation because of
possible fetal respiratory depression and withdrawal symptoms
Analgesics to Use During1st and 2nd Trimester
bull Category B (for best)bull Paracetamol Ibuprofenbull Naproxenbull Category C (use with caution)bull Paracetamol with codeine or
hydrocodonebull Paracetamol with oxycodone
Analgesics to Avoid During theThird Trimesterbull Causes delivery problemsbull Aspirin (C 3D)bull Ibuprofen (B3D)bull Naproxen (B3D)bull Causes neonatal respiratory
depression and opioid withdrawalbull Codeine (C3D)bull Hydrocodone (C3D)bull Oxycodone(C3D)
Sedation in Pregnancy
bull SedativesAnxiolytics (eg Diazepam ) are rated D and can cause oral clefts with prolonged exposure
bull Nitrous oxide should not be used in 1st trimester (If used in 2nd and 3rd do not go below 50 O2)
Common Antibioticsbull To treat oral abscess or cellulitis
ndash Penicillin (B) ndash Amoxicillin (B) ndash Cephalexin (B)ndash Erythromycin base (B) (Not estolate as it
cause cholestatic hepatitis)ndash Clindamycin (B)
Antibioticsbull penicillin V and amoxicillin is preferred drug
for mild to moderate infectionsbull widely used for many years with no ill effectsbull no studies show penicillin to be teratogenicbull amoxicillin extensively used without harming
the fetusbull Drug classes1048715 B penicillin cephalosporins erythromycin clindamycin Azithromycin D Tetracycline
Antibiotics To Use During Pregnancy
bull Penicillin Vbull Amoxicillinbull Erythromycin (base form)bull Cephalexin cephalosporinbull Clindamycinbull Metronidazole
Antibiotics to Avoid duringPregnancy
bull Doxycyclinebull Tetracyclinebull Erythromycin (estolate form)bull Vancomycin
The Problem With Tetracycline
bull Accumulates in bones and chelates calcium
bull Inhibits bone growthbull Discolors teeth
Other Antimicrobial Agentsbull OK to usebull Nystatin (B)bull Chlorhexidine rinse (B)bull Use with cautionbull Clotrimazole (C)bull Ketoconazole (C)bull Fluconazole (C)bull Do not usebull Doxycycline (D)
Local Anesthetic Use inPregnancy
bull Class Bbull Lidocaine (Xylocaine)bull Etidocainebull Prilocaine bull Class Cbull Procainebull Bupivicainebull Mepivicaine
Use of Local Anestheticsbull Lidocaine + vasoconstrictor most common
local anesthetic used in dentistrybull extensively used in pregnancy with no proven ill
effectsbull accidental intravascular injections of lidocaine
pass through the placenta but the concentrations are too low to harm fetus
bull prilocaine might cause methemoglobinemia
Ulcer healing drugsCimetidine bull FDA category B Famotidinebull FDA category BRanitidinebull FDA category Bbull not known to be harmful
Ulcer healing drugsOmeprazolebull FDA category BNot known to be
harmful Esomeprazolebull FDA category BLansoprazolebull FDA category BPantoprazolebull Avoid unless potential benefit
outweighs riskmdashfetotoxic in animals
Ulcer healing drugs
Misoprostolbull First second third trimesters Avoidmdash
potent uterine stimulant (has been used to induce abortion) and may be teratogenic
Ulcer healing drugs
Antacidsbull Almunium hydroxideMagnesium
hydroxidemdashFDA category B Calcium carbonatemdashFDA category C
SimetheconemdashFDA category C
Use of Nitrous Oxide Gas
bull used over 150 years bull safety is being debatedbull SHORT TERM exposure do not cause
birth defects or spontaneous abortionbull CHRONIC exposure may result in fetal
loss and infertilitybull literature suggests that nitrous oxide
should be avoided until more conclusive research is available
bull FDA Drug class not yet assigned
Common Preventives
bull Fluoridendash No increased risk during pregnancy
bull Xylitolndash No studies no harm reported
bull Chlorhexidinendash No increased risk during pregnancy
Are topical agents safe
bull Fluoridebull Toothpaste amp mouthrinse
bull Xylitol chewing gum bull Chlorhexidine (11 alcohol)bull No over the counter mouthrinses with
alcohol (Listerine 20 alcohol)
Pre-natal Fluoride
bull Daily 22 mg tablet of sodium fluoride during 3rd through 9th months
bull decreases caries rate in offspringbull Safe and effective
Glenn FB 1982
Is it safe to use mercury restorations
bull No evidence of harmful effect
bull Benefits outweigh risks
bull Canada Germany and New Zealand have some restrictions
bull Determine the best option
Referencesbull Wasylko L Matsui D Dykxhoorn SM Rieder MJ Weinberg
S A Review of Common Dental Treatments During Pregnancy J Canadian Dental Association 64434-439 1998
bull Little JW Donald AF Craig SM Rhodus NL Dental Management of the Medically Compromised Patient - 5th edition Mosby Toronto Pp434-442 1997
bull Livingston HM Dellinger TM Holder R Considerations in the management of the pregnant patient Special Care in Dentistry 185 pp183-188 1998
bull Larimore WL Petrie KA Drug use during pregnacy and lactation Primary Care Clinics in Office Practice 271 35-53 2000
bull Health Canada The Safety of DentalAmalgam Minister Of Supply and Services Canada 1996
REFERENCESbull 1 Weiss G Endocrinology of parturition J Clin
Endocrinol Metab 2000854421-5bull 2 Theunissen IM Parer JT Fluid and electrolytes in
pregnancy Clin Obstet Gynecol 1994373-15bull 3 Duvekot JJ Peeters LLH Renal hemodynamics and
volume homeostasis in pregnancy Obstet Gynecol Surv 199449830-9
bull 4 Barron WM Lindheimer MD Medical disorders during pregnancy 2nd ed St Louis Mosby 1995 p 129
bull 5 Thornburg KL Jacobson SL Giraud GD Morton MJ Hemodynamic changes in pregnancy Semin Perinatol 20002411-4
bull 6 Fiese R Herzog S Issues in dental and surgical management of the pregnant patient Oral Surg Oral Med Oral Pathol 198865292-7
bull 7 Martin C Varner MW Physiologic changes in pregnancysurgical implications Clin Obstet Gynecol 199437241-55
bull 8 Clark SL Cotton DB Lee W Bishop C Hill T Southwick J et al Central hemodynamic assessment of normal term pregnancy Am J Obstet Gynecol 19891611439-42
bull 9 Mabie WC Di Sessa TG Crocker LG Sibai BM Arheart KL A longitudinal study of cardiac output in normal human pregnancy Am J Obstet Gynecol 1994170849-56
bull 10 Clapp JF 3rd Capeless E Cardiovascular function before during and after the first and subsequent pregnancies Am J Cardiol 1997801469-73
bull 11 Duvekot JJ Peeters LL Maternal cardiovascular hemodynamic adaptation to pregnancy Obstet Gynecol Surv 199449(Suppl) S1-14
bull 12 Bhagwat AR Engel PJ Heart disease and pregnancy Cardiol Clin 199513163-78
bull 13 Lanni SM Tillinghast J Silver H Hemodynamic changes and baroreflex gain in the supine hypotensive syndrome Am J Obstet Gynecol 20021871636-41
bull 14 Little JW Falace DA Miller CS Rhodus NL Dental management of the medically compromised patient 6th ed St Louis Mosby 2002 p 303
bull 15 Garcia-Rio F Pino JM Gomez L Alvarez-Sala R Villasante C Villamor J Regulation of breathing and perception of dyspnea in healthy pregnant women Chest 1996110446-53
bull 16 McAuliffe F Kametas N Costello J Rafferty GF Greenough A Nicolaides K Respiratory function in singleton and twin pregnancy BJOG 2002109765-9
bull 17 Clapp JF 3rd Seaward BL Sleamaker RH Hiser J Maternal physiologic adaptations to early human pregnancy Am J Obstet Gynecol 19881591456-60
bull 18 OrsquoDay MP Cardio-respiratory physiological adaptation of pregnancy Semin Perinatol 199721268-75
bull 19 Contreras G Gutierrez M Beroiza T Fantin A Oddo H Villarroel L et al Ventilatory drive and respiratory muscle function in pregnancy Am Rev Respir Dis 1991144837-41
bull 20 Turner M Aziz SR Management of the pregnant oral and maxillofac
bull 21 Sifakis S Pharmakides G Anemia in pregnancy Ann N Y Acad Sci 2000900125-36
bull 22 Branch DW Physiologic adaptations of pregnancy Am J Reprod Immunol 199228120-2
bull 23 Burrows RF Kelton JG Incidentally detected thrombocytopenia in healthy mothers and their infants N Engl J Med 1988319 142-5
bull 24 Hanly JG Antiphospholipid syndrome an overview CMAJ 200324(168)1675-82
bull 25 Heilmann L von Tempelhoff GF Pollow K Antiphospholipid syndrome in obstetrics Clin Appl Thromb Hemost 20039 143-50
bull 26 Sherman P Flaxman SM Nausea and vomiting of pregnancy in an evolutionary perspective Am J Obstet Gynecol 2002 185(Suppl)s190-7
bull 27 Koch KL Gastrointestinal factors in nausea and vomiting of pregnancy Am J Obstet Gynecol 2002185(Suppl)s198-203
bull 28 Koch KL Frissora CL Nausea and vomiting during pregnancy Gastroenterol Clin N Am 200332201-34
bull 29 Baron TH Ramirez B Richter JE Gastrointestinal motility disorders during pregnancy Ann Intern Med 1993118 366-75
bull 30 Richter JE Gastroesophageal reflux disease during pregnancy Gastroenterol Clin N Am 200332235-61
bull 31 Marrero JM Goggin PM de Caestecker JS Pearce JM Maxwell JD Determinants of pregnancy heartburn Br J Obstet Gynaecol 199299731-4
bull 32 Hamaoui E Hamaoui M Nutritional assessment and support during pregnancy Gastroenterol Clin N Am 20033259-121
bull 33 King JC Physiology of pregnancy and nutrient metabolism Am J Clin Nutr 200071(suppl)1218s-25s
bull 34 Casanueva E Pfeffer F Fernandez-Gaxiola AC Gutierrez- Valenzuela V Rothenberg SJ Iron and folate status before pregnancy and anemia during pregnancy Ann Nutr Metab 2003 4760-3
bull 35 Chrsquong CL Morgan M Hainsworth I Kingham JG Prospective study of liver dysfunction in Southwest Wales Gut 200251 876-80
bull 36 Rahman TM Wendon J Severe hepatic dysfunction in pregnancy QJM 200295343-57
bull 37 Knox TA Olans LB Liver disease in pregnancy N Engl J Med 1996335569-76
bull 38 Saftlas AF Olson DR Franks AL Atrash H Pokras R Epidemiology of preeclampsia and eclampsia in the United States 1979e1986 Am J Obstet Gynecol 1990163460-5
bull 39 Walker JJ Pre-eclampsia Lancet 20003561260-5
bull 40 Davidson JM Renal disorders in pregnancy Curr Opin Obstet Gynecol 200113109-14
bull 41 Dafnis E Sabatini S The effect of pregnancy on renal function physiology and pathophysiologyAmJMedSci 1992303184-205
bull 42 Davison JM Shiells EA Philips PR Lindheimer MD Serial evaluation of vasopressin release and thirst in human pregnancy Role of human chorionic gonadotrophin in the osmoregulatory changes of gestation J Clin Invest 198881798-806
bull 43 Glinoer D de Nayer P Bourdoux P Lemone M Robyn C van Steirteghem A et al Regulation of maternal thyroid during pregnancy J Clin Endocrinol Metab 199071276-87
bull 44 Wilson SG Retallack RW Kent JC Worth GK Gutteridge DH Serum free 125-dihydroxyvitamin D and the free 125- dihydroxyvitamin D index during a longitudinal study of human pregnancy and lactation Clin Endocrinol 199032613-22
bull 45 Rasmussen N Frolich A Hornnes PJ Hegedus L Serum ionized calcium and intact parathyroid hormone levels during pregnancy and postpartum Br J Obstet Gynaecol 199097857-9
bull 46 Guyton AC Textbook of medical physiology 8th ed Philadelphia W B Saunders 1991 p 915e28
bull 47 Trainer PJ Corticosteroids and pregnancy Semin Reprod Med 200220375-80
bull 48 Soory M Hormonal factors in periodontal disease Dent Update 200027380-3
bull 49 Hugoson A Gingivitis in pregnant women A longitudinal clinical study Odontol Revy 19712265-84
bull 50 Neville BW Damm DD Allen CM Bouquot JE Oral amp Maxillofacial Pathology 3rd ed Philadelphia W B Saunders 2002 p 329-30 447-9
bull 51 Tilakaratne A Soory M Ranasinghe AW Corea SM Ekanayake SL de Silva M Periodontal disease status during pregnancy and 3 months post-partum in rural population of Sri-Lankan women J Clin Periodontol 200027787-92
bull 52 Laine M Tenovuo J Lehtonen OP Ojanatko-Harri A Vilja P Tuohimaa P Pregnancy e related changes in human whole saliva Arch Oral Biol 198833913-7
bull 53 Yuan K Wing LY Lin MT Pathogenetic roles of angiogenic factors in pyogenic granulomas in pregnancy are modulated by female sex hormones J Periodontol 200273701-8
bull 54 Evans RD Briggs PF Tooth-surface loss related to pregnancyinduced vomiting Prim Dent Care 1994124-6
bull 55 Salvolini E Di Giorgio R Curatola A Mazzanti L Fratto G Biochemical modifications of human whole saliva induced by pregnancy Br J Obstet Gynaec 1998105656-60
bull 56 Mauldin JG Newman RB Preterm birth risk assessment Semin Perinatol 200125215-22
bull 57 Heine RP McGregor JA Goodwin TM Artal R Hayashi RH Robertson PA et al Serial salivary estriol to detect an increased risk of preterm birth Obstet Gynecol 200096490-7
bull 58 Kauh YC Zachian TF Melasma Adv Exp Med Biol 1999455 491-9
bull 59 Wong RC Ellis CN Physiologic skin changes in pregnancy J Am Acad Dermatol 198410929-40
bull 60 Errickson CV Matus NR Skin disorders of pregnancy Am Fam Physician 199449605-10
bull 61 Lopez NJ Smith PC Gutierrez J Periodontal therapy may reduce the risk of preterm low birth weight in women with periodontal disease a randomized controlled trial J Periodontol 200273911-24
bull 62 McGaw T Periodontal disease and preterm delivery of lowbirth- weight infants J Can Dent Assoc 200268165-9
bull 63 Richards AG Dental x-ray protection Dent Clin North Am 1968631-41
bull 64 1990 Recommendations of the International Commission on Radiological Protection Ann ICRP 1991211-201
bull 65 Hall EJ Radiation the two-edged sword cancer risks at high and low doses Cancer J 20006343-50
bull 66 Diethelm L Xu H Diagnostic imaging of the lung during pregnancy Clin Obstet Gynecol 19963936-55
bull 67 Brent RL The effects of embryonic and fetal exposure to x-rays microwaves and ultrasound ClinObstetGynecol 198326484-510
bull 68 National Council on Radiation Protection NCRP report no128 1998 Bethesda Md Author
bull 69 Wasylko L Matsui D Dykxhoorn SM Reider MJ Weinberg S A review of common dental treatments during pregnancy implications for patients and dental personnel J Can Dent Assoc 199864434-9
bull 70 Freeman JP Brand JW Radiation doses of commonly used dental radiographic surveys Oral Surg Oral Med Oral Pathol 199477285-9
bull 71 Kircos LTAngin LL Lorton LOrder ofmagnitude dose reduction in intraoral radiography J Am Dent Assoc 1987114344-7
bull 72 Updegrave WJ Simplified and standardized intraoral radiography with reduced tissue irradiation J Am Dent Assoc 197285861-9
bull 73 Wood RE Harris AM van der Merwe EJ Nortje CJ The leaded apron revisited does it reduce gonadal radiation dose in dental radiology Oral Surg Oral Med Oral Pathol 199171642-6
bull 74 An update on radiographic practices information and recommendations ADA Council on Scientific Affairs J Am Dent Assoc 2001132234-8
bull 75 Rayburn WF Recommending medications during pregnancy an evidence based approach Clin Obstet Gynecol 2002451-5
bull 76 Rathmell JP Viscomi C Ashburn MA Management of nonobstetric pain during pregnancy and lactation Anesth Analg 1997851074-87
bull 77 Teratology society public affairs committee FDA classification of drugs for teratogenic risk Teratology 199449446-7
bull 78 Moore PA Selecting drugs for the pregnant dental patient J Am Dent Assoc 19981291281-6
bull 79 Haas DA An update on analgesics for the management of acute postoperative dental pain J Can Dent Assoc 200268476-82
bull 80 Haas DA Pynn BR Sands TD Drug use for the pregnant or lactating patient Gen Dent 20004854-60
bull 81 Committee on Drugs American Academy of Pediatrics The transfer of drugs and other chemicals into human milk Pediatrics 199493137-50
bull 82 Nielsen GL Sorensen HT Larsen H Pedersen L Risk of adverse birth outcome and miscarriage in pregnant users of nonsteroidal anti-inflammatory drugs population based observational study and case-control study BMJ 2001322266-70
bull 83 Janssen N Genta M The effects of immunosuppressive and anti-inflammatory medications on fertility pregnancy and lactation Arch Intern Med 200016610-9
bull 84 Ostensen M Nonsteroidal anti-inflammatory drugs during pregnancy Scand J Rheumatol Suppl 1998107128-32
bull 85 USPDI -Drug information for the health care professional 22nd ed Greenwood Village CO Micromedex 2002 p 152-79
bull 86 Denson DD Coyle DE Thompson GA Santos D Turner PA Myers JA et al Bupivacaine protein binding in the term parturient effects of lactic acidosis Clin Pharmacol Ther 198435702-9
bull 87 Dillon DE Wagner CL Wiest D Newman RB Drug therapy in the nursing mother Obstet Gynecol Clin North Am 199724 675-96
bull 88 Dashe JS Gilstrap LC Antibiotic use in pregnancy Obstet Gynecol Clin North Am 199724617-29
bull 89 American College of Rheumatology Ad hoc Committee on Clinical Guidelines Guidelines for monitoring drug therapy in rheumatoid arthritis Arthritis Rheum 199639723-31
bull 90 Ng PC The fetal and neonatal hypothalamic-pituitary-adrenal axis Arch Dis Child Fetal Neonatal Ed 200082F250-4
bull 91 Crowley P Antenatal corticosteroidsmdashcurrent thinking BJOG 2003110(Suppl 20)77-8
bull 92 ACOG committee opinion antenatal corticosteroid therapy for fetal maturation Obstet Gynecol 200299871-3
bull 93 Ost L Wettrell G Bjorkhem I Rane A Prednisolone excretion in human milk J Pediatr 19851061008-11
bull 94 Rowland AS Baird DD Shore DL Weinberg CR Savitz DA Wilcox AJ Nitrous oxide and spontaneous abortion in female dental assistants Am J Epidemiol 1995141531-8
bull 95 McGlothlin JD Jensen PA Fischbach TJ Hughes RT Jones JH Control of anesthetic gases in dental operatories Scand J Work Environ Health 199218(Suppl 2)103-5
bull ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY Volume 97 Number 6 Suresh and Radfar 681
bull 96 Rosen MA Nitrous oxide for relief of labor pain a systematic review Am J Obstet Gynecol 2002186(Suppl Nature)S110-6
bull 97 Sands TD Pynn BR Management considerations for the pregnant or nursing emergency patient Ont Dent 199875 17-9
bull 98 Daya S Recurrent spontaneous early pregnancy loss and low dose aspirin Minerva Ginecol 200355441-9
bull 99 Sinclair C Handbook of obstetrical emergencies 1st ed Philadelphia WB Saunders 1996 p 29-39 69
bull 100 Tarsitano BF Rollings RE The pregnant dental patient evaluation and management Gen Dent 199341226-34
bull 101 Livingston MH Dlllinger TM Holder R Consideration in the management of the pregnant patient SCD Special Care in Dentistry 199818183-8
Thank you
- A Review on the principle of Dental Management of the Pregnant patient
- Slide 2
- Questions that a dentist may ask
- Stages of Pregnancy
- Slide 5
- Slide 6
- Physiologic Changes in Pregnancy
- Systemic changes in pregnancy
- FLAT SUPINE POSITIONING
- SUPINE HYPOTENSION SYNDROME (Vena Cava Compression)
- Supine Hypotension Syndrome
- Slide 12
- Supine Hypotension Syndrome
- Prevention of Supine Hypotensive Syndrome
- Treatment of Supine Hypotensive Syndrome
- How should the pregnant woman be positioned
- Slide 17
- Slide 18
- Slide 19
- Slide 20
- Slide 21
- Slide 22
- Slide 23
- Pregnancy Related Oral Health Problems
- Oral Problems in Pregnancy
- Pregnancy Gingivitis Pathophysiology
- Pregnancy Gingivitis
- Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Gum Problems - Pregnancy Granuloma
- Slide 31
- Gum Changes - Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Candidiasis
- Pregnancy Myths
- Other Oral Conditions in Pregnancy
- Changes During Pregnancy that Affect Oral Health
- Saliva changes
- Increased Bacteria
- Slide 40
- Enamel erosion caused by frequent vomiting
- Treatment for Acid Exposure
- Oral Diseases Can Effect Pregnancy
- Periodontal Disease and Preterm Labor
- Periodontal Disease and Low Birth Weight
- Periodontal Disease and Preeclampsia
- Periodontitis and Pre-eclampsia
- Dental Considerations
- Treatment Timing
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Slide 52
- Use of Radiation on Pregnant Patient
- Radiographs during Pregnancy
- Risks of Dental X-Rays
- FDA drug classification for pregnancy
- Slide 57
- FDA drug classification for pregnancy
- Slide 59
- Slide 60
- Slide 61
- Common Analgesics
- Analgesics
- Analgesics - continued
- Analgesics to Use During 1st and 2nd Trimester
- Analgesics to Avoid During the Third Trimester
- Sedation in Pregnancy
- Common Antibiotics
- Antibiotics
- Antibiotics To Use During Pregnancy
- Antibiotics to Avoid during Pregnancy
- The Problem With Tetracycline
- Other Antimicrobial Agents
- Local Anesthetic Use in Pregnancy
- Use of Local Anesthetics
- Ulcer healing drugs
- Slide 77
- Slide 78
- Slide 79
- Use of Nitrous Oxide Gas
- Common Preventives
- Are topical agents safe
- Pre-natal Fluoride
- Is it safe to use mercury restorations
- References
- REFERENCES
- Slide 87
- Slide 88
- Slide 89
- Slide 90
- Slide 91
- Slide 92
- Slide 93
- Slide 94
- Slide 95
- Slide 96
- Slide 97
- Slide 98
- Thank you
-
Treatment for Acid Exposure
bull Do NOT brush immediately after vomiting
bull Rinse ndash Water with baking sodandash Antacidndash Plain water
bull Eat some cheese
Oral Diseases Can Effect Pregnancy
bull Preterm low birth weight (LBW) linked to periodontal disease
bull Thorough calculus (tartar) removal in pregnant women with periodontitis may reduce pre-term births
Periodontal Disease and Preterm LaborbullMaternal periodontal disease is associated with increased risk of preterm laborbullAnaerobic oral gram-negative bacteria cause inflammatory responsebullInflammatory response stimulates prostaglandin and cytokine production to stimulate labor
Periodontal Disease and Low Birth Weight
bull Periodontal disease is associated with low birth weight
bull Evidence is not conclusivebull Biochemical mechanism similar cascade
as in preterm labor leading to placental blood flow restriction and necrosis
Periodontal Disease and Preeclampsia
bull Emerging databull Mechanism unclearbull Proposed mechanism
ndash Periodontal infection leads to inflammatory vascular damage
ndash Triggers cell damage in placenta
Periodontitis and Pre-eclampsia
bull Periodontal disease may be associated with pre-eclampsia (Boggess 2003)
bull PGE2 IL-1 and TNF-α from gingival crevicular fluid were higher in women with preeclampsia compared with healthy matched pregnant women (Oettinger-Barak 2003)
Dental Considerations
bull timing of treatment for pregnant patientsbull dental radiation exposurebull use of local anestheticsbull prescription of common antibiotics and
analgesicsbull nitrous oxide gas administration
Treatment Timing
bull First Trimesterndash Spontaneous miscarriages naturally occur
more often in 1st trimesterndash Avoid elective treatment that can be delayedndash Offer anticipatory guidance
bull Second Trimesterndash The optimal time for dental treatmentndash Organogenesis complete fetus not largendash Easier to prevent than treat established disease
bull Third Trimesterndash Late in term very uncomfortable (short visits)ndash Position slightly on left side
Timing of Dental Treatment During Pregnancy - From Little and Fallace
First Trimester
bull Plaque controlbull Oral hygiene instructionbull Scaling polishing curettagebull Avoid elective treatment urgent care
only
Timing of Dental Treatment During Pregnancy - From Little and Fallace
Second Trimester
bull Plaque controlbull Oral hygiene instructionbull Scaling polishing curettagebull Routine dental care
Timing of Dental Treatment During Pregnancy - From Little and Fallace
Third Trimester
bull Plaque controlbull Oral hygiene instructionbull Scaling polishing curettagebull Routine dental care (after middle of third
trimester elective care should be avoided)
Use of Radiation on Pregnant Patientbull Dose given and time of gestation are
importantbull doses lt 5-10 rads (cGy) not teratogenicbull fetus is most susceptible to radiation
between the 2nd and 6th week of gestationbull single dental x-ray exposes patient to 001
millirads of radiation In relative terms this amount is 40 times less than daily dose acquired from cosmic radiation Therefore diagnostic radiation should not be withheld during pregnancy
Radiographs during Pregnancy
bull Take as needed with optimal methods for reducing secondary radiation and exposure time
bull Always use a lead apronbull Exposure to fetus (with apron use) is 00001
centiGray(rad)bull Daily cosmic radiation - 0004 centiGray (rad)
Risks of Dental X-Rays
bull X-ray only if necessary (ie root canal therapy trauma)
bull When x-rays are indicated radiation exposure is extremely low
bull Exposure can be limited byndash Lead apron shielding ndash Modern fast film ndash Avoiding retakes
FDA drug classification for pregnancybull Combines risk statements including
congenital anomalies fetal effects perinatal risks and therapeutic risk-benefit ratio
bull Untreated disease or condition may pose more serious risks to both mother and fetus than any theoretical risks from the medication
bull Category A thru D and X
FDA drug classification for pregnancy
bull A = Controlled Studies in women fail to demonstrate a risk to the fetus in the first trimester and the possibility of fetal harm appears remote
FDA drug classification for pregnancy
bull B = Animal studies show no risk or if risk shown in animals controlled
trials in women showed no risk
FDA drug classification for pregnancy
bull C = Studies in animals with adverse effects and no human studies
OR no animal or human studies but benefits of use may outweigh potential harms
FDA drug classification for pregnancy
bull D = There is evidence of human fetal risk but benefits may outweigh risks
FDA drug classification for pregnancy
bull X = Contraindicated
Common Analgesics
bull paracetamol (B)bull Ibuprofen (BD) bull Oxycodone (BD) bull Hydrocodone and codeine
(CD)
avoid in third trimester
Analgesics
bull Paracetamol is the analgesic of choice for all stages of gestation
bull used to treat mild to moderate pain and fevers
bull short term usage is believed to be safebull avoid chronic and large doses of
paracetamol1048715
Analgesics - continuedbull Aspirin is nonteratogenic but may cause
maternal and fetal hemorrhagebull large and chronic doses during last trimester
may result in premature closure of ductus arteriosus fetal hypertension anemia and low birth weight
bull avoid ibuprofen in 3rd trimester because of possible adverse circulatory effects
bull short term use of codeine seems safebull avoid codeine late in gestation because of
possible fetal respiratory depression and withdrawal symptoms
Analgesics to Use During1st and 2nd Trimester
bull Category B (for best)bull Paracetamol Ibuprofenbull Naproxenbull Category C (use with caution)bull Paracetamol with codeine or
hydrocodonebull Paracetamol with oxycodone
Analgesics to Avoid During theThird Trimesterbull Causes delivery problemsbull Aspirin (C 3D)bull Ibuprofen (B3D)bull Naproxen (B3D)bull Causes neonatal respiratory
depression and opioid withdrawalbull Codeine (C3D)bull Hydrocodone (C3D)bull Oxycodone(C3D)
Sedation in Pregnancy
bull SedativesAnxiolytics (eg Diazepam ) are rated D and can cause oral clefts with prolonged exposure
bull Nitrous oxide should not be used in 1st trimester (If used in 2nd and 3rd do not go below 50 O2)
Common Antibioticsbull To treat oral abscess or cellulitis
ndash Penicillin (B) ndash Amoxicillin (B) ndash Cephalexin (B)ndash Erythromycin base (B) (Not estolate as it
cause cholestatic hepatitis)ndash Clindamycin (B)
Antibioticsbull penicillin V and amoxicillin is preferred drug
for mild to moderate infectionsbull widely used for many years with no ill effectsbull no studies show penicillin to be teratogenicbull amoxicillin extensively used without harming
the fetusbull Drug classes1048715 B penicillin cephalosporins erythromycin clindamycin Azithromycin D Tetracycline
Antibiotics To Use During Pregnancy
bull Penicillin Vbull Amoxicillinbull Erythromycin (base form)bull Cephalexin cephalosporinbull Clindamycinbull Metronidazole
Antibiotics to Avoid duringPregnancy
bull Doxycyclinebull Tetracyclinebull Erythromycin (estolate form)bull Vancomycin
The Problem With Tetracycline
bull Accumulates in bones and chelates calcium
bull Inhibits bone growthbull Discolors teeth
Other Antimicrobial Agentsbull OK to usebull Nystatin (B)bull Chlorhexidine rinse (B)bull Use with cautionbull Clotrimazole (C)bull Ketoconazole (C)bull Fluconazole (C)bull Do not usebull Doxycycline (D)
Local Anesthetic Use inPregnancy
bull Class Bbull Lidocaine (Xylocaine)bull Etidocainebull Prilocaine bull Class Cbull Procainebull Bupivicainebull Mepivicaine
Use of Local Anestheticsbull Lidocaine + vasoconstrictor most common
local anesthetic used in dentistrybull extensively used in pregnancy with no proven ill
effectsbull accidental intravascular injections of lidocaine
pass through the placenta but the concentrations are too low to harm fetus
bull prilocaine might cause methemoglobinemia
Ulcer healing drugsCimetidine bull FDA category B Famotidinebull FDA category BRanitidinebull FDA category Bbull not known to be harmful
Ulcer healing drugsOmeprazolebull FDA category BNot known to be
harmful Esomeprazolebull FDA category BLansoprazolebull FDA category BPantoprazolebull Avoid unless potential benefit
outweighs riskmdashfetotoxic in animals
Ulcer healing drugs
Misoprostolbull First second third trimesters Avoidmdash
potent uterine stimulant (has been used to induce abortion) and may be teratogenic
Ulcer healing drugs
Antacidsbull Almunium hydroxideMagnesium
hydroxidemdashFDA category B Calcium carbonatemdashFDA category C
SimetheconemdashFDA category C
Use of Nitrous Oxide Gas
bull used over 150 years bull safety is being debatedbull SHORT TERM exposure do not cause
birth defects or spontaneous abortionbull CHRONIC exposure may result in fetal
loss and infertilitybull literature suggests that nitrous oxide
should be avoided until more conclusive research is available
bull FDA Drug class not yet assigned
Common Preventives
bull Fluoridendash No increased risk during pregnancy
bull Xylitolndash No studies no harm reported
bull Chlorhexidinendash No increased risk during pregnancy
Are topical agents safe
bull Fluoridebull Toothpaste amp mouthrinse
bull Xylitol chewing gum bull Chlorhexidine (11 alcohol)bull No over the counter mouthrinses with
alcohol (Listerine 20 alcohol)
Pre-natal Fluoride
bull Daily 22 mg tablet of sodium fluoride during 3rd through 9th months
bull decreases caries rate in offspringbull Safe and effective
Glenn FB 1982
Is it safe to use mercury restorations
bull No evidence of harmful effect
bull Benefits outweigh risks
bull Canada Germany and New Zealand have some restrictions
bull Determine the best option
Referencesbull Wasylko L Matsui D Dykxhoorn SM Rieder MJ Weinberg
S A Review of Common Dental Treatments During Pregnancy J Canadian Dental Association 64434-439 1998
bull Little JW Donald AF Craig SM Rhodus NL Dental Management of the Medically Compromised Patient - 5th edition Mosby Toronto Pp434-442 1997
bull Livingston HM Dellinger TM Holder R Considerations in the management of the pregnant patient Special Care in Dentistry 185 pp183-188 1998
bull Larimore WL Petrie KA Drug use during pregnacy and lactation Primary Care Clinics in Office Practice 271 35-53 2000
bull Health Canada The Safety of DentalAmalgam Minister Of Supply and Services Canada 1996
REFERENCESbull 1 Weiss G Endocrinology of parturition J Clin
Endocrinol Metab 2000854421-5bull 2 Theunissen IM Parer JT Fluid and electrolytes in
pregnancy Clin Obstet Gynecol 1994373-15bull 3 Duvekot JJ Peeters LLH Renal hemodynamics and
volume homeostasis in pregnancy Obstet Gynecol Surv 199449830-9
bull 4 Barron WM Lindheimer MD Medical disorders during pregnancy 2nd ed St Louis Mosby 1995 p 129
bull 5 Thornburg KL Jacobson SL Giraud GD Morton MJ Hemodynamic changes in pregnancy Semin Perinatol 20002411-4
bull 6 Fiese R Herzog S Issues in dental and surgical management of the pregnant patient Oral Surg Oral Med Oral Pathol 198865292-7
bull 7 Martin C Varner MW Physiologic changes in pregnancysurgical implications Clin Obstet Gynecol 199437241-55
bull 8 Clark SL Cotton DB Lee W Bishop C Hill T Southwick J et al Central hemodynamic assessment of normal term pregnancy Am J Obstet Gynecol 19891611439-42
bull 9 Mabie WC Di Sessa TG Crocker LG Sibai BM Arheart KL A longitudinal study of cardiac output in normal human pregnancy Am J Obstet Gynecol 1994170849-56
bull 10 Clapp JF 3rd Capeless E Cardiovascular function before during and after the first and subsequent pregnancies Am J Cardiol 1997801469-73
bull 11 Duvekot JJ Peeters LL Maternal cardiovascular hemodynamic adaptation to pregnancy Obstet Gynecol Surv 199449(Suppl) S1-14
bull 12 Bhagwat AR Engel PJ Heart disease and pregnancy Cardiol Clin 199513163-78
bull 13 Lanni SM Tillinghast J Silver H Hemodynamic changes and baroreflex gain in the supine hypotensive syndrome Am J Obstet Gynecol 20021871636-41
bull 14 Little JW Falace DA Miller CS Rhodus NL Dental management of the medically compromised patient 6th ed St Louis Mosby 2002 p 303
bull 15 Garcia-Rio F Pino JM Gomez L Alvarez-Sala R Villasante C Villamor J Regulation of breathing and perception of dyspnea in healthy pregnant women Chest 1996110446-53
bull 16 McAuliffe F Kametas N Costello J Rafferty GF Greenough A Nicolaides K Respiratory function in singleton and twin pregnancy BJOG 2002109765-9
bull 17 Clapp JF 3rd Seaward BL Sleamaker RH Hiser J Maternal physiologic adaptations to early human pregnancy Am J Obstet Gynecol 19881591456-60
bull 18 OrsquoDay MP Cardio-respiratory physiological adaptation of pregnancy Semin Perinatol 199721268-75
bull 19 Contreras G Gutierrez M Beroiza T Fantin A Oddo H Villarroel L et al Ventilatory drive and respiratory muscle function in pregnancy Am Rev Respir Dis 1991144837-41
bull 20 Turner M Aziz SR Management of the pregnant oral and maxillofac
bull 21 Sifakis S Pharmakides G Anemia in pregnancy Ann N Y Acad Sci 2000900125-36
bull 22 Branch DW Physiologic adaptations of pregnancy Am J Reprod Immunol 199228120-2
bull 23 Burrows RF Kelton JG Incidentally detected thrombocytopenia in healthy mothers and their infants N Engl J Med 1988319 142-5
bull 24 Hanly JG Antiphospholipid syndrome an overview CMAJ 200324(168)1675-82
bull 25 Heilmann L von Tempelhoff GF Pollow K Antiphospholipid syndrome in obstetrics Clin Appl Thromb Hemost 20039 143-50
bull 26 Sherman P Flaxman SM Nausea and vomiting of pregnancy in an evolutionary perspective Am J Obstet Gynecol 2002 185(Suppl)s190-7
bull 27 Koch KL Gastrointestinal factors in nausea and vomiting of pregnancy Am J Obstet Gynecol 2002185(Suppl)s198-203
bull 28 Koch KL Frissora CL Nausea and vomiting during pregnancy Gastroenterol Clin N Am 200332201-34
bull 29 Baron TH Ramirez B Richter JE Gastrointestinal motility disorders during pregnancy Ann Intern Med 1993118 366-75
bull 30 Richter JE Gastroesophageal reflux disease during pregnancy Gastroenterol Clin N Am 200332235-61
bull 31 Marrero JM Goggin PM de Caestecker JS Pearce JM Maxwell JD Determinants of pregnancy heartburn Br J Obstet Gynaecol 199299731-4
bull 32 Hamaoui E Hamaoui M Nutritional assessment and support during pregnancy Gastroenterol Clin N Am 20033259-121
bull 33 King JC Physiology of pregnancy and nutrient metabolism Am J Clin Nutr 200071(suppl)1218s-25s
bull 34 Casanueva E Pfeffer F Fernandez-Gaxiola AC Gutierrez- Valenzuela V Rothenberg SJ Iron and folate status before pregnancy and anemia during pregnancy Ann Nutr Metab 2003 4760-3
bull 35 Chrsquong CL Morgan M Hainsworth I Kingham JG Prospective study of liver dysfunction in Southwest Wales Gut 200251 876-80
bull 36 Rahman TM Wendon J Severe hepatic dysfunction in pregnancy QJM 200295343-57
bull 37 Knox TA Olans LB Liver disease in pregnancy N Engl J Med 1996335569-76
bull 38 Saftlas AF Olson DR Franks AL Atrash H Pokras R Epidemiology of preeclampsia and eclampsia in the United States 1979e1986 Am J Obstet Gynecol 1990163460-5
bull 39 Walker JJ Pre-eclampsia Lancet 20003561260-5
bull 40 Davidson JM Renal disorders in pregnancy Curr Opin Obstet Gynecol 200113109-14
bull 41 Dafnis E Sabatini S The effect of pregnancy on renal function physiology and pathophysiologyAmJMedSci 1992303184-205
bull 42 Davison JM Shiells EA Philips PR Lindheimer MD Serial evaluation of vasopressin release and thirst in human pregnancy Role of human chorionic gonadotrophin in the osmoregulatory changes of gestation J Clin Invest 198881798-806
bull 43 Glinoer D de Nayer P Bourdoux P Lemone M Robyn C van Steirteghem A et al Regulation of maternal thyroid during pregnancy J Clin Endocrinol Metab 199071276-87
bull 44 Wilson SG Retallack RW Kent JC Worth GK Gutteridge DH Serum free 125-dihydroxyvitamin D and the free 125- dihydroxyvitamin D index during a longitudinal study of human pregnancy and lactation Clin Endocrinol 199032613-22
bull 45 Rasmussen N Frolich A Hornnes PJ Hegedus L Serum ionized calcium and intact parathyroid hormone levels during pregnancy and postpartum Br J Obstet Gynaecol 199097857-9
bull 46 Guyton AC Textbook of medical physiology 8th ed Philadelphia W B Saunders 1991 p 915e28
bull 47 Trainer PJ Corticosteroids and pregnancy Semin Reprod Med 200220375-80
bull 48 Soory M Hormonal factors in periodontal disease Dent Update 200027380-3
bull 49 Hugoson A Gingivitis in pregnant women A longitudinal clinical study Odontol Revy 19712265-84
bull 50 Neville BW Damm DD Allen CM Bouquot JE Oral amp Maxillofacial Pathology 3rd ed Philadelphia W B Saunders 2002 p 329-30 447-9
bull 51 Tilakaratne A Soory M Ranasinghe AW Corea SM Ekanayake SL de Silva M Periodontal disease status during pregnancy and 3 months post-partum in rural population of Sri-Lankan women J Clin Periodontol 200027787-92
bull 52 Laine M Tenovuo J Lehtonen OP Ojanatko-Harri A Vilja P Tuohimaa P Pregnancy e related changes in human whole saliva Arch Oral Biol 198833913-7
bull 53 Yuan K Wing LY Lin MT Pathogenetic roles of angiogenic factors in pyogenic granulomas in pregnancy are modulated by female sex hormones J Periodontol 200273701-8
bull 54 Evans RD Briggs PF Tooth-surface loss related to pregnancyinduced vomiting Prim Dent Care 1994124-6
bull 55 Salvolini E Di Giorgio R Curatola A Mazzanti L Fratto G Biochemical modifications of human whole saliva induced by pregnancy Br J Obstet Gynaec 1998105656-60
bull 56 Mauldin JG Newman RB Preterm birth risk assessment Semin Perinatol 200125215-22
bull 57 Heine RP McGregor JA Goodwin TM Artal R Hayashi RH Robertson PA et al Serial salivary estriol to detect an increased risk of preterm birth Obstet Gynecol 200096490-7
bull 58 Kauh YC Zachian TF Melasma Adv Exp Med Biol 1999455 491-9
bull 59 Wong RC Ellis CN Physiologic skin changes in pregnancy J Am Acad Dermatol 198410929-40
bull 60 Errickson CV Matus NR Skin disorders of pregnancy Am Fam Physician 199449605-10
bull 61 Lopez NJ Smith PC Gutierrez J Periodontal therapy may reduce the risk of preterm low birth weight in women with periodontal disease a randomized controlled trial J Periodontol 200273911-24
bull 62 McGaw T Periodontal disease and preterm delivery of lowbirth- weight infants J Can Dent Assoc 200268165-9
bull 63 Richards AG Dental x-ray protection Dent Clin North Am 1968631-41
bull 64 1990 Recommendations of the International Commission on Radiological Protection Ann ICRP 1991211-201
bull 65 Hall EJ Radiation the two-edged sword cancer risks at high and low doses Cancer J 20006343-50
bull 66 Diethelm L Xu H Diagnostic imaging of the lung during pregnancy Clin Obstet Gynecol 19963936-55
bull 67 Brent RL The effects of embryonic and fetal exposure to x-rays microwaves and ultrasound ClinObstetGynecol 198326484-510
bull 68 National Council on Radiation Protection NCRP report no128 1998 Bethesda Md Author
bull 69 Wasylko L Matsui D Dykxhoorn SM Reider MJ Weinberg S A review of common dental treatments during pregnancy implications for patients and dental personnel J Can Dent Assoc 199864434-9
bull 70 Freeman JP Brand JW Radiation doses of commonly used dental radiographic surveys Oral Surg Oral Med Oral Pathol 199477285-9
bull 71 Kircos LTAngin LL Lorton LOrder ofmagnitude dose reduction in intraoral radiography J Am Dent Assoc 1987114344-7
bull 72 Updegrave WJ Simplified and standardized intraoral radiography with reduced tissue irradiation J Am Dent Assoc 197285861-9
bull 73 Wood RE Harris AM van der Merwe EJ Nortje CJ The leaded apron revisited does it reduce gonadal radiation dose in dental radiology Oral Surg Oral Med Oral Pathol 199171642-6
bull 74 An update on radiographic practices information and recommendations ADA Council on Scientific Affairs J Am Dent Assoc 2001132234-8
bull 75 Rayburn WF Recommending medications during pregnancy an evidence based approach Clin Obstet Gynecol 2002451-5
bull 76 Rathmell JP Viscomi C Ashburn MA Management of nonobstetric pain during pregnancy and lactation Anesth Analg 1997851074-87
bull 77 Teratology society public affairs committee FDA classification of drugs for teratogenic risk Teratology 199449446-7
bull 78 Moore PA Selecting drugs for the pregnant dental patient J Am Dent Assoc 19981291281-6
bull 79 Haas DA An update on analgesics for the management of acute postoperative dental pain J Can Dent Assoc 200268476-82
bull 80 Haas DA Pynn BR Sands TD Drug use for the pregnant or lactating patient Gen Dent 20004854-60
bull 81 Committee on Drugs American Academy of Pediatrics The transfer of drugs and other chemicals into human milk Pediatrics 199493137-50
bull 82 Nielsen GL Sorensen HT Larsen H Pedersen L Risk of adverse birth outcome and miscarriage in pregnant users of nonsteroidal anti-inflammatory drugs population based observational study and case-control study BMJ 2001322266-70
bull 83 Janssen N Genta M The effects of immunosuppressive and anti-inflammatory medications on fertility pregnancy and lactation Arch Intern Med 200016610-9
bull 84 Ostensen M Nonsteroidal anti-inflammatory drugs during pregnancy Scand J Rheumatol Suppl 1998107128-32
bull 85 USPDI -Drug information for the health care professional 22nd ed Greenwood Village CO Micromedex 2002 p 152-79
bull 86 Denson DD Coyle DE Thompson GA Santos D Turner PA Myers JA et al Bupivacaine protein binding in the term parturient effects of lactic acidosis Clin Pharmacol Ther 198435702-9
bull 87 Dillon DE Wagner CL Wiest D Newman RB Drug therapy in the nursing mother Obstet Gynecol Clin North Am 199724 675-96
bull 88 Dashe JS Gilstrap LC Antibiotic use in pregnancy Obstet Gynecol Clin North Am 199724617-29
bull 89 American College of Rheumatology Ad hoc Committee on Clinical Guidelines Guidelines for monitoring drug therapy in rheumatoid arthritis Arthritis Rheum 199639723-31
bull 90 Ng PC The fetal and neonatal hypothalamic-pituitary-adrenal axis Arch Dis Child Fetal Neonatal Ed 200082F250-4
bull 91 Crowley P Antenatal corticosteroidsmdashcurrent thinking BJOG 2003110(Suppl 20)77-8
bull 92 ACOG committee opinion antenatal corticosteroid therapy for fetal maturation Obstet Gynecol 200299871-3
bull 93 Ost L Wettrell G Bjorkhem I Rane A Prednisolone excretion in human milk J Pediatr 19851061008-11
bull 94 Rowland AS Baird DD Shore DL Weinberg CR Savitz DA Wilcox AJ Nitrous oxide and spontaneous abortion in female dental assistants Am J Epidemiol 1995141531-8
bull 95 McGlothlin JD Jensen PA Fischbach TJ Hughes RT Jones JH Control of anesthetic gases in dental operatories Scand J Work Environ Health 199218(Suppl 2)103-5
bull ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY Volume 97 Number 6 Suresh and Radfar 681
bull 96 Rosen MA Nitrous oxide for relief of labor pain a systematic review Am J Obstet Gynecol 2002186(Suppl Nature)S110-6
bull 97 Sands TD Pynn BR Management considerations for the pregnant or nursing emergency patient Ont Dent 199875 17-9
bull 98 Daya S Recurrent spontaneous early pregnancy loss and low dose aspirin Minerva Ginecol 200355441-9
bull 99 Sinclair C Handbook of obstetrical emergencies 1st ed Philadelphia WB Saunders 1996 p 29-39 69
bull 100 Tarsitano BF Rollings RE The pregnant dental patient evaluation and management Gen Dent 199341226-34
bull 101 Livingston MH Dlllinger TM Holder R Consideration in the management of the pregnant patient SCD Special Care in Dentistry 199818183-8
Thank you
- A Review on the principle of Dental Management of the Pregnant patient
- Slide 2
- Questions that a dentist may ask
- Stages of Pregnancy
- Slide 5
- Slide 6
- Physiologic Changes in Pregnancy
- Systemic changes in pregnancy
- FLAT SUPINE POSITIONING
- SUPINE HYPOTENSION SYNDROME (Vena Cava Compression)
- Supine Hypotension Syndrome
- Slide 12
- Supine Hypotension Syndrome
- Prevention of Supine Hypotensive Syndrome
- Treatment of Supine Hypotensive Syndrome
- How should the pregnant woman be positioned
- Slide 17
- Slide 18
- Slide 19
- Slide 20
- Slide 21
- Slide 22
- Slide 23
- Pregnancy Related Oral Health Problems
- Oral Problems in Pregnancy
- Pregnancy Gingivitis Pathophysiology
- Pregnancy Gingivitis
- Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Gum Problems - Pregnancy Granuloma
- Slide 31
- Gum Changes - Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Candidiasis
- Pregnancy Myths
- Other Oral Conditions in Pregnancy
- Changes During Pregnancy that Affect Oral Health
- Saliva changes
- Increased Bacteria
- Slide 40
- Enamel erosion caused by frequent vomiting
- Treatment for Acid Exposure
- Oral Diseases Can Effect Pregnancy
- Periodontal Disease and Preterm Labor
- Periodontal Disease and Low Birth Weight
- Periodontal Disease and Preeclampsia
- Periodontitis and Pre-eclampsia
- Dental Considerations
- Treatment Timing
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Slide 52
- Use of Radiation on Pregnant Patient
- Radiographs during Pregnancy
- Risks of Dental X-Rays
- FDA drug classification for pregnancy
- Slide 57
- FDA drug classification for pregnancy
- Slide 59
- Slide 60
- Slide 61
- Common Analgesics
- Analgesics
- Analgesics - continued
- Analgesics to Use During 1st and 2nd Trimester
- Analgesics to Avoid During the Third Trimester
- Sedation in Pregnancy
- Common Antibiotics
- Antibiotics
- Antibiotics To Use During Pregnancy
- Antibiotics to Avoid during Pregnancy
- The Problem With Tetracycline
- Other Antimicrobial Agents
- Local Anesthetic Use in Pregnancy
- Use of Local Anesthetics
- Ulcer healing drugs
- Slide 77
- Slide 78
- Slide 79
- Use of Nitrous Oxide Gas
- Common Preventives
- Are topical agents safe
- Pre-natal Fluoride
- Is it safe to use mercury restorations
- References
- REFERENCES
- Slide 87
- Slide 88
- Slide 89
- Slide 90
- Slide 91
- Slide 92
- Slide 93
- Slide 94
- Slide 95
- Slide 96
- Slide 97
- Slide 98
- Thank you
-
Oral Diseases Can Effect Pregnancy
bull Preterm low birth weight (LBW) linked to periodontal disease
bull Thorough calculus (tartar) removal in pregnant women with periodontitis may reduce pre-term births
Periodontal Disease and Preterm LaborbullMaternal periodontal disease is associated with increased risk of preterm laborbullAnaerobic oral gram-negative bacteria cause inflammatory responsebullInflammatory response stimulates prostaglandin and cytokine production to stimulate labor
Periodontal Disease and Low Birth Weight
bull Periodontal disease is associated with low birth weight
bull Evidence is not conclusivebull Biochemical mechanism similar cascade
as in preterm labor leading to placental blood flow restriction and necrosis
Periodontal Disease and Preeclampsia
bull Emerging databull Mechanism unclearbull Proposed mechanism
ndash Periodontal infection leads to inflammatory vascular damage
ndash Triggers cell damage in placenta
Periodontitis and Pre-eclampsia
bull Periodontal disease may be associated with pre-eclampsia (Boggess 2003)
bull PGE2 IL-1 and TNF-α from gingival crevicular fluid were higher in women with preeclampsia compared with healthy matched pregnant women (Oettinger-Barak 2003)
Dental Considerations
bull timing of treatment for pregnant patientsbull dental radiation exposurebull use of local anestheticsbull prescription of common antibiotics and
analgesicsbull nitrous oxide gas administration
Treatment Timing
bull First Trimesterndash Spontaneous miscarriages naturally occur
more often in 1st trimesterndash Avoid elective treatment that can be delayedndash Offer anticipatory guidance
bull Second Trimesterndash The optimal time for dental treatmentndash Organogenesis complete fetus not largendash Easier to prevent than treat established disease
bull Third Trimesterndash Late in term very uncomfortable (short visits)ndash Position slightly on left side
Timing of Dental Treatment During Pregnancy - From Little and Fallace
First Trimester
bull Plaque controlbull Oral hygiene instructionbull Scaling polishing curettagebull Avoid elective treatment urgent care
only
Timing of Dental Treatment During Pregnancy - From Little and Fallace
Second Trimester
bull Plaque controlbull Oral hygiene instructionbull Scaling polishing curettagebull Routine dental care
Timing of Dental Treatment During Pregnancy - From Little and Fallace
Third Trimester
bull Plaque controlbull Oral hygiene instructionbull Scaling polishing curettagebull Routine dental care (after middle of third
trimester elective care should be avoided)
Use of Radiation on Pregnant Patientbull Dose given and time of gestation are
importantbull doses lt 5-10 rads (cGy) not teratogenicbull fetus is most susceptible to radiation
between the 2nd and 6th week of gestationbull single dental x-ray exposes patient to 001
millirads of radiation In relative terms this amount is 40 times less than daily dose acquired from cosmic radiation Therefore diagnostic radiation should not be withheld during pregnancy
Radiographs during Pregnancy
bull Take as needed with optimal methods for reducing secondary radiation and exposure time
bull Always use a lead apronbull Exposure to fetus (with apron use) is 00001
centiGray(rad)bull Daily cosmic radiation - 0004 centiGray (rad)
Risks of Dental X-Rays
bull X-ray only if necessary (ie root canal therapy trauma)
bull When x-rays are indicated radiation exposure is extremely low
bull Exposure can be limited byndash Lead apron shielding ndash Modern fast film ndash Avoiding retakes
FDA drug classification for pregnancybull Combines risk statements including
congenital anomalies fetal effects perinatal risks and therapeutic risk-benefit ratio
bull Untreated disease or condition may pose more serious risks to both mother and fetus than any theoretical risks from the medication
bull Category A thru D and X
FDA drug classification for pregnancy
bull A = Controlled Studies in women fail to demonstrate a risk to the fetus in the first trimester and the possibility of fetal harm appears remote
FDA drug classification for pregnancy
bull B = Animal studies show no risk or if risk shown in animals controlled
trials in women showed no risk
FDA drug classification for pregnancy
bull C = Studies in animals with adverse effects and no human studies
OR no animal or human studies but benefits of use may outweigh potential harms
FDA drug classification for pregnancy
bull D = There is evidence of human fetal risk but benefits may outweigh risks
FDA drug classification for pregnancy
bull X = Contraindicated
Common Analgesics
bull paracetamol (B)bull Ibuprofen (BD) bull Oxycodone (BD) bull Hydrocodone and codeine
(CD)
avoid in third trimester
Analgesics
bull Paracetamol is the analgesic of choice for all stages of gestation
bull used to treat mild to moderate pain and fevers
bull short term usage is believed to be safebull avoid chronic and large doses of
paracetamol1048715
Analgesics - continuedbull Aspirin is nonteratogenic but may cause
maternal and fetal hemorrhagebull large and chronic doses during last trimester
may result in premature closure of ductus arteriosus fetal hypertension anemia and low birth weight
bull avoid ibuprofen in 3rd trimester because of possible adverse circulatory effects
bull short term use of codeine seems safebull avoid codeine late in gestation because of
possible fetal respiratory depression and withdrawal symptoms
Analgesics to Use During1st and 2nd Trimester
bull Category B (for best)bull Paracetamol Ibuprofenbull Naproxenbull Category C (use with caution)bull Paracetamol with codeine or
hydrocodonebull Paracetamol with oxycodone
Analgesics to Avoid During theThird Trimesterbull Causes delivery problemsbull Aspirin (C 3D)bull Ibuprofen (B3D)bull Naproxen (B3D)bull Causes neonatal respiratory
depression and opioid withdrawalbull Codeine (C3D)bull Hydrocodone (C3D)bull Oxycodone(C3D)
Sedation in Pregnancy
bull SedativesAnxiolytics (eg Diazepam ) are rated D and can cause oral clefts with prolonged exposure
bull Nitrous oxide should not be used in 1st trimester (If used in 2nd and 3rd do not go below 50 O2)
Common Antibioticsbull To treat oral abscess or cellulitis
ndash Penicillin (B) ndash Amoxicillin (B) ndash Cephalexin (B)ndash Erythromycin base (B) (Not estolate as it
cause cholestatic hepatitis)ndash Clindamycin (B)
Antibioticsbull penicillin V and amoxicillin is preferred drug
for mild to moderate infectionsbull widely used for many years with no ill effectsbull no studies show penicillin to be teratogenicbull amoxicillin extensively used without harming
the fetusbull Drug classes1048715 B penicillin cephalosporins erythromycin clindamycin Azithromycin D Tetracycline
Antibiotics To Use During Pregnancy
bull Penicillin Vbull Amoxicillinbull Erythromycin (base form)bull Cephalexin cephalosporinbull Clindamycinbull Metronidazole
Antibiotics to Avoid duringPregnancy
bull Doxycyclinebull Tetracyclinebull Erythromycin (estolate form)bull Vancomycin
The Problem With Tetracycline
bull Accumulates in bones and chelates calcium
bull Inhibits bone growthbull Discolors teeth
Other Antimicrobial Agentsbull OK to usebull Nystatin (B)bull Chlorhexidine rinse (B)bull Use with cautionbull Clotrimazole (C)bull Ketoconazole (C)bull Fluconazole (C)bull Do not usebull Doxycycline (D)
Local Anesthetic Use inPregnancy
bull Class Bbull Lidocaine (Xylocaine)bull Etidocainebull Prilocaine bull Class Cbull Procainebull Bupivicainebull Mepivicaine
Use of Local Anestheticsbull Lidocaine + vasoconstrictor most common
local anesthetic used in dentistrybull extensively used in pregnancy with no proven ill
effectsbull accidental intravascular injections of lidocaine
pass through the placenta but the concentrations are too low to harm fetus
bull prilocaine might cause methemoglobinemia
Ulcer healing drugsCimetidine bull FDA category B Famotidinebull FDA category BRanitidinebull FDA category Bbull not known to be harmful
Ulcer healing drugsOmeprazolebull FDA category BNot known to be
harmful Esomeprazolebull FDA category BLansoprazolebull FDA category BPantoprazolebull Avoid unless potential benefit
outweighs riskmdashfetotoxic in animals
Ulcer healing drugs
Misoprostolbull First second third trimesters Avoidmdash
potent uterine stimulant (has been used to induce abortion) and may be teratogenic
Ulcer healing drugs
Antacidsbull Almunium hydroxideMagnesium
hydroxidemdashFDA category B Calcium carbonatemdashFDA category C
SimetheconemdashFDA category C
Use of Nitrous Oxide Gas
bull used over 150 years bull safety is being debatedbull SHORT TERM exposure do not cause
birth defects or spontaneous abortionbull CHRONIC exposure may result in fetal
loss and infertilitybull literature suggests that nitrous oxide
should be avoided until more conclusive research is available
bull FDA Drug class not yet assigned
Common Preventives
bull Fluoridendash No increased risk during pregnancy
bull Xylitolndash No studies no harm reported
bull Chlorhexidinendash No increased risk during pregnancy
Are topical agents safe
bull Fluoridebull Toothpaste amp mouthrinse
bull Xylitol chewing gum bull Chlorhexidine (11 alcohol)bull No over the counter mouthrinses with
alcohol (Listerine 20 alcohol)
Pre-natal Fluoride
bull Daily 22 mg tablet of sodium fluoride during 3rd through 9th months
bull decreases caries rate in offspringbull Safe and effective
Glenn FB 1982
Is it safe to use mercury restorations
bull No evidence of harmful effect
bull Benefits outweigh risks
bull Canada Germany and New Zealand have some restrictions
bull Determine the best option
Referencesbull Wasylko L Matsui D Dykxhoorn SM Rieder MJ Weinberg
S A Review of Common Dental Treatments During Pregnancy J Canadian Dental Association 64434-439 1998
bull Little JW Donald AF Craig SM Rhodus NL Dental Management of the Medically Compromised Patient - 5th edition Mosby Toronto Pp434-442 1997
bull Livingston HM Dellinger TM Holder R Considerations in the management of the pregnant patient Special Care in Dentistry 185 pp183-188 1998
bull Larimore WL Petrie KA Drug use during pregnacy and lactation Primary Care Clinics in Office Practice 271 35-53 2000
bull Health Canada The Safety of DentalAmalgam Minister Of Supply and Services Canada 1996
REFERENCESbull 1 Weiss G Endocrinology of parturition J Clin
Endocrinol Metab 2000854421-5bull 2 Theunissen IM Parer JT Fluid and electrolytes in
pregnancy Clin Obstet Gynecol 1994373-15bull 3 Duvekot JJ Peeters LLH Renal hemodynamics and
volume homeostasis in pregnancy Obstet Gynecol Surv 199449830-9
bull 4 Barron WM Lindheimer MD Medical disorders during pregnancy 2nd ed St Louis Mosby 1995 p 129
bull 5 Thornburg KL Jacobson SL Giraud GD Morton MJ Hemodynamic changes in pregnancy Semin Perinatol 20002411-4
bull 6 Fiese R Herzog S Issues in dental and surgical management of the pregnant patient Oral Surg Oral Med Oral Pathol 198865292-7
bull 7 Martin C Varner MW Physiologic changes in pregnancysurgical implications Clin Obstet Gynecol 199437241-55
bull 8 Clark SL Cotton DB Lee W Bishop C Hill T Southwick J et al Central hemodynamic assessment of normal term pregnancy Am J Obstet Gynecol 19891611439-42
bull 9 Mabie WC Di Sessa TG Crocker LG Sibai BM Arheart KL A longitudinal study of cardiac output in normal human pregnancy Am J Obstet Gynecol 1994170849-56
bull 10 Clapp JF 3rd Capeless E Cardiovascular function before during and after the first and subsequent pregnancies Am J Cardiol 1997801469-73
bull 11 Duvekot JJ Peeters LL Maternal cardiovascular hemodynamic adaptation to pregnancy Obstet Gynecol Surv 199449(Suppl) S1-14
bull 12 Bhagwat AR Engel PJ Heart disease and pregnancy Cardiol Clin 199513163-78
bull 13 Lanni SM Tillinghast J Silver H Hemodynamic changes and baroreflex gain in the supine hypotensive syndrome Am J Obstet Gynecol 20021871636-41
bull 14 Little JW Falace DA Miller CS Rhodus NL Dental management of the medically compromised patient 6th ed St Louis Mosby 2002 p 303
bull 15 Garcia-Rio F Pino JM Gomez L Alvarez-Sala R Villasante C Villamor J Regulation of breathing and perception of dyspnea in healthy pregnant women Chest 1996110446-53
bull 16 McAuliffe F Kametas N Costello J Rafferty GF Greenough A Nicolaides K Respiratory function in singleton and twin pregnancy BJOG 2002109765-9
bull 17 Clapp JF 3rd Seaward BL Sleamaker RH Hiser J Maternal physiologic adaptations to early human pregnancy Am J Obstet Gynecol 19881591456-60
bull 18 OrsquoDay MP Cardio-respiratory physiological adaptation of pregnancy Semin Perinatol 199721268-75
bull 19 Contreras G Gutierrez M Beroiza T Fantin A Oddo H Villarroel L et al Ventilatory drive and respiratory muscle function in pregnancy Am Rev Respir Dis 1991144837-41
bull 20 Turner M Aziz SR Management of the pregnant oral and maxillofac
bull 21 Sifakis S Pharmakides G Anemia in pregnancy Ann N Y Acad Sci 2000900125-36
bull 22 Branch DW Physiologic adaptations of pregnancy Am J Reprod Immunol 199228120-2
bull 23 Burrows RF Kelton JG Incidentally detected thrombocytopenia in healthy mothers and their infants N Engl J Med 1988319 142-5
bull 24 Hanly JG Antiphospholipid syndrome an overview CMAJ 200324(168)1675-82
bull 25 Heilmann L von Tempelhoff GF Pollow K Antiphospholipid syndrome in obstetrics Clin Appl Thromb Hemost 20039 143-50
bull 26 Sherman P Flaxman SM Nausea and vomiting of pregnancy in an evolutionary perspective Am J Obstet Gynecol 2002 185(Suppl)s190-7
bull 27 Koch KL Gastrointestinal factors in nausea and vomiting of pregnancy Am J Obstet Gynecol 2002185(Suppl)s198-203
bull 28 Koch KL Frissora CL Nausea and vomiting during pregnancy Gastroenterol Clin N Am 200332201-34
bull 29 Baron TH Ramirez B Richter JE Gastrointestinal motility disorders during pregnancy Ann Intern Med 1993118 366-75
bull 30 Richter JE Gastroesophageal reflux disease during pregnancy Gastroenterol Clin N Am 200332235-61
bull 31 Marrero JM Goggin PM de Caestecker JS Pearce JM Maxwell JD Determinants of pregnancy heartburn Br J Obstet Gynaecol 199299731-4
bull 32 Hamaoui E Hamaoui M Nutritional assessment and support during pregnancy Gastroenterol Clin N Am 20033259-121
bull 33 King JC Physiology of pregnancy and nutrient metabolism Am J Clin Nutr 200071(suppl)1218s-25s
bull 34 Casanueva E Pfeffer F Fernandez-Gaxiola AC Gutierrez- Valenzuela V Rothenberg SJ Iron and folate status before pregnancy and anemia during pregnancy Ann Nutr Metab 2003 4760-3
bull 35 Chrsquong CL Morgan M Hainsworth I Kingham JG Prospective study of liver dysfunction in Southwest Wales Gut 200251 876-80
bull 36 Rahman TM Wendon J Severe hepatic dysfunction in pregnancy QJM 200295343-57
bull 37 Knox TA Olans LB Liver disease in pregnancy N Engl J Med 1996335569-76
bull 38 Saftlas AF Olson DR Franks AL Atrash H Pokras R Epidemiology of preeclampsia and eclampsia in the United States 1979e1986 Am J Obstet Gynecol 1990163460-5
bull 39 Walker JJ Pre-eclampsia Lancet 20003561260-5
bull 40 Davidson JM Renal disorders in pregnancy Curr Opin Obstet Gynecol 200113109-14
bull 41 Dafnis E Sabatini S The effect of pregnancy on renal function physiology and pathophysiologyAmJMedSci 1992303184-205
bull 42 Davison JM Shiells EA Philips PR Lindheimer MD Serial evaluation of vasopressin release and thirst in human pregnancy Role of human chorionic gonadotrophin in the osmoregulatory changes of gestation J Clin Invest 198881798-806
bull 43 Glinoer D de Nayer P Bourdoux P Lemone M Robyn C van Steirteghem A et al Regulation of maternal thyroid during pregnancy J Clin Endocrinol Metab 199071276-87
bull 44 Wilson SG Retallack RW Kent JC Worth GK Gutteridge DH Serum free 125-dihydroxyvitamin D and the free 125- dihydroxyvitamin D index during a longitudinal study of human pregnancy and lactation Clin Endocrinol 199032613-22
bull 45 Rasmussen N Frolich A Hornnes PJ Hegedus L Serum ionized calcium and intact parathyroid hormone levels during pregnancy and postpartum Br J Obstet Gynaecol 199097857-9
bull 46 Guyton AC Textbook of medical physiology 8th ed Philadelphia W B Saunders 1991 p 915e28
bull 47 Trainer PJ Corticosteroids and pregnancy Semin Reprod Med 200220375-80
bull 48 Soory M Hormonal factors in periodontal disease Dent Update 200027380-3
bull 49 Hugoson A Gingivitis in pregnant women A longitudinal clinical study Odontol Revy 19712265-84
bull 50 Neville BW Damm DD Allen CM Bouquot JE Oral amp Maxillofacial Pathology 3rd ed Philadelphia W B Saunders 2002 p 329-30 447-9
bull 51 Tilakaratne A Soory M Ranasinghe AW Corea SM Ekanayake SL de Silva M Periodontal disease status during pregnancy and 3 months post-partum in rural population of Sri-Lankan women J Clin Periodontol 200027787-92
bull 52 Laine M Tenovuo J Lehtonen OP Ojanatko-Harri A Vilja P Tuohimaa P Pregnancy e related changes in human whole saliva Arch Oral Biol 198833913-7
bull 53 Yuan K Wing LY Lin MT Pathogenetic roles of angiogenic factors in pyogenic granulomas in pregnancy are modulated by female sex hormones J Periodontol 200273701-8
bull 54 Evans RD Briggs PF Tooth-surface loss related to pregnancyinduced vomiting Prim Dent Care 1994124-6
bull 55 Salvolini E Di Giorgio R Curatola A Mazzanti L Fratto G Biochemical modifications of human whole saliva induced by pregnancy Br J Obstet Gynaec 1998105656-60
bull 56 Mauldin JG Newman RB Preterm birth risk assessment Semin Perinatol 200125215-22
bull 57 Heine RP McGregor JA Goodwin TM Artal R Hayashi RH Robertson PA et al Serial salivary estriol to detect an increased risk of preterm birth Obstet Gynecol 200096490-7
bull 58 Kauh YC Zachian TF Melasma Adv Exp Med Biol 1999455 491-9
bull 59 Wong RC Ellis CN Physiologic skin changes in pregnancy J Am Acad Dermatol 198410929-40
bull 60 Errickson CV Matus NR Skin disorders of pregnancy Am Fam Physician 199449605-10
bull 61 Lopez NJ Smith PC Gutierrez J Periodontal therapy may reduce the risk of preterm low birth weight in women with periodontal disease a randomized controlled trial J Periodontol 200273911-24
bull 62 McGaw T Periodontal disease and preterm delivery of lowbirth- weight infants J Can Dent Assoc 200268165-9
bull 63 Richards AG Dental x-ray protection Dent Clin North Am 1968631-41
bull 64 1990 Recommendations of the International Commission on Radiological Protection Ann ICRP 1991211-201
bull 65 Hall EJ Radiation the two-edged sword cancer risks at high and low doses Cancer J 20006343-50
bull 66 Diethelm L Xu H Diagnostic imaging of the lung during pregnancy Clin Obstet Gynecol 19963936-55
bull 67 Brent RL The effects of embryonic and fetal exposure to x-rays microwaves and ultrasound ClinObstetGynecol 198326484-510
bull 68 National Council on Radiation Protection NCRP report no128 1998 Bethesda Md Author
bull 69 Wasylko L Matsui D Dykxhoorn SM Reider MJ Weinberg S A review of common dental treatments during pregnancy implications for patients and dental personnel J Can Dent Assoc 199864434-9
bull 70 Freeman JP Brand JW Radiation doses of commonly used dental radiographic surveys Oral Surg Oral Med Oral Pathol 199477285-9
bull 71 Kircos LTAngin LL Lorton LOrder ofmagnitude dose reduction in intraoral radiography J Am Dent Assoc 1987114344-7
bull 72 Updegrave WJ Simplified and standardized intraoral radiography with reduced tissue irradiation J Am Dent Assoc 197285861-9
bull 73 Wood RE Harris AM van der Merwe EJ Nortje CJ The leaded apron revisited does it reduce gonadal radiation dose in dental radiology Oral Surg Oral Med Oral Pathol 199171642-6
bull 74 An update on radiographic practices information and recommendations ADA Council on Scientific Affairs J Am Dent Assoc 2001132234-8
bull 75 Rayburn WF Recommending medications during pregnancy an evidence based approach Clin Obstet Gynecol 2002451-5
bull 76 Rathmell JP Viscomi C Ashburn MA Management of nonobstetric pain during pregnancy and lactation Anesth Analg 1997851074-87
bull 77 Teratology society public affairs committee FDA classification of drugs for teratogenic risk Teratology 199449446-7
bull 78 Moore PA Selecting drugs for the pregnant dental patient J Am Dent Assoc 19981291281-6
bull 79 Haas DA An update on analgesics for the management of acute postoperative dental pain J Can Dent Assoc 200268476-82
bull 80 Haas DA Pynn BR Sands TD Drug use for the pregnant or lactating patient Gen Dent 20004854-60
bull 81 Committee on Drugs American Academy of Pediatrics The transfer of drugs and other chemicals into human milk Pediatrics 199493137-50
bull 82 Nielsen GL Sorensen HT Larsen H Pedersen L Risk of adverse birth outcome and miscarriage in pregnant users of nonsteroidal anti-inflammatory drugs population based observational study and case-control study BMJ 2001322266-70
bull 83 Janssen N Genta M The effects of immunosuppressive and anti-inflammatory medications on fertility pregnancy and lactation Arch Intern Med 200016610-9
bull 84 Ostensen M Nonsteroidal anti-inflammatory drugs during pregnancy Scand J Rheumatol Suppl 1998107128-32
bull 85 USPDI -Drug information for the health care professional 22nd ed Greenwood Village CO Micromedex 2002 p 152-79
bull 86 Denson DD Coyle DE Thompson GA Santos D Turner PA Myers JA et al Bupivacaine protein binding in the term parturient effects of lactic acidosis Clin Pharmacol Ther 198435702-9
bull 87 Dillon DE Wagner CL Wiest D Newman RB Drug therapy in the nursing mother Obstet Gynecol Clin North Am 199724 675-96
bull 88 Dashe JS Gilstrap LC Antibiotic use in pregnancy Obstet Gynecol Clin North Am 199724617-29
bull 89 American College of Rheumatology Ad hoc Committee on Clinical Guidelines Guidelines for monitoring drug therapy in rheumatoid arthritis Arthritis Rheum 199639723-31
bull 90 Ng PC The fetal and neonatal hypothalamic-pituitary-adrenal axis Arch Dis Child Fetal Neonatal Ed 200082F250-4
bull 91 Crowley P Antenatal corticosteroidsmdashcurrent thinking BJOG 2003110(Suppl 20)77-8
bull 92 ACOG committee opinion antenatal corticosteroid therapy for fetal maturation Obstet Gynecol 200299871-3
bull 93 Ost L Wettrell G Bjorkhem I Rane A Prednisolone excretion in human milk J Pediatr 19851061008-11
bull 94 Rowland AS Baird DD Shore DL Weinberg CR Savitz DA Wilcox AJ Nitrous oxide and spontaneous abortion in female dental assistants Am J Epidemiol 1995141531-8
bull 95 McGlothlin JD Jensen PA Fischbach TJ Hughes RT Jones JH Control of anesthetic gases in dental operatories Scand J Work Environ Health 199218(Suppl 2)103-5
bull ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY Volume 97 Number 6 Suresh and Radfar 681
bull 96 Rosen MA Nitrous oxide for relief of labor pain a systematic review Am J Obstet Gynecol 2002186(Suppl Nature)S110-6
bull 97 Sands TD Pynn BR Management considerations for the pregnant or nursing emergency patient Ont Dent 199875 17-9
bull 98 Daya S Recurrent spontaneous early pregnancy loss and low dose aspirin Minerva Ginecol 200355441-9
bull 99 Sinclair C Handbook of obstetrical emergencies 1st ed Philadelphia WB Saunders 1996 p 29-39 69
bull 100 Tarsitano BF Rollings RE The pregnant dental patient evaluation and management Gen Dent 199341226-34
bull 101 Livingston MH Dlllinger TM Holder R Consideration in the management of the pregnant patient SCD Special Care in Dentistry 199818183-8
Thank you
- A Review on the principle of Dental Management of the Pregnant patient
- Slide 2
- Questions that a dentist may ask
- Stages of Pregnancy
- Slide 5
- Slide 6
- Physiologic Changes in Pregnancy
- Systemic changes in pregnancy
- FLAT SUPINE POSITIONING
- SUPINE HYPOTENSION SYNDROME (Vena Cava Compression)
- Supine Hypotension Syndrome
- Slide 12
- Supine Hypotension Syndrome
- Prevention of Supine Hypotensive Syndrome
- Treatment of Supine Hypotensive Syndrome
- How should the pregnant woman be positioned
- Slide 17
- Slide 18
- Slide 19
- Slide 20
- Slide 21
- Slide 22
- Slide 23
- Pregnancy Related Oral Health Problems
- Oral Problems in Pregnancy
- Pregnancy Gingivitis Pathophysiology
- Pregnancy Gingivitis
- Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Gum Problems - Pregnancy Granuloma
- Slide 31
- Gum Changes - Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Candidiasis
- Pregnancy Myths
- Other Oral Conditions in Pregnancy
- Changes During Pregnancy that Affect Oral Health
- Saliva changes
- Increased Bacteria
- Slide 40
- Enamel erosion caused by frequent vomiting
- Treatment for Acid Exposure
- Oral Diseases Can Effect Pregnancy
- Periodontal Disease and Preterm Labor
- Periodontal Disease and Low Birth Weight
- Periodontal Disease and Preeclampsia
- Periodontitis and Pre-eclampsia
- Dental Considerations
- Treatment Timing
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Slide 52
- Use of Radiation on Pregnant Patient
- Radiographs during Pregnancy
- Risks of Dental X-Rays
- FDA drug classification for pregnancy
- Slide 57
- FDA drug classification for pregnancy
- Slide 59
- Slide 60
- Slide 61
- Common Analgesics
- Analgesics
- Analgesics - continued
- Analgesics to Use During 1st and 2nd Trimester
- Analgesics to Avoid During the Third Trimester
- Sedation in Pregnancy
- Common Antibiotics
- Antibiotics
- Antibiotics To Use During Pregnancy
- Antibiotics to Avoid during Pregnancy
- The Problem With Tetracycline
- Other Antimicrobial Agents
- Local Anesthetic Use in Pregnancy
- Use of Local Anesthetics
- Ulcer healing drugs
- Slide 77
- Slide 78
- Slide 79
- Use of Nitrous Oxide Gas
- Common Preventives
- Are topical agents safe
- Pre-natal Fluoride
- Is it safe to use mercury restorations
- References
- REFERENCES
- Slide 87
- Slide 88
- Slide 89
- Slide 90
- Slide 91
- Slide 92
- Slide 93
- Slide 94
- Slide 95
- Slide 96
- Slide 97
- Slide 98
- Thank you
-
Periodontal Disease and Preterm LaborbullMaternal periodontal disease is associated with increased risk of preterm laborbullAnaerobic oral gram-negative bacteria cause inflammatory responsebullInflammatory response stimulates prostaglandin and cytokine production to stimulate labor
Periodontal Disease and Low Birth Weight
bull Periodontal disease is associated with low birth weight
bull Evidence is not conclusivebull Biochemical mechanism similar cascade
as in preterm labor leading to placental blood flow restriction and necrosis
Periodontal Disease and Preeclampsia
bull Emerging databull Mechanism unclearbull Proposed mechanism
ndash Periodontal infection leads to inflammatory vascular damage
ndash Triggers cell damage in placenta
Periodontitis and Pre-eclampsia
bull Periodontal disease may be associated with pre-eclampsia (Boggess 2003)
bull PGE2 IL-1 and TNF-α from gingival crevicular fluid were higher in women with preeclampsia compared with healthy matched pregnant women (Oettinger-Barak 2003)
Dental Considerations
bull timing of treatment for pregnant patientsbull dental radiation exposurebull use of local anestheticsbull prescription of common antibiotics and
analgesicsbull nitrous oxide gas administration
Treatment Timing
bull First Trimesterndash Spontaneous miscarriages naturally occur
more often in 1st trimesterndash Avoid elective treatment that can be delayedndash Offer anticipatory guidance
bull Second Trimesterndash The optimal time for dental treatmentndash Organogenesis complete fetus not largendash Easier to prevent than treat established disease
bull Third Trimesterndash Late in term very uncomfortable (short visits)ndash Position slightly on left side
Timing of Dental Treatment During Pregnancy - From Little and Fallace
First Trimester
bull Plaque controlbull Oral hygiene instructionbull Scaling polishing curettagebull Avoid elective treatment urgent care
only
Timing of Dental Treatment During Pregnancy - From Little and Fallace
Second Trimester
bull Plaque controlbull Oral hygiene instructionbull Scaling polishing curettagebull Routine dental care
Timing of Dental Treatment During Pregnancy - From Little and Fallace
Third Trimester
bull Plaque controlbull Oral hygiene instructionbull Scaling polishing curettagebull Routine dental care (after middle of third
trimester elective care should be avoided)
Use of Radiation on Pregnant Patientbull Dose given and time of gestation are
importantbull doses lt 5-10 rads (cGy) not teratogenicbull fetus is most susceptible to radiation
between the 2nd and 6th week of gestationbull single dental x-ray exposes patient to 001
millirads of radiation In relative terms this amount is 40 times less than daily dose acquired from cosmic radiation Therefore diagnostic radiation should not be withheld during pregnancy
Radiographs during Pregnancy
bull Take as needed with optimal methods for reducing secondary radiation and exposure time
bull Always use a lead apronbull Exposure to fetus (with apron use) is 00001
centiGray(rad)bull Daily cosmic radiation - 0004 centiGray (rad)
Risks of Dental X-Rays
bull X-ray only if necessary (ie root canal therapy trauma)
bull When x-rays are indicated radiation exposure is extremely low
bull Exposure can be limited byndash Lead apron shielding ndash Modern fast film ndash Avoiding retakes
FDA drug classification for pregnancybull Combines risk statements including
congenital anomalies fetal effects perinatal risks and therapeutic risk-benefit ratio
bull Untreated disease or condition may pose more serious risks to both mother and fetus than any theoretical risks from the medication
bull Category A thru D and X
FDA drug classification for pregnancy
bull A = Controlled Studies in women fail to demonstrate a risk to the fetus in the first trimester and the possibility of fetal harm appears remote
FDA drug classification for pregnancy
bull B = Animal studies show no risk or if risk shown in animals controlled
trials in women showed no risk
FDA drug classification for pregnancy
bull C = Studies in animals with adverse effects and no human studies
OR no animal or human studies but benefits of use may outweigh potential harms
FDA drug classification for pregnancy
bull D = There is evidence of human fetal risk but benefits may outweigh risks
FDA drug classification for pregnancy
bull X = Contraindicated
Common Analgesics
bull paracetamol (B)bull Ibuprofen (BD) bull Oxycodone (BD) bull Hydrocodone and codeine
(CD)
avoid in third trimester
Analgesics
bull Paracetamol is the analgesic of choice for all stages of gestation
bull used to treat mild to moderate pain and fevers
bull short term usage is believed to be safebull avoid chronic and large doses of
paracetamol1048715
Analgesics - continuedbull Aspirin is nonteratogenic but may cause
maternal and fetal hemorrhagebull large and chronic doses during last trimester
may result in premature closure of ductus arteriosus fetal hypertension anemia and low birth weight
bull avoid ibuprofen in 3rd trimester because of possible adverse circulatory effects
bull short term use of codeine seems safebull avoid codeine late in gestation because of
possible fetal respiratory depression and withdrawal symptoms
Analgesics to Use During1st and 2nd Trimester
bull Category B (for best)bull Paracetamol Ibuprofenbull Naproxenbull Category C (use with caution)bull Paracetamol with codeine or
hydrocodonebull Paracetamol with oxycodone
Analgesics to Avoid During theThird Trimesterbull Causes delivery problemsbull Aspirin (C 3D)bull Ibuprofen (B3D)bull Naproxen (B3D)bull Causes neonatal respiratory
depression and opioid withdrawalbull Codeine (C3D)bull Hydrocodone (C3D)bull Oxycodone(C3D)
Sedation in Pregnancy
bull SedativesAnxiolytics (eg Diazepam ) are rated D and can cause oral clefts with prolonged exposure
bull Nitrous oxide should not be used in 1st trimester (If used in 2nd and 3rd do not go below 50 O2)
Common Antibioticsbull To treat oral abscess or cellulitis
ndash Penicillin (B) ndash Amoxicillin (B) ndash Cephalexin (B)ndash Erythromycin base (B) (Not estolate as it
cause cholestatic hepatitis)ndash Clindamycin (B)
Antibioticsbull penicillin V and amoxicillin is preferred drug
for mild to moderate infectionsbull widely used for many years with no ill effectsbull no studies show penicillin to be teratogenicbull amoxicillin extensively used without harming
the fetusbull Drug classes1048715 B penicillin cephalosporins erythromycin clindamycin Azithromycin D Tetracycline
Antibiotics To Use During Pregnancy
bull Penicillin Vbull Amoxicillinbull Erythromycin (base form)bull Cephalexin cephalosporinbull Clindamycinbull Metronidazole
Antibiotics to Avoid duringPregnancy
bull Doxycyclinebull Tetracyclinebull Erythromycin (estolate form)bull Vancomycin
The Problem With Tetracycline
bull Accumulates in bones and chelates calcium
bull Inhibits bone growthbull Discolors teeth
Other Antimicrobial Agentsbull OK to usebull Nystatin (B)bull Chlorhexidine rinse (B)bull Use with cautionbull Clotrimazole (C)bull Ketoconazole (C)bull Fluconazole (C)bull Do not usebull Doxycycline (D)
Local Anesthetic Use inPregnancy
bull Class Bbull Lidocaine (Xylocaine)bull Etidocainebull Prilocaine bull Class Cbull Procainebull Bupivicainebull Mepivicaine
Use of Local Anestheticsbull Lidocaine + vasoconstrictor most common
local anesthetic used in dentistrybull extensively used in pregnancy with no proven ill
effectsbull accidental intravascular injections of lidocaine
pass through the placenta but the concentrations are too low to harm fetus
bull prilocaine might cause methemoglobinemia
Ulcer healing drugsCimetidine bull FDA category B Famotidinebull FDA category BRanitidinebull FDA category Bbull not known to be harmful
Ulcer healing drugsOmeprazolebull FDA category BNot known to be
harmful Esomeprazolebull FDA category BLansoprazolebull FDA category BPantoprazolebull Avoid unless potential benefit
outweighs riskmdashfetotoxic in animals
Ulcer healing drugs
Misoprostolbull First second third trimesters Avoidmdash
potent uterine stimulant (has been used to induce abortion) and may be teratogenic
Ulcer healing drugs
Antacidsbull Almunium hydroxideMagnesium
hydroxidemdashFDA category B Calcium carbonatemdashFDA category C
SimetheconemdashFDA category C
Use of Nitrous Oxide Gas
bull used over 150 years bull safety is being debatedbull SHORT TERM exposure do not cause
birth defects or spontaneous abortionbull CHRONIC exposure may result in fetal
loss and infertilitybull literature suggests that nitrous oxide
should be avoided until more conclusive research is available
bull FDA Drug class not yet assigned
Common Preventives
bull Fluoridendash No increased risk during pregnancy
bull Xylitolndash No studies no harm reported
bull Chlorhexidinendash No increased risk during pregnancy
Are topical agents safe
bull Fluoridebull Toothpaste amp mouthrinse
bull Xylitol chewing gum bull Chlorhexidine (11 alcohol)bull No over the counter mouthrinses with
alcohol (Listerine 20 alcohol)
Pre-natal Fluoride
bull Daily 22 mg tablet of sodium fluoride during 3rd through 9th months
bull decreases caries rate in offspringbull Safe and effective
Glenn FB 1982
Is it safe to use mercury restorations
bull No evidence of harmful effect
bull Benefits outweigh risks
bull Canada Germany and New Zealand have some restrictions
bull Determine the best option
Referencesbull Wasylko L Matsui D Dykxhoorn SM Rieder MJ Weinberg
S A Review of Common Dental Treatments During Pregnancy J Canadian Dental Association 64434-439 1998
bull Little JW Donald AF Craig SM Rhodus NL Dental Management of the Medically Compromised Patient - 5th edition Mosby Toronto Pp434-442 1997
bull Livingston HM Dellinger TM Holder R Considerations in the management of the pregnant patient Special Care in Dentistry 185 pp183-188 1998
bull Larimore WL Petrie KA Drug use during pregnacy and lactation Primary Care Clinics in Office Practice 271 35-53 2000
bull Health Canada The Safety of DentalAmalgam Minister Of Supply and Services Canada 1996
REFERENCESbull 1 Weiss G Endocrinology of parturition J Clin
Endocrinol Metab 2000854421-5bull 2 Theunissen IM Parer JT Fluid and electrolytes in
pregnancy Clin Obstet Gynecol 1994373-15bull 3 Duvekot JJ Peeters LLH Renal hemodynamics and
volume homeostasis in pregnancy Obstet Gynecol Surv 199449830-9
bull 4 Barron WM Lindheimer MD Medical disorders during pregnancy 2nd ed St Louis Mosby 1995 p 129
bull 5 Thornburg KL Jacobson SL Giraud GD Morton MJ Hemodynamic changes in pregnancy Semin Perinatol 20002411-4
bull 6 Fiese R Herzog S Issues in dental and surgical management of the pregnant patient Oral Surg Oral Med Oral Pathol 198865292-7
bull 7 Martin C Varner MW Physiologic changes in pregnancysurgical implications Clin Obstet Gynecol 199437241-55
bull 8 Clark SL Cotton DB Lee W Bishop C Hill T Southwick J et al Central hemodynamic assessment of normal term pregnancy Am J Obstet Gynecol 19891611439-42
bull 9 Mabie WC Di Sessa TG Crocker LG Sibai BM Arheart KL A longitudinal study of cardiac output in normal human pregnancy Am J Obstet Gynecol 1994170849-56
bull 10 Clapp JF 3rd Capeless E Cardiovascular function before during and after the first and subsequent pregnancies Am J Cardiol 1997801469-73
bull 11 Duvekot JJ Peeters LL Maternal cardiovascular hemodynamic adaptation to pregnancy Obstet Gynecol Surv 199449(Suppl) S1-14
bull 12 Bhagwat AR Engel PJ Heart disease and pregnancy Cardiol Clin 199513163-78
bull 13 Lanni SM Tillinghast J Silver H Hemodynamic changes and baroreflex gain in the supine hypotensive syndrome Am J Obstet Gynecol 20021871636-41
bull 14 Little JW Falace DA Miller CS Rhodus NL Dental management of the medically compromised patient 6th ed St Louis Mosby 2002 p 303
bull 15 Garcia-Rio F Pino JM Gomez L Alvarez-Sala R Villasante C Villamor J Regulation of breathing and perception of dyspnea in healthy pregnant women Chest 1996110446-53
bull 16 McAuliffe F Kametas N Costello J Rafferty GF Greenough A Nicolaides K Respiratory function in singleton and twin pregnancy BJOG 2002109765-9
bull 17 Clapp JF 3rd Seaward BL Sleamaker RH Hiser J Maternal physiologic adaptations to early human pregnancy Am J Obstet Gynecol 19881591456-60
bull 18 OrsquoDay MP Cardio-respiratory physiological adaptation of pregnancy Semin Perinatol 199721268-75
bull 19 Contreras G Gutierrez M Beroiza T Fantin A Oddo H Villarroel L et al Ventilatory drive and respiratory muscle function in pregnancy Am Rev Respir Dis 1991144837-41
bull 20 Turner M Aziz SR Management of the pregnant oral and maxillofac
bull 21 Sifakis S Pharmakides G Anemia in pregnancy Ann N Y Acad Sci 2000900125-36
bull 22 Branch DW Physiologic adaptations of pregnancy Am J Reprod Immunol 199228120-2
bull 23 Burrows RF Kelton JG Incidentally detected thrombocytopenia in healthy mothers and their infants N Engl J Med 1988319 142-5
bull 24 Hanly JG Antiphospholipid syndrome an overview CMAJ 200324(168)1675-82
bull 25 Heilmann L von Tempelhoff GF Pollow K Antiphospholipid syndrome in obstetrics Clin Appl Thromb Hemost 20039 143-50
bull 26 Sherman P Flaxman SM Nausea and vomiting of pregnancy in an evolutionary perspective Am J Obstet Gynecol 2002 185(Suppl)s190-7
bull 27 Koch KL Gastrointestinal factors in nausea and vomiting of pregnancy Am J Obstet Gynecol 2002185(Suppl)s198-203
bull 28 Koch KL Frissora CL Nausea and vomiting during pregnancy Gastroenterol Clin N Am 200332201-34
bull 29 Baron TH Ramirez B Richter JE Gastrointestinal motility disorders during pregnancy Ann Intern Med 1993118 366-75
bull 30 Richter JE Gastroesophageal reflux disease during pregnancy Gastroenterol Clin N Am 200332235-61
bull 31 Marrero JM Goggin PM de Caestecker JS Pearce JM Maxwell JD Determinants of pregnancy heartburn Br J Obstet Gynaecol 199299731-4
bull 32 Hamaoui E Hamaoui M Nutritional assessment and support during pregnancy Gastroenterol Clin N Am 20033259-121
bull 33 King JC Physiology of pregnancy and nutrient metabolism Am J Clin Nutr 200071(suppl)1218s-25s
bull 34 Casanueva E Pfeffer F Fernandez-Gaxiola AC Gutierrez- Valenzuela V Rothenberg SJ Iron and folate status before pregnancy and anemia during pregnancy Ann Nutr Metab 2003 4760-3
bull 35 Chrsquong CL Morgan M Hainsworth I Kingham JG Prospective study of liver dysfunction in Southwest Wales Gut 200251 876-80
bull 36 Rahman TM Wendon J Severe hepatic dysfunction in pregnancy QJM 200295343-57
bull 37 Knox TA Olans LB Liver disease in pregnancy N Engl J Med 1996335569-76
bull 38 Saftlas AF Olson DR Franks AL Atrash H Pokras R Epidemiology of preeclampsia and eclampsia in the United States 1979e1986 Am J Obstet Gynecol 1990163460-5
bull 39 Walker JJ Pre-eclampsia Lancet 20003561260-5
bull 40 Davidson JM Renal disorders in pregnancy Curr Opin Obstet Gynecol 200113109-14
bull 41 Dafnis E Sabatini S The effect of pregnancy on renal function physiology and pathophysiologyAmJMedSci 1992303184-205
bull 42 Davison JM Shiells EA Philips PR Lindheimer MD Serial evaluation of vasopressin release and thirst in human pregnancy Role of human chorionic gonadotrophin in the osmoregulatory changes of gestation J Clin Invest 198881798-806
bull 43 Glinoer D de Nayer P Bourdoux P Lemone M Robyn C van Steirteghem A et al Regulation of maternal thyroid during pregnancy J Clin Endocrinol Metab 199071276-87
bull 44 Wilson SG Retallack RW Kent JC Worth GK Gutteridge DH Serum free 125-dihydroxyvitamin D and the free 125- dihydroxyvitamin D index during a longitudinal study of human pregnancy and lactation Clin Endocrinol 199032613-22
bull 45 Rasmussen N Frolich A Hornnes PJ Hegedus L Serum ionized calcium and intact parathyroid hormone levels during pregnancy and postpartum Br J Obstet Gynaecol 199097857-9
bull 46 Guyton AC Textbook of medical physiology 8th ed Philadelphia W B Saunders 1991 p 915e28
bull 47 Trainer PJ Corticosteroids and pregnancy Semin Reprod Med 200220375-80
bull 48 Soory M Hormonal factors in periodontal disease Dent Update 200027380-3
bull 49 Hugoson A Gingivitis in pregnant women A longitudinal clinical study Odontol Revy 19712265-84
bull 50 Neville BW Damm DD Allen CM Bouquot JE Oral amp Maxillofacial Pathology 3rd ed Philadelphia W B Saunders 2002 p 329-30 447-9
bull 51 Tilakaratne A Soory M Ranasinghe AW Corea SM Ekanayake SL de Silva M Periodontal disease status during pregnancy and 3 months post-partum in rural population of Sri-Lankan women J Clin Periodontol 200027787-92
bull 52 Laine M Tenovuo J Lehtonen OP Ojanatko-Harri A Vilja P Tuohimaa P Pregnancy e related changes in human whole saliva Arch Oral Biol 198833913-7
bull 53 Yuan K Wing LY Lin MT Pathogenetic roles of angiogenic factors in pyogenic granulomas in pregnancy are modulated by female sex hormones J Periodontol 200273701-8
bull 54 Evans RD Briggs PF Tooth-surface loss related to pregnancyinduced vomiting Prim Dent Care 1994124-6
bull 55 Salvolini E Di Giorgio R Curatola A Mazzanti L Fratto G Biochemical modifications of human whole saliva induced by pregnancy Br J Obstet Gynaec 1998105656-60
bull 56 Mauldin JG Newman RB Preterm birth risk assessment Semin Perinatol 200125215-22
bull 57 Heine RP McGregor JA Goodwin TM Artal R Hayashi RH Robertson PA et al Serial salivary estriol to detect an increased risk of preterm birth Obstet Gynecol 200096490-7
bull 58 Kauh YC Zachian TF Melasma Adv Exp Med Biol 1999455 491-9
bull 59 Wong RC Ellis CN Physiologic skin changes in pregnancy J Am Acad Dermatol 198410929-40
bull 60 Errickson CV Matus NR Skin disorders of pregnancy Am Fam Physician 199449605-10
bull 61 Lopez NJ Smith PC Gutierrez J Periodontal therapy may reduce the risk of preterm low birth weight in women with periodontal disease a randomized controlled trial J Periodontol 200273911-24
bull 62 McGaw T Periodontal disease and preterm delivery of lowbirth- weight infants J Can Dent Assoc 200268165-9
bull 63 Richards AG Dental x-ray protection Dent Clin North Am 1968631-41
bull 64 1990 Recommendations of the International Commission on Radiological Protection Ann ICRP 1991211-201
bull 65 Hall EJ Radiation the two-edged sword cancer risks at high and low doses Cancer J 20006343-50
bull 66 Diethelm L Xu H Diagnostic imaging of the lung during pregnancy Clin Obstet Gynecol 19963936-55
bull 67 Brent RL The effects of embryonic and fetal exposure to x-rays microwaves and ultrasound ClinObstetGynecol 198326484-510
bull 68 National Council on Radiation Protection NCRP report no128 1998 Bethesda Md Author
bull 69 Wasylko L Matsui D Dykxhoorn SM Reider MJ Weinberg S A review of common dental treatments during pregnancy implications for patients and dental personnel J Can Dent Assoc 199864434-9
bull 70 Freeman JP Brand JW Radiation doses of commonly used dental radiographic surveys Oral Surg Oral Med Oral Pathol 199477285-9
bull 71 Kircos LTAngin LL Lorton LOrder ofmagnitude dose reduction in intraoral radiography J Am Dent Assoc 1987114344-7
bull 72 Updegrave WJ Simplified and standardized intraoral radiography with reduced tissue irradiation J Am Dent Assoc 197285861-9
bull 73 Wood RE Harris AM van der Merwe EJ Nortje CJ The leaded apron revisited does it reduce gonadal radiation dose in dental radiology Oral Surg Oral Med Oral Pathol 199171642-6
bull 74 An update on radiographic practices information and recommendations ADA Council on Scientific Affairs J Am Dent Assoc 2001132234-8
bull 75 Rayburn WF Recommending medications during pregnancy an evidence based approach Clin Obstet Gynecol 2002451-5
bull 76 Rathmell JP Viscomi C Ashburn MA Management of nonobstetric pain during pregnancy and lactation Anesth Analg 1997851074-87
bull 77 Teratology society public affairs committee FDA classification of drugs for teratogenic risk Teratology 199449446-7
bull 78 Moore PA Selecting drugs for the pregnant dental patient J Am Dent Assoc 19981291281-6
bull 79 Haas DA An update on analgesics for the management of acute postoperative dental pain J Can Dent Assoc 200268476-82
bull 80 Haas DA Pynn BR Sands TD Drug use for the pregnant or lactating patient Gen Dent 20004854-60
bull 81 Committee on Drugs American Academy of Pediatrics The transfer of drugs and other chemicals into human milk Pediatrics 199493137-50
bull 82 Nielsen GL Sorensen HT Larsen H Pedersen L Risk of adverse birth outcome and miscarriage in pregnant users of nonsteroidal anti-inflammatory drugs population based observational study and case-control study BMJ 2001322266-70
bull 83 Janssen N Genta M The effects of immunosuppressive and anti-inflammatory medications on fertility pregnancy and lactation Arch Intern Med 200016610-9
bull 84 Ostensen M Nonsteroidal anti-inflammatory drugs during pregnancy Scand J Rheumatol Suppl 1998107128-32
bull 85 USPDI -Drug information for the health care professional 22nd ed Greenwood Village CO Micromedex 2002 p 152-79
bull 86 Denson DD Coyle DE Thompson GA Santos D Turner PA Myers JA et al Bupivacaine protein binding in the term parturient effects of lactic acidosis Clin Pharmacol Ther 198435702-9
bull 87 Dillon DE Wagner CL Wiest D Newman RB Drug therapy in the nursing mother Obstet Gynecol Clin North Am 199724 675-96
bull 88 Dashe JS Gilstrap LC Antibiotic use in pregnancy Obstet Gynecol Clin North Am 199724617-29
bull 89 American College of Rheumatology Ad hoc Committee on Clinical Guidelines Guidelines for monitoring drug therapy in rheumatoid arthritis Arthritis Rheum 199639723-31
bull 90 Ng PC The fetal and neonatal hypothalamic-pituitary-adrenal axis Arch Dis Child Fetal Neonatal Ed 200082F250-4
bull 91 Crowley P Antenatal corticosteroidsmdashcurrent thinking BJOG 2003110(Suppl 20)77-8
bull 92 ACOG committee opinion antenatal corticosteroid therapy for fetal maturation Obstet Gynecol 200299871-3
bull 93 Ost L Wettrell G Bjorkhem I Rane A Prednisolone excretion in human milk J Pediatr 19851061008-11
bull 94 Rowland AS Baird DD Shore DL Weinberg CR Savitz DA Wilcox AJ Nitrous oxide and spontaneous abortion in female dental assistants Am J Epidemiol 1995141531-8
bull 95 McGlothlin JD Jensen PA Fischbach TJ Hughes RT Jones JH Control of anesthetic gases in dental operatories Scand J Work Environ Health 199218(Suppl 2)103-5
bull ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY Volume 97 Number 6 Suresh and Radfar 681
bull 96 Rosen MA Nitrous oxide for relief of labor pain a systematic review Am J Obstet Gynecol 2002186(Suppl Nature)S110-6
bull 97 Sands TD Pynn BR Management considerations for the pregnant or nursing emergency patient Ont Dent 199875 17-9
bull 98 Daya S Recurrent spontaneous early pregnancy loss and low dose aspirin Minerva Ginecol 200355441-9
bull 99 Sinclair C Handbook of obstetrical emergencies 1st ed Philadelphia WB Saunders 1996 p 29-39 69
bull 100 Tarsitano BF Rollings RE The pregnant dental patient evaluation and management Gen Dent 199341226-34
bull 101 Livingston MH Dlllinger TM Holder R Consideration in the management of the pregnant patient SCD Special Care in Dentistry 199818183-8
Thank you
- A Review on the principle of Dental Management of the Pregnant patient
- Slide 2
- Questions that a dentist may ask
- Stages of Pregnancy
- Slide 5
- Slide 6
- Physiologic Changes in Pregnancy
- Systemic changes in pregnancy
- FLAT SUPINE POSITIONING
- SUPINE HYPOTENSION SYNDROME (Vena Cava Compression)
- Supine Hypotension Syndrome
- Slide 12
- Supine Hypotension Syndrome
- Prevention of Supine Hypotensive Syndrome
- Treatment of Supine Hypotensive Syndrome
- How should the pregnant woman be positioned
- Slide 17
- Slide 18
- Slide 19
- Slide 20
- Slide 21
- Slide 22
- Slide 23
- Pregnancy Related Oral Health Problems
- Oral Problems in Pregnancy
- Pregnancy Gingivitis Pathophysiology
- Pregnancy Gingivitis
- Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Gum Problems - Pregnancy Granuloma
- Slide 31
- Gum Changes - Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Candidiasis
- Pregnancy Myths
- Other Oral Conditions in Pregnancy
- Changes During Pregnancy that Affect Oral Health
- Saliva changes
- Increased Bacteria
- Slide 40
- Enamel erosion caused by frequent vomiting
- Treatment for Acid Exposure
- Oral Diseases Can Effect Pregnancy
- Periodontal Disease and Preterm Labor
- Periodontal Disease and Low Birth Weight
- Periodontal Disease and Preeclampsia
- Periodontitis and Pre-eclampsia
- Dental Considerations
- Treatment Timing
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Slide 52
- Use of Radiation on Pregnant Patient
- Radiographs during Pregnancy
- Risks of Dental X-Rays
- FDA drug classification for pregnancy
- Slide 57
- FDA drug classification for pregnancy
- Slide 59
- Slide 60
- Slide 61
- Common Analgesics
- Analgesics
- Analgesics - continued
- Analgesics to Use During 1st and 2nd Trimester
- Analgesics to Avoid During the Third Trimester
- Sedation in Pregnancy
- Common Antibiotics
- Antibiotics
- Antibiotics To Use During Pregnancy
- Antibiotics to Avoid during Pregnancy
- The Problem With Tetracycline
- Other Antimicrobial Agents
- Local Anesthetic Use in Pregnancy
- Use of Local Anesthetics
- Ulcer healing drugs
- Slide 77
- Slide 78
- Slide 79
- Use of Nitrous Oxide Gas
- Common Preventives
- Are topical agents safe
- Pre-natal Fluoride
- Is it safe to use mercury restorations
- References
- REFERENCES
- Slide 87
- Slide 88
- Slide 89
- Slide 90
- Slide 91
- Slide 92
- Slide 93
- Slide 94
- Slide 95
- Slide 96
- Slide 97
- Slide 98
- Thank you
-
Periodontal Disease and Low Birth Weight
bull Periodontal disease is associated with low birth weight
bull Evidence is not conclusivebull Biochemical mechanism similar cascade
as in preterm labor leading to placental blood flow restriction and necrosis
Periodontal Disease and Preeclampsia
bull Emerging databull Mechanism unclearbull Proposed mechanism
ndash Periodontal infection leads to inflammatory vascular damage
ndash Triggers cell damage in placenta
Periodontitis and Pre-eclampsia
bull Periodontal disease may be associated with pre-eclampsia (Boggess 2003)
bull PGE2 IL-1 and TNF-α from gingival crevicular fluid were higher in women with preeclampsia compared with healthy matched pregnant women (Oettinger-Barak 2003)
Dental Considerations
bull timing of treatment for pregnant patientsbull dental radiation exposurebull use of local anestheticsbull prescription of common antibiotics and
analgesicsbull nitrous oxide gas administration
Treatment Timing
bull First Trimesterndash Spontaneous miscarriages naturally occur
more often in 1st trimesterndash Avoid elective treatment that can be delayedndash Offer anticipatory guidance
bull Second Trimesterndash The optimal time for dental treatmentndash Organogenesis complete fetus not largendash Easier to prevent than treat established disease
bull Third Trimesterndash Late in term very uncomfortable (short visits)ndash Position slightly on left side
Timing of Dental Treatment During Pregnancy - From Little and Fallace
First Trimester
bull Plaque controlbull Oral hygiene instructionbull Scaling polishing curettagebull Avoid elective treatment urgent care
only
Timing of Dental Treatment During Pregnancy - From Little and Fallace
Second Trimester
bull Plaque controlbull Oral hygiene instructionbull Scaling polishing curettagebull Routine dental care
Timing of Dental Treatment During Pregnancy - From Little and Fallace
Third Trimester
bull Plaque controlbull Oral hygiene instructionbull Scaling polishing curettagebull Routine dental care (after middle of third
trimester elective care should be avoided)
Use of Radiation on Pregnant Patientbull Dose given and time of gestation are
importantbull doses lt 5-10 rads (cGy) not teratogenicbull fetus is most susceptible to radiation
between the 2nd and 6th week of gestationbull single dental x-ray exposes patient to 001
millirads of radiation In relative terms this amount is 40 times less than daily dose acquired from cosmic radiation Therefore diagnostic radiation should not be withheld during pregnancy
Radiographs during Pregnancy
bull Take as needed with optimal methods for reducing secondary radiation and exposure time
bull Always use a lead apronbull Exposure to fetus (with apron use) is 00001
centiGray(rad)bull Daily cosmic radiation - 0004 centiGray (rad)
Risks of Dental X-Rays
bull X-ray only if necessary (ie root canal therapy trauma)
bull When x-rays are indicated radiation exposure is extremely low
bull Exposure can be limited byndash Lead apron shielding ndash Modern fast film ndash Avoiding retakes
FDA drug classification for pregnancybull Combines risk statements including
congenital anomalies fetal effects perinatal risks and therapeutic risk-benefit ratio
bull Untreated disease or condition may pose more serious risks to both mother and fetus than any theoretical risks from the medication
bull Category A thru D and X
FDA drug classification for pregnancy
bull A = Controlled Studies in women fail to demonstrate a risk to the fetus in the first trimester and the possibility of fetal harm appears remote
FDA drug classification for pregnancy
bull B = Animal studies show no risk or if risk shown in animals controlled
trials in women showed no risk
FDA drug classification for pregnancy
bull C = Studies in animals with adverse effects and no human studies
OR no animal or human studies but benefits of use may outweigh potential harms
FDA drug classification for pregnancy
bull D = There is evidence of human fetal risk but benefits may outweigh risks
FDA drug classification for pregnancy
bull X = Contraindicated
Common Analgesics
bull paracetamol (B)bull Ibuprofen (BD) bull Oxycodone (BD) bull Hydrocodone and codeine
(CD)
avoid in third trimester
Analgesics
bull Paracetamol is the analgesic of choice for all stages of gestation
bull used to treat mild to moderate pain and fevers
bull short term usage is believed to be safebull avoid chronic and large doses of
paracetamol1048715
Analgesics - continuedbull Aspirin is nonteratogenic but may cause
maternal and fetal hemorrhagebull large and chronic doses during last trimester
may result in premature closure of ductus arteriosus fetal hypertension anemia and low birth weight
bull avoid ibuprofen in 3rd trimester because of possible adverse circulatory effects
bull short term use of codeine seems safebull avoid codeine late in gestation because of
possible fetal respiratory depression and withdrawal symptoms
Analgesics to Use During1st and 2nd Trimester
bull Category B (for best)bull Paracetamol Ibuprofenbull Naproxenbull Category C (use with caution)bull Paracetamol with codeine or
hydrocodonebull Paracetamol with oxycodone
Analgesics to Avoid During theThird Trimesterbull Causes delivery problemsbull Aspirin (C 3D)bull Ibuprofen (B3D)bull Naproxen (B3D)bull Causes neonatal respiratory
depression and opioid withdrawalbull Codeine (C3D)bull Hydrocodone (C3D)bull Oxycodone(C3D)
Sedation in Pregnancy
bull SedativesAnxiolytics (eg Diazepam ) are rated D and can cause oral clefts with prolonged exposure
bull Nitrous oxide should not be used in 1st trimester (If used in 2nd and 3rd do not go below 50 O2)
Common Antibioticsbull To treat oral abscess or cellulitis
ndash Penicillin (B) ndash Amoxicillin (B) ndash Cephalexin (B)ndash Erythromycin base (B) (Not estolate as it
cause cholestatic hepatitis)ndash Clindamycin (B)
Antibioticsbull penicillin V and amoxicillin is preferred drug
for mild to moderate infectionsbull widely used for many years with no ill effectsbull no studies show penicillin to be teratogenicbull amoxicillin extensively used without harming
the fetusbull Drug classes1048715 B penicillin cephalosporins erythromycin clindamycin Azithromycin D Tetracycline
Antibiotics To Use During Pregnancy
bull Penicillin Vbull Amoxicillinbull Erythromycin (base form)bull Cephalexin cephalosporinbull Clindamycinbull Metronidazole
Antibiotics to Avoid duringPregnancy
bull Doxycyclinebull Tetracyclinebull Erythromycin (estolate form)bull Vancomycin
The Problem With Tetracycline
bull Accumulates in bones and chelates calcium
bull Inhibits bone growthbull Discolors teeth
Other Antimicrobial Agentsbull OK to usebull Nystatin (B)bull Chlorhexidine rinse (B)bull Use with cautionbull Clotrimazole (C)bull Ketoconazole (C)bull Fluconazole (C)bull Do not usebull Doxycycline (D)
Local Anesthetic Use inPregnancy
bull Class Bbull Lidocaine (Xylocaine)bull Etidocainebull Prilocaine bull Class Cbull Procainebull Bupivicainebull Mepivicaine
Use of Local Anestheticsbull Lidocaine + vasoconstrictor most common
local anesthetic used in dentistrybull extensively used in pregnancy with no proven ill
effectsbull accidental intravascular injections of lidocaine
pass through the placenta but the concentrations are too low to harm fetus
bull prilocaine might cause methemoglobinemia
Ulcer healing drugsCimetidine bull FDA category B Famotidinebull FDA category BRanitidinebull FDA category Bbull not known to be harmful
Ulcer healing drugsOmeprazolebull FDA category BNot known to be
harmful Esomeprazolebull FDA category BLansoprazolebull FDA category BPantoprazolebull Avoid unless potential benefit
outweighs riskmdashfetotoxic in animals
Ulcer healing drugs
Misoprostolbull First second third trimesters Avoidmdash
potent uterine stimulant (has been used to induce abortion) and may be teratogenic
Ulcer healing drugs
Antacidsbull Almunium hydroxideMagnesium
hydroxidemdashFDA category B Calcium carbonatemdashFDA category C
SimetheconemdashFDA category C
Use of Nitrous Oxide Gas
bull used over 150 years bull safety is being debatedbull SHORT TERM exposure do not cause
birth defects or spontaneous abortionbull CHRONIC exposure may result in fetal
loss and infertilitybull literature suggests that nitrous oxide
should be avoided until more conclusive research is available
bull FDA Drug class not yet assigned
Common Preventives
bull Fluoridendash No increased risk during pregnancy
bull Xylitolndash No studies no harm reported
bull Chlorhexidinendash No increased risk during pregnancy
Are topical agents safe
bull Fluoridebull Toothpaste amp mouthrinse
bull Xylitol chewing gum bull Chlorhexidine (11 alcohol)bull No over the counter mouthrinses with
alcohol (Listerine 20 alcohol)
Pre-natal Fluoride
bull Daily 22 mg tablet of sodium fluoride during 3rd through 9th months
bull decreases caries rate in offspringbull Safe and effective
Glenn FB 1982
Is it safe to use mercury restorations
bull No evidence of harmful effect
bull Benefits outweigh risks
bull Canada Germany and New Zealand have some restrictions
bull Determine the best option
Referencesbull Wasylko L Matsui D Dykxhoorn SM Rieder MJ Weinberg
S A Review of Common Dental Treatments During Pregnancy J Canadian Dental Association 64434-439 1998
bull Little JW Donald AF Craig SM Rhodus NL Dental Management of the Medically Compromised Patient - 5th edition Mosby Toronto Pp434-442 1997
bull Livingston HM Dellinger TM Holder R Considerations in the management of the pregnant patient Special Care in Dentistry 185 pp183-188 1998
bull Larimore WL Petrie KA Drug use during pregnacy and lactation Primary Care Clinics in Office Practice 271 35-53 2000
bull Health Canada The Safety of DentalAmalgam Minister Of Supply and Services Canada 1996
REFERENCESbull 1 Weiss G Endocrinology of parturition J Clin
Endocrinol Metab 2000854421-5bull 2 Theunissen IM Parer JT Fluid and electrolytes in
pregnancy Clin Obstet Gynecol 1994373-15bull 3 Duvekot JJ Peeters LLH Renal hemodynamics and
volume homeostasis in pregnancy Obstet Gynecol Surv 199449830-9
bull 4 Barron WM Lindheimer MD Medical disorders during pregnancy 2nd ed St Louis Mosby 1995 p 129
bull 5 Thornburg KL Jacobson SL Giraud GD Morton MJ Hemodynamic changes in pregnancy Semin Perinatol 20002411-4
bull 6 Fiese R Herzog S Issues in dental and surgical management of the pregnant patient Oral Surg Oral Med Oral Pathol 198865292-7
bull 7 Martin C Varner MW Physiologic changes in pregnancysurgical implications Clin Obstet Gynecol 199437241-55
bull 8 Clark SL Cotton DB Lee W Bishop C Hill T Southwick J et al Central hemodynamic assessment of normal term pregnancy Am J Obstet Gynecol 19891611439-42
bull 9 Mabie WC Di Sessa TG Crocker LG Sibai BM Arheart KL A longitudinal study of cardiac output in normal human pregnancy Am J Obstet Gynecol 1994170849-56
bull 10 Clapp JF 3rd Capeless E Cardiovascular function before during and after the first and subsequent pregnancies Am J Cardiol 1997801469-73
bull 11 Duvekot JJ Peeters LL Maternal cardiovascular hemodynamic adaptation to pregnancy Obstet Gynecol Surv 199449(Suppl) S1-14
bull 12 Bhagwat AR Engel PJ Heart disease and pregnancy Cardiol Clin 199513163-78
bull 13 Lanni SM Tillinghast J Silver H Hemodynamic changes and baroreflex gain in the supine hypotensive syndrome Am J Obstet Gynecol 20021871636-41
bull 14 Little JW Falace DA Miller CS Rhodus NL Dental management of the medically compromised patient 6th ed St Louis Mosby 2002 p 303
bull 15 Garcia-Rio F Pino JM Gomez L Alvarez-Sala R Villasante C Villamor J Regulation of breathing and perception of dyspnea in healthy pregnant women Chest 1996110446-53
bull 16 McAuliffe F Kametas N Costello J Rafferty GF Greenough A Nicolaides K Respiratory function in singleton and twin pregnancy BJOG 2002109765-9
bull 17 Clapp JF 3rd Seaward BL Sleamaker RH Hiser J Maternal physiologic adaptations to early human pregnancy Am J Obstet Gynecol 19881591456-60
bull 18 OrsquoDay MP Cardio-respiratory physiological adaptation of pregnancy Semin Perinatol 199721268-75
bull 19 Contreras G Gutierrez M Beroiza T Fantin A Oddo H Villarroel L et al Ventilatory drive and respiratory muscle function in pregnancy Am Rev Respir Dis 1991144837-41
bull 20 Turner M Aziz SR Management of the pregnant oral and maxillofac
bull 21 Sifakis S Pharmakides G Anemia in pregnancy Ann N Y Acad Sci 2000900125-36
bull 22 Branch DW Physiologic adaptations of pregnancy Am J Reprod Immunol 199228120-2
bull 23 Burrows RF Kelton JG Incidentally detected thrombocytopenia in healthy mothers and their infants N Engl J Med 1988319 142-5
bull 24 Hanly JG Antiphospholipid syndrome an overview CMAJ 200324(168)1675-82
bull 25 Heilmann L von Tempelhoff GF Pollow K Antiphospholipid syndrome in obstetrics Clin Appl Thromb Hemost 20039 143-50
bull 26 Sherman P Flaxman SM Nausea and vomiting of pregnancy in an evolutionary perspective Am J Obstet Gynecol 2002 185(Suppl)s190-7
bull 27 Koch KL Gastrointestinal factors in nausea and vomiting of pregnancy Am J Obstet Gynecol 2002185(Suppl)s198-203
bull 28 Koch KL Frissora CL Nausea and vomiting during pregnancy Gastroenterol Clin N Am 200332201-34
bull 29 Baron TH Ramirez B Richter JE Gastrointestinal motility disorders during pregnancy Ann Intern Med 1993118 366-75
bull 30 Richter JE Gastroesophageal reflux disease during pregnancy Gastroenterol Clin N Am 200332235-61
bull 31 Marrero JM Goggin PM de Caestecker JS Pearce JM Maxwell JD Determinants of pregnancy heartburn Br J Obstet Gynaecol 199299731-4
bull 32 Hamaoui E Hamaoui M Nutritional assessment and support during pregnancy Gastroenterol Clin N Am 20033259-121
bull 33 King JC Physiology of pregnancy and nutrient metabolism Am J Clin Nutr 200071(suppl)1218s-25s
bull 34 Casanueva E Pfeffer F Fernandez-Gaxiola AC Gutierrez- Valenzuela V Rothenberg SJ Iron and folate status before pregnancy and anemia during pregnancy Ann Nutr Metab 2003 4760-3
bull 35 Chrsquong CL Morgan M Hainsworth I Kingham JG Prospective study of liver dysfunction in Southwest Wales Gut 200251 876-80
bull 36 Rahman TM Wendon J Severe hepatic dysfunction in pregnancy QJM 200295343-57
bull 37 Knox TA Olans LB Liver disease in pregnancy N Engl J Med 1996335569-76
bull 38 Saftlas AF Olson DR Franks AL Atrash H Pokras R Epidemiology of preeclampsia and eclampsia in the United States 1979e1986 Am J Obstet Gynecol 1990163460-5
bull 39 Walker JJ Pre-eclampsia Lancet 20003561260-5
bull 40 Davidson JM Renal disorders in pregnancy Curr Opin Obstet Gynecol 200113109-14
bull 41 Dafnis E Sabatini S The effect of pregnancy on renal function physiology and pathophysiologyAmJMedSci 1992303184-205
bull 42 Davison JM Shiells EA Philips PR Lindheimer MD Serial evaluation of vasopressin release and thirst in human pregnancy Role of human chorionic gonadotrophin in the osmoregulatory changes of gestation J Clin Invest 198881798-806
bull 43 Glinoer D de Nayer P Bourdoux P Lemone M Robyn C van Steirteghem A et al Regulation of maternal thyroid during pregnancy J Clin Endocrinol Metab 199071276-87
bull 44 Wilson SG Retallack RW Kent JC Worth GK Gutteridge DH Serum free 125-dihydroxyvitamin D and the free 125- dihydroxyvitamin D index during a longitudinal study of human pregnancy and lactation Clin Endocrinol 199032613-22
bull 45 Rasmussen N Frolich A Hornnes PJ Hegedus L Serum ionized calcium and intact parathyroid hormone levels during pregnancy and postpartum Br J Obstet Gynaecol 199097857-9
bull 46 Guyton AC Textbook of medical physiology 8th ed Philadelphia W B Saunders 1991 p 915e28
bull 47 Trainer PJ Corticosteroids and pregnancy Semin Reprod Med 200220375-80
bull 48 Soory M Hormonal factors in periodontal disease Dent Update 200027380-3
bull 49 Hugoson A Gingivitis in pregnant women A longitudinal clinical study Odontol Revy 19712265-84
bull 50 Neville BW Damm DD Allen CM Bouquot JE Oral amp Maxillofacial Pathology 3rd ed Philadelphia W B Saunders 2002 p 329-30 447-9
bull 51 Tilakaratne A Soory M Ranasinghe AW Corea SM Ekanayake SL de Silva M Periodontal disease status during pregnancy and 3 months post-partum in rural population of Sri-Lankan women J Clin Periodontol 200027787-92
bull 52 Laine M Tenovuo J Lehtonen OP Ojanatko-Harri A Vilja P Tuohimaa P Pregnancy e related changes in human whole saliva Arch Oral Biol 198833913-7
bull 53 Yuan K Wing LY Lin MT Pathogenetic roles of angiogenic factors in pyogenic granulomas in pregnancy are modulated by female sex hormones J Periodontol 200273701-8
bull 54 Evans RD Briggs PF Tooth-surface loss related to pregnancyinduced vomiting Prim Dent Care 1994124-6
bull 55 Salvolini E Di Giorgio R Curatola A Mazzanti L Fratto G Biochemical modifications of human whole saliva induced by pregnancy Br J Obstet Gynaec 1998105656-60
bull 56 Mauldin JG Newman RB Preterm birth risk assessment Semin Perinatol 200125215-22
bull 57 Heine RP McGregor JA Goodwin TM Artal R Hayashi RH Robertson PA et al Serial salivary estriol to detect an increased risk of preterm birth Obstet Gynecol 200096490-7
bull 58 Kauh YC Zachian TF Melasma Adv Exp Med Biol 1999455 491-9
bull 59 Wong RC Ellis CN Physiologic skin changes in pregnancy J Am Acad Dermatol 198410929-40
bull 60 Errickson CV Matus NR Skin disorders of pregnancy Am Fam Physician 199449605-10
bull 61 Lopez NJ Smith PC Gutierrez J Periodontal therapy may reduce the risk of preterm low birth weight in women with periodontal disease a randomized controlled trial J Periodontol 200273911-24
bull 62 McGaw T Periodontal disease and preterm delivery of lowbirth- weight infants J Can Dent Assoc 200268165-9
bull 63 Richards AG Dental x-ray protection Dent Clin North Am 1968631-41
bull 64 1990 Recommendations of the International Commission on Radiological Protection Ann ICRP 1991211-201
bull 65 Hall EJ Radiation the two-edged sword cancer risks at high and low doses Cancer J 20006343-50
bull 66 Diethelm L Xu H Diagnostic imaging of the lung during pregnancy Clin Obstet Gynecol 19963936-55
bull 67 Brent RL The effects of embryonic and fetal exposure to x-rays microwaves and ultrasound ClinObstetGynecol 198326484-510
bull 68 National Council on Radiation Protection NCRP report no128 1998 Bethesda Md Author
bull 69 Wasylko L Matsui D Dykxhoorn SM Reider MJ Weinberg S A review of common dental treatments during pregnancy implications for patients and dental personnel J Can Dent Assoc 199864434-9
bull 70 Freeman JP Brand JW Radiation doses of commonly used dental radiographic surveys Oral Surg Oral Med Oral Pathol 199477285-9
bull 71 Kircos LTAngin LL Lorton LOrder ofmagnitude dose reduction in intraoral radiography J Am Dent Assoc 1987114344-7
bull 72 Updegrave WJ Simplified and standardized intraoral radiography with reduced tissue irradiation J Am Dent Assoc 197285861-9
bull 73 Wood RE Harris AM van der Merwe EJ Nortje CJ The leaded apron revisited does it reduce gonadal radiation dose in dental radiology Oral Surg Oral Med Oral Pathol 199171642-6
bull 74 An update on radiographic practices information and recommendations ADA Council on Scientific Affairs J Am Dent Assoc 2001132234-8
bull 75 Rayburn WF Recommending medications during pregnancy an evidence based approach Clin Obstet Gynecol 2002451-5
bull 76 Rathmell JP Viscomi C Ashburn MA Management of nonobstetric pain during pregnancy and lactation Anesth Analg 1997851074-87
bull 77 Teratology society public affairs committee FDA classification of drugs for teratogenic risk Teratology 199449446-7
bull 78 Moore PA Selecting drugs for the pregnant dental patient J Am Dent Assoc 19981291281-6
bull 79 Haas DA An update on analgesics for the management of acute postoperative dental pain J Can Dent Assoc 200268476-82
bull 80 Haas DA Pynn BR Sands TD Drug use for the pregnant or lactating patient Gen Dent 20004854-60
bull 81 Committee on Drugs American Academy of Pediatrics The transfer of drugs and other chemicals into human milk Pediatrics 199493137-50
bull 82 Nielsen GL Sorensen HT Larsen H Pedersen L Risk of adverse birth outcome and miscarriage in pregnant users of nonsteroidal anti-inflammatory drugs population based observational study and case-control study BMJ 2001322266-70
bull 83 Janssen N Genta M The effects of immunosuppressive and anti-inflammatory medications on fertility pregnancy and lactation Arch Intern Med 200016610-9
bull 84 Ostensen M Nonsteroidal anti-inflammatory drugs during pregnancy Scand J Rheumatol Suppl 1998107128-32
bull 85 USPDI -Drug information for the health care professional 22nd ed Greenwood Village CO Micromedex 2002 p 152-79
bull 86 Denson DD Coyle DE Thompson GA Santos D Turner PA Myers JA et al Bupivacaine protein binding in the term parturient effects of lactic acidosis Clin Pharmacol Ther 198435702-9
bull 87 Dillon DE Wagner CL Wiest D Newman RB Drug therapy in the nursing mother Obstet Gynecol Clin North Am 199724 675-96
bull 88 Dashe JS Gilstrap LC Antibiotic use in pregnancy Obstet Gynecol Clin North Am 199724617-29
bull 89 American College of Rheumatology Ad hoc Committee on Clinical Guidelines Guidelines for monitoring drug therapy in rheumatoid arthritis Arthritis Rheum 199639723-31
bull 90 Ng PC The fetal and neonatal hypothalamic-pituitary-adrenal axis Arch Dis Child Fetal Neonatal Ed 200082F250-4
bull 91 Crowley P Antenatal corticosteroidsmdashcurrent thinking BJOG 2003110(Suppl 20)77-8
bull 92 ACOG committee opinion antenatal corticosteroid therapy for fetal maturation Obstet Gynecol 200299871-3
bull 93 Ost L Wettrell G Bjorkhem I Rane A Prednisolone excretion in human milk J Pediatr 19851061008-11
bull 94 Rowland AS Baird DD Shore DL Weinberg CR Savitz DA Wilcox AJ Nitrous oxide and spontaneous abortion in female dental assistants Am J Epidemiol 1995141531-8
bull 95 McGlothlin JD Jensen PA Fischbach TJ Hughes RT Jones JH Control of anesthetic gases in dental operatories Scand J Work Environ Health 199218(Suppl 2)103-5
bull ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY Volume 97 Number 6 Suresh and Radfar 681
bull 96 Rosen MA Nitrous oxide for relief of labor pain a systematic review Am J Obstet Gynecol 2002186(Suppl Nature)S110-6
bull 97 Sands TD Pynn BR Management considerations for the pregnant or nursing emergency patient Ont Dent 199875 17-9
bull 98 Daya S Recurrent spontaneous early pregnancy loss and low dose aspirin Minerva Ginecol 200355441-9
bull 99 Sinclair C Handbook of obstetrical emergencies 1st ed Philadelphia WB Saunders 1996 p 29-39 69
bull 100 Tarsitano BF Rollings RE The pregnant dental patient evaluation and management Gen Dent 199341226-34
bull 101 Livingston MH Dlllinger TM Holder R Consideration in the management of the pregnant patient SCD Special Care in Dentistry 199818183-8
Thank you
- A Review on the principle of Dental Management of the Pregnant patient
- Slide 2
- Questions that a dentist may ask
- Stages of Pregnancy
- Slide 5
- Slide 6
- Physiologic Changes in Pregnancy
- Systemic changes in pregnancy
- FLAT SUPINE POSITIONING
- SUPINE HYPOTENSION SYNDROME (Vena Cava Compression)
- Supine Hypotension Syndrome
- Slide 12
- Supine Hypotension Syndrome
- Prevention of Supine Hypotensive Syndrome
- Treatment of Supine Hypotensive Syndrome
- How should the pregnant woman be positioned
- Slide 17
- Slide 18
- Slide 19
- Slide 20
- Slide 21
- Slide 22
- Slide 23
- Pregnancy Related Oral Health Problems
- Oral Problems in Pregnancy
- Pregnancy Gingivitis Pathophysiology
- Pregnancy Gingivitis
- Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Gum Problems - Pregnancy Granuloma
- Slide 31
- Gum Changes - Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Candidiasis
- Pregnancy Myths
- Other Oral Conditions in Pregnancy
- Changes During Pregnancy that Affect Oral Health
- Saliva changes
- Increased Bacteria
- Slide 40
- Enamel erosion caused by frequent vomiting
- Treatment for Acid Exposure
- Oral Diseases Can Effect Pregnancy
- Periodontal Disease and Preterm Labor
- Periodontal Disease and Low Birth Weight
- Periodontal Disease and Preeclampsia
- Periodontitis and Pre-eclampsia
- Dental Considerations
- Treatment Timing
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Slide 52
- Use of Radiation on Pregnant Patient
- Radiographs during Pregnancy
- Risks of Dental X-Rays
- FDA drug classification for pregnancy
- Slide 57
- FDA drug classification for pregnancy
- Slide 59
- Slide 60
- Slide 61
- Common Analgesics
- Analgesics
- Analgesics - continued
- Analgesics to Use During 1st and 2nd Trimester
- Analgesics to Avoid During the Third Trimester
- Sedation in Pregnancy
- Common Antibiotics
- Antibiotics
- Antibiotics To Use During Pregnancy
- Antibiotics to Avoid during Pregnancy
- The Problem With Tetracycline
- Other Antimicrobial Agents
- Local Anesthetic Use in Pregnancy
- Use of Local Anesthetics
- Ulcer healing drugs
- Slide 77
- Slide 78
- Slide 79
- Use of Nitrous Oxide Gas
- Common Preventives
- Are topical agents safe
- Pre-natal Fluoride
- Is it safe to use mercury restorations
- References
- REFERENCES
- Slide 87
- Slide 88
- Slide 89
- Slide 90
- Slide 91
- Slide 92
- Slide 93
- Slide 94
- Slide 95
- Slide 96
- Slide 97
- Slide 98
- Thank you
-
Periodontal Disease and Preeclampsia
bull Emerging databull Mechanism unclearbull Proposed mechanism
ndash Periodontal infection leads to inflammatory vascular damage
ndash Triggers cell damage in placenta
Periodontitis and Pre-eclampsia
bull Periodontal disease may be associated with pre-eclampsia (Boggess 2003)
bull PGE2 IL-1 and TNF-α from gingival crevicular fluid were higher in women with preeclampsia compared with healthy matched pregnant women (Oettinger-Barak 2003)
Dental Considerations
bull timing of treatment for pregnant patientsbull dental radiation exposurebull use of local anestheticsbull prescription of common antibiotics and
analgesicsbull nitrous oxide gas administration
Treatment Timing
bull First Trimesterndash Spontaneous miscarriages naturally occur
more often in 1st trimesterndash Avoid elective treatment that can be delayedndash Offer anticipatory guidance
bull Second Trimesterndash The optimal time for dental treatmentndash Organogenesis complete fetus not largendash Easier to prevent than treat established disease
bull Third Trimesterndash Late in term very uncomfortable (short visits)ndash Position slightly on left side
Timing of Dental Treatment During Pregnancy - From Little and Fallace
First Trimester
bull Plaque controlbull Oral hygiene instructionbull Scaling polishing curettagebull Avoid elective treatment urgent care
only
Timing of Dental Treatment During Pregnancy - From Little and Fallace
Second Trimester
bull Plaque controlbull Oral hygiene instructionbull Scaling polishing curettagebull Routine dental care
Timing of Dental Treatment During Pregnancy - From Little and Fallace
Third Trimester
bull Plaque controlbull Oral hygiene instructionbull Scaling polishing curettagebull Routine dental care (after middle of third
trimester elective care should be avoided)
Use of Radiation on Pregnant Patientbull Dose given and time of gestation are
importantbull doses lt 5-10 rads (cGy) not teratogenicbull fetus is most susceptible to radiation
between the 2nd and 6th week of gestationbull single dental x-ray exposes patient to 001
millirads of radiation In relative terms this amount is 40 times less than daily dose acquired from cosmic radiation Therefore diagnostic radiation should not be withheld during pregnancy
Radiographs during Pregnancy
bull Take as needed with optimal methods for reducing secondary radiation and exposure time
bull Always use a lead apronbull Exposure to fetus (with apron use) is 00001
centiGray(rad)bull Daily cosmic radiation - 0004 centiGray (rad)
Risks of Dental X-Rays
bull X-ray only if necessary (ie root canal therapy trauma)
bull When x-rays are indicated radiation exposure is extremely low
bull Exposure can be limited byndash Lead apron shielding ndash Modern fast film ndash Avoiding retakes
FDA drug classification for pregnancybull Combines risk statements including
congenital anomalies fetal effects perinatal risks and therapeutic risk-benefit ratio
bull Untreated disease or condition may pose more serious risks to both mother and fetus than any theoretical risks from the medication
bull Category A thru D and X
FDA drug classification for pregnancy
bull A = Controlled Studies in women fail to demonstrate a risk to the fetus in the first trimester and the possibility of fetal harm appears remote
FDA drug classification for pregnancy
bull B = Animal studies show no risk or if risk shown in animals controlled
trials in women showed no risk
FDA drug classification for pregnancy
bull C = Studies in animals with adverse effects and no human studies
OR no animal or human studies but benefits of use may outweigh potential harms
FDA drug classification for pregnancy
bull D = There is evidence of human fetal risk but benefits may outweigh risks
FDA drug classification for pregnancy
bull X = Contraindicated
Common Analgesics
bull paracetamol (B)bull Ibuprofen (BD) bull Oxycodone (BD) bull Hydrocodone and codeine
(CD)
avoid in third trimester
Analgesics
bull Paracetamol is the analgesic of choice for all stages of gestation
bull used to treat mild to moderate pain and fevers
bull short term usage is believed to be safebull avoid chronic and large doses of
paracetamol1048715
Analgesics - continuedbull Aspirin is nonteratogenic but may cause
maternal and fetal hemorrhagebull large and chronic doses during last trimester
may result in premature closure of ductus arteriosus fetal hypertension anemia and low birth weight
bull avoid ibuprofen in 3rd trimester because of possible adverse circulatory effects
bull short term use of codeine seems safebull avoid codeine late in gestation because of
possible fetal respiratory depression and withdrawal symptoms
Analgesics to Use During1st and 2nd Trimester
bull Category B (for best)bull Paracetamol Ibuprofenbull Naproxenbull Category C (use with caution)bull Paracetamol with codeine or
hydrocodonebull Paracetamol with oxycodone
Analgesics to Avoid During theThird Trimesterbull Causes delivery problemsbull Aspirin (C 3D)bull Ibuprofen (B3D)bull Naproxen (B3D)bull Causes neonatal respiratory
depression and opioid withdrawalbull Codeine (C3D)bull Hydrocodone (C3D)bull Oxycodone(C3D)
Sedation in Pregnancy
bull SedativesAnxiolytics (eg Diazepam ) are rated D and can cause oral clefts with prolonged exposure
bull Nitrous oxide should not be used in 1st trimester (If used in 2nd and 3rd do not go below 50 O2)
Common Antibioticsbull To treat oral abscess or cellulitis
ndash Penicillin (B) ndash Amoxicillin (B) ndash Cephalexin (B)ndash Erythromycin base (B) (Not estolate as it
cause cholestatic hepatitis)ndash Clindamycin (B)
Antibioticsbull penicillin V and amoxicillin is preferred drug
for mild to moderate infectionsbull widely used for many years with no ill effectsbull no studies show penicillin to be teratogenicbull amoxicillin extensively used without harming
the fetusbull Drug classes1048715 B penicillin cephalosporins erythromycin clindamycin Azithromycin D Tetracycline
Antibiotics To Use During Pregnancy
bull Penicillin Vbull Amoxicillinbull Erythromycin (base form)bull Cephalexin cephalosporinbull Clindamycinbull Metronidazole
Antibiotics to Avoid duringPregnancy
bull Doxycyclinebull Tetracyclinebull Erythromycin (estolate form)bull Vancomycin
The Problem With Tetracycline
bull Accumulates in bones and chelates calcium
bull Inhibits bone growthbull Discolors teeth
Other Antimicrobial Agentsbull OK to usebull Nystatin (B)bull Chlorhexidine rinse (B)bull Use with cautionbull Clotrimazole (C)bull Ketoconazole (C)bull Fluconazole (C)bull Do not usebull Doxycycline (D)
Local Anesthetic Use inPregnancy
bull Class Bbull Lidocaine (Xylocaine)bull Etidocainebull Prilocaine bull Class Cbull Procainebull Bupivicainebull Mepivicaine
Use of Local Anestheticsbull Lidocaine + vasoconstrictor most common
local anesthetic used in dentistrybull extensively used in pregnancy with no proven ill
effectsbull accidental intravascular injections of lidocaine
pass through the placenta but the concentrations are too low to harm fetus
bull prilocaine might cause methemoglobinemia
Ulcer healing drugsCimetidine bull FDA category B Famotidinebull FDA category BRanitidinebull FDA category Bbull not known to be harmful
Ulcer healing drugsOmeprazolebull FDA category BNot known to be
harmful Esomeprazolebull FDA category BLansoprazolebull FDA category BPantoprazolebull Avoid unless potential benefit
outweighs riskmdashfetotoxic in animals
Ulcer healing drugs
Misoprostolbull First second third trimesters Avoidmdash
potent uterine stimulant (has been used to induce abortion) and may be teratogenic
Ulcer healing drugs
Antacidsbull Almunium hydroxideMagnesium
hydroxidemdashFDA category B Calcium carbonatemdashFDA category C
SimetheconemdashFDA category C
Use of Nitrous Oxide Gas
bull used over 150 years bull safety is being debatedbull SHORT TERM exposure do not cause
birth defects or spontaneous abortionbull CHRONIC exposure may result in fetal
loss and infertilitybull literature suggests that nitrous oxide
should be avoided until more conclusive research is available
bull FDA Drug class not yet assigned
Common Preventives
bull Fluoridendash No increased risk during pregnancy
bull Xylitolndash No studies no harm reported
bull Chlorhexidinendash No increased risk during pregnancy
Are topical agents safe
bull Fluoridebull Toothpaste amp mouthrinse
bull Xylitol chewing gum bull Chlorhexidine (11 alcohol)bull No over the counter mouthrinses with
alcohol (Listerine 20 alcohol)
Pre-natal Fluoride
bull Daily 22 mg tablet of sodium fluoride during 3rd through 9th months
bull decreases caries rate in offspringbull Safe and effective
Glenn FB 1982
Is it safe to use mercury restorations
bull No evidence of harmful effect
bull Benefits outweigh risks
bull Canada Germany and New Zealand have some restrictions
bull Determine the best option
Referencesbull Wasylko L Matsui D Dykxhoorn SM Rieder MJ Weinberg
S A Review of Common Dental Treatments During Pregnancy J Canadian Dental Association 64434-439 1998
bull Little JW Donald AF Craig SM Rhodus NL Dental Management of the Medically Compromised Patient - 5th edition Mosby Toronto Pp434-442 1997
bull Livingston HM Dellinger TM Holder R Considerations in the management of the pregnant patient Special Care in Dentistry 185 pp183-188 1998
bull Larimore WL Petrie KA Drug use during pregnacy and lactation Primary Care Clinics in Office Practice 271 35-53 2000
bull Health Canada The Safety of DentalAmalgam Minister Of Supply and Services Canada 1996
REFERENCESbull 1 Weiss G Endocrinology of parturition J Clin
Endocrinol Metab 2000854421-5bull 2 Theunissen IM Parer JT Fluid and electrolytes in
pregnancy Clin Obstet Gynecol 1994373-15bull 3 Duvekot JJ Peeters LLH Renal hemodynamics and
volume homeostasis in pregnancy Obstet Gynecol Surv 199449830-9
bull 4 Barron WM Lindheimer MD Medical disorders during pregnancy 2nd ed St Louis Mosby 1995 p 129
bull 5 Thornburg KL Jacobson SL Giraud GD Morton MJ Hemodynamic changes in pregnancy Semin Perinatol 20002411-4
bull 6 Fiese R Herzog S Issues in dental and surgical management of the pregnant patient Oral Surg Oral Med Oral Pathol 198865292-7
bull 7 Martin C Varner MW Physiologic changes in pregnancysurgical implications Clin Obstet Gynecol 199437241-55
bull 8 Clark SL Cotton DB Lee W Bishop C Hill T Southwick J et al Central hemodynamic assessment of normal term pregnancy Am J Obstet Gynecol 19891611439-42
bull 9 Mabie WC Di Sessa TG Crocker LG Sibai BM Arheart KL A longitudinal study of cardiac output in normal human pregnancy Am J Obstet Gynecol 1994170849-56
bull 10 Clapp JF 3rd Capeless E Cardiovascular function before during and after the first and subsequent pregnancies Am J Cardiol 1997801469-73
bull 11 Duvekot JJ Peeters LL Maternal cardiovascular hemodynamic adaptation to pregnancy Obstet Gynecol Surv 199449(Suppl) S1-14
bull 12 Bhagwat AR Engel PJ Heart disease and pregnancy Cardiol Clin 199513163-78
bull 13 Lanni SM Tillinghast J Silver H Hemodynamic changes and baroreflex gain in the supine hypotensive syndrome Am J Obstet Gynecol 20021871636-41
bull 14 Little JW Falace DA Miller CS Rhodus NL Dental management of the medically compromised patient 6th ed St Louis Mosby 2002 p 303
bull 15 Garcia-Rio F Pino JM Gomez L Alvarez-Sala R Villasante C Villamor J Regulation of breathing and perception of dyspnea in healthy pregnant women Chest 1996110446-53
bull 16 McAuliffe F Kametas N Costello J Rafferty GF Greenough A Nicolaides K Respiratory function in singleton and twin pregnancy BJOG 2002109765-9
bull 17 Clapp JF 3rd Seaward BL Sleamaker RH Hiser J Maternal physiologic adaptations to early human pregnancy Am J Obstet Gynecol 19881591456-60
bull 18 OrsquoDay MP Cardio-respiratory physiological adaptation of pregnancy Semin Perinatol 199721268-75
bull 19 Contreras G Gutierrez M Beroiza T Fantin A Oddo H Villarroel L et al Ventilatory drive and respiratory muscle function in pregnancy Am Rev Respir Dis 1991144837-41
bull 20 Turner M Aziz SR Management of the pregnant oral and maxillofac
bull 21 Sifakis S Pharmakides G Anemia in pregnancy Ann N Y Acad Sci 2000900125-36
bull 22 Branch DW Physiologic adaptations of pregnancy Am J Reprod Immunol 199228120-2
bull 23 Burrows RF Kelton JG Incidentally detected thrombocytopenia in healthy mothers and their infants N Engl J Med 1988319 142-5
bull 24 Hanly JG Antiphospholipid syndrome an overview CMAJ 200324(168)1675-82
bull 25 Heilmann L von Tempelhoff GF Pollow K Antiphospholipid syndrome in obstetrics Clin Appl Thromb Hemost 20039 143-50
bull 26 Sherman P Flaxman SM Nausea and vomiting of pregnancy in an evolutionary perspective Am J Obstet Gynecol 2002 185(Suppl)s190-7
bull 27 Koch KL Gastrointestinal factors in nausea and vomiting of pregnancy Am J Obstet Gynecol 2002185(Suppl)s198-203
bull 28 Koch KL Frissora CL Nausea and vomiting during pregnancy Gastroenterol Clin N Am 200332201-34
bull 29 Baron TH Ramirez B Richter JE Gastrointestinal motility disorders during pregnancy Ann Intern Med 1993118 366-75
bull 30 Richter JE Gastroesophageal reflux disease during pregnancy Gastroenterol Clin N Am 200332235-61
bull 31 Marrero JM Goggin PM de Caestecker JS Pearce JM Maxwell JD Determinants of pregnancy heartburn Br J Obstet Gynaecol 199299731-4
bull 32 Hamaoui E Hamaoui M Nutritional assessment and support during pregnancy Gastroenterol Clin N Am 20033259-121
bull 33 King JC Physiology of pregnancy and nutrient metabolism Am J Clin Nutr 200071(suppl)1218s-25s
bull 34 Casanueva E Pfeffer F Fernandez-Gaxiola AC Gutierrez- Valenzuela V Rothenberg SJ Iron and folate status before pregnancy and anemia during pregnancy Ann Nutr Metab 2003 4760-3
bull 35 Chrsquong CL Morgan M Hainsworth I Kingham JG Prospective study of liver dysfunction in Southwest Wales Gut 200251 876-80
bull 36 Rahman TM Wendon J Severe hepatic dysfunction in pregnancy QJM 200295343-57
bull 37 Knox TA Olans LB Liver disease in pregnancy N Engl J Med 1996335569-76
bull 38 Saftlas AF Olson DR Franks AL Atrash H Pokras R Epidemiology of preeclampsia and eclampsia in the United States 1979e1986 Am J Obstet Gynecol 1990163460-5
bull 39 Walker JJ Pre-eclampsia Lancet 20003561260-5
bull 40 Davidson JM Renal disorders in pregnancy Curr Opin Obstet Gynecol 200113109-14
bull 41 Dafnis E Sabatini S The effect of pregnancy on renal function physiology and pathophysiologyAmJMedSci 1992303184-205
bull 42 Davison JM Shiells EA Philips PR Lindheimer MD Serial evaluation of vasopressin release and thirst in human pregnancy Role of human chorionic gonadotrophin in the osmoregulatory changes of gestation J Clin Invest 198881798-806
bull 43 Glinoer D de Nayer P Bourdoux P Lemone M Robyn C van Steirteghem A et al Regulation of maternal thyroid during pregnancy J Clin Endocrinol Metab 199071276-87
bull 44 Wilson SG Retallack RW Kent JC Worth GK Gutteridge DH Serum free 125-dihydroxyvitamin D and the free 125- dihydroxyvitamin D index during a longitudinal study of human pregnancy and lactation Clin Endocrinol 199032613-22
bull 45 Rasmussen N Frolich A Hornnes PJ Hegedus L Serum ionized calcium and intact parathyroid hormone levels during pregnancy and postpartum Br J Obstet Gynaecol 199097857-9
bull 46 Guyton AC Textbook of medical physiology 8th ed Philadelphia W B Saunders 1991 p 915e28
bull 47 Trainer PJ Corticosteroids and pregnancy Semin Reprod Med 200220375-80
bull 48 Soory M Hormonal factors in periodontal disease Dent Update 200027380-3
bull 49 Hugoson A Gingivitis in pregnant women A longitudinal clinical study Odontol Revy 19712265-84
bull 50 Neville BW Damm DD Allen CM Bouquot JE Oral amp Maxillofacial Pathology 3rd ed Philadelphia W B Saunders 2002 p 329-30 447-9
bull 51 Tilakaratne A Soory M Ranasinghe AW Corea SM Ekanayake SL de Silva M Periodontal disease status during pregnancy and 3 months post-partum in rural population of Sri-Lankan women J Clin Periodontol 200027787-92
bull 52 Laine M Tenovuo J Lehtonen OP Ojanatko-Harri A Vilja P Tuohimaa P Pregnancy e related changes in human whole saliva Arch Oral Biol 198833913-7
bull 53 Yuan K Wing LY Lin MT Pathogenetic roles of angiogenic factors in pyogenic granulomas in pregnancy are modulated by female sex hormones J Periodontol 200273701-8
bull 54 Evans RD Briggs PF Tooth-surface loss related to pregnancyinduced vomiting Prim Dent Care 1994124-6
bull 55 Salvolini E Di Giorgio R Curatola A Mazzanti L Fratto G Biochemical modifications of human whole saliva induced by pregnancy Br J Obstet Gynaec 1998105656-60
bull 56 Mauldin JG Newman RB Preterm birth risk assessment Semin Perinatol 200125215-22
bull 57 Heine RP McGregor JA Goodwin TM Artal R Hayashi RH Robertson PA et al Serial salivary estriol to detect an increased risk of preterm birth Obstet Gynecol 200096490-7
bull 58 Kauh YC Zachian TF Melasma Adv Exp Med Biol 1999455 491-9
bull 59 Wong RC Ellis CN Physiologic skin changes in pregnancy J Am Acad Dermatol 198410929-40
bull 60 Errickson CV Matus NR Skin disorders of pregnancy Am Fam Physician 199449605-10
bull 61 Lopez NJ Smith PC Gutierrez J Periodontal therapy may reduce the risk of preterm low birth weight in women with periodontal disease a randomized controlled trial J Periodontol 200273911-24
bull 62 McGaw T Periodontal disease and preterm delivery of lowbirth- weight infants J Can Dent Assoc 200268165-9
bull 63 Richards AG Dental x-ray protection Dent Clin North Am 1968631-41
bull 64 1990 Recommendations of the International Commission on Radiological Protection Ann ICRP 1991211-201
bull 65 Hall EJ Radiation the two-edged sword cancer risks at high and low doses Cancer J 20006343-50
bull 66 Diethelm L Xu H Diagnostic imaging of the lung during pregnancy Clin Obstet Gynecol 19963936-55
bull 67 Brent RL The effects of embryonic and fetal exposure to x-rays microwaves and ultrasound ClinObstetGynecol 198326484-510
bull 68 National Council on Radiation Protection NCRP report no128 1998 Bethesda Md Author
bull 69 Wasylko L Matsui D Dykxhoorn SM Reider MJ Weinberg S A review of common dental treatments during pregnancy implications for patients and dental personnel J Can Dent Assoc 199864434-9
bull 70 Freeman JP Brand JW Radiation doses of commonly used dental radiographic surveys Oral Surg Oral Med Oral Pathol 199477285-9
bull 71 Kircos LTAngin LL Lorton LOrder ofmagnitude dose reduction in intraoral radiography J Am Dent Assoc 1987114344-7
bull 72 Updegrave WJ Simplified and standardized intraoral radiography with reduced tissue irradiation J Am Dent Assoc 197285861-9
bull 73 Wood RE Harris AM van der Merwe EJ Nortje CJ The leaded apron revisited does it reduce gonadal radiation dose in dental radiology Oral Surg Oral Med Oral Pathol 199171642-6
bull 74 An update on radiographic practices information and recommendations ADA Council on Scientific Affairs J Am Dent Assoc 2001132234-8
bull 75 Rayburn WF Recommending medications during pregnancy an evidence based approach Clin Obstet Gynecol 2002451-5
bull 76 Rathmell JP Viscomi C Ashburn MA Management of nonobstetric pain during pregnancy and lactation Anesth Analg 1997851074-87
bull 77 Teratology society public affairs committee FDA classification of drugs for teratogenic risk Teratology 199449446-7
bull 78 Moore PA Selecting drugs for the pregnant dental patient J Am Dent Assoc 19981291281-6
bull 79 Haas DA An update on analgesics for the management of acute postoperative dental pain J Can Dent Assoc 200268476-82
bull 80 Haas DA Pynn BR Sands TD Drug use for the pregnant or lactating patient Gen Dent 20004854-60
bull 81 Committee on Drugs American Academy of Pediatrics The transfer of drugs and other chemicals into human milk Pediatrics 199493137-50
bull 82 Nielsen GL Sorensen HT Larsen H Pedersen L Risk of adverse birth outcome and miscarriage in pregnant users of nonsteroidal anti-inflammatory drugs population based observational study and case-control study BMJ 2001322266-70
bull 83 Janssen N Genta M The effects of immunosuppressive and anti-inflammatory medications on fertility pregnancy and lactation Arch Intern Med 200016610-9
bull 84 Ostensen M Nonsteroidal anti-inflammatory drugs during pregnancy Scand J Rheumatol Suppl 1998107128-32
bull 85 USPDI -Drug information for the health care professional 22nd ed Greenwood Village CO Micromedex 2002 p 152-79
bull 86 Denson DD Coyle DE Thompson GA Santos D Turner PA Myers JA et al Bupivacaine protein binding in the term parturient effects of lactic acidosis Clin Pharmacol Ther 198435702-9
bull 87 Dillon DE Wagner CL Wiest D Newman RB Drug therapy in the nursing mother Obstet Gynecol Clin North Am 199724 675-96
bull 88 Dashe JS Gilstrap LC Antibiotic use in pregnancy Obstet Gynecol Clin North Am 199724617-29
bull 89 American College of Rheumatology Ad hoc Committee on Clinical Guidelines Guidelines for monitoring drug therapy in rheumatoid arthritis Arthritis Rheum 199639723-31
bull 90 Ng PC The fetal and neonatal hypothalamic-pituitary-adrenal axis Arch Dis Child Fetal Neonatal Ed 200082F250-4
bull 91 Crowley P Antenatal corticosteroidsmdashcurrent thinking BJOG 2003110(Suppl 20)77-8
bull 92 ACOG committee opinion antenatal corticosteroid therapy for fetal maturation Obstet Gynecol 200299871-3
bull 93 Ost L Wettrell G Bjorkhem I Rane A Prednisolone excretion in human milk J Pediatr 19851061008-11
bull 94 Rowland AS Baird DD Shore DL Weinberg CR Savitz DA Wilcox AJ Nitrous oxide and spontaneous abortion in female dental assistants Am J Epidemiol 1995141531-8
bull 95 McGlothlin JD Jensen PA Fischbach TJ Hughes RT Jones JH Control of anesthetic gases in dental operatories Scand J Work Environ Health 199218(Suppl 2)103-5
bull ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY Volume 97 Number 6 Suresh and Radfar 681
bull 96 Rosen MA Nitrous oxide for relief of labor pain a systematic review Am J Obstet Gynecol 2002186(Suppl Nature)S110-6
bull 97 Sands TD Pynn BR Management considerations for the pregnant or nursing emergency patient Ont Dent 199875 17-9
bull 98 Daya S Recurrent spontaneous early pregnancy loss and low dose aspirin Minerva Ginecol 200355441-9
bull 99 Sinclair C Handbook of obstetrical emergencies 1st ed Philadelphia WB Saunders 1996 p 29-39 69
bull 100 Tarsitano BF Rollings RE The pregnant dental patient evaluation and management Gen Dent 199341226-34
bull 101 Livingston MH Dlllinger TM Holder R Consideration in the management of the pregnant patient SCD Special Care in Dentistry 199818183-8
Thank you
- A Review on the principle of Dental Management of the Pregnant patient
- Slide 2
- Questions that a dentist may ask
- Stages of Pregnancy
- Slide 5
- Slide 6
- Physiologic Changes in Pregnancy
- Systemic changes in pregnancy
- FLAT SUPINE POSITIONING
- SUPINE HYPOTENSION SYNDROME (Vena Cava Compression)
- Supine Hypotension Syndrome
- Slide 12
- Supine Hypotension Syndrome
- Prevention of Supine Hypotensive Syndrome
- Treatment of Supine Hypotensive Syndrome
- How should the pregnant woman be positioned
- Slide 17
- Slide 18
- Slide 19
- Slide 20
- Slide 21
- Slide 22
- Slide 23
- Pregnancy Related Oral Health Problems
- Oral Problems in Pregnancy
- Pregnancy Gingivitis Pathophysiology
- Pregnancy Gingivitis
- Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Gum Problems - Pregnancy Granuloma
- Slide 31
- Gum Changes - Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Candidiasis
- Pregnancy Myths
- Other Oral Conditions in Pregnancy
- Changes During Pregnancy that Affect Oral Health
- Saliva changes
- Increased Bacteria
- Slide 40
- Enamel erosion caused by frequent vomiting
- Treatment for Acid Exposure
- Oral Diseases Can Effect Pregnancy
- Periodontal Disease and Preterm Labor
- Periodontal Disease and Low Birth Weight
- Periodontal Disease and Preeclampsia
- Periodontitis and Pre-eclampsia
- Dental Considerations
- Treatment Timing
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Slide 52
- Use of Radiation on Pregnant Patient
- Radiographs during Pregnancy
- Risks of Dental X-Rays
- FDA drug classification for pregnancy
- Slide 57
- FDA drug classification for pregnancy
- Slide 59
- Slide 60
- Slide 61
- Common Analgesics
- Analgesics
- Analgesics - continued
- Analgesics to Use During 1st and 2nd Trimester
- Analgesics to Avoid During the Third Trimester
- Sedation in Pregnancy
- Common Antibiotics
- Antibiotics
- Antibiotics To Use During Pregnancy
- Antibiotics to Avoid during Pregnancy
- The Problem With Tetracycline
- Other Antimicrobial Agents
- Local Anesthetic Use in Pregnancy
- Use of Local Anesthetics
- Ulcer healing drugs
- Slide 77
- Slide 78
- Slide 79
- Use of Nitrous Oxide Gas
- Common Preventives
- Are topical agents safe
- Pre-natal Fluoride
- Is it safe to use mercury restorations
- References
- REFERENCES
- Slide 87
- Slide 88
- Slide 89
- Slide 90
- Slide 91
- Slide 92
- Slide 93
- Slide 94
- Slide 95
- Slide 96
- Slide 97
- Slide 98
- Thank you
-
Periodontitis and Pre-eclampsia
bull Periodontal disease may be associated with pre-eclampsia (Boggess 2003)
bull PGE2 IL-1 and TNF-α from gingival crevicular fluid were higher in women with preeclampsia compared with healthy matched pregnant women (Oettinger-Barak 2003)
Dental Considerations
bull timing of treatment for pregnant patientsbull dental radiation exposurebull use of local anestheticsbull prescription of common antibiotics and
analgesicsbull nitrous oxide gas administration
Treatment Timing
bull First Trimesterndash Spontaneous miscarriages naturally occur
more often in 1st trimesterndash Avoid elective treatment that can be delayedndash Offer anticipatory guidance
bull Second Trimesterndash The optimal time for dental treatmentndash Organogenesis complete fetus not largendash Easier to prevent than treat established disease
bull Third Trimesterndash Late in term very uncomfortable (short visits)ndash Position slightly on left side
Timing of Dental Treatment During Pregnancy - From Little and Fallace
First Trimester
bull Plaque controlbull Oral hygiene instructionbull Scaling polishing curettagebull Avoid elective treatment urgent care
only
Timing of Dental Treatment During Pregnancy - From Little and Fallace
Second Trimester
bull Plaque controlbull Oral hygiene instructionbull Scaling polishing curettagebull Routine dental care
Timing of Dental Treatment During Pregnancy - From Little and Fallace
Third Trimester
bull Plaque controlbull Oral hygiene instructionbull Scaling polishing curettagebull Routine dental care (after middle of third
trimester elective care should be avoided)
Use of Radiation on Pregnant Patientbull Dose given and time of gestation are
importantbull doses lt 5-10 rads (cGy) not teratogenicbull fetus is most susceptible to radiation
between the 2nd and 6th week of gestationbull single dental x-ray exposes patient to 001
millirads of radiation In relative terms this amount is 40 times less than daily dose acquired from cosmic radiation Therefore diagnostic radiation should not be withheld during pregnancy
Radiographs during Pregnancy
bull Take as needed with optimal methods for reducing secondary radiation and exposure time
bull Always use a lead apronbull Exposure to fetus (with apron use) is 00001
centiGray(rad)bull Daily cosmic radiation - 0004 centiGray (rad)
Risks of Dental X-Rays
bull X-ray only if necessary (ie root canal therapy trauma)
bull When x-rays are indicated radiation exposure is extremely low
bull Exposure can be limited byndash Lead apron shielding ndash Modern fast film ndash Avoiding retakes
FDA drug classification for pregnancybull Combines risk statements including
congenital anomalies fetal effects perinatal risks and therapeutic risk-benefit ratio
bull Untreated disease or condition may pose more serious risks to both mother and fetus than any theoretical risks from the medication
bull Category A thru D and X
FDA drug classification for pregnancy
bull A = Controlled Studies in women fail to demonstrate a risk to the fetus in the first trimester and the possibility of fetal harm appears remote
FDA drug classification for pregnancy
bull B = Animal studies show no risk or if risk shown in animals controlled
trials in women showed no risk
FDA drug classification for pregnancy
bull C = Studies in animals with adverse effects and no human studies
OR no animal or human studies but benefits of use may outweigh potential harms
FDA drug classification for pregnancy
bull D = There is evidence of human fetal risk but benefits may outweigh risks
FDA drug classification for pregnancy
bull X = Contraindicated
Common Analgesics
bull paracetamol (B)bull Ibuprofen (BD) bull Oxycodone (BD) bull Hydrocodone and codeine
(CD)
avoid in third trimester
Analgesics
bull Paracetamol is the analgesic of choice for all stages of gestation
bull used to treat mild to moderate pain and fevers
bull short term usage is believed to be safebull avoid chronic and large doses of
paracetamol1048715
Analgesics - continuedbull Aspirin is nonteratogenic but may cause
maternal and fetal hemorrhagebull large and chronic doses during last trimester
may result in premature closure of ductus arteriosus fetal hypertension anemia and low birth weight
bull avoid ibuprofen in 3rd trimester because of possible adverse circulatory effects
bull short term use of codeine seems safebull avoid codeine late in gestation because of
possible fetal respiratory depression and withdrawal symptoms
Analgesics to Use During1st and 2nd Trimester
bull Category B (for best)bull Paracetamol Ibuprofenbull Naproxenbull Category C (use with caution)bull Paracetamol with codeine or
hydrocodonebull Paracetamol with oxycodone
Analgesics to Avoid During theThird Trimesterbull Causes delivery problemsbull Aspirin (C 3D)bull Ibuprofen (B3D)bull Naproxen (B3D)bull Causes neonatal respiratory
depression and opioid withdrawalbull Codeine (C3D)bull Hydrocodone (C3D)bull Oxycodone(C3D)
Sedation in Pregnancy
bull SedativesAnxiolytics (eg Diazepam ) are rated D and can cause oral clefts with prolonged exposure
bull Nitrous oxide should not be used in 1st trimester (If used in 2nd and 3rd do not go below 50 O2)
Common Antibioticsbull To treat oral abscess or cellulitis
ndash Penicillin (B) ndash Amoxicillin (B) ndash Cephalexin (B)ndash Erythromycin base (B) (Not estolate as it
cause cholestatic hepatitis)ndash Clindamycin (B)
Antibioticsbull penicillin V and amoxicillin is preferred drug
for mild to moderate infectionsbull widely used for many years with no ill effectsbull no studies show penicillin to be teratogenicbull amoxicillin extensively used without harming
the fetusbull Drug classes1048715 B penicillin cephalosporins erythromycin clindamycin Azithromycin D Tetracycline
Antibiotics To Use During Pregnancy
bull Penicillin Vbull Amoxicillinbull Erythromycin (base form)bull Cephalexin cephalosporinbull Clindamycinbull Metronidazole
Antibiotics to Avoid duringPregnancy
bull Doxycyclinebull Tetracyclinebull Erythromycin (estolate form)bull Vancomycin
The Problem With Tetracycline
bull Accumulates in bones and chelates calcium
bull Inhibits bone growthbull Discolors teeth
Other Antimicrobial Agentsbull OK to usebull Nystatin (B)bull Chlorhexidine rinse (B)bull Use with cautionbull Clotrimazole (C)bull Ketoconazole (C)bull Fluconazole (C)bull Do not usebull Doxycycline (D)
Local Anesthetic Use inPregnancy
bull Class Bbull Lidocaine (Xylocaine)bull Etidocainebull Prilocaine bull Class Cbull Procainebull Bupivicainebull Mepivicaine
Use of Local Anestheticsbull Lidocaine + vasoconstrictor most common
local anesthetic used in dentistrybull extensively used in pregnancy with no proven ill
effectsbull accidental intravascular injections of lidocaine
pass through the placenta but the concentrations are too low to harm fetus
bull prilocaine might cause methemoglobinemia
Ulcer healing drugsCimetidine bull FDA category B Famotidinebull FDA category BRanitidinebull FDA category Bbull not known to be harmful
Ulcer healing drugsOmeprazolebull FDA category BNot known to be
harmful Esomeprazolebull FDA category BLansoprazolebull FDA category BPantoprazolebull Avoid unless potential benefit
outweighs riskmdashfetotoxic in animals
Ulcer healing drugs
Misoprostolbull First second third trimesters Avoidmdash
potent uterine stimulant (has been used to induce abortion) and may be teratogenic
Ulcer healing drugs
Antacidsbull Almunium hydroxideMagnesium
hydroxidemdashFDA category B Calcium carbonatemdashFDA category C
SimetheconemdashFDA category C
Use of Nitrous Oxide Gas
bull used over 150 years bull safety is being debatedbull SHORT TERM exposure do not cause
birth defects or spontaneous abortionbull CHRONIC exposure may result in fetal
loss and infertilitybull literature suggests that nitrous oxide
should be avoided until more conclusive research is available
bull FDA Drug class not yet assigned
Common Preventives
bull Fluoridendash No increased risk during pregnancy
bull Xylitolndash No studies no harm reported
bull Chlorhexidinendash No increased risk during pregnancy
Are topical agents safe
bull Fluoridebull Toothpaste amp mouthrinse
bull Xylitol chewing gum bull Chlorhexidine (11 alcohol)bull No over the counter mouthrinses with
alcohol (Listerine 20 alcohol)
Pre-natal Fluoride
bull Daily 22 mg tablet of sodium fluoride during 3rd through 9th months
bull decreases caries rate in offspringbull Safe and effective
Glenn FB 1982
Is it safe to use mercury restorations
bull No evidence of harmful effect
bull Benefits outweigh risks
bull Canada Germany and New Zealand have some restrictions
bull Determine the best option
Referencesbull Wasylko L Matsui D Dykxhoorn SM Rieder MJ Weinberg
S A Review of Common Dental Treatments During Pregnancy J Canadian Dental Association 64434-439 1998
bull Little JW Donald AF Craig SM Rhodus NL Dental Management of the Medically Compromised Patient - 5th edition Mosby Toronto Pp434-442 1997
bull Livingston HM Dellinger TM Holder R Considerations in the management of the pregnant patient Special Care in Dentistry 185 pp183-188 1998
bull Larimore WL Petrie KA Drug use during pregnacy and lactation Primary Care Clinics in Office Practice 271 35-53 2000
bull Health Canada The Safety of DentalAmalgam Minister Of Supply and Services Canada 1996
REFERENCESbull 1 Weiss G Endocrinology of parturition J Clin
Endocrinol Metab 2000854421-5bull 2 Theunissen IM Parer JT Fluid and electrolytes in
pregnancy Clin Obstet Gynecol 1994373-15bull 3 Duvekot JJ Peeters LLH Renal hemodynamics and
volume homeostasis in pregnancy Obstet Gynecol Surv 199449830-9
bull 4 Barron WM Lindheimer MD Medical disorders during pregnancy 2nd ed St Louis Mosby 1995 p 129
bull 5 Thornburg KL Jacobson SL Giraud GD Morton MJ Hemodynamic changes in pregnancy Semin Perinatol 20002411-4
bull 6 Fiese R Herzog S Issues in dental and surgical management of the pregnant patient Oral Surg Oral Med Oral Pathol 198865292-7
bull 7 Martin C Varner MW Physiologic changes in pregnancysurgical implications Clin Obstet Gynecol 199437241-55
bull 8 Clark SL Cotton DB Lee W Bishop C Hill T Southwick J et al Central hemodynamic assessment of normal term pregnancy Am J Obstet Gynecol 19891611439-42
bull 9 Mabie WC Di Sessa TG Crocker LG Sibai BM Arheart KL A longitudinal study of cardiac output in normal human pregnancy Am J Obstet Gynecol 1994170849-56
bull 10 Clapp JF 3rd Capeless E Cardiovascular function before during and after the first and subsequent pregnancies Am J Cardiol 1997801469-73
bull 11 Duvekot JJ Peeters LL Maternal cardiovascular hemodynamic adaptation to pregnancy Obstet Gynecol Surv 199449(Suppl) S1-14
bull 12 Bhagwat AR Engel PJ Heart disease and pregnancy Cardiol Clin 199513163-78
bull 13 Lanni SM Tillinghast J Silver H Hemodynamic changes and baroreflex gain in the supine hypotensive syndrome Am J Obstet Gynecol 20021871636-41
bull 14 Little JW Falace DA Miller CS Rhodus NL Dental management of the medically compromised patient 6th ed St Louis Mosby 2002 p 303
bull 15 Garcia-Rio F Pino JM Gomez L Alvarez-Sala R Villasante C Villamor J Regulation of breathing and perception of dyspnea in healthy pregnant women Chest 1996110446-53
bull 16 McAuliffe F Kametas N Costello J Rafferty GF Greenough A Nicolaides K Respiratory function in singleton and twin pregnancy BJOG 2002109765-9
bull 17 Clapp JF 3rd Seaward BL Sleamaker RH Hiser J Maternal physiologic adaptations to early human pregnancy Am J Obstet Gynecol 19881591456-60
bull 18 OrsquoDay MP Cardio-respiratory physiological adaptation of pregnancy Semin Perinatol 199721268-75
bull 19 Contreras G Gutierrez M Beroiza T Fantin A Oddo H Villarroel L et al Ventilatory drive and respiratory muscle function in pregnancy Am Rev Respir Dis 1991144837-41
bull 20 Turner M Aziz SR Management of the pregnant oral and maxillofac
bull 21 Sifakis S Pharmakides G Anemia in pregnancy Ann N Y Acad Sci 2000900125-36
bull 22 Branch DW Physiologic adaptations of pregnancy Am J Reprod Immunol 199228120-2
bull 23 Burrows RF Kelton JG Incidentally detected thrombocytopenia in healthy mothers and their infants N Engl J Med 1988319 142-5
bull 24 Hanly JG Antiphospholipid syndrome an overview CMAJ 200324(168)1675-82
bull 25 Heilmann L von Tempelhoff GF Pollow K Antiphospholipid syndrome in obstetrics Clin Appl Thromb Hemost 20039 143-50
bull 26 Sherman P Flaxman SM Nausea and vomiting of pregnancy in an evolutionary perspective Am J Obstet Gynecol 2002 185(Suppl)s190-7
bull 27 Koch KL Gastrointestinal factors in nausea and vomiting of pregnancy Am J Obstet Gynecol 2002185(Suppl)s198-203
bull 28 Koch KL Frissora CL Nausea and vomiting during pregnancy Gastroenterol Clin N Am 200332201-34
bull 29 Baron TH Ramirez B Richter JE Gastrointestinal motility disorders during pregnancy Ann Intern Med 1993118 366-75
bull 30 Richter JE Gastroesophageal reflux disease during pregnancy Gastroenterol Clin N Am 200332235-61
bull 31 Marrero JM Goggin PM de Caestecker JS Pearce JM Maxwell JD Determinants of pregnancy heartburn Br J Obstet Gynaecol 199299731-4
bull 32 Hamaoui E Hamaoui M Nutritional assessment and support during pregnancy Gastroenterol Clin N Am 20033259-121
bull 33 King JC Physiology of pregnancy and nutrient metabolism Am J Clin Nutr 200071(suppl)1218s-25s
bull 34 Casanueva E Pfeffer F Fernandez-Gaxiola AC Gutierrez- Valenzuela V Rothenberg SJ Iron and folate status before pregnancy and anemia during pregnancy Ann Nutr Metab 2003 4760-3
bull 35 Chrsquong CL Morgan M Hainsworth I Kingham JG Prospective study of liver dysfunction in Southwest Wales Gut 200251 876-80
bull 36 Rahman TM Wendon J Severe hepatic dysfunction in pregnancy QJM 200295343-57
bull 37 Knox TA Olans LB Liver disease in pregnancy N Engl J Med 1996335569-76
bull 38 Saftlas AF Olson DR Franks AL Atrash H Pokras R Epidemiology of preeclampsia and eclampsia in the United States 1979e1986 Am J Obstet Gynecol 1990163460-5
bull 39 Walker JJ Pre-eclampsia Lancet 20003561260-5
bull 40 Davidson JM Renal disorders in pregnancy Curr Opin Obstet Gynecol 200113109-14
bull 41 Dafnis E Sabatini S The effect of pregnancy on renal function physiology and pathophysiologyAmJMedSci 1992303184-205
bull 42 Davison JM Shiells EA Philips PR Lindheimer MD Serial evaluation of vasopressin release and thirst in human pregnancy Role of human chorionic gonadotrophin in the osmoregulatory changes of gestation J Clin Invest 198881798-806
bull 43 Glinoer D de Nayer P Bourdoux P Lemone M Robyn C van Steirteghem A et al Regulation of maternal thyroid during pregnancy J Clin Endocrinol Metab 199071276-87
bull 44 Wilson SG Retallack RW Kent JC Worth GK Gutteridge DH Serum free 125-dihydroxyvitamin D and the free 125- dihydroxyvitamin D index during a longitudinal study of human pregnancy and lactation Clin Endocrinol 199032613-22
bull 45 Rasmussen N Frolich A Hornnes PJ Hegedus L Serum ionized calcium and intact parathyroid hormone levels during pregnancy and postpartum Br J Obstet Gynaecol 199097857-9
bull 46 Guyton AC Textbook of medical physiology 8th ed Philadelphia W B Saunders 1991 p 915e28
bull 47 Trainer PJ Corticosteroids and pregnancy Semin Reprod Med 200220375-80
bull 48 Soory M Hormonal factors in periodontal disease Dent Update 200027380-3
bull 49 Hugoson A Gingivitis in pregnant women A longitudinal clinical study Odontol Revy 19712265-84
bull 50 Neville BW Damm DD Allen CM Bouquot JE Oral amp Maxillofacial Pathology 3rd ed Philadelphia W B Saunders 2002 p 329-30 447-9
bull 51 Tilakaratne A Soory M Ranasinghe AW Corea SM Ekanayake SL de Silva M Periodontal disease status during pregnancy and 3 months post-partum in rural population of Sri-Lankan women J Clin Periodontol 200027787-92
bull 52 Laine M Tenovuo J Lehtonen OP Ojanatko-Harri A Vilja P Tuohimaa P Pregnancy e related changes in human whole saliva Arch Oral Biol 198833913-7
bull 53 Yuan K Wing LY Lin MT Pathogenetic roles of angiogenic factors in pyogenic granulomas in pregnancy are modulated by female sex hormones J Periodontol 200273701-8
bull 54 Evans RD Briggs PF Tooth-surface loss related to pregnancyinduced vomiting Prim Dent Care 1994124-6
bull 55 Salvolini E Di Giorgio R Curatola A Mazzanti L Fratto G Biochemical modifications of human whole saliva induced by pregnancy Br J Obstet Gynaec 1998105656-60
bull 56 Mauldin JG Newman RB Preterm birth risk assessment Semin Perinatol 200125215-22
bull 57 Heine RP McGregor JA Goodwin TM Artal R Hayashi RH Robertson PA et al Serial salivary estriol to detect an increased risk of preterm birth Obstet Gynecol 200096490-7
bull 58 Kauh YC Zachian TF Melasma Adv Exp Med Biol 1999455 491-9
bull 59 Wong RC Ellis CN Physiologic skin changes in pregnancy J Am Acad Dermatol 198410929-40
bull 60 Errickson CV Matus NR Skin disorders of pregnancy Am Fam Physician 199449605-10
bull 61 Lopez NJ Smith PC Gutierrez J Periodontal therapy may reduce the risk of preterm low birth weight in women with periodontal disease a randomized controlled trial J Periodontol 200273911-24
bull 62 McGaw T Periodontal disease and preterm delivery of lowbirth- weight infants J Can Dent Assoc 200268165-9
bull 63 Richards AG Dental x-ray protection Dent Clin North Am 1968631-41
bull 64 1990 Recommendations of the International Commission on Radiological Protection Ann ICRP 1991211-201
bull 65 Hall EJ Radiation the two-edged sword cancer risks at high and low doses Cancer J 20006343-50
bull 66 Diethelm L Xu H Diagnostic imaging of the lung during pregnancy Clin Obstet Gynecol 19963936-55
bull 67 Brent RL The effects of embryonic and fetal exposure to x-rays microwaves and ultrasound ClinObstetGynecol 198326484-510
bull 68 National Council on Radiation Protection NCRP report no128 1998 Bethesda Md Author
bull 69 Wasylko L Matsui D Dykxhoorn SM Reider MJ Weinberg S A review of common dental treatments during pregnancy implications for patients and dental personnel J Can Dent Assoc 199864434-9
bull 70 Freeman JP Brand JW Radiation doses of commonly used dental radiographic surveys Oral Surg Oral Med Oral Pathol 199477285-9
bull 71 Kircos LTAngin LL Lorton LOrder ofmagnitude dose reduction in intraoral radiography J Am Dent Assoc 1987114344-7
bull 72 Updegrave WJ Simplified and standardized intraoral radiography with reduced tissue irradiation J Am Dent Assoc 197285861-9
bull 73 Wood RE Harris AM van der Merwe EJ Nortje CJ The leaded apron revisited does it reduce gonadal radiation dose in dental radiology Oral Surg Oral Med Oral Pathol 199171642-6
bull 74 An update on radiographic practices information and recommendations ADA Council on Scientific Affairs J Am Dent Assoc 2001132234-8
bull 75 Rayburn WF Recommending medications during pregnancy an evidence based approach Clin Obstet Gynecol 2002451-5
bull 76 Rathmell JP Viscomi C Ashburn MA Management of nonobstetric pain during pregnancy and lactation Anesth Analg 1997851074-87
bull 77 Teratology society public affairs committee FDA classification of drugs for teratogenic risk Teratology 199449446-7
bull 78 Moore PA Selecting drugs for the pregnant dental patient J Am Dent Assoc 19981291281-6
bull 79 Haas DA An update on analgesics for the management of acute postoperative dental pain J Can Dent Assoc 200268476-82
bull 80 Haas DA Pynn BR Sands TD Drug use for the pregnant or lactating patient Gen Dent 20004854-60
bull 81 Committee on Drugs American Academy of Pediatrics The transfer of drugs and other chemicals into human milk Pediatrics 199493137-50
bull 82 Nielsen GL Sorensen HT Larsen H Pedersen L Risk of adverse birth outcome and miscarriage in pregnant users of nonsteroidal anti-inflammatory drugs population based observational study and case-control study BMJ 2001322266-70
bull 83 Janssen N Genta M The effects of immunosuppressive and anti-inflammatory medications on fertility pregnancy and lactation Arch Intern Med 200016610-9
bull 84 Ostensen M Nonsteroidal anti-inflammatory drugs during pregnancy Scand J Rheumatol Suppl 1998107128-32
bull 85 USPDI -Drug information for the health care professional 22nd ed Greenwood Village CO Micromedex 2002 p 152-79
bull 86 Denson DD Coyle DE Thompson GA Santos D Turner PA Myers JA et al Bupivacaine protein binding in the term parturient effects of lactic acidosis Clin Pharmacol Ther 198435702-9
bull 87 Dillon DE Wagner CL Wiest D Newman RB Drug therapy in the nursing mother Obstet Gynecol Clin North Am 199724 675-96
bull 88 Dashe JS Gilstrap LC Antibiotic use in pregnancy Obstet Gynecol Clin North Am 199724617-29
bull 89 American College of Rheumatology Ad hoc Committee on Clinical Guidelines Guidelines for monitoring drug therapy in rheumatoid arthritis Arthritis Rheum 199639723-31
bull 90 Ng PC The fetal and neonatal hypothalamic-pituitary-adrenal axis Arch Dis Child Fetal Neonatal Ed 200082F250-4
bull 91 Crowley P Antenatal corticosteroidsmdashcurrent thinking BJOG 2003110(Suppl 20)77-8
bull 92 ACOG committee opinion antenatal corticosteroid therapy for fetal maturation Obstet Gynecol 200299871-3
bull 93 Ost L Wettrell G Bjorkhem I Rane A Prednisolone excretion in human milk J Pediatr 19851061008-11
bull 94 Rowland AS Baird DD Shore DL Weinberg CR Savitz DA Wilcox AJ Nitrous oxide and spontaneous abortion in female dental assistants Am J Epidemiol 1995141531-8
bull 95 McGlothlin JD Jensen PA Fischbach TJ Hughes RT Jones JH Control of anesthetic gases in dental operatories Scand J Work Environ Health 199218(Suppl 2)103-5
bull ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY Volume 97 Number 6 Suresh and Radfar 681
bull 96 Rosen MA Nitrous oxide for relief of labor pain a systematic review Am J Obstet Gynecol 2002186(Suppl Nature)S110-6
bull 97 Sands TD Pynn BR Management considerations for the pregnant or nursing emergency patient Ont Dent 199875 17-9
bull 98 Daya S Recurrent spontaneous early pregnancy loss and low dose aspirin Minerva Ginecol 200355441-9
bull 99 Sinclair C Handbook of obstetrical emergencies 1st ed Philadelphia WB Saunders 1996 p 29-39 69
bull 100 Tarsitano BF Rollings RE The pregnant dental patient evaluation and management Gen Dent 199341226-34
bull 101 Livingston MH Dlllinger TM Holder R Consideration in the management of the pregnant patient SCD Special Care in Dentistry 199818183-8
Thank you
- A Review on the principle of Dental Management of the Pregnant patient
- Slide 2
- Questions that a dentist may ask
- Stages of Pregnancy
- Slide 5
- Slide 6
- Physiologic Changes in Pregnancy
- Systemic changes in pregnancy
- FLAT SUPINE POSITIONING
- SUPINE HYPOTENSION SYNDROME (Vena Cava Compression)
- Supine Hypotension Syndrome
- Slide 12
- Supine Hypotension Syndrome
- Prevention of Supine Hypotensive Syndrome
- Treatment of Supine Hypotensive Syndrome
- How should the pregnant woman be positioned
- Slide 17
- Slide 18
- Slide 19
- Slide 20
- Slide 21
- Slide 22
- Slide 23
- Pregnancy Related Oral Health Problems
- Oral Problems in Pregnancy
- Pregnancy Gingivitis Pathophysiology
- Pregnancy Gingivitis
- Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Gum Problems - Pregnancy Granuloma
- Slide 31
- Gum Changes - Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Candidiasis
- Pregnancy Myths
- Other Oral Conditions in Pregnancy
- Changes During Pregnancy that Affect Oral Health
- Saliva changes
- Increased Bacteria
- Slide 40
- Enamel erosion caused by frequent vomiting
- Treatment for Acid Exposure
- Oral Diseases Can Effect Pregnancy
- Periodontal Disease and Preterm Labor
- Periodontal Disease and Low Birth Weight
- Periodontal Disease and Preeclampsia
- Periodontitis and Pre-eclampsia
- Dental Considerations
- Treatment Timing
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Slide 52
- Use of Radiation on Pregnant Patient
- Radiographs during Pregnancy
- Risks of Dental X-Rays
- FDA drug classification for pregnancy
- Slide 57
- FDA drug classification for pregnancy
- Slide 59
- Slide 60
- Slide 61
- Common Analgesics
- Analgesics
- Analgesics - continued
- Analgesics to Use During 1st and 2nd Trimester
- Analgesics to Avoid During the Third Trimester
- Sedation in Pregnancy
- Common Antibiotics
- Antibiotics
- Antibiotics To Use During Pregnancy
- Antibiotics to Avoid during Pregnancy
- The Problem With Tetracycline
- Other Antimicrobial Agents
- Local Anesthetic Use in Pregnancy
- Use of Local Anesthetics
- Ulcer healing drugs
- Slide 77
- Slide 78
- Slide 79
- Use of Nitrous Oxide Gas
- Common Preventives
- Are topical agents safe
- Pre-natal Fluoride
- Is it safe to use mercury restorations
- References
- REFERENCES
- Slide 87
- Slide 88
- Slide 89
- Slide 90
- Slide 91
- Slide 92
- Slide 93
- Slide 94
- Slide 95
- Slide 96
- Slide 97
- Slide 98
- Thank you
-
Dental Considerations
bull timing of treatment for pregnant patientsbull dental radiation exposurebull use of local anestheticsbull prescription of common antibiotics and
analgesicsbull nitrous oxide gas administration
Treatment Timing
bull First Trimesterndash Spontaneous miscarriages naturally occur
more often in 1st trimesterndash Avoid elective treatment that can be delayedndash Offer anticipatory guidance
bull Second Trimesterndash The optimal time for dental treatmentndash Organogenesis complete fetus not largendash Easier to prevent than treat established disease
bull Third Trimesterndash Late in term very uncomfortable (short visits)ndash Position slightly on left side
Timing of Dental Treatment During Pregnancy - From Little and Fallace
First Trimester
bull Plaque controlbull Oral hygiene instructionbull Scaling polishing curettagebull Avoid elective treatment urgent care
only
Timing of Dental Treatment During Pregnancy - From Little and Fallace
Second Trimester
bull Plaque controlbull Oral hygiene instructionbull Scaling polishing curettagebull Routine dental care
Timing of Dental Treatment During Pregnancy - From Little and Fallace
Third Trimester
bull Plaque controlbull Oral hygiene instructionbull Scaling polishing curettagebull Routine dental care (after middle of third
trimester elective care should be avoided)
Use of Radiation on Pregnant Patientbull Dose given and time of gestation are
importantbull doses lt 5-10 rads (cGy) not teratogenicbull fetus is most susceptible to radiation
between the 2nd and 6th week of gestationbull single dental x-ray exposes patient to 001
millirads of radiation In relative terms this amount is 40 times less than daily dose acquired from cosmic radiation Therefore diagnostic radiation should not be withheld during pregnancy
Radiographs during Pregnancy
bull Take as needed with optimal methods for reducing secondary radiation and exposure time
bull Always use a lead apronbull Exposure to fetus (with apron use) is 00001
centiGray(rad)bull Daily cosmic radiation - 0004 centiGray (rad)
Risks of Dental X-Rays
bull X-ray only if necessary (ie root canal therapy trauma)
bull When x-rays are indicated radiation exposure is extremely low
bull Exposure can be limited byndash Lead apron shielding ndash Modern fast film ndash Avoiding retakes
FDA drug classification for pregnancybull Combines risk statements including
congenital anomalies fetal effects perinatal risks and therapeutic risk-benefit ratio
bull Untreated disease or condition may pose more serious risks to both mother and fetus than any theoretical risks from the medication
bull Category A thru D and X
FDA drug classification for pregnancy
bull A = Controlled Studies in women fail to demonstrate a risk to the fetus in the first trimester and the possibility of fetal harm appears remote
FDA drug classification for pregnancy
bull B = Animal studies show no risk or if risk shown in animals controlled
trials in women showed no risk
FDA drug classification for pregnancy
bull C = Studies in animals with adverse effects and no human studies
OR no animal or human studies but benefits of use may outweigh potential harms
FDA drug classification for pregnancy
bull D = There is evidence of human fetal risk but benefits may outweigh risks
FDA drug classification for pregnancy
bull X = Contraindicated
Common Analgesics
bull paracetamol (B)bull Ibuprofen (BD) bull Oxycodone (BD) bull Hydrocodone and codeine
(CD)
avoid in third trimester
Analgesics
bull Paracetamol is the analgesic of choice for all stages of gestation
bull used to treat mild to moderate pain and fevers
bull short term usage is believed to be safebull avoid chronic and large doses of
paracetamol1048715
Analgesics - continuedbull Aspirin is nonteratogenic but may cause
maternal and fetal hemorrhagebull large and chronic doses during last trimester
may result in premature closure of ductus arteriosus fetal hypertension anemia and low birth weight
bull avoid ibuprofen in 3rd trimester because of possible adverse circulatory effects
bull short term use of codeine seems safebull avoid codeine late in gestation because of
possible fetal respiratory depression and withdrawal symptoms
Analgesics to Use During1st and 2nd Trimester
bull Category B (for best)bull Paracetamol Ibuprofenbull Naproxenbull Category C (use with caution)bull Paracetamol with codeine or
hydrocodonebull Paracetamol with oxycodone
Analgesics to Avoid During theThird Trimesterbull Causes delivery problemsbull Aspirin (C 3D)bull Ibuprofen (B3D)bull Naproxen (B3D)bull Causes neonatal respiratory
depression and opioid withdrawalbull Codeine (C3D)bull Hydrocodone (C3D)bull Oxycodone(C3D)
Sedation in Pregnancy
bull SedativesAnxiolytics (eg Diazepam ) are rated D and can cause oral clefts with prolonged exposure
bull Nitrous oxide should not be used in 1st trimester (If used in 2nd and 3rd do not go below 50 O2)
Common Antibioticsbull To treat oral abscess or cellulitis
ndash Penicillin (B) ndash Amoxicillin (B) ndash Cephalexin (B)ndash Erythromycin base (B) (Not estolate as it
cause cholestatic hepatitis)ndash Clindamycin (B)
Antibioticsbull penicillin V and amoxicillin is preferred drug
for mild to moderate infectionsbull widely used for many years with no ill effectsbull no studies show penicillin to be teratogenicbull amoxicillin extensively used without harming
the fetusbull Drug classes1048715 B penicillin cephalosporins erythromycin clindamycin Azithromycin D Tetracycline
Antibiotics To Use During Pregnancy
bull Penicillin Vbull Amoxicillinbull Erythromycin (base form)bull Cephalexin cephalosporinbull Clindamycinbull Metronidazole
Antibiotics to Avoid duringPregnancy
bull Doxycyclinebull Tetracyclinebull Erythromycin (estolate form)bull Vancomycin
The Problem With Tetracycline
bull Accumulates in bones and chelates calcium
bull Inhibits bone growthbull Discolors teeth
Other Antimicrobial Agentsbull OK to usebull Nystatin (B)bull Chlorhexidine rinse (B)bull Use with cautionbull Clotrimazole (C)bull Ketoconazole (C)bull Fluconazole (C)bull Do not usebull Doxycycline (D)
Local Anesthetic Use inPregnancy
bull Class Bbull Lidocaine (Xylocaine)bull Etidocainebull Prilocaine bull Class Cbull Procainebull Bupivicainebull Mepivicaine
Use of Local Anestheticsbull Lidocaine + vasoconstrictor most common
local anesthetic used in dentistrybull extensively used in pregnancy with no proven ill
effectsbull accidental intravascular injections of lidocaine
pass through the placenta but the concentrations are too low to harm fetus
bull prilocaine might cause methemoglobinemia
Ulcer healing drugsCimetidine bull FDA category B Famotidinebull FDA category BRanitidinebull FDA category Bbull not known to be harmful
Ulcer healing drugsOmeprazolebull FDA category BNot known to be
harmful Esomeprazolebull FDA category BLansoprazolebull FDA category BPantoprazolebull Avoid unless potential benefit
outweighs riskmdashfetotoxic in animals
Ulcer healing drugs
Misoprostolbull First second third trimesters Avoidmdash
potent uterine stimulant (has been used to induce abortion) and may be teratogenic
Ulcer healing drugs
Antacidsbull Almunium hydroxideMagnesium
hydroxidemdashFDA category B Calcium carbonatemdashFDA category C
SimetheconemdashFDA category C
Use of Nitrous Oxide Gas
bull used over 150 years bull safety is being debatedbull SHORT TERM exposure do not cause
birth defects or spontaneous abortionbull CHRONIC exposure may result in fetal
loss and infertilitybull literature suggests that nitrous oxide
should be avoided until more conclusive research is available
bull FDA Drug class not yet assigned
Common Preventives
bull Fluoridendash No increased risk during pregnancy
bull Xylitolndash No studies no harm reported
bull Chlorhexidinendash No increased risk during pregnancy
Are topical agents safe
bull Fluoridebull Toothpaste amp mouthrinse
bull Xylitol chewing gum bull Chlorhexidine (11 alcohol)bull No over the counter mouthrinses with
alcohol (Listerine 20 alcohol)
Pre-natal Fluoride
bull Daily 22 mg tablet of sodium fluoride during 3rd through 9th months
bull decreases caries rate in offspringbull Safe and effective
Glenn FB 1982
Is it safe to use mercury restorations
bull No evidence of harmful effect
bull Benefits outweigh risks
bull Canada Germany and New Zealand have some restrictions
bull Determine the best option
Referencesbull Wasylko L Matsui D Dykxhoorn SM Rieder MJ Weinberg
S A Review of Common Dental Treatments During Pregnancy J Canadian Dental Association 64434-439 1998
bull Little JW Donald AF Craig SM Rhodus NL Dental Management of the Medically Compromised Patient - 5th edition Mosby Toronto Pp434-442 1997
bull Livingston HM Dellinger TM Holder R Considerations in the management of the pregnant patient Special Care in Dentistry 185 pp183-188 1998
bull Larimore WL Petrie KA Drug use during pregnacy and lactation Primary Care Clinics in Office Practice 271 35-53 2000
bull Health Canada The Safety of DentalAmalgam Minister Of Supply and Services Canada 1996
REFERENCESbull 1 Weiss G Endocrinology of parturition J Clin
Endocrinol Metab 2000854421-5bull 2 Theunissen IM Parer JT Fluid and electrolytes in
pregnancy Clin Obstet Gynecol 1994373-15bull 3 Duvekot JJ Peeters LLH Renal hemodynamics and
volume homeostasis in pregnancy Obstet Gynecol Surv 199449830-9
bull 4 Barron WM Lindheimer MD Medical disorders during pregnancy 2nd ed St Louis Mosby 1995 p 129
bull 5 Thornburg KL Jacobson SL Giraud GD Morton MJ Hemodynamic changes in pregnancy Semin Perinatol 20002411-4
bull 6 Fiese R Herzog S Issues in dental and surgical management of the pregnant patient Oral Surg Oral Med Oral Pathol 198865292-7
bull 7 Martin C Varner MW Physiologic changes in pregnancysurgical implications Clin Obstet Gynecol 199437241-55
bull 8 Clark SL Cotton DB Lee W Bishop C Hill T Southwick J et al Central hemodynamic assessment of normal term pregnancy Am J Obstet Gynecol 19891611439-42
bull 9 Mabie WC Di Sessa TG Crocker LG Sibai BM Arheart KL A longitudinal study of cardiac output in normal human pregnancy Am J Obstet Gynecol 1994170849-56
bull 10 Clapp JF 3rd Capeless E Cardiovascular function before during and after the first and subsequent pregnancies Am J Cardiol 1997801469-73
bull 11 Duvekot JJ Peeters LL Maternal cardiovascular hemodynamic adaptation to pregnancy Obstet Gynecol Surv 199449(Suppl) S1-14
bull 12 Bhagwat AR Engel PJ Heart disease and pregnancy Cardiol Clin 199513163-78
bull 13 Lanni SM Tillinghast J Silver H Hemodynamic changes and baroreflex gain in the supine hypotensive syndrome Am J Obstet Gynecol 20021871636-41
bull 14 Little JW Falace DA Miller CS Rhodus NL Dental management of the medically compromised patient 6th ed St Louis Mosby 2002 p 303
bull 15 Garcia-Rio F Pino JM Gomez L Alvarez-Sala R Villasante C Villamor J Regulation of breathing and perception of dyspnea in healthy pregnant women Chest 1996110446-53
bull 16 McAuliffe F Kametas N Costello J Rafferty GF Greenough A Nicolaides K Respiratory function in singleton and twin pregnancy BJOG 2002109765-9
bull 17 Clapp JF 3rd Seaward BL Sleamaker RH Hiser J Maternal physiologic adaptations to early human pregnancy Am J Obstet Gynecol 19881591456-60
bull 18 OrsquoDay MP Cardio-respiratory physiological adaptation of pregnancy Semin Perinatol 199721268-75
bull 19 Contreras G Gutierrez M Beroiza T Fantin A Oddo H Villarroel L et al Ventilatory drive and respiratory muscle function in pregnancy Am Rev Respir Dis 1991144837-41
bull 20 Turner M Aziz SR Management of the pregnant oral and maxillofac
bull 21 Sifakis S Pharmakides G Anemia in pregnancy Ann N Y Acad Sci 2000900125-36
bull 22 Branch DW Physiologic adaptations of pregnancy Am J Reprod Immunol 199228120-2
bull 23 Burrows RF Kelton JG Incidentally detected thrombocytopenia in healthy mothers and their infants N Engl J Med 1988319 142-5
bull 24 Hanly JG Antiphospholipid syndrome an overview CMAJ 200324(168)1675-82
bull 25 Heilmann L von Tempelhoff GF Pollow K Antiphospholipid syndrome in obstetrics Clin Appl Thromb Hemost 20039 143-50
bull 26 Sherman P Flaxman SM Nausea and vomiting of pregnancy in an evolutionary perspective Am J Obstet Gynecol 2002 185(Suppl)s190-7
bull 27 Koch KL Gastrointestinal factors in nausea and vomiting of pregnancy Am J Obstet Gynecol 2002185(Suppl)s198-203
bull 28 Koch KL Frissora CL Nausea and vomiting during pregnancy Gastroenterol Clin N Am 200332201-34
bull 29 Baron TH Ramirez B Richter JE Gastrointestinal motility disorders during pregnancy Ann Intern Med 1993118 366-75
bull 30 Richter JE Gastroesophageal reflux disease during pregnancy Gastroenterol Clin N Am 200332235-61
bull 31 Marrero JM Goggin PM de Caestecker JS Pearce JM Maxwell JD Determinants of pregnancy heartburn Br J Obstet Gynaecol 199299731-4
bull 32 Hamaoui E Hamaoui M Nutritional assessment and support during pregnancy Gastroenterol Clin N Am 20033259-121
bull 33 King JC Physiology of pregnancy and nutrient metabolism Am J Clin Nutr 200071(suppl)1218s-25s
bull 34 Casanueva E Pfeffer F Fernandez-Gaxiola AC Gutierrez- Valenzuela V Rothenberg SJ Iron and folate status before pregnancy and anemia during pregnancy Ann Nutr Metab 2003 4760-3
bull 35 Chrsquong CL Morgan M Hainsworth I Kingham JG Prospective study of liver dysfunction in Southwest Wales Gut 200251 876-80
bull 36 Rahman TM Wendon J Severe hepatic dysfunction in pregnancy QJM 200295343-57
bull 37 Knox TA Olans LB Liver disease in pregnancy N Engl J Med 1996335569-76
bull 38 Saftlas AF Olson DR Franks AL Atrash H Pokras R Epidemiology of preeclampsia and eclampsia in the United States 1979e1986 Am J Obstet Gynecol 1990163460-5
bull 39 Walker JJ Pre-eclampsia Lancet 20003561260-5
bull 40 Davidson JM Renal disorders in pregnancy Curr Opin Obstet Gynecol 200113109-14
bull 41 Dafnis E Sabatini S The effect of pregnancy on renal function physiology and pathophysiologyAmJMedSci 1992303184-205
bull 42 Davison JM Shiells EA Philips PR Lindheimer MD Serial evaluation of vasopressin release and thirst in human pregnancy Role of human chorionic gonadotrophin in the osmoregulatory changes of gestation J Clin Invest 198881798-806
bull 43 Glinoer D de Nayer P Bourdoux P Lemone M Robyn C van Steirteghem A et al Regulation of maternal thyroid during pregnancy J Clin Endocrinol Metab 199071276-87
bull 44 Wilson SG Retallack RW Kent JC Worth GK Gutteridge DH Serum free 125-dihydroxyvitamin D and the free 125- dihydroxyvitamin D index during a longitudinal study of human pregnancy and lactation Clin Endocrinol 199032613-22
bull 45 Rasmussen N Frolich A Hornnes PJ Hegedus L Serum ionized calcium and intact parathyroid hormone levels during pregnancy and postpartum Br J Obstet Gynaecol 199097857-9
bull 46 Guyton AC Textbook of medical physiology 8th ed Philadelphia W B Saunders 1991 p 915e28
bull 47 Trainer PJ Corticosteroids and pregnancy Semin Reprod Med 200220375-80
bull 48 Soory M Hormonal factors in periodontal disease Dent Update 200027380-3
bull 49 Hugoson A Gingivitis in pregnant women A longitudinal clinical study Odontol Revy 19712265-84
bull 50 Neville BW Damm DD Allen CM Bouquot JE Oral amp Maxillofacial Pathology 3rd ed Philadelphia W B Saunders 2002 p 329-30 447-9
bull 51 Tilakaratne A Soory M Ranasinghe AW Corea SM Ekanayake SL de Silva M Periodontal disease status during pregnancy and 3 months post-partum in rural population of Sri-Lankan women J Clin Periodontol 200027787-92
bull 52 Laine M Tenovuo J Lehtonen OP Ojanatko-Harri A Vilja P Tuohimaa P Pregnancy e related changes in human whole saliva Arch Oral Biol 198833913-7
bull 53 Yuan K Wing LY Lin MT Pathogenetic roles of angiogenic factors in pyogenic granulomas in pregnancy are modulated by female sex hormones J Periodontol 200273701-8
bull 54 Evans RD Briggs PF Tooth-surface loss related to pregnancyinduced vomiting Prim Dent Care 1994124-6
bull 55 Salvolini E Di Giorgio R Curatola A Mazzanti L Fratto G Biochemical modifications of human whole saliva induced by pregnancy Br J Obstet Gynaec 1998105656-60
bull 56 Mauldin JG Newman RB Preterm birth risk assessment Semin Perinatol 200125215-22
bull 57 Heine RP McGregor JA Goodwin TM Artal R Hayashi RH Robertson PA et al Serial salivary estriol to detect an increased risk of preterm birth Obstet Gynecol 200096490-7
bull 58 Kauh YC Zachian TF Melasma Adv Exp Med Biol 1999455 491-9
bull 59 Wong RC Ellis CN Physiologic skin changes in pregnancy J Am Acad Dermatol 198410929-40
bull 60 Errickson CV Matus NR Skin disorders of pregnancy Am Fam Physician 199449605-10
bull 61 Lopez NJ Smith PC Gutierrez J Periodontal therapy may reduce the risk of preterm low birth weight in women with periodontal disease a randomized controlled trial J Periodontol 200273911-24
bull 62 McGaw T Periodontal disease and preterm delivery of lowbirth- weight infants J Can Dent Assoc 200268165-9
bull 63 Richards AG Dental x-ray protection Dent Clin North Am 1968631-41
bull 64 1990 Recommendations of the International Commission on Radiological Protection Ann ICRP 1991211-201
bull 65 Hall EJ Radiation the two-edged sword cancer risks at high and low doses Cancer J 20006343-50
bull 66 Diethelm L Xu H Diagnostic imaging of the lung during pregnancy Clin Obstet Gynecol 19963936-55
bull 67 Brent RL The effects of embryonic and fetal exposure to x-rays microwaves and ultrasound ClinObstetGynecol 198326484-510
bull 68 National Council on Radiation Protection NCRP report no128 1998 Bethesda Md Author
bull 69 Wasylko L Matsui D Dykxhoorn SM Reider MJ Weinberg S A review of common dental treatments during pregnancy implications for patients and dental personnel J Can Dent Assoc 199864434-9
bull 70 Freeman JP Brand JW Radiation doses of commonly used dental radiographic surveys Oral Surg Oral Med Oral Pathol 199477285-9
bull 71 Kircos LTAngin LL Lorton LOrder ofmagnitude dose reduction in intraoral radiography J Am Dent Assoc 1987114344-7
bull 72 Updegrave WJ Simplified and standardized intraoral radiography with reduced tissue irradiation J Am Dent Assoc 197285861-9
bull 73 Wood RE Harris AM van der Merwe EJ Nortje CJ The leaded apron revisited does it reduce gonadal radiation dose in dental radiology Oral Surg Oral Med Oral Pathol 199171642-6
bull 74 An update on radiographic practices information and recommendations ADA Council on Scientific Affairs J Am Dent Assoc 2001132234-8
bull 75 Rayburn WF Recommending medications during pregnancy an evidence based approach Clin Obstet Gynecol 2002451-5
bull 76 Rathmell JP Viscomi C Ashburn MA Management of nonobstetric pain during pregnancy and lactation Anesth Analg 1997851074-87
bull 77 Teratology society public affairs committee FDA classification of drugs for teratogenic risk Teratology 199449446-7
bull 78 Moore PA Selecting drugs for the pregnant dental patient J Am Dent Assoc 19981291281-6
bull 79 Haas DA An update on analgesics for the management of acute postoperative dental pain J Can Dent Assoc 200268476-82
bull 80 Haas DA Pynn BR Sands TD Drug use for the pregnant or lactating patient Gen Dent 20004854-60
bull 81 Committee on Drugs American Academy of Pediatrics The transfer of drugs and other chemicals into human milk Pediatrics 199493137-50
bull 82 Nielsen GL Sorensen HT Larsen H Pedersen L Risk of adverse birth outcome and miscarriage in pregnant users of nonsteroidal anti-inflammatory drugs population based observational study and case-control study BMJ 2001322266-70
bull 83 Janssen N Genta M The effects of immunosuppressive and anti-inflammatory medications on fertility pregnancy and lactation Arch Intern Med 200016610-9
bull 84 Ostensen M Nonsteroidal anti-inflammatory drugs during pregnancy Scand J Rheumatol Suppl 1998107128-32
bull 85 USPDI -Drug information for the health care professional 22nd ed Greenwood Village CO Micromedex 2002 p 152-79
bull 86 Denson DD Coyle DE Thompson GA Santos D Turner PA Myers JA et al Bupivacaine protein binding in the term parturient effects of lactic acidosis Clin Pharmacol Ther 198435702-9
bull 87 Dillon DE Wagner CL Wiest D Newman RB Drug therapy in the nursing mother Obstet Gynecol Clin North Am 199724 675-96
bull 88 Dashe JS Gilstrap LC Antibiotic use in pregnancy Obstet Gynecol Clin North Am 199724617-29
bull 89 American College of Rheumatology Ad hoc Committee on Clinical Guidelines Guidelines for monitoring drug therapy in rheumatoid arthritis Arthritis Rheum 199639723-31
bull 90 Ng PC The fetal and neonatal hypothalamic-pituitary-adrenal axis Arch Dis Child Fetal Neonatal Ed 200082F250-4
bull 91 Crowley P Antenatal corticosteroidsmdashcurrent thinking BJOG 2003110(Suppl 20)77-8
bull 92 ACOG committee opinion antenatal corticosteroid therapy for fetal maturation Obstet Gynecol 200299871-3
bull 93 Ost L Wettrell G Bjorkhem I Rane A Prednisolone excretion in human milk J Pediatr 19851061008-11
bull 94 Rowland AS Baird DD Shore DL Weinberg CR Savitz DA Wilcox AJ Nitrous oxide and spontaneous abortion in female dental assistants Am J Epidemiol 1995141531-8
bull 95 McGlothlin JD Jensen PA Fischbach TJ Hughes RT Jones JH Control of anesthetic gases in dental operatories Scand J Work Environ Health 199218(Suppl 2)103-5
bull ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY Volume 97 Number 6 Suresh and Radfar 681
bull 96 Rosen MA Nitrous oxide for relief of labor pain a systematic review Am J Obstet Gynecol 2002186(Suppl Nature)S110-6
bull 97 Sands TD Pynn BR Management considerations for the pregnant or nursing emergency patient Ont Dent 199875 17-9
bull 98 Daya S Recurrent spontaneous early pregnancy loss and low dose aspirin Minerva Ginecol 200355441-9
bull 99 Sinclair C Handbook of obstetrical emergencies 1st ed Philadelphia WB Saunders 1996 p 29-39 69
bull 100 Tarsitano BF Rollings RE The pregnant dental patient evaluation and management Gen Dent 199341226-34
bull 101 Livingston MH Dlllinger TM Holder R Consideration in the management of the pregnant patient SCD Special Care in Dentistry 199818183-8
Thank you
- A Review on the principle of Dental Management of the Pregnant patient
- Slide 2
- Questions that a dentist may ask
- Stages of Pregnancy
- Slide 5
- Slide 6
- Physiologic Changes in Pregnancy
- Systemic changes in pregnancy
- FLAT SUPINE POSITIONING
- SUPINE HYPOTENSION SYNDROME (Vena Cava Compression)
- Supine Hypotension Syndrome
- Slide 12
- Supine Hypotension Syndrome
- Prevention of Supine Hypotensive Syndrome
- Treatment of Supine Hypotensive Syndrome
- How should the pregnant woman be positioned
- Slide 17
- Slide 18
- Slide 19
- Slide 20
- Slide 21
- Slide 22
- Slide 23
- Pregnancy Related Oral Health Problems
- Oral Problems in Pregnancy
- Pregnancy Gingivitis Pathophysiology
- Pregnancy Gingivitis
- Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Gum Problems - Pregnancy Granuloma
- Slide 31
- Gum Changes - Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Candidiasis
- Pregnancy Myths
- Other Oral Conditions in Pregnancy
- Changes During Pregnancy that Affect Oral Health
- Saliva changes
- Increased Bacteria
- Slide 40
- Enamel erosion caused by frequent vomiting
- Treatment for Acid Exposure
- Oral Diseases Can Effect Pregnancy
- Periodontal Disease and Preterm Labor
- Periodontal Disease and Low Birth Weight
- Periodontal Disease and Preeclampsia
- Periodontitis and Pre-eclampsia
- Dental Considerations
- Treatment Timing
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Slide 52
- Use of Radiation on Pregnant Patient
- Radiographs during Pregnancy
- Risks of Dental X-Rays
- FDA drug classification for pregnancy
- Slide 57
- FDA drug classification for pregnancy
- Slide 59
- Slide 60
- Slide 61
- Common Analgesics
- Analgesics
- Analgesics - continued
- Analgesics to Use During 1st and 2nd Trimester
- Analgesics to Avoid During the Third Trimester
- Sedation in Pregnancy
- Common Antibiotics
- Antibiotics
- Antibiotics To Use During Pregnancy
- Antibiotics to Avoid during Pregnancy
- The Problem With Tetracycline
- Other Antimicrobial Agents
- Local Anesthetic Use in Pregnancy
- Use of Local Anesthetics
- Ulcer healing drugs
- Slide 77
- Slide 78
- Slide 79
- Use of Nitrous Oxide Gas
- Common Preventives
- Are topical agents safe
- Pre-natal Fluoride
- Is it safe to use mercury restorations
- References
- REFERENCES
- Slide 87
- Slide 88
- Slide 89
- Slide 90
- Slide 91
- Slide 92
- Slide 93
- Slide 94
- Slide 95
- Slide 96
- Slide 97
- Slide 98
- Thank you
-
Treatment Timing
bull First Trimesterndash Spontaneous miscarriages naturally occur
more often in 1st trimesterndash Avoid elective treatment that can be delayedndash Offer anticipatory guidance
bull Second Trimesterndash The optimal time for dental treatmentndash Organogenesis complete fetus not largendash Easier to prevent than treat established disease
bull Third Trimesterndash Late in term very uncomfortable (short visits)ndash Position slightly on left side
Timing of Dental Treatment During Pregnancy - From Little and Fallace
First Trimester
bull Plaque controlbull Oral hygiene instructionbull Scaling polishing curettagebull Avoid elective treatment urgent care
only
Timing of Dental Treatment During Pregnancy - From Little and Fallace
Second Trimester
bull Plaque controlbull Oral hygiene instructionbull Scaling polishing curettagebull Routine dental care
Timing of Dental Treatment During Pregnancy - From Little and Fallace
Third Trimester
bull Plaque controlbull Oral hygiene instructionbull Scaling polishing curettagebull Routine dental care (after middle of third
trimester elective care should be avoided)
Use of Radiation on Pregnant Patientbull Dose given and time of gestation are
importantbull doses lt 5-10 rads (cGy) not teratogenicbull fetus is most susceptible to radiation
between the 2nd and 6th week of gestationbull single dental x-ray exposes patient to 001
millirads of radiation In relative terms this amount is 40 times less than daily dose acquired from cosmic radiation Therefore diagnostic radiation should not be withheld during pregnancy
Radiographs during Pregnancy
bull Take as needed with optimal methods for reducing secondary radiation and exposure time
bull Always use a lead apronbull Exposure to fetus (with apron use) is 00001
centiGray(rad)bull Daily cosmic radiation - 0004 centiGray (rad)
Risks of Dental X-Rays
bull X-ray only if necessary (ie root canal therapy trauma)
bull When x-rays are indicated radiation exposure is extremely low
bull Exposure can be limited byndash Lead apron shielding ndash Modern fast film ndash Avoiding retakes
FDA drug classification for pregnancybull Combines risk statements including
congenital anomalies fetal effects perinatal risks and therapeutic risk-benefit ratio
bull Untreated disease or condition may pose more serious risks to both mother and fetus than any theoretical risks from the medication
bull Category A thru D and X
FDA drug classification for pregnancy
bull A = Controlled Studies in women fail to demonstrate a risk to the fetus in the first trimester and the possibility of fetal harm appears remote
FDA drug classification for pregnancy
bull B = Animal studies show no risk or if risk shown in animals controlled
trials in women showed no risk
FDA drug classification for pregnancy
bull C = Studies in animals with adverse effects and no human studies
OR no animal or human studies but benefits of use may outweigh potential harms
FDA drug classification for pregnancy
bull D = There is evidence of human fetal risk but benefits may outweigh risks
FDA drug classification for pregnancy
bull X = Contraindicated
Common Analgesics
bull paracetamol (B)bull Ibuprofen (BD) bull Oxycodone (BD) bull Hydrocodone and codeine
(CD)
avoid in third trimester
Analgesics
bull Paracetamol is the analgesic of choice for all stages of gestation
bull used to treat mild to moderate pain and fevers
bull short term usage is believed to be safebull avoid chronic and large doses of
paracetamol1048715
Analgesics - continuedbull Aspirin is nonteratogenic but may cause
maternal and fetal hemorrhagebull large and chronic doses during last trimester
may result in premature closure of ductus arteriosus fetal hypertension anemia and low birth weight
bull avoid ibuprofen in 3rd trimester because of possible adverse circulatory effects
bull short term use of codeine seems safebull avoid codeine late in gestation because of
possible fetal respiratory depression and withdrawal symptoms
Analgesics to Use During1st and 2nd Trimester
bull Category B (for best)bull Paracetamol Ibuprofenbull Naproxenbull Category C (use with caution)bull Paracetamol with codeine or
hydrocodonebull Paracetamol with oxycodone
Analgesics to Avoid During theThird Trimesterbull Causes delivery problemsbull Aspirin (C 3D)bull Ibuprofen (B3D)bull Naproxen (B3D)bull Causes neonatal respiratory
depression and opioid withdrawalbull Codeine (C3D)bull Hydrocodone (C3D)bull Oxycodone(C3D)
Sedation in Pregnancy
bull SedativesAnxiolytics (eg Diazepam ) are rated D and can cause oral clefts with prolonged exposure
bull Nitrous oxide should not be used in 1st trimester (If used in 2nd and 3rd do not go below 50 O2)
Common Antibioticsbull To treat oral abscess or cellulitis
ndash Penicillin (B) ndash Amoxicillin (B) ndash Cephalexin (B)ndash Erythromycin base (B) (Not estolate as it
cause cholestatic hepatitis)ndash Clindamycin (B)
Antibioticsbull penicillin V and amoxicillin is preferred drug
for mild to moderate infectionsbull widely used for many years with no ill effectsbull no studies show penicillin to be teratogenicbull amoxicillin extensively used without harming
the fetusbull Drug classes1048715 B penicillin cephalosporins erythromycin clindamycin Azithromycin D Tetracycline
Antibiotics To Use During Pregnancy
bull Penicillin Vbull Amoxicillinbull Erythromycin (base form)bull Cephalexin cephalosporinbull Clindamycinbull Metronidazole
Antibiotics to Avoid duringPregnancy
bull Doxycyclinebull Tetracyclinebull Erythromycin (estolate form)bull Vancomycin
The Problem With Tetracycline
bull Accumulates in bones and chelates calcium
bull Inhibits bone growthbull Discolors teeth
Other Antimicrobial Agentsbull OK to usebull Nystatin (B)bull Chlorhexidine rinse (B)bull Use with cautionbull Clotrimazole (C)bull Ketoconazole (C)bull Fluconazole (C)bull Do not usebull Doxycycline (D)
Local Anesthetic Use inPregnancy
bull Class Bbull Lidocaine (Xylocaine)bull Etidocainebull Prilocaine bull Class Cbull Procainebull Bupivicainebull Mepivicaine
Use of Local Anestheticsbull Lidocaine + vasoconstrictor most common
local anesthetic used in dentistrybull extensively used in pregnancy with no proven ill
effectsbull accidental intravascular injections of lidocaine
pass through the placenta but the concentrations are too low to harm fetus
bull prilocaine might cause methemoglobinemia
Ulcer healing drugsCimetidine bull FDA category B Famotidinebull FDA category BRanitidinebull FDA category Bbull not known to be harmful
Ulcer healing drugsOmeprazolebull FDA category BNot known to be
harmful Esomeprazolebull FDA category BLansoprazolebull FDA category BPantoprazolebull Avoid unless potential benefit
outweighs riskmdashfetotoxic in animals
Ulcer healing drugs
Misoprostolbull First second third trimesters Avoidmdash
potent uterine stimulant (has been used to induce abortion) and may be teratogenic
Ulcer healing drugs
Antacidsbull Almunium hydroxideMagnesium
hydroxidemdashFDA category B Calcium carbonatemdashFDA category C
SimetheconemdashFDA category C
Use of Nitrous Oxide Gas
bull used over 150 years bull safety is being debatedbull SHORT TERM exposure do not cause
birth defects or spontaneous abortionbull CHRONIC exposure may result in fetal
loss and infertilitybull literature suggests that nitrous oxide
should be avoided until more conclusive research is available
bull FDA Drug class not yet assigned
Common Preventives
bull Fluoridendash No increased risk during pregnancy
bull Xylitolndash No studies no harm reported
bull Chlorhexidinendash No increased risk during pregnancy
Are topical agents safe
bull Fluoridebull Toothpaste amp mouthrinse
bull Xylitol chewing gum bull Chlorhexidine (11 alcohol)bull No over the counter mouthrinses with
alcohol (Listerine 20 alcohol)
Pre-natal Fluoride
bull Daily 22 mg tablet of sodium fluoride during 3rd through 9th months
bull decreases caries rate in offspringbull Safe and effective
Glenn FB 1982
Is it safe to use mercury restorations
bull No evidence of harmful effect
bull Benefits outweigh risks
bull Canada Germany and New Zealand have some restrictions
bull Determine the best option
Referencesbull Wasylko L Matsui D Dykxhoorn SM Rieder MJ Weinberg
S A Review of Common Dental Treatments During Pregnancy J Canadian Dental Association 64434-439 1998
bull Little JW Donald AF Craig SM Rhodus NL Dental Management of the Medically Compromised Patient - 5th edition Mosby Toronto Pp434-442 1997
bull Livingston HM Dellinger TM Holder R Considerations in the management of the pregnant patient Special Care in Dentistry 185 pp183-188 1998
bull Larimore WL Petrie KA Drug use during pregnacy and lactation Primary Care Clinics in Office Practice 271 35-53 2000
bull Health Canada The Safety of DentalAmalgam Minister Of Supply and Services Canada 1996
REFERENCESbull 1 Weiss G Endocrinology of parturition J Clin
Endocrinol Metab 2000854421-5bull 2 Theunissen IM Parer JT Fluid and electrolytes in
pregnancy Clin Obstet Gynecol 1994373-15bull 3 Duvekot JJ Peeters LLH Renal hemodynamics and
volume homeostasis in pregnancy Obstet Gynecol Surv 199449830-9
bull 4 Barron WM Lindheimer MD Medical disorders during pregnancy 2nd ed St Louis Mosby 1995 p 129
bull 5 Thornburg KL Jacobson SL Giraud GD Morton MJ Hemodynamic changes in pregnancy Semin Perinatol 20002411-4
bull 6 Fiese R Herzog S Issues in dental and surgical management of the pregnant patient Oral Surg Oral Med Oral Pathol 198865292-7
bull 7 Martin C Varner MW Physiologic changes in pregnancysurgical implications Clin Obstet Gynecol 199437241-55
bull 8 Clark SL Cotton DB Lee W Bishop C Hill T Southwick J et al Central hemodynamic assessment of normal term pregnancy Am J Obstet Gynecol 19891611439-42
bull 9 Mabie WC Di Sessa TG Crocker LG Sibai BM Arheart KL A longitudinal study of cardiac output in normal human pregnancy Am J Obstet Gynecol 1994170849-56
bull 10 Clapp JF 3rd Capeless E Cardiovascular function before during and after the first and subsequent pregnancies Am J Cardiol 1997801469-73
bull 11 Duvekot JJ Peeters LL Maternal cardiovascular hemodynamic adaptation to pregnancy Obstet Gynecol Surv 199449(Suppl) S1-14
bull 12 Bhagwat AR Engel PJ Heart disease and pregnancy Cardiol Clin 199513163-78
bull 13 Lanni SM Tillinghast J Silver H Hemodynamic changes and baroreflex gain in the supine hypotensive syndrome Am J Obstet Gynecol 20021871636-41
bull 14 Little JW Falace DA Miller CS Rhodus NL Dental management of the medically compromised patient 6th ed St Louis Mosby 2002 p 303
bull 15 Garcia-Rio F Pino JM Gomez L Alvarez-Sala R Villasante C Villamor J Regulation of breathing and perception of dyspnea in healthy pregnant women Chest 1996110446-53
bull 16 McAuliffe F Kametas N Costello J Rafferty GF Greenough A Nicolaides K Respiratory function in singleton and twin pregnancy BJOG 2002109765-9
bull 17 Clapp JF 3rd Seaward BL Sleamaker RH Hiser J Maternal physiologic adaptations to early human pregnancy Am J Obstet Gynecol 19881591456-60
bull 18 OrsquoDay MP Cardio-respiratory physiological adaptation of pregnancy Semin Perinatol 199721268-75
bull 19 Contreras G Gutierrez M Beroiza T Fantin A Oddo H Villarroel L et al Ventilatory drive and respiratory muscle function in pregnancy Am Rev Respir Dis 1991144837-41
bull 20 Turner M Aziz SR Management of the pregnant oral and maxillofac
bull 21 Sifakis S Pharmakides G Anemia in pregnancy Ann N Y Acad Sci 2000900125-36
bull 22 Branch DW Physiologic adaptations of pregnancy Am J Reprod Immunol 199228120-2
bull 23 Burrows RF Kelton JG Incidentally detected thrombocytopenia in healthy mothers and their infants N Engl J Med 1988319 142-5
bull 24 Hanly JG Antiphospholipid syndrome an overview CMAJ 200324(168)1675-82
bull 25 Heilmann L von Tempelhoff GF Pollow K Antiphospholipid syndrome in obstetrics Clin Appl Thromb Hemost 20039 143-50
bull 26 Sherman P Flaxman SM Nausea and vomiting of pregnancy in an evolutionary perspective Am J Obstet Gynecol 2002 185(Suppl)s190-7
bull 27 Koch KL Gastrointestinal factors in nausea and vomiting of pregnancy Am J Obstet Gynecol 2002185(Suppl)s198-203
bull 28 Koch KL Frissora CL Nausea and vomiting during pregnancy Gastroenterol Clin N Am 200332201-34
bull 29 Baron TH Ramirez B Richter JE Gastrointestinal motility disorders during pregnancy Ann Intern Med 1993118 366-75
bull 30 Richter JE Gastroesophageal reflux disease during pregnancy Gastroenterol Clin N Am 200332235-61
bull 31 Marrero JM Goggin PM de Caestecker JS Pearce JM Maxwell JD Determinants of pregnancy heartburn Br J Obstet Gynaecol 199299731-4
bull 32 Hamaoui E Hamaoui M Nutritional assessment and support during pregnancy Gastroenterol Clin N Am 20033259-121
bull 33 King JC Physiology of pregnancy and nutrient metabolism Am J Clin Nutr 200071(suppl)1218s-25s
bull 34 Casanueva E Pfeffer F Fernandez-Gaxiola AC Gutierrez- Valenzuela V Rothenberg SJ Iron and folate status before pregnancy and anemia during pregnancy Ann Nutr Metab 2003 4760-3
bull 35 Chrsquong CL Morgan M Hainsworth I Kingham JG Prospective study of liver dysfunction in Southwest Wales Gut 200251 876-80
bull 36 Rahman TM Wendon J Severe hepatic dysfunction in pregnancy QJM 200295343-57
bull 37 Knox TA Olans LB Liver disease in pregnancy N Engl J Med 1996335569-76
bull 38 Saftlas AF Olson DR Franks AL Atrash H Pokras R Epidemiology of preeclampsia and eclampsia in the United States 1979e1986 Am J Obstet Gynecol 1990163460-5
bull 39 Walker JJ Pre-eclampsia Lancet 20003561260-5
bull 40 Davidson JM Renal disorders in pregnancy Curr Opin Obstet Gynecol 200113109-14
bull 41 Dafnis E Sabatini S The effect of pregnancy on renal function physiology and pathophysiologyAmJMedSci 1992303184-205
bull 42 Davison JM Shiells EA Philips PR Lindheimer MD Serial evaluation of vasopressin release and thirst in human pregnancy Role of human chorionic gonadotrophin in the osmoregulatory changes of gestation J Clin Invest 198881798-806
bull 43 Glinoer D de Nayer P Bourdoux P Lemone M Robyn C van Steirteghem A et al Regulation of maternal thyroid during pregnancy J Clin Endocrinol Metab 199071276-87
bull 44 Wilson SG Retallack RW Kent JC Worth GK Gutteridge DH Serum free 125-dihydroxyvitamin D and the free 125- dihydroxyvitamin D index during a longitudinal study of human pregnancy and lactation Clin Endocrinol 199032613-22
bull 45 Rasmussen N Frolich A Hornnes PJ Hegedus L Serum ionized calcium and intact parathyroid hormone levels during pregnancy and postpartum Br J Obstet Gynaecol 199097857-9
bull 46 Guyton AC Textbook of medical physiology 8th ed Philadelphia W B Saunders 1991 p 915e28
bull 47 Trainer PJ Corticosteroids and pregnancy Semin Reprod Med 200220375-80
bull 48 Soory M Hormonal factors in periodontal disease Dent Update 200027380-3
bull 49 Hugoson A Gingivitis in pregnant women A longitudinal clinical study Odontol Revy 19712265-84
bull 50 Neville BW Damm DD Allen CM Bouquot JE Oral amp Maxillofacial Pathology 3rd ed Philadelphia W B Saunders 2002 p 329-30 447-9
bull 51 Tilakaratne A Soory M Ranasinghe AW Corea SM Ekanayake SL de Silva M Periodontal disease status during pregnancy and 3 months post-partum in rural population of Sri-Lankan women J Clin Periodontol 200027787-92
bull 52 Laine M Tenovuo J Lehtonen OP Ojanatko-Harri A Vilja P Tuohimaa P Pregnancy e related changes in human whole saliva Arch Oral Biol 198833913-7
bull 53 Yuan K Wing LY Lin MT Pathogenetic roles of angiogenic factors in pyogenic granulomas in pregnancy are modulated by female sex hormones J Periodontol 200273701-8
bull 54 Evans RD Briggs PF Tooth-surface loss related to pregnancyinduced vomiting Prim Dent Care 1994124-6
bull 55 Salvolini E Di Giorgio R Curatola A Mazzanti L Fratto G Biochemical modifications of human whole saliva induced by pregnancy Br J Obstet Gynaec 1998105656-60
bull 56 Mauldin JG Newman RB Preterm birth risk assessment Semin Perinatol 200125215-22
bull 57 Heine RP McGregor JA Goodwin TM Artal R Hayashi RH Robertson PA et al Serial salivary estriol to detect an increased risk of preterm birth Obstet Gynecol 200096490-7
bull 58 Kauh YC Zachian TF Melasma Adv Exp Med Biol 1999455 491-9
bull 59 Wong RC Ellis CN Physiologic skin changes in pregnancy J Am Acad Dermatol 198410929-40
bull 60 Errickson CV Matus NR Skin disorders of pregnancy Am Fam Physician 199449605-10
bull 61 Lopez NJ Smith PC Gutierrez J Periodontal therapy may reduce the risk of preterm low birth weight in women with periodontal disease a randomized controlled trial J Periodontol 200273911-24
bull 62 McGaw T Periodontal disease and preterm delivery of lowbirth- weight infants J Can Dent Assoc 200268165-9
bull 63 Richards AG Dental x-ray protection Dent Clin North Am 1968631-41
bull 64 1990 Recommendations of the International Commission on Radiological Protection Ann ICRP 1991211-201
bull 65 Hall EJ Radiation the two-edged sword cancer risks at high and low doses Cancer J 20006343-50
bull 66 Diethelm L Xu H Diagnostic imaging of the lung during pregnancy Clin Obstet Gynecol 19963936-55
bull 67 Brent RL The effects of embryonic and fetal exposure to x-rays microwaves and ultrasound ClinObstetGynecol 198326484-510
bull 68 National Council on Radiation Protection NCRP report no128 1998 Bethesda Md Author
bull 69 Wasylko L Matsui D Dykxhoorn SM Reider MJ Weinberg S A review of common dental treatments during pregnancy implications for patients and dental personnel J Can Dent Assoc 199864434-9
bull 70 Freeman JP Brand JW Radiation doses of commonly used dental radiographic surveys Oral Surg Oral Med Oral Pathol 199477285-9
bull 71 Kircos LTAngin LL Lorton LOrder ofmagnitude dose reduction in intraoral radiography J Am Dent Assoc 1987114344-7
bull 72 Updegrave WJ Simplified and standardized intraoral radiography with reduced tissue irradiation J Am Dent Assoc 197285861-9
bull 73 Wood RE Harris AM van der Merwe EJ Nortje CJ The leaded apron revisited does it reduce gonadal radiation dose in dental radiology Oral Surg Oral Med Oral Pathol 199171642-6
bull 74 An update on radiographic practices information and recommendations ADA Council on Scientific Affairs J Am Dent Assoc 2001132234-8
bull 75 Rayburn WF Recommending medications during pregnancy an evidence based approach Clin Obstet Gynecol 2002451-5
bull 76 Rathmell JP Viscomi C Ashburn MA Management of nonobstetric pain during pregnancy and lactation Anesth Analg 1997851074-87
bull 77 Teratology society public affairs committee FDA classification of drugs for teratogenic risk Teratology 199449446-7
bull 78 Moore PA Selecting drugs for the pregnant dental patient J Am Dent Assoc 19981291281-6
bull 79 Haas DA An update on analgesics for the management of acute postoperative dental pain J Can Dent Assoc 200268476-82
bull 80 Haas DA Pynn BR Sands TD Drug use for the pregnant or lactating patient Gen Dent 20004854-60
bull 81 Committee on Drugs American Academy of Pediatrics The transfer of drugs and other chemicals into human milk Pediatrics 199493137-50
bull 82 Nielsen GL Sorensen HT Larsen H Pedersen L Risk of adverse birth outcome and miscarriage in pregnant users of nonsteroidal anti-inflammatory drugs population based observational study and case-control study BMJ 2001322266-70
bull 83 Janssen N Genta M The effects of immunosuppressive and anti-inflammatory medications on fertility pregnancy and lactation Arch Intern Med 200016610-9
bull 84 Ostensen M Nonsteroidal anti-inflammatory drugs during pregnancy Scand J Rheumatol Suppl 1998107128-32
bull 85 USPDI -Drug information for the health care professional 22nd ed Greenwood Village CO Micromedex 2002 p 152-79
bull 86 Denson DD Coyle DE Thompson GA Santos D Turner PA Myers JA et al Bupivacaine protein binding in the term parturient effects of lactic acidosis Clin Pharmacol Ther 198435702-9
bull 87 Dillon DE Wagner CL Wiest D Newman RB Drug therapy in the nursing mother Obstet Gynecol Clin North Am 199724 675-96
bull 88 Dashe JS Gilstrap LC Antibiotic use in pregnancy Obstet Gynecol Clin North Am 199724617-29
bull 89 American College of Rheumatology Ad hoc Committee on Clinical Guidelines Guidelines for monitoring drug therapy in rheumatoid arthritis Arthritis Rheum 199639723-31
bull 90 Ng PC The fetal and neonatal hypothalamic-pituitary-adrenal axis Arch Dis Child Fetal Neonatal Ed 200082F250-4
bull 91 Crowley P Antenatal corticosteroidsmdashcurrent thinking BJOG 2003110(Suppl 20)77-8
bull 92 ACOG committee opinion antenatal corticosteroid therapy for fetal maturation Obstet Gynecol 200299871-3
bull 93 Ost L Wettrell G Bjorkhem I Rane A Prednisolone excretion in human milk J Pediatr 19851061008-11
bull 94 Rowland AS Baird DD Shore DL Weinberg CR Savitz DA Wilcox AJ Nitrous oxide and spontaneous abortion in female dental assistants Am J Epidemiol 1995141531-8
bull 95 McGlothlin JD Jensen PA Fischbach TJ Hughes RT Jones JH Control of anesthetic gases in dental operatories Scand J Work Environ Health 199218(Suppl 2)103-5
bull ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY Volume 97 Number 6 Suresh and Radfar 681
bull 96 Rosen MA Nitrous oxide for relief of labor pain a systematic review Am J Obstet Gynecol 2002186(Suppl Nature)S110-6
bull 97 Sands TD Pynn BR Management considerations for the pregnant or nursing emergency patient Ont Dent 199875 17-9
bull 98 Daya S Recurrent spontaneous early pregnancy loss and low dose aspirin Minerva Ginecol 200355441-9
bull 99 Sinclair C Handbook of obstetrical emergencies 1st ed Philadelphia WB Saunders 1996 p 29-39 69
bull 100 Tarsitano BF Rollings RE The pregnant dental patient evaluation and management Gen Dent 199341226-34
bull 101 Livingston MH Dlllinger TM Holder R Consideration in the management of the pregnant patient SCD Special Care in Dentistry 199818183-8
Thank you
- A Review on the principle of Dental Management of the Pregnant patient
- Slide 2
- Questions that a dentist may ask
- Stages of Pregnancy
- Slide 5
- Slide 6
- Physiologic Changes in Pregnancy
- Systemic changes in pregnancy
- FLAT SUPINE POSITIONING
- SUPINE HYPOTENSION SYNDROME (Vena Cava Compression)
- Supine Hypotension Syndrome
- Slide 12
- Supine Hypotension Syndrome
- Prevention of Supine Hypotensive Syndrome
- Treatment of Supine Hypotensive Syndrome
- How should the pregnant woman be positioned
- Slide 17
- Slide 18
- Slide 19
- Slide 20
- Slide 21
- Slide 22
- Slide 23
- Pregnancy Related Oral Health Problems
- Oral Problems in Pregnancy
- Pregnancy Gingivitis Pathophysiology
- Pregnancy Gingivitis
- Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Gum Problems - Pregnancy Granuloma
- Slide 31
- Gum Changes - Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Candidiasis
- Pregnancy Myths
- Other Oral Conditions in Pregnancy
- Changes During Pregnancy that Affect Oral Health
- Saliva changes
- Increased Bacteria
- Slide 40
- Enamel erosion caused by frequent vomiting
- Treatment for Acid Exposure
- Oral Diseases Can Effect Pregnancy
- Periodontal Disease and Preterm Labor
- Periodontal Disease and Low Birth Weight
- Periodontal Disease and Preeclampsia
- Periodontitis and Pre-eclampsia
- Dental Considerations
- Treatment Timing
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Slide 52
- Use of Radiation on Pregnant Patient
- Radiographs during Pregnancy
- Risks of Dental X-Rays
- FDA drug classification for pregnancy
- Slide 57
- FDA drug classification for pregnancy
- Slide 59
- Slide 60
- Slide 61
- Common Analgesics
- Analgesics
- Analgesics - continued
- Analgesics to Use During 1st and 2nd Trimester
- Analgesics to Avoid During the Third Trimester
- Sedation in Pregnancy
- Common Antibiotics
- Antibiotics
- Antibiotics To Use During Pregnancy
- Antibiotics to Avoid during Pregnancy
- The Problem With Tetracycline
- Other Antimicrobial Agents
- Local Anesthetic Use in Pregnancy
- Use of Local Anesthetics
- Ulcer healing drugs
- Slide 77
- Slide 78
- Slide 79
- Use of Nitrous Oxide Gas
- Common Preventives
- Are topical agents safe
- Pre-natal Fluoride
- Is it safe to use mercury restorations
- References
- REFERENCES
- Slide 87
- Slide 88
- Slide 89
- Slide 90
- Slide 91
- Slide 92
- Slide 93
- Slide 94
- Slide 95
- Slide 96
- Slide 97
- Slide 98
- Thank you
-
Timing of Dental Treatment During Pregnancy - From Little and Fallace
First Trimester
bull Plaque controlbull Oral hygiene instructionbull Scaling polishing curettagebull Avoid elective treatment urgent care
only
Timing of Dental Treatment During Pregnancy - From Little and Fallace
Second Trimester
bull Plaque controlbull Oral hygiene instructionbull Scaling polishing curettagebull Routine dental care
Timing of Dental Treatment During Pregnancy - From Little and Fallace
Third Trimester
bull Plaque controlbull Oral hygiene instructionbull Scaling polishing curettagebull Routine dental care (after middle of third
trimester elective care should be avoided)
Use of Radiation on Pregnant Patientbull Dose given and time of gestation are
importantbull doses lt 5-10 rads (cGy) not teratogenicbull fetus is most susceptible to radiation
between the 2nd and 6th week of gestationbull single dental x-ray exposes patient to 001
millirads of radiation In relative terms this amount is 40 times less than daily dose acquired from cosmic radiation Therefore diagnostic radiation should not be withheld during pregnancy
Radiographs during Pregnancy
bull Take as needed with optimal methods for reducing secondary radiation and exposure time
bull Always use a lead apronbull Exposure to fetus (with apron use) is 00001
centiGray(rad)bull Daily cosmic radiation - 0004 centiGray (rad)
Risks of Dental X-Rays
bull X-ray only if necessary (ie root canal therapy trauma)
bull When x-rays are indicated radiation exposure is extremely low
bull Exposure can be limited byndash Lead apron shielding ndash Modern fast film ndash Avoiding retakes
FDA drug classification for pregnancybull Combines risk statements including
congenital anomalies fetal effects perinatal risks and therapeutic risk-benefit ratio
bull Untreated disease or condition may pose more serious risks to both mother and fetus than any theoretical risks from the medication
bull Category A thru D and X
FDA drug classification for pregnancy
bull A = Controlled Studies in women fail to demonstrate a risk to the fetus in the first trimester and the possibility of fetal harm appears remote
FDA drug classification for pregnancy
bull B = Animal studies show no risk or if risk shown in animals controlled
trials in women showed no risk
FDA drug classification for pregnancy
bull C = Studies in animals with adverse effects and no human studies
OR no animal or human studies but benefits of use may outweigh potential harms
FDA drug classification for pregnancy
bull D = There is evidence of human fetal risk but benefits may outweigh risks
FDA drug classification for pregnancy
bull X = Contraindicated
Common Analgesics
bull paracetamol (B)bull Ibuprofen (BD) bull Oxycodone (BD) bull Hydrocodone and codeine
(CD)
avoid in third trimester
Analgesics
bull Paracetamol is the analgesic of choice for all stages of gestation
bull used to treat mild to moderate pain and fevers
bull short term usage is believed to be safebull avoid chronic and large doses of
paracetamol1048715
Analgesics - continuedbull Aspirin is nonteratogenic but may cause
maternal and fetal hemorrhagebull large and chronic doses during last trimester
may result in premature closure of ductus arteriosus fetal hypertension anemia and low birth weight
bull avoid ibuprofen in 3rd trimester because of possible adverse circulatory effects
bull short term use of codeine seems safebull avoid codeine late in gestation because of
possible fetal respiratory depression and withdrawal symptoms
Analgesics to Use During1st and 2nd Trimester
bull Category B (for best)bull Paracetamol Ibuprofenbull Naproxenbull Category C (use with caution)bull Paracetamol with codeine or
hydrocodonebull Paracetamol with oxycodone
Analgesics to Avoid During theThird Trimesterbull Causes delivery problemsbull Aspirin (C 3D)bull Ibuprofen (B3D)bull Naproxen (B3D)bull Causes neonatal respiratory
depression and opioid withdrawalbull Codeine (C3D)bull Hydrocodone (C3D)bull Oxycodone(C3D)
Sedation in Pregnancy
bull SedativesAnxiolytics (eg Diazepam ) are rated D and can cause oral clefts with prolonged exposure
bull Nitrous oxide should not be used in 1st trimester (If used in 2nd and 3rd do not go below 50 O2)
Common Antibioticsbull To treat oral abscess or cellulitis
ndash Penicillin (B) ndash Amoxicillin (B) ndash Cephalexin (B)ndash Erythromycin base (B) (Not estolate as it
cause cholestatic hepatitis)ndash Clindamycin (B)
Antibioticsbull penicillin V and amoxicillin is preferred drug
for mild to moderate infectionsbull widely used for many years with no ill effectsbull no studies show penicillin to be teratogenicbull amoxicillin extensively used without harming
the fetusbull Drug classes1048715 B penicillin cephalosporins erythromycin clindamycin Azithromycin D Tetracycline
Antibiotics To Use During Pregnancy
bull Penicillin Vbull Amoxicillinbull Erythromycin (base form)bull Cephalexin cephalosporinbull Clindamycinbull Metronidazole
Antibiotics to Avoid duringPregnancy
bull Doxycyclinebull Tetracyclinebull Erythromycin (estolate form)bull Vancomycin
The Problem With Tetracycline
bull Accumulates in bones and chelates calcium
bull Inhibits bone growthbull Discolors teeth
Other Antimicrobial Agentsbull OK to usebull Nystatin (B)bull Chlorhexidine rinse (B)bull Use with cautionbull Clotrimazole (C)bull Ketoconazole (C)bull Fluconazole (C)bull Do not usebull Doxycycline (D)
Local Anesthetic Use inPregnancy
bull Class Bbull Lidocaine (Xylocaine)bull Etidocainebull Prilocaine bull Class Cbull Procainebull Bupivicainebull Mepivicaine
Use of Local Anestheticsbull Lidocaine + vasoconstrictor most common
local anesthetic used in dentistrybull extensively used in pregnancy with no proven ill
effectsbull accidental intravascular injections of lidocaine
pass through the placenta but the concentrations are too low to harm fetus
bull prilocaine might cause methemoglobinemia
Ulcer healing drugsCimetidine bull FDA category B Famotidinebull FDA category BRanitidinebull FDA category Bbull not known to be harmful
Ulcer healing drugsOmeprazolebull FDA category BNot known to be
harmful Esomeprazolebull FDA category BLansoprazolebull FDA category BPantoprazolebull Avoid unless potential benefit
outweighs riskmdashfetotoxic in animals
Ulcer healing drugs
Misoprostolbull First second third trimesters Avoidmdash
potent uterine stimulant (has been used to induce abortion) and may be teratogenic
Ulcer healing drugs
Antacidsbull Almunium hydroxideMagnesium
hydroxidemdashFDA category B Calcium carbonatemdashFDA category C
SimetheconemdashFDA category C
Use of Nitrous Oxide Gas
bull used over 150 years bull safety is being debatedbull SHORT TERM exposure do not cause
birth defects or spontaneous abortionbull CHRONIC exposure may result in fetal
loss and infertilitybull literature suggests that nitrous oxide
should be avoided until more conclusive research is available
bull FDA Drug class not yet assigned
Common Preventives
bull Fluoridendash No increased risk during pregnancy
bull Xylitolndash No studies no harm reported
bull Chlorhexidinendash No increased risk during pregnancy
Are topical agents safe
bull Fluoridebull Toothpaste amp mouthrinse
bull Xylitol chewing gum bull Chlorhexidine (11 alcohol)bull No over the counter mouthrinses with
alcohol (Listerine 20 alcohol)
Pre-natal Fluoride
bull Daily 22 mg tablet of sodium fluoride during 3rd through 9th months
bull decreases caries rate in offspringbull Safe and effective
Glenn FB 1982
Is it safe to use mercury restorations
bull No evidence of harmful effect
bull Benefits outweigh risks
bull Canada Germany and New Zealand have some restrictions
bull Determine the best option
Referencesbull Wasylko L Matsui D Dykxhoorn SM Rieder MJ Weinberg
S A Review of Common Dental Treatments During Pregnancy J Canadian Dental Association 64434-439 1998
bull Little JW Donald AF Craig SM Rhodus NL Dental Management of the Medically Compromised Patient - 5th edition Mosby Toronto Pp434-442 1997
bull Livingston HM Dellinger TM Holder R Considerations in the management of the pregnant patient Special Care in Dentistry 185 pp183-188 1998
bull Larimore WL Petrie KA Drug use during pregnacy and lactation Primary Care Clinics in Office Practice 271 35-53 2000
bull Health Canada The Safety of DentalAmalgam Minister Of Supply and Services Canada 1996
REFERENCESbull 1 Weiss G Endocrinology of parturition J Clin
Endocrinol Metab 2000854421-5bull 2 Theunissen IM Parer JT Fluid and electrolytes in
pregnancy Clin Obstet Gynecol 1994373-15bull 3 Duvekot JJ Peeters LLH Renal hemodynamics and
volume homeostasis in pregnancy Obstet Gynecol Surv 199449830-9
bull 4 Barron WM Lindheimer MD Medical disorders during pregnancy 2nd ed St Louis Mosby 1995 p 129
bull 5 Thornburg KL Jacobson SL Giraud GD Morton MJ Hemodynamic changes in pregnancy Semin Perinatol 20002411-4
bull 6 Fiese R Herzog S Issues in dental and surgical management of the pregnant patient Oral Surg Oral Med Oral Pathol 198865292-7
bull 7 Martin C Varner MW Physiologic changes in pregnancysurgical implications Clin Obstet Gynecol 199437241-55
bull 8 Clark SL Cotton DB Lee W Bishop C Hill T Southwick J et al Central hemodynamic assessment of normal term pregnancy Am J Obstet Gynecol 19891611439-42
bull 9 Mabie WC Di Sessa TG Crocker LG Sibai BM Arheart KL A longitudinal study of cardiac output in normal human pregnancy Am J Obstet Gynecol 1994170849-56
bull 10 Clapp JF 3rd Capeless E Cardiovascular function before during and after the first and subsequent pregnancies Am J Cardiol 1997801469-73
bull 11 Duvekot JJ Peeters LL Maternal cardiovascular hemodynamic adaptation to pregnancy Obstet Gynecol Surv 199449(Suppl) S1-14
bull 12 Bhagwat AR Engel PJ Heart disease and pregnancy Cardiol Clin 199513163-78
bull 13 Lanni SM Tillinghast J Silver H Hemodynamic changes and baroreflex gain in the supine hypotensive syndrome Am J Obstet Gynecol 20021871636-41
bull 14 Little JW Falace DA Miller CS Rhodus NL Dental management of the medically compromised patient 6th ed St Louis Mosby 2002 p 303
bull 15 Garcia-Rio F Pino JM Gomez L Alvarez-Sala R Villasante C Villamor J Regulation of breathing and perception of dyspnea in healthy pregnant women Chest 1996110446-53
bull 16 McAuliffe F Kametas N Costello J Rafferty GF Greenough A Nicolaides K Respiratory function in singleton and twin pregnancy BJOG 2002109765-9
bull 17 Clapp JF 3rd Seaward BL Sleamaker RH Hiser J Maternal physiologic adaptations to early human pregnancy Am J Obstet Gynecol 19881591456-60
bull 18 OrsquoDay MP Cardio-respiratory physiological adaptation of pregnancy Semin Perinatol 199721268-75
bull 19 Contreras G Gutierrez M Beroiza T Fantin A Oddo H Villarroel L et al Ventilatory drive and respiratory muscle function in pregnancy Am Rev Respir Dis 1991144837-41
bull 20 Turner M Aziz SR Management of the pregnant oral and maxillofac
bull 21 Sifakis S Pharmakides G Anemia in pregnancy Ann N Y Acad Sci 2000900125-36
bull 22 Branch DW Physiologic adaptations of pregnancy Am J Reprod Immunol 199228120-2
bull 23 Burrows RF Kelton JG Incidentally detected thrombocytopenia in healthy mothers and their infants N Engl J Med 1988319 142-5
bull 24 Hanly JG Antiphospholipid syndrome an overview CMAJ 200324(168)1675-82
bull 25 Heilmann L von Tempelhoff GF Pollow K Antiphospholipid syndrome in obstetrics Clin Appl Thromb Hemost 20039 143-50
bull 26 Sherman P Flaxman SM Nausea and vomiting of pregnancy in an evolutionary perspective Am J Obstet Gynecol 2002 185(Suppl)s190-7
bull 27 Koch KL Gastrointestinal factors in nausea and vomiting of pregnancy Am J Obstet Gynecol 2002185(Suppl)s198-203
bull 28 Koch KL Frissora CL Nausea and vomiting during pregnancy Gastroenterol Clin N Am 200332201-34
bull 29 Baron TH Ramirez B Richter JE Gastrointestinal motility disorders during pregnancy Ann Intern Med 1993118 366-75
bull 30 Richter JE Gastroesophageal reflux disease during pregnancy Gastroenterol Clin N Am 200332235-61
bull 31 Marrero JM Goggin PM de Caestecker JS Pearce JM Maxwell JD Determinants of pregnancy heartburn Br J Obstet Gynaecol 199299731-4
bull 32 Hamaoui E Hamaoui M Nutritional assessment and support during pregnancy Gastroenterol Clin N Am 20033259-121
bull 33 King JC Physiology of pregnancy and nutrient metabolism Am J Clin Nutr 200071(suppl)1218s-25s
bull 34 Casanueva E Pfeffer F Fernandez-Gaxiola AC Gutierrez- Valenzuela V Rothenberg SJ Iron and folate status before pregnancy and anemia during pregnancy Ann Nutr Metab 2003 4760-3
bull 35 Chrsquong CL Morgan M Hainsworth I Kingham JG Prospective study of liver dysfunction in Southwest Wales Gut 200251 876-80
bull 36 Rahman TM Wendon J Severe hepatic dysfunction in pregnancy QJM 200295343-57
bull 37 Knox TA Olans LB Liver disease in pregnancy N Engl J Med 1996335569-76
bull 38 Saftlas AF Olson DR Franks AL Atrash H Pokras R Epidemiology of preeclampsia and eclampsia in the United States 1979e1986 Am J Obstet Gynecol 1990163460-5
bull 39 Walker JJ Pre-eclampsia Lancet 20003561260-5
bull 40 Davidson JM Renal disorders in pregnancy Curr Opin Obstet Gynecol 200113109-14
bull 41 Dafnis E Sabatini S The effect of pregnancy on renal function physiology and pathophysiologyAmJMedSci 1992303184-205
bull 42 Davison JM Shiells EA Philips PR Lindheimer MD Serial evaluation of vasopressin release and thirst in human pregnancy Role of human chorionic gonadotrophin in the osmoregulatory changes of gestation J Clin Invest 198881798-806
bull 43 Glinoer D de Nayer P Bourdoux P Lemone M Robyn C van Steirteghem A et al Regulation of maternal thyroid during pregnancy J Clin Endocrinol Metab 199071276-87
bull 44 Wilson SG Retallack RW Kent JC Worth GK Gutteridge DH Serum free 125-dihydroxyvitamin D and the free 125- dihydroxyvitamin D index during a longitudinal study of human pregnancy and lactation Clin Endocrinol 199032613-22
bull 45 Rasmussen N Frolich A Hornnes PJ Hegedus L Serum ionized calcium and intact parathyroid hormone levels during pregnancy and postpartum Br J Obstet Gynaecol 199097857-9
bull 46 Guyton AC Textbook of medical physiology 8th ed Philadelphia W B Saunders 1991 p 915e28
bull 47 Trainer PJ Corticosteroids and pregnancy Semin Reprod Med 200220375-80
bull 48 Soory M Hormonal factors in periodontal disease Dent Update 200027380-3
bull 49 Hugoson A Gingivitis in pregnant women A longitudinal clinical study Odontol Revy 19712265-84
bull 50 Neville BW Damm DD Allen CM Bouquot JE Oral amp Maxillofacial Pathology 3rd ed Philadelphia W B Saunders 2002 p 329-30 447-9
bull 51 Tilakaratne A Soory M Ranasinghe AW Corea SM Ekanayake SL de Silva M Periodontal disease status during pregnancy and 3 months post-partum in rural population of Sri-Lankan women J Clin Periodontol 200027787-92
bull 52 Laine M Tenovuo J Lehtonen OP Ojanatko-Harri A Vilja P Tuohimaa P Pregnancy e related changes in human whole saliva Arch Oral Biol 198833913-7
bull 53 Yuan K Wing LY Lin MT Pathogenetic roles of angiogenic factors in pyogenic granulomas in pregnancy are modulated by female sex hormones J Periodontol 200273701-8
bull 54 Evans RD Briggs PF Tooth-surface loss related to pregnancyinduced vomiting Prim Dent Care 1994124-6
bull 55 Salvolini E Di Giorgio R Curatola A Mazzanti L Fratto G Biochemical modifications of human whole saliva induced by pregnancy Br J Obstet Gynaec 1998105656-60
bull 56 Mauldin JG Newman RB Preterm birth risk assessment Semin Perinatol 200125215-22
bull 57 Heine RP McGregor JA Goodwin TM Artal R Hayashi RH Robertson PA et al Serial salivary estriol to detect an increased risk of preterm birth Obstet Gynecol 200096490-7
bull 58 Kauh YC Zachian TF Melasma Adv Exp Med Biol 1999455 491-9
bull 59 Wong RC Ellis CN Physiologic skin changes in pregnancy J Am Acad Dermatol 198410929-40
bull 60 Errickson CV Matus NR Skin disorders of pregnancy Am Fam Physician 199449605-10
bull 61 Lopez NJ Smith PC Gutierrez J Periodontal therapy may reduce the risk of preterm low birth weight in women with periodontal disease a randomized controlled trial J Periodontol 200273911-24
bull 62 McGaw T Periodontal disease and preterm delivery of lowbirth- weight infants J Can Dent Assoc 200268165-9
bull 63 Richards AG Dental x-ray protection Dent Clin North Am 1968631-41
bull 64 1990 Recommendations of the International Commission on Radiological Protection Ann ICRP 1991211-201
bull 65 Hall EJ Radiation the two-edged sword cancer risks at high and low doses Cancer J 20006343-50
bull 66 Diethelm L Xu H Diagnostic imaging of the lung during pregnancy Clin Obstet Gynecol 19963936-55
bull 67 Brent RL The effects of embryonic and fetal exposure to x-rays microwaves and ultrasound ClinObstetGynecol 198326484-510
bull 68 National Council on Radiation Protection NCRP report no128 1998 Bethesda Md Author
bull 69 Wasylko L Matsui D Dykxhoorn SM Reider MJ Weinberg S A review of common dental treatments during pregnancy implications for patients and dental personnel J Can Dent Assoc 199864434-9
bull 70 Freeman JP Brand JW Radiation doses of commonly used dental radiographic surveys Oral Surg Oral Med Oral Pathol 199477285-9
bull 71 Kircos LTAngin LL Lorton LOrder ofmagnitude dose reduction in intraoral radiography J Am Dent Assoc 1987114344-7
bull 72 Updegrave WJ Simplified and standardized intraoral radiography with reduced tissue irradiation J Am Dent Assoc 197285861-9
bull 73 Wood RE Harris AM van der Merwe EJ Nortje CJ The leaded apron revisited does it reduce gonadal radiation dose in dental radiology Oral Surg Oral Med Oral Pathol 199171642-6
bull 74 An update on radiographic practices information and recommendations ADA Council on Scientific Affairs J Am Dent Assoc 2001132234-8
bull 75 Rayburn WF Recommending medications during pregnancy an evidence based approach Clin Obstet Gynecol 2002451-5
bull 76 Rathmell JP Viscomi C Ashburn MA Management of nonobstetric pain during pregnancy and lactation Anesth Analg 1997851074-87
bull 77 Teratology society public affairs committee FDA classification of drugs for teratogenic risk Teratology 199449446-7
bull 78 Moore PA Selecting drugs for the pregnant dental patient J Am Dent Assoc 19981291281-6
bull 79 Haas DA An update on analgesics for the management of acute postoperative dental pain J Can Dent Assoc 200268476-82
bull 80 Haas DA Pynn BR Sands TD Drug use for the pregnant or lactating patient Gen Dent 20004854-60
bull 81 Committee on Drugs American Academy of Pediatrics The transfer of drugs and other chemicals into human milk Pediatrics 199493137-50
bull 82 Nielsen GL Sorensen HT Larsen H Pedersen L Risk of adverse birth outcome and miscarriage in pregnant users of nonsteroidal anti-inflammatory drugs population based observational study and case-control study BMJ 2001322266-70
bull 83 Janssen N Genta M The effects of immunosuppressive and anti-inflammatory medications on fertility pregnancy and lactation Arch Intern Med 200016610-9
bull 84 Ostensen M Nonsteroidal anti-inflammatory drugs during pregnancy Scand J Rheumatol Suppl 1998107128-32
bull 85 USPDI -Drug information for the health care professional 22nd ed Greenwood Village CO Micromedex 2002 p 152-79
bull 86 Denson DD Coyle DE Thompson GA Santos D Turner PA Myers JA et al Bupivacaine protein binding in the term parturient effects of lactic acidosis Clin Pharmacol Ther 198435702-9
bull 87 Dillon DE Wagner CL Wiest D Newman RB Drug therapy in the nursing mother Obstet Gynecol Clin North Am 199724 675-96
bull 88 Dashe JS Gilstrap LC Antibiotic use in pregnancy Obstet Gynecol Clin North Am 199724617-29
bull 89 American College of Rheumatology Ad hoc Committee on Clinical Guidelines Guidelines for monitoring drug therapy in rheumatoid arthritis Arthritis Rheum 199639723-31
bull 90 Ng PC The fetal and neonatal hypothalamic-pituitary-adrenal axis Arch Dis Child Fetal Neonatal Ed 200082F250-4
bull 91 Crowley P Antenatal corticosteroidsmdashcurrent thinking BJOG 2003110(Suppl 20)77-8
bull 92 ACOG committee opinion antenatal corticosteroid therapy for fetal maturation Obstet Gynecol 200299871-3
bull 93 Ost L Wettrell G Bjorkhem I Rane A Prednisolone excretion in human milk J Pediatr 19851061008-11
bull 94 Rowland AS Baird DD Shore DL Weinberg CR Savitz DA Wilcox AJ Nitrous oxide and spontaneous abortion in female dental assistants Am J Epidemiol 1995141531-8
bull 95 McGlothlin JD Jensen PA Fischbach TJ Hughes RT Jones JH Control of anesthetic gases in dental operatories Scand J Work Environ Health 199218(Suppl 2)103-5
bull ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY Volume 97 Number 6 Suresh and Radfar 681
bull 96 Rosen MA Nitrous oxide for relief of labor pain a systematic review Am J Obstet Gynecol 2002186(Suppl Nature)S110-6
bull 97 Sands TD Pynn BR Management considerations for the pregnant or nursing emergency patient Ont Dent 199875 17-9
bull 98 Daya S Recurrent spontaneous early pregnancy loss and low dose aspirin Minerva Ginecol 200355441-9
bull 99 Sinclair C Handbook of obstetrical emergencies 1st ed Philadelphia WB Saunders 1996 p 29-39 69
bull 100 Tarsitano BF Rollings RE The pregnant dental patient evaluation and management Gen Dent 199341226-34
bull 101 Livingston MH Dlllinger TM Holder R Consideration in the management of the pregnant patient SCD Special Care in Dentistry 199818183-8
Thank you
- A Review on the principle of Dental Management of the Pregnant patient
- Slide 2
- Questions that a dentist may ask
- Stages of Pregnancy
- Slide 5
- Slide 6
- Physiologic Changes in Pregnancy
- Systemic changes in pregnancy
- FLAT SUPINE POSITIONING
- SUPINE HYPOTENSION SYNDROME (Vena Cava Compression)
- Supine Hypotension Syndrome
- Slide 12
- Supine Hypotension Syndrome
- Prevention of Supine Hypotensive Syndrome
- Treatment of Supine Hypotensive Syndrome
- How should the pregnant woman be positioned
- Slide 17
- Slide 18
- Slide 19
- Slide 20
- Slide 21
- Slide 22
- Slide 23
- Pregnancy Related Oral Health Problems
- Oral Problems in Pregnancy
- Pregnancy Gingivitis Pathophysiology
- Pregnancy Gingivitis
- Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Gum Problems - Pregnancy Granuloma
- Slide 31
- Gum Changes - Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Candidiasis
- Pregnancy Myths
- Other Oral Conditions in Pregnancy
- Changes During Pregnancy that Affect Oral Health
- Saliva changes
- Increased Bacteria
- Slide 40
- Enamel erosion caused by frequent vomiting
- Treatment for Acid Exposure
- Oral Diseases Can Effect Pregnancy
- Periodontal Disease and Preterm Labor
- Periodontal Disease and Low Birth Weight
- Periodontal Disease and Preeclampsia
- Periodontitis and Pre-eclampsia
- Dental Considerations
- Treatment Timing
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Slide 52
- Use of Radiation on Pregnant Patient
- Radiographs during Pregnancy
- Risks of Dental X-Rays
- FDA drug classification for pregnancy
- Slide 57
- FDA drug classification for pregnancy
- Slide 59
- Slide 60
- Slide 61
- Common Analgesics
- Analgesics
- Analgesics - continued
- Analgesics to Use During 1st and 2nd Trimester
- Analgesics to Avoid During the Third Trimester
- Sedation in Pregnancy
- Common Antibiotics
- Antibiotics
- Antibiotics To Use During Pregnancy
- Antibiotics to Avoid during Pregnancy
- The Problem With Tetracycline
- Other Antimicrobial Agents
- Local Anesthetic Use in Pregnancy
- Use of Local Anesthetics
- Ulcer healing drugs
- Slide 77
- Slide 78
- Slide 79
- Use of Nitrous Oxide Gas
- Common Preventives
- Are topical agents safe
- Pre-natal Fluoride
- Is it safe to use mercury restorations
- References
- REFERENCES
- Slide 87
- Slide 88
- Slide 89
- Slide 90
- Slide 91
- Slide 92
- Slide 93
- Slide 94
- Slide 95
- Slide 96
- Slide 97
- Slide 98
- Thank you
-
Timing of Dental Treatment During Pregnancy - From Little and Fallace
Second Trimester
bull Plaque controlbull Oral hygiene instructionbull Scaling polishing curettagebull Routine dental care
Timing of Dental Treatment During Pregnancy - From Little and Fallace
Third Trimester
bull Plaque controlbull Oral hygiene instructionbull Scaling polishing curettagebull Routine dental care (after middle of third
trimester elective care should be avoided)
Use of Radiation on Pregnant Patientbull Dose given and time of gestation are
importantbull doses lt 5-10 rads (cGy) not teratogenicbull fetus is most susceptible to radiation
between the 2nd and 6th week of gestationbull single dental x-ray exposes patient to 001
millirads of radiation In relative terms this amount is 40 times less than daily dose acquired from cosmic radiation Therefore diagnostic radiation should not be withheld during pregnancy
Radiographs during Pregnancy
bull Take as needed with optimal methods for reducing secondary radiation and exposure time
bull Always use a lead apronbull Exposure to fetus (with apron use) is 00001
centiGray(rad)bull Daily cosmic radiation - 0004 centiGray (rad)
Risks of Dental X-Rays
bull X-ray only if necessary (ie root canal therapy trauma)
bull When x-rays are indicated radiation exposure is extremely low
bull Exposure can be limited byndash Lead apron shielding ndash Modern fast film ndash Avoiding retakes
FDA drug classification for pregnancybull Combines risk statements including
congenital anomalies fetal effects perinatal risks and therapeutic risk-benefit ratio
bull Untreated disease or condition may pose more serious risks to both mother and fetus than any theoretical risks from the medication
bull Category A thru D and X
FDA drug classification for pregnancy
bull A = Controlled Studies in women fail to demonstrate a risk to the fetus in the first trimester and the possibility of fetal harm appears remote
FDA drug classification for pregnancy
bull B = Animal studies show no risk or if risk shown in animals controlled
trials in women showed no risk
FDA drug classification for pregnancy
bull C = Studies in animals with adverse effects and no human studies
OR no animal or human studies but benefits of use may outweigh potential harms
FDA drug classification for pregnancy
bull D = There is evidence of human fetal risk but benefits may outweigh risks
FDA drug classification for pregnancy
bull X = Contraindicated
Common Analgesics
bull paracetamol (B)bull Ibuprofen (BD) bull Oxycodone (BD) bull Hydrocodone and codeine
(CD)
avoid in third trimester
Analgesics
bull Paracetamol is the analgesic of choice for all stages of gestation
bull used to treat mild to moderate pain and fevers
bull short term usage is believed to be safebull avoid chronic and large doses of
paracetamol1048715
Analgesics - continuedbull Aspirin is nonteratogenic but may cause
maternal and fetal hemorrhagebull large and chronic doses during last trimester
may result in premature closure of ductus arteriosus fetal hypertension anemia and low birth weight
bull avoid ibuprofen in 3rd trimester because of possible adverse circulatory effects
bull short term use of codeine seems safebull avoid codeine late in gestation because of
possible fetal respiratory depression and withdrawal symptoms
Analgesics to Use During1st and 2nd Trimester
bull Category B (for best)bull Paracetamol Ibuprofenbull Naproxenbull Category C (use with caution)bull Paracetamol with codeine or
hydrocodonebull Paracetamol with oxycodone
Analgesics to Avoid During theThird Trimesterbull Causes delivery problemsbull Aspirin (C 3D)bull Ibuprofen (B3D)bull Naproxen (B3D)bull Causes neonatal respiratory
depression and opioid withdrawalbull Codeine (C3D)bull Hydrocodone (C3D)bull Oxycodone(C3D)
Sedation in Pregnancy
bull SedativesAnxiolytics (eg Diazepam ) are rated D and can cause oral clefts with prolonged exposure
bull Nitrous oxide should not be used in 1st trimester (If used in 2nd and 3rd do not go below 50 O2)
Common Antibioticsbull To treat oral abscess or cellulitis
ndash Penicillin (B) ndash Amoxicillin (B) ndash Cephalexin (B)ndash Erythromycin base (B) (Not estolate as it
cause cholestatic hepatitis)ndash Clindamycin (B)
Antibioticsbull penicillin V and amoxicillin is preferred drug
for mild to moderate infectionsbull widely used for many years with no ill effectsbull no studies show penicillin to be teratogenicbull amoxicillin extensively used without harming
the fetusbull Drug classes1048715 B penicillin cephalosporins erythromycin clindamycin Azithromycin D Tetracycline
Antibiotics To Use During Pregnancy
bull Penicillin Vbull Amoxicillinbull Erythromycin (base form)bull Cephalexin cephalosporinbull Clindamycinbull Metronidazole
Antibiotics to Avoid duringPregnancy
bull Doxycyclinebull Tetracyclinebull Erythromycin (estolate form)bull Vancomycin
The Problem With Tetracycline
bull Accumulates in bones and chelates calcium
bull Inhibits bone growthbull Discolors teeth
Other Antimicrobial Agentsbull OK to usebull Nystatin (B)bull Chlorhexidine rinse (B)bull Use with cautionbull Clotrimazole (C)bull Ketoconazole (C)bull Fluconazole (C)bull Do not usebull Doxycycline (D)
Local Anesthetic Use inPregnancy
bull Class Bbull Lidocaine (Xylocaine)bull Etidocainebull Prilocaine bull Class Cbull Procainebull Bupivicainebull Mepivicaine
Use of Local Anestheticsbull Lidocaine + vasoconstrictor most common
local anesthetic used in dentistrybull extensively used in pregnancy with no proven ill
effectsbull accidental intravascular injections of lidocaine
pass through the placenta but the concentrations are too low to harm fetus
bull prilocaine might cause methemoglobinemia
Ulcer healing drugsCimetidine bull FDA category B Famotidinebull FDA category BRanitidinebull FDA category Bbull not known to be harmful
Ulcer healing drugsOmeprazolebull FDA category BNot known to be
harmful Esomeprazolebull FDA category BLansoprazolebull FDA category BPantoprazolebull Avoid unless potential benefit
outweighs riskmdashfetotoxic in animals
Ulcer healing drugs
Misoprostolbull First second third trimesters Avoidmdash
potent uterine stimulant (has been used to induce abortion) and may be teratogenic
Ulcer healing drugs
Antacidsbull Almunium hydroxideMagnesium
hydroxidemdashFDA category B Calcium carbonatemdashFDA category C
SimetheconemdashFDA category C
Use of Nitrous Oxide Gas
bull used over 150 years bull safety is being debatedbull SHORT TERM exposure do not cause
birth defects or spontaneous abortionbull CHRONIC exposure may result in fetal
loss and infertilitybull literature suggests that nitrous oxide
should be avoided until more conclusive research is available
bull FDA Drug class not yet assigned
Common Preventives
bull Fluoridendash No increased risk during pregnancy
bull Xylitolndash No studies no harm reported
bull Chlorhexidinendash No increased risk during pregnancy
Are topical agents safe
bull Fluoridebull Toothpaste amp mouthrinse
bull Xylitol chewing gum bull Chlorhexidine (11 alcohol)bull No over the counter mouthrinses with
alcohol (Listerine 20 alcohol)
Pre-natal Fluoride
bull Daily 22 mg tablet of sodium fluoride during 3rd through 9th months
bull decreases caries rate in offspringbull Safe and effective
Glenn FB 1982
Is it safe to use mercury restorations
bull No evidence of harmful effect
bull Benefits outweigh risks
bull Canada Germany and New Zealand have some restrictions
bull Determine the best option
Referencesbull Wasylko L Matsui D Dykxhoorn SM Rieder MJ Weinberg
S A Review of Common Dental Treatments During Pregnancy J Canadian Dental Association 64434-439 1998
bull Little JW Donald AF Craig SM Rhodus NL Dental Management of the Medically Compromised Patient - 5th edition Mosby Toronto Pp434-442 1997
bull Livingston HM Dellinger TM Holder R Considerations in the management of the pregnant patient Special Care in Dentistry 185 pp183-188 1998
bull Larimore WL Petrie KA Drug use during pregnacy and lactation Primary Care Clinics in Office Practice 271 35-53 2000
bull Health Canada The Safety of DentalAmalgam Minister Of Supply and Services Canada 1996
REFERENCESbull 1 Weiss G Endocrinology of parturition J Clin
Endocrinol Metab 2000854421-5bull 2 Theunissen IM Parer JT Fluid and electrolytes in
pregnancy Clin Obstet Gynecol 1994373-15bull 3 Duvekot JJ Peeters LLH Renal hemodynamics and
volume homeostasis in pregnancy Obstet Gynecol Surv 199449830-9
bull 4 Barron WM Lindheimer MD Medical disorders during pregnancy 2nd ed St Louis Mosby 1995 p 129
bull 5 Thornburg KL Jacobson SL Giraud GD Morton MJ Hemodynamic changes in pregnancy Semin Perinatol 20002411-4
bull 6 Fiese R Herzog S Issues in dental and surgical management of the pregnant patient Oral Surg Oral Med Oral Pathol 198865292-7
bull 7 Martin C Varner MW Physiologic changes in pregnancysurgical implications Clin Obstet Gynecol 199437241-55
bull 8 Clark SL Cotton DB Lee W Bishop C Hill T Southwick J et al Central hemodynamic assessment of normal term pregnancy Am J Obstet Gynecol 19891611439-42
bull 9 Mabie WC Di Sessa TG Crocker LG Sibai BM Arheart KL A longitudinal study of cardiac output in normal human pregnancy Am J Obstet Gynecol 1994170849-56
bull 10 Clapp JF 3rd Capeless E Cardiovascular function before during and after the first and subsequent pregnancies Am J Cardiol 1997801469-73
bull 11 Duvekot JJ Peeters LL Maternal cardiovascular hemodynamic adaptation to pregnancy Obstet Gynecol Surv 199449(Suppl) S1-14
bull 12 Bhagwat AR Engel PJ Heart disease and pregnancy Cardiol Clin 199513163-78
bull 13 Lanni SM Tillinghast J Silver H Hemodynamic changes and baroreflex gain in the supine hypotensive syndrome Am J Obstet Gynecol 20021871636-41
bull 14 Little JW Falace DA Miller CS Rhodus NL Dental management of the medically compromised patient 6th ed St Louis Mosby 2002 p 303
bull 15 Garcia-Rio F Pino JM Gomez L Alvarez-Sala R Villasante C Villamor J Regulation of breathing and perception of dyspnea in healthy pregnant women Chest 1996110446-53
bull 16 McAuliffe F Kametas N Costello J Rafferty GF Greenough A Nicolaides K Respiratory function in singleton and twin pregnancy BJOG 2002109765-9
bull 17 Clapp JF 3rd Seaward BL Sleamaker RH Hiser J Maternal physiologic adaptations to early human pregnancy Am J Obstet Gynecol 19881591456-60
bull 18 OrsquoDay MP Cardio-respiratory physiological adaptation of pregnancy Semin Perinatol 199721268-75
bull 19 Contreras G Gutierrez M Beroiza T Fantin A Oddo H Villarroel L et al Ventilatory drive and respiratory muscle function in pregnancy Am Rev Respir Dis 1991144837-41
bull 20 Turner M Aziz SR Management of the pregnant oral and maxillofac
bull 21 Sifakis S Pharmakides G Anemia in pregnancy Ann N Y Acad Sci 2000900125-36
bull 22 Branch DW Physiologic adaptations of pregnancy Am J Reprod Immunol 199228120-2
bull 23 Burrows RF Kelton JG Incidentally detected thrombocytopenia in healthy mothers and their infants N Engl J Med 1988319 142-5
bull 24 Hanly JG Antiphospholipid syndrome an overview CMAJ 200324(168)1675-82
bull 25 Heilmann L von Tempelhoff GF Pollow K Antiphospholipid syndrome in obstetrics Clin Appl Thromb Hemost 20039 143-50
bull 26 Sherman P Flaxman SM Nausea and vomiting of pregnancy in an evolutionary perspective Am J Obstet Gynecol 2002 185(Suppl)s190-7
bull 27 Koch KL Gastrointestinal factors in nausea and vomiting of pregnancy Am J Obstet Gynecol 2002185(Suppl)s198-203
bull 28 Koch KL Frissora CL Nausea and vomiting during pregnancy Gastroenterol Clin N Am 200332201-34
bull 29 Baron TH Ramirez B Richter JE Gastrointestinal motility disorders during pregnancy Ann Intern Med 1993118 366-75
bull 30 Richter JE Gastroesophageal reflux disease during pregnancy Gastroenterol Clin N Am 200332235-61
bull 31 Marrero JM Goggin PM de Caestecker JS Pearce JM Maxwell JD Determinants of pregnancy heartburn Br J Obstet Gynaecol 199299731-4
bull 32 Hamaoui E Hamaoui M Nutritional assessment and support during pregnancy Gastroenterol Clin N Am 20033259-121
bull 33 King JC Physiology of pregnancy and nutrient metabolism Am J Clin Nutr 200071(suppl)1218s-25s
bull 34 Casanueva E Pfeffer F Fernandez-Gaxiola AC Gutierrez- Valenzuela V Rothenberg SJ Iron and folate status before pregnancy and anemia during pregnancy Ann Nutr Metab 2003 4760-3
bull 35 Chrsquong CL Morgan M Hainsworth I Kingham JG Prospective study of liver dysfunction in Southwest Wales Gut 200251 876-80
bull 36 Rahman TM Wendon J Severe hepatic dysfunction in pregnancy QJM 200295343-57
bull 37 Knox TA Olans LB Liver disease in pregnancy N Engl J Med 1996335569-76
bull 38 Saftlas AF Olson DR Franks AL Atrash H Pokras R Epidemiology of preeclampsia and eclampsia in the United States 1979e1986 Am J Obstet Gynecol 1990163460-5
bull 39 Walker JJ Pre-eclampsia Lancet 20003561260-5
bull 40 Davidson JM Renal disorders in pregnancy Curr Opin Obstet Gynecol 200113109-14
bull 41 Dafnis E Sabatini S The effect of pregnancy on renal function physiology and pathophysiologyAmJMedSci 1992303184-205
bull 42 Davison JM Shiells EA Philips PR Lindheimer MD Serial evaluation of vasopressin release and thirst in human pregnancy Role of human chorionic gonadotrophin in the osmoregulatory changes of gestation J Clin Invest 198881798-806
bull 43 Glinoer D de Nayer P Bourdoux P Lemone M Robyn C van Steirteghem A et al Regulation of maternal thyroid during pregnancy J Clin Endocrinol Metab 199071276-87
bull 44 Wilson SG Retallack RW Kent JC Worth GK Gutteridge DH Serum free 125-dihydroxyvitamin D and the free 125- dihydroxyvitamin D index during a longitudinal study of human pregnancy and lactation Clin Endocrinol 199032613-22
bull 45 Rasmussen N Frolich A Hornnes PJ Hegedus L Serum ionized calcium and intact parathyroid hormone levels during pregnancy and postpartum Br J Obstet Gynaecol 199097857-9
bull 46 Guyton AC Textbook of medical physiology 8th ed Philadelphia W B Saunders 1991 p 915e28
bull 47 Trainer PJ Corticosteroids and pregnancy Semin Reprod Med 200220375-80
bull 48 Soory M Hormonal factors in periodontal disease Dent Update 200027380-3
bull 49 Hugoson A Gingivitis in pregnant women A longitudinal clinical study Odontol Revy 19712265-84
bull 50 Neville BW Damm DD Allen CM Bouquot JE Oral amp Maxillofacial Pathology 3rd ed Philadelphia W B Saunders 2002 p 329-30 447-9
bull 51 Tilakaratne A Soory M Ranasinghe AW Corea SM Ekanayake SL de Silva M Periodontal disease status during pregnancy and 3 months post-partum in rural population of Sri-Lankan women J Clin Periodontol 200027787-92
bull 52 Laine M Tenovuo J Lehtonen OP Ojanatko-Harri A Vilja P Tuohimaa P Pregnancy e related changes in human whole saliva Arch Oral Biol 198833913-7
bull 53 Yuan K Wing LY Lin MT Pathogenetic roles of angiogenic factors in pyogenic granulomas in pregnancy are modulated by female sex hormones J Periodontol 200273701-8
bull 54 Evans RD Briggs PF Tooth-surface loss related to pregnancyinduced vomiting Prim Dent Care 1994124-6
bull 55 Salvolini E Di Giorgio R Curatola A Mazzanti L Fratto G Biochemical modifications of human whole saliva induced by pregnancy Br J Obstet Gynaec 1998105656-60
bull 56 Mauldin JG Newman RB Preterm birth risk assessment Semin Perinatol 200125215-22
bull 57 Heine RP McGregor JA Goodwin TM Artal R Hayashi RH Robertson PA et al Serial salivary estriol to detect an increased risk of preterm birth Obstet Gynecol 200096490-7
bull 58 Kauh YC Zachian TF Melasma Adv Exp Med Biol 1999455 491-9
bull 59 Wong RC Ellis CN Physiologic skin changes in pregnancy J Am Acad Dermatol 198410929-40
bull 60 Errickson CV Matus NR Skin disorders of pregnancy Am Fam Physician 199449605-10
bull 61 Lopez NJ Smith PC Gutierrez J Periodontal therapy may reduce the risk of preterm low birth weight in women with periodontal disease a randomized controlled trial J Periodontol 200273911-24
bull 62 McGaw T Periodontal disease and preterm delivery of lowbirth- weight infants J Can Dent Assoc 200268165-9
bull 63 Richards AG Dental x-ray protection Dent Clin North Am 1968631-41
bull 64 1990 Recommendations of the International Commission on Radiological Protection Ann ICRP 1991211-201
bull 65 Hall EJ Radiation the two-edged sword cancer risks at high and low doses Cancer J 20006343-50
bull 66 Diethelm L Xu H Diagnostic imaging of the lung during pregnancy Clin Obstet Gynecol 19963936-55
bull 67 Brent RL The effects of embryonic and fetal exposure to x-rays microwaves and ultrasound ClinObstetGynecol 198326484-510
bull 68 National Council on Radiation Protection NCRP report no128 1998 Bethesda Md Author
bull 69 Wasylko L Matsui D Dykxhoorn SM Reider MJ Weinberg S A review of common dental treatments during pregnancy implications for patients and dental personnel J Can Dent Assoc 199864434-9
bull 70 Freeman JP Brand JW Radiation doses of commonly used dental radiographic surveys Oral Surg Oral Med Oral Pathol 199477285-9
bull 71 Kircos LTAngin LL Lorton LOrder ofmagnitude dose reduction in intraoral radiography J Am Dent Assoc 1987114344-7
bull 72 Updegrave WJ Simplified and standardized intraoral radiography with reduced tissue irradiation J Am Dent Assoc 197285861-9
bull 73 Wood RE Harris AM van der Merwe EJ Nortje CJ The leaded apron revisited does it reduce gonadal radiation dose in dental radiology Oral Surg Oral Med Oral Pathol 199171642-6
bull 74 An update on radiographic practices information and recommendations ADA Council on Scientific Affairs J Am Dent Assoc 2001132234-8
bull 75 Rayburn WF Recommending medications during pregnancy an evidence based approach Clin Obstet Gynecol 2002451-5
bull 76 Rathmell JP Viscomi C Ashburn MA Management of nonobstetric pain during pregnancy and lactation Anesth Analg 1997851074-87
bull 77 Teratology society public affairs committee FDA classification of drugs for teratogenic risk Teratology 199449446-7
bull 78 Moore PA Selecting drugs for the pregnant dental patient J Am Dent Assoc 19981291281-6
bull 79 Haas DA An update on analgesics for the management of acute postoperative dental pain J Can Dent Assoc 200268476-82
bull 80 Haas DA Pynn BR Sands TD Drug use for the pregnant or lactating patient Gen Dent 20004854-60
bull 81 Committee on Drugs American Academy of Pediatrics The transfer of drugs and other chemicals into human milk Pediatrics 199493137-50
bull 82 Nielsen GL Sorensen HT Larsen H Pedersen L Risk of adverse birth outcome and miscarriage in pregnant users of nonsteroidal anti-inflammatory drugs population based observational study and case-control study BMJ 2001322266-70
bull 83 Janssen N Genta M The effects of immunosuppressive and anti-inflammatory medications on fertility pregnancy and lactation Arch Intern Med 200016610-9
bull 84 Ostensen M Nonsteroidal anti-inflammatory drugs during pregnancy Scand J Rheumatol Suppl 1998107128-32
bull 85 USPDI -Drug information for the health care professional 22nd ed Greenwood Village CO Micromedex 2002 p 152-79
bull 86 Denson DD Coyle DE Thompson GA Santos D Turner PA Myers JA et al Bupivacaine protein binding in the term parturient effects of lactic acidosis Clin Pharmacol Ther 198435702-9
bull 87 Dillon DE Wagner CL Wiest D Newman RB Drug therapy in the nursing mother Obstet Gynecol Clin North Am 199724 675-96
bull 88 Dashe JS Gilstrap LC Antibiotic use in pregnancy Obstet Gynecol Clin North Am 199724617-29
bull 89 American College of Rheumatology Ad hoc Committee on Clinical Guidelines Guidelines for monitoring drug therapy in rheumatoid arthritis Arthritis Rheum 199639723-31
bull 90 Ng PC The fetal and neonatal hypothalamic-pituitary-adrenal axis Arch Dis Child Fetal Neonatal Ed 200082F250-4
bull 91 Crowley P Antenatal corticosteroidsmdashcurrent thinking BJOG 2003110(Suppl 20)77-8
bull 92 ACOG committee opinion antenatal corticosteroid therapy for fetal maturation Obstet Gynecol 200299871-3
bull 93 Ost L Wettrell G Bjorkhem I Rane A Prednisolone excretion in human milk J Pediatr 19851061008-11
bull 94 Rowland AS Baird DD Shore DL Weinberg CR Savitz DA Wilcox AJ Nitrous oxide and spontaneous abortion in female dental assistants Am J Epidemiol 1995141531-8
bull 95 McGlothlin JD Jensen PA Fischbach TJ Hughes RT Jones JH Control of anesthetic gases in dental operatories Scand J Work Environ Health 199218(Suppl 2)103-5
bull ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY Volume 97 Number 6 Suresh and Radfar 681
bull 96 Rosen MA Nitrous oxide for relief of labor pain a systematic review Am J Obstet Gynecol 2002186(Suppl Nature)S110-6
bull 97 Sands TD Pynn BR Management considerations for the pregnant or nursing emergency patient Ont Dent 199875 17-9
bull 98 Daya S Recurrent spontaneous early pregnancy loss and low dose aspirin Minerva Ginecol 200355441-9
bull 99 Sinclair C Handbook of obstetrical emergencies 1st ed Philadelphia WB Saunders 1996 p 29-39 69
bull 100 Tarsitano BF Rollings RE The pregnant dental patient evaluation and management Gen Dent 199341226-34
bull 101 Livingston MH Dlllinger TM Holder R Consideration in the management of the pregnant patient SCD Special Care in Dentistry 199818183-8
Thank you
- A Review on the principle of Dental Management of the Pregnant patient
- Slide 2
- Questions that a dentist may ask
- Stages of Pregnancy
- Slide 5
- Slide 6
- Physiologic Changes in Pregnancy
- Systemic changes in pregnancy
- FLAT SUPINE POSITIONING
- SUPINE HYPOTENSION SYNDROME (Vena Cava Compression)
- Supine Hypotension Syndrome
- Slide 12
- Supine Hypotension Syndrome
- Prevention of Supine Hypotensive Syndrome
- Treatment of Supine Hypotensive Syndrome
- How should the pregnant woman be positioned
- Slide 17
- Slide 18
- Slide 19
- Slide 20
- Slide 21
- Slide 22
- Slide 23
- Pregnancy Related Oral Health Problems
- Oral Problems in Pregnancy
- Pregnancy Gingivitis Pathophysiology
- Pregnancy Gingivitis
- Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Gum Problems - Pregnancy Granuloma
- Slide 31
- Gum Changes - Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Candidiasis
- Pregnancy Myths
- Other Oral Conditions in Pregnancy
- Changes During Pregnancy that Affect Oral Health
- Saliva changes
- Increased Bacteria
- Slide 40
- Enamel erosion caused by frequent vomiting
- Treatment for Acid Exposure
- Oral Diseases Can Effect Pregnancy
- Periodontal Disease and Preterm Labor
- Periodontal Disease and Low Birth Weight
- Periodontal Disease and Preeclampsia
- Periodontitis and Pre-eclampsia
- Dental Considerations
- Treatment Timing
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Slide 52
- Use of Radiation on Pregnant Patient
- Radiographs during Pregnancy
- Risks of Dental X-Rays
- FDA drug classification for pregnancy
- Slide 57
- FDA drug classification for pregnancy
- Slide 59
- Slide 60
- Slide 61
- Common Analgesics
- Analgesics
- Analgesics - continued
- Analgesics to Use During 1st and 2nd Trimester
- Analgesics to Avoid During the Third Trimester
- Sedation in Pregnancy
- Common Antibiotics
- Antibiotics
- Antibiotics To Use During Pregnancy
- Antibiotics to Avoid during Pregnancy
- The Problem With Tetracycline
- Other Antimicrobial Agents
- Local Anesthetic Use in Pregnancy
- Use of Local Anesthetics
- Ulcer healing drugs
- Slide 77
- Slide 78
- Slide 79
- Use of Nitrous Oxide Gas
- Common Preventives
- Are topical agents safe
- Pre-natal Fluoride
- Is it safe to use mercury restorations
- References
- REFERENCES
- Slide 87
- Slide 88
- Slide 89
- Slide 90
- Slide 91
- Slide 92
- Slide 93
- Slide 94
- Slide 95
- Slide 96
- Slide 97
- Slide 98
- Thank you
-
Timing of Dental Treatment During Pregnancy - From Little and Fallace
Third Trimester
bull Plaque controlbull Oral hygiene instructionbull Scaling polishing curettagebull Routine dental care (after middle of third
trimester elective care should be avoided)
Use of Radiation on Pregnant Patientbull Dose given and time of gestation are
importantbull doses lt 5-10 rads (cGy) not teratogenicbull fetus is most susceptible to radiation
between the 2nd and 6th week of gestationbull single dental x-ray exposes patient to 001
millirads of radiation In relative terms this amount is 40 times less than daily dose acquired from cosmic radiation Therefore diagnostic radiation should not be withheld during pregnancy
Radiographs during Pregnancy
bull Take as needed with optimal methods for reducing secondary radiation and exposure time
bull Always use a lead apronbull Exposure to fetus (with apron use) is 00001
centiGray(rad)bull Daily cosmic radiation - 0004 centiGray (rad)
Risks of Dental X-Rays
bull X-ray only if necessary (ie root canal therapy trauma)
bull When x-rays are indicated radiation exposure is extremely low
bull Exposure can be limited byndash Lead apron shielding ndash Modern fast film ndash Avoiding retakes
FDA drug classification for pregnancybull Combines risk statements including
congenital anomalies fetal effects perinatal risks and therapeutic risk-benefit ratio
bull Untreated disease or condition may pose more serious risks to both mother and fetus than any theoretical risks from the medication
bull Category A thru D and X
FDA drug classification for pregnancy
bull A = Controlled Studies in women fail to demonstrate a risk to the fetus in the first trimester and the possibility of fetal harm appears remote
FDA drug classification for pregnancy
bull B = Animal studies show no risk or if risk shown in animals controlled
trials in women showed no risk
FDA drug classification for pregnancy
bull C = Studies in animals with adverse effects and no human studies
OR no animal or human studies but benefits of use may outweigh potential harms
FDA drug classification for pregnancy
bull D = There is evidence of human fetal risk but benefits may outweigh risks
FDA drug classification for pregnancy
bull X = Contraindicated
Common Analgesics
bull paracetamol (B)bull Ibuprofen (BD) bull Oxycodone (BD) bull Hydrocodone and codeine
(CD)
avoid in third trimester
Analgesics
bull Paracetamol is the analgesic of choice for all stages of gestation
bull used to treat mild to moderate pain and fevers
bull short term usage is believed to be safebull avoid chronic and large doses of
paracetamol1048715
Analgesics - continuedbull Aspirin is nonteratogenic but may cause
maternal and fetal hemorrhagebull large and chronic doses during last trimester
may result in premature closure of ductus arteriosus fetal hypertension anemia and low birth weight
bull avoid ibuprofen in 3rd trimester because of possible adverse circulatory effects
bull short term use of codeine seems safebull avoid codeine late in gestation because of
possible fetal respiratory depression and withdrawal symptoms
Analgesics to Use During1st and 2nd Trimester
bull Category B (for best)bull Paracetamol Ibuprofenbull Naproxenbull Category C (use with caution)bull Paracetamol with codeine or
hydrocodonebull Paracetamol with oxycodone
Analgesics to Avoid During theThird Trimesterbull Causes delivery problemsbull Aspirin (C 3D)bull Ibuprofen (B3D)bull Naproxen (B3D)bull Causes neonatal respiratory
depression and opioid withdrawalbull Codeine (C3D)bull Hydrocodone (C3D)bull Oxycodone(C3D)
Sedation in Pregnancy
bull SedativesAnxiolytics (eg Diazepam ) are rated D and can cause oral clefts with prolonged exposure
bull Nitrous oxide should not be used in 1st trimester (If used in 2nd and 3rd do not go below 50 O2)
Common Antibioticsbull To treat oral abscess or cellulitis
ndash Penicillin (B) ndash Amoxicillin (B) ndash Cephalexin (B)ndash Erythromycin base (B) (Not estolate as it
cause cholestatic hepatitis)ndash Clindamycin (B)
Antibioticsbull penicillin V and amoxicillin is preferred drug
for mild to moderate infectionsbull widely used for many years with no ill effectsbull no studies show penicillin to be teratogenicbull amoxicillin extensively used without harming
the fetusbull Drug classes1048715 B penicillin cephalosporins erythromycin clindamycin Azithromycin D Tetracycline
Antibiotics To Use During Pregnancy
bull Penicillin Vbull Amoxicillinbull Erythromycin (base form)bull Cephalexin cephalosporinbull Clindamycinbull Metronidazole
Antibiotics to Avoid duringPregnancy
bull Doxycyclinebull Tetracyclinebull Erythromycin (estolate form)bull Vancomycin
The Problem With Tetracycline
bull Accumulates in bones and chelates calcium
bull Inhibits bone growthbull Discolors teeth
Other Antimicrobial Agentsbull OK to usebull Nystatin (B)bull Chlorhexidine rinse (B)bull Use with cautionbull Clotrimazole (C)bull Ketoconazole (C)bull Fluconazole (C)bull Do not usebull Doxycycline (D)
Local Anesthetic Use inPregnancy
bull Class Bbull Lidocaine (Xylocaine)bull Etidocainebull Prilocaine bull Class Cbull Procainebull Bupivicainebull Mepivicaine
Use of Local Anestheticsbull Lidocaine + vasoconstrictor most common
local anesthetic used in dentistrybull extensively used in pregnancy with no proven ill
effectsbull accidental intravascular injections of lidocaine
pass through the placenta but the concentrations are too low to harm fetus
bull prilocaine might cause methemoglobinemia
Ulcer healing drugsCimetidine bull FDA category B Famotidinebull FDA category BRanitidinebull FDA category Bbull not known to be harmful
Ulcer healing drugsOmeprazolebull FDA category BNot known to be
harmful Esomeprazolebull FDA category BLansoprazolebull FDA category BPantoprazolebull Avoid unless potential benefit
outweighs riskmdashfetotoxic in animals
Ulcer healing drugs
Misoprostolbull First second third trimesters Avoidmdash
potent uterine stimulant (has been used to induce abortion) and may be teratogenic
Ulcer healing drugs
Antacidsbull Almunium hydroxideMagnesium
hydroxidemdashFDA category B Calcium carbonatemdashFDA category C
SimetheconemdashFDA category C
Use of Nitrous Oxide Gas
bull used over 150 years bull safety is being debatedbull SHORT TERM exposure do not cause
birth defects or spontaneous abortionbull CHRONIC exposure may result in fetal
loss and infertilitybull literature suggests that nitrous oxide
should be avoided until more conclusive research is available
bull FDA Drug class not yet assigned
Common Preventives
bull Fluoridendash No increased risk during pregnancy
bull Xylitolndash No studies no harm reported
bull Chlorhexidinendash No increased risk during pregnancy
Are topical agents safe
bull Fluoridebull Toothpaste amp mouthrinse
bull Xylitol chewing gum bull Chlorhexidine (11 alcohol)bull No over the counter mouthrinses with
alcohol (Listerine 20 alcohol)
Pre-natal Fluoride
bull Daily 22 mg tablet of sodium fluoride during 3rd through 9th months
bull decreases caries rate in offspringbull Safe and effective
Glenn FB 1982
Is it safe to use mercury restorations
bull No evidence of harmful effect
bull Benefits outweigh risks
bull Canada Germany and New Zealand have some restrictions
bull Determine the best option
Referencesbull Wasylko L Matsui D Dykxhoorn SM Rieder MJ Weinberg
S A Review of Common Dental Treatments During Pregnancy J Canadian Dental Association 64434-439 1998
bull Little JW Donald AF Craig SM Rhodus NL Dental Management of the Medically Compromised Patient - 5th edition Mosby Toronto Pp434-442 1997
bull Livingston HM Dellinger TM Holder R Considerations in the management of the pregnant patient Special Care in Dentistry 185 pp183-188 1998
bull Larimore WL Petrie KA Drug use during pregnacy and lactation Primary Care Clinics in Office Practice 271 35-53 2000
bull Health Canada The Safety of DentalAmalgam Minister Of Supply and Services Canada 1996
REFERENCESbull 1 Weiss G Endocrinology of parturition J Clin
Endocrinol Metab 2000854421-5bull 2 Theunissen IM Parer JT Fluid and electrolytes in
pregnancy Clin Obstet Gynecol 1994373-15bull 3 Duvekot JJ Peeters LLH Renal hemodynamics and
volume homeostasis in pregnancy Obstet Gynecol Surv 199449830-9
bull 4 Barron WM Lindheimer MD Medical disorders during pregnancy 2nd ed St Louis Mosby 1995 p 129
bull 5 Thornburg KL Jacobson SL Giraud GD Morton MJ Hemodynamic changes in pregnancy Semin Perinatol 20002411-4
bull 6 Fiese R Herzog S Issues in dental and surgical management of the pregnant patient Oral Surg Oral Med Oral Pathol 198865292-7
bull 7 Martin C Varner MW Physiologic changes in pregnancysurgical implications Clin Obstet Gynecol 199437241-55
bull 8 Clark SL Cotton DB Lee W Bishop C Hill T Southwick J et al Central hemodynamic assessment of normal term pregnancy Am J Obstet Gynecol 19891611439-42
bull 9 Mabie WC Di Sessa TG Crocker LG Sibai BM Arheart KL A longitudinal study of cardiac output in normal human pregnancy Am J Obstet Gynecol 1994170849-56
bull 10 Clapp JF 3rd Capeless E Cardiovascular function before during and after the first and subsequent pregnancies Am J Cardiol 1997801469-73
bull 11 Duvekot JJ Peeters LL Maternal cardiovascular hemodynamic adaptation to pregnancy Obstet Gynecol Surv 199449(Suppl) S1-14
bull 12 Bhagwat AR Engel PJ Heart disease and pregnancy Cardiol Clin 199513163-78
bull 13 Lanni SM Tillinghast J Silver H Hemodynamic changes and baroreflex gain in the supine hypotensive syndrome Am J Obstet Gynecol 20021871636-41
bull 14 Little JW Falace DA Miller CS Rhodus NL Dental management of the medically compromised patient 6th ed St Louis Mosby 2002 p 303
bull 15 Garcia-Rio F Pino JM Gomez L Alvarez-Sala R Villasante C Villamor J Regulation of breathing and perception of dyspnea in healthy pregnant women Chest 1996110446-53
bull 16 McAuliffe F Kametas N Costello J Rafferty GF Greenough A Nicolaides K Respiratory function in singleton and twin pregnancy BJOG 2002109765-9
bull 17 Clapp JF 3rd Seaward BL Sleamaker RH Hiser J Maternal physiologic adaptations to early human pregnancy Am J Obstet Gynecol 19881591456-60
bull 18 OrsquoDay MP Cardio-respiratory physiological adaptation of pregnancy Semin Perinatol 199721268-75
bull 19 Contreras G Gutierrez M Beroiza T Fantin A Oddo H Villarroel L et al Ventilatory drive and respiratory muscle function in pregnancy Am Rev Respir Dis 1991144837-41
bull 20 Turner M Aziz SR Management of the pregnant oral and maxillofac
bull 21 Sifakis S Pharmakides G Anemia in pregnancy Ann N Y Acad Sci 2000900125-36
bull 22 Branch DW Physiologic adaptations of pregnancy Am J Reprod Immunol 199228120-2
bull 23 Burrows RF Kelton JG Incidentally detected thrombocytopenia in healthy mothers and their infants N Engl J Med 1988319 142-5
bull 24 Hanly JG Antiphospholipid syndrome an overview CMAJ 200324(168)1675-82
bull 25 Heilmann L von Tempelhoff GF Pollow K Antiphospholipid syndrome in obstetrics Clin Appl Thromb Hemost 20039 143-50
bull 26 Sherman P Flaxman SM Nausea and vomiting of pregnancy in an evolutionary perspective Am J Obstet Gynecol 2002 185(Suppl)s190-7
bull 27 Koch KL Gastrointestinal factors in nausea and vomiting of pregnancy Am J Obstet Gynecol 2002185(Suppl)s198-203
bull 28 Koch KL Frissora CL Nausea and vomiting during pregnancy Gastroenterol Clin N Am 200332201-34
bull 29 Baron TH Ramirez B Richter JE Gastrointestinal motility disorders during pregnancy Ann Intern Med 1993118 366-75
bull 30 Richter JE Gastroesophageal reflux disease during pregnancy Gastroenterol Clin N Am 200332235-61
bull 31 Marrero JM Goggin PM de Caestecker JS Pearce JM Maxwell JD Determinants of pregnancy heartburn Br J Obstet Gynaecol 199299731-4
bull 32 Hamaoui E Hamaoui M Nutritional assessment and support during pregnancy Gastroenterol Clin N Am 20033259-121
bull 33 King JC Physiology of pregnancy and nutrient metabolism Am J Clin Nutr 200071(suppl)1218s-25s
bull 34 Casanueva E Pfeffer F Fernandez-Gaxiola AC Gutierrez- Valenzuela V Rothenberg SJ Iron and folate status before pregnancy and anemia during pregnancy Ann Nutr Metab 2003 4760-3
bull 35 Chrsquong CL Morgan M Hainsworth I Kingham JG Prospective study of liver dysfunction in Southwest Wales Gut 200251 876-80
bull 36 Rahman TM Wendon J Severe hepatic dysfunction in pregnancy QJM 200295343-57
bull 37 Knox TA Olans LB Liver disease in pregnancy N Engl J Med 1996335569-76
bull 38 Saftlas AF Olson DR Franks AL Atrash H Pokras R Epidemiology of preeclampsia and eclampsia in the United States 1979e1986 Am J Obstet Gynecol 1990163460-5
bull 39 Walker JJ Pre-eclampsia Lancet 20003561260-5
bull 40 Davidson JM Renal disorders in pregnancy Curr Opin Obstet Gynecol 200113109-14
bull 41 Dafnis E Sabatini S The effect of pregnancy on renal function physiology and pathophysiologyAmJMedSci 1992303184-205
bull 42 Davison JM Shiells EA Philips PR Lindheimer MD Serial evaluation of vasopressin release and thirst in human pregnancy Role of human chorionic gonadotrophin in the osmoregulatory changes of gestation J Clin Invest 198881798-806
bull 43 Glinoer D de Nayer P Bourdoux P Lemone M Robyn C van Steirteghem A et al Regulation of maternal thyroid during pregnancy J Clin Endocrinol Metab 199071276-87
bull 44 Wilson SG Retallack RW Kent JC Worth GK Gutteridge DH Serum free 125-dihydroxyvitamin D and the free 125- dihydroxyvitamin D index during a longitudinal study of human pregnancy and lactation Clin Endocrinol 199032613-22
bull 45 Rasmussen N Frolich A Hornnes PJ Hegedus L Serum ionized calcium and intact parathyroid hormone levels during pregnancy and postpartum Br J Obstet Gynaecol 199097857-9
bull 46 Guyton AC Textbook of medical physiology 8th ed Philadelphia W B Saunders 1991 p 915e28
bull 47 Trainer PJ Corticosteroids and pregnancy Semin Reprod Med 200220375-80
bull 48 Soory M Hormonal factors in periodontal disease Dent Update 200027380-3
bull 49 Hugoson A Gingivitis in pregnant women A longitudinal clinical study Odontol Revy 19712265-84
bull 50 Neville BW Damm DD Allen CM Bouquot JE Oral amp Maxillofacial Pathology 3rd ed Philadelphia W B Saunders 2002 p 329-30 447-9
bull 51 Tilakaratne A Soory M Ranasinghe AW Corea SM Ekanayake SL de Silva M Periodontal disease status during pregnancy and 3 months post-partum in rural population of Sri-Lankan women J Clin Periodontol 200027787-92
bull 52 Laine M Tenovuo J Lehtonen OP Ojanatko-Harri A Vilja P Tuohimaa P Pregnancy e related changes in human whole saliva Arch Oral Biol 198833913-7
bull 53 Yuan K Wing LY Lin MT Pathogenetic roles of angiogenic factors in pyogenic granulomas in pregnancy are modulated by female sex hormones J Periodontol 200273701-8
bull 54 Evans RD Briggs PF Tooth-surface loss related to pregnancyinduced vomiting Prim Dent Care 1994124-6
bull 55 Salvolini E Di Giorgio R Curatola A Mazzanti L Fratto G Biochemical modifications of human whole saliva induced by pregnancy Br J Obstet Gynaec 1998105656-60
bull 56 Mauldin JG Newman RB Preterm birth risk assessment Semin Perinatol 200125215-22
bull 57 Heine RP McGregor JA Goodwin TM Artal R Hayashi RH Robertson PA et al Serial salivary estriol to detect an increased risk of preterm birth Obstet Gynecol 200096490-7
bull 58 Kauh YC Zachian TF Melasma Adv Exp Med Biol 1999455 491-9
bull 59 Wong RC Ellis CN Physiologic skin changes in pregnancy J Am Acad Dermatol 198410929-40
bull 60 Errickson CV Matus NR Skin disorders of pregnancy Am Fam Physician 199449605-10
bull 61 Lopez NJ Smith PC Gutierrez J Periodontal therapy may reduce the risk of preterm low birth weight in women with periodontal disease a randomized controlled trial J Periodontol 200273911-24
bull 62 McGaw T Periodontal disease and preterm delivery of lowbirth- weight infants J Can Dent Assoc 200268165-9
bull 63 Richards AG Dental x-ray protection Dent Clin North Am 1968631-41
bull 64 1990 Recommendations of the International Commission on Radiological Protection Ann ICRP 1991211-201
bull 65 Hall EJ Radiation the two-edged sword cancer risks at high and low doses Cancer J 20006343-50
bull 66 Diethelm L Xu H Diagnostic imaging of the lung during pregnancy Clin Obstet Gynecol 19963936-55
bull 67 Brent RL The effects of embryonic and fetal exposure to x-rays microwaves and ultrasound ClinObstetGynecol 198326484-510
bull 68 National Council on Radiation Protection NCRP report no128 1998 Bethesda Md Author
bull 69 Wasylko L Matsui D Dykxhoorn SM Reider MJ Weinberg S A review of common dental treatments during pregnancy implications for patients and dental personnel J Can Dent Assoc 199864434-9
bull 70 Freeman JP Brand JW Radiation doses of commonly used dental radiographic surveys Oral Surg Oral Med Oral Pathol 199477285-9
bull 71 Kircos LTAngin LL Lorton LOrder ofmagnitude dose reduction in intraoral radiography J Am Dent Assoc 1987114344-7
bull 72 Updegrave WJ Simplified and standardized intraoral radiography with reduced tissue irradiation J Am Dent Assoc 197285861-9
bull 73 Wood RE Harris AM van der Merwe EJ Nortje CJ The leaded apron revisited does it reduce gonadal radiation dose in dental radiology Oral Surg Oral Med Oral Pathol 199171642-6
bull 74 An update on radiographic practices information and recommendations ADA Council on Scientific Affairs J Am Dent Assoc 2001132234-8
bull 75 Rayburn WF Recommending medications during pregnancy an evidence based approach Clin Obstet Gynecol 2002451-5
bull 76 Rathmell JP Viscomi C Ashburn MA Management of nonobstetric pain during pregnancy and lactation Anesth Analg 1997851074-87
bull 77 Teratology society public affairs committee FDA classification of drugs for teratogenic risk Teratology 199449446-7
bull 78 Moore PA Selecting drugs for the pregnant dental patient J Am Dent Assoc 19981291281-6
bull 79 Haas DA An update on analgesics for the management of acute postoperative dental pain J Can Dent Assoc 200268476-82
bull 80 Haas DA Pynn BR Sands TD Drug use for the pregnant or lactating patient Gen Dent 20004854-60
bull 81 Committee on Drugs American Academy of Pediatrics The transfer of drugs and other chemicals into human milk Pediatrics 199493137-50
bull 82 Nielsen GL Sorensen HT Larsen H Pedersen L Risk of adverse birth outcome and miscarriage in pregnant users of nonsteroidal anti-inflammatory drugs population based observational study and case-control study BMJ 2001322266-70
bull 83 Janssen N Genta M The effects of immunosuppressive and anti-inflammatory medications on fertility pregnancy and lactation Arch Intern Med 200016610-9
bull 84 Ostensen M Nonsteroidal anti-inflammatory drugs during pregnancy Scand J Rheumatol Suppl 1998107128-32
bull 85 USPDI -Drug information for the health care professional 22nd ed Greenwood Village CO Micromedex 2002 p 152-79
bull 86 Denson DD Coyle DE Thompson GA Santos D Turner PA Myers JA et al Bupivacaine protein binding in the term parturient effects of lactic acidosis Clin Pharmacol Ther 198435702-9
bull 87 Dillon DE Wagner CL Wiest D Newman RB Drug therapy in the nursing mother Obstet Gynecol Clin North Am 199724 675-96
bull 88 Dashe JS Gilstrap LC Antibiotic use in pregnancy Obstet Gynecol Clin North Am 199724617-29
bull 89 American College of Rheumatology Ad hoc Committee on Clinical Guidelines Guidelines for monitoring drug therapy in rheumatoid arthritis Arthritis Rheum 199639723-31
bull 90 Ng PC The fetal and neonatal hypothalamic-pituitary-adrenal axis Arch Dis Child Fetal Neonatal Ed 200082F250-4
bull 91 Crowley P Antenatal corticosteroidsmdashcurrent thinking BJOG 2003110(Suppl 20)77-8
bull 92 ACOG committee opinion antenatal corticosteroid therapy for fetal maturation Obstet Gynecol 200299871-3
bull 93 Ost L Wettrell G Bjorkhem I Rane A Prednisolone excretion in human milk J Pediatr 19851061008-11
bull 94 Rowland AS Baird DD Shore DL Weinberg CR Savitz DA Wilcox AJ Nitrous oxide and spontaneous abortion in female dental assistants Am J Epidemiol 1995141531-8
bull 95 McGlothlin JD Jensen PA Fischbach TJ Hughes RT Jones JH Control of anesthetic gases in dental operatories Scand J Work Environ Health 199218(Suppl 2)103-5
bull ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY Volume 97 Number 6 Suresh and Radfar 681
bull 96 Rosen MA Nitrous oxide for relief of labor pain a systematic review Am J Obstet Gynecol 2002186(Suppl Nature)S110-6
bull 97 Sands TD Pynn BR Management considerations for the pregnant or nursing emergency patient Ont Dent 199875 17-9
bull 98 Daya S Recurrent spontaneous early pregnancy loss and low dose aspirin Minerva Ginecol 200355441-9
bull 99 Sinclair C Handbook of obstetrical emergencies 1st ed Philadelphia WB Saunders 1996 p 29-39 69
bull 100 Tarsitano BF Rollings RE The pregnant dental patient evaluation and management Gen Dent 199341226-34
bull 101 Livingston MH Dlllinger TM Holder R Consideration in the management of the pregnant patient SCD Special Care in Dentistry 199818183-8
Thank you
- A Review on the principle of Dental Management of the Pregnant patient
- Slide 2
- Questions that a dentist may ask
- Stages of Pregnancy
- Slide 5
- Slide 6
- Physiologic Changes in Pregnancy
- Systemic changes in pregnancy
- FLAT SUPINE POSITIONING
- SUPINE HYPOTENSION SYNDROME (Vena Cava Compression)
- Supine Hypotension Syndrome
- Slide 12
- Supine Hypotension Syndrome
- Prevention of Supine Hypotensive Syndrome
- Treatment of Supine Hypotensive Syndrome
- How should the pregnant woman be positioned
- Slide 17
- Slide 18
- Slide 19
- Slide 20
- Slide 21
- Slide 22
- Slide 23
- Pregnancy Related Oral Health Problems
- Oral Problems in Pregnancy
- Pregnancy Gingivitis Pathophysiology
- Pregnancy Gingivitis
- Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Gum Problems - Pregnancy Granuloma
- Slide 31
- Gum Changes - Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Candidiasis
- Pregnancy Myths
- Other Oral Conditions in Pregnancy
- Changes During Pregnancy that Affect Oral Health
- Saliva changes
- Increased Bacteria
- Slide 40
- Enamel erosion caused by frequent vomiting
- Treatment for Acid Exposure
- Oral Diseases Can Effect Pregnancy
- Periodontal Disease and Preterm Labor
- Periodontal Disease and Low Birth Weight
- Periodontal Disease and Preeclampsia
- Periodontitis and Pre-eclampsia
- Dental Considerations
- Treatment Timing
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Slide 52
- Use of Radiation on Pregnant Patient
- Radiographs during Pregnancy
- Risks of Dental X-Rays
- FDA drug classification for pregnancy
- Slide 57
- FDA drug classification for pregnancy
- Slide 59
- Slide 60
- Slide 61
- Common Analgesics
- Analgesics
- Analgesics - continued
- Analgesics to Use During 1st and 2nd Trimester
- Analgesics to Avoid During the Third Trimester
- Sedation in Pregnancy
- Common Antibiotics
- Antibiotics
- Antibiotics To Use During Pregnancy
- Antibiotics to Avoid during Pregnancy
- The Problem With Tetracycline
- Other Antimicrobial Agents
- Local Anesthetic Use in Pregnancy
- Use of Local Anesthetics
- Ulcer healing drugs
- Slide 77
- Slide 78
- Slide 79
- Use of Nitrous Oxide Gas
- Common Preventives
- Are topical agents safe
- Pre-natal Fluoride
- Is it safe to use mercury restorations
- References
- REFERENCES
- Slide 87
- Slide 88
- Slide 89
- Slide 90
- Slide 91
- Slide 92
- Slide 93
- Slide 94
- Slide 95
- Slide 96
- Slide 97
- Slide 98
- Thank you
-
Use of Radiation on Pregnant Patientbull Dose given and time of gestation are
importantbull doses lt 5-10 rads (cGy) not teratogenicbull fetus is most susceptible to radiation
between the 2nd and 6th week of gestationbull single dental x-ray exposes patient to 001
millirads of radiation In relative terms this amount is 40 times less than daily dose acquired from cosmic radiation Therefore diagnostic radiation should not be withheld during pregnancy
Radiographs during Pregnancy
bull Take as needed with optimal methods for reducing secondary radiation and exposure time
bull Always use a lead apronbull Exposure to fetus (with apron use) is 00001
centiGray(rad)bull Daily cosmic radiation - 0004 centiGray (rad)
Risks of Dental X-Rays
bull X-ray only if necessary (ie root canal therapy trauma)
bull When x-rays are indicated radiation exposure is extremely low
bull Exposure can be limited byndash Lead apron shielding ndash Modern fast film ndash Avoiding retakes
FDA drug classification for pregnancybull Combines risk statements including
congenital anomalies fetal effects perinatal risks and therapeutic risk-benefit ratio
bull Untreated disease or condition may pose more serious risks to both mother and fetus than any theoretical risks from the medication
bull Category A thru D and X
FDA drug classification for pregnancy
bull A = Controlled Studies in women fail to demonstrate a risk to the fetus in the first trimester and the possibility of fetal harm appears remote
FDA drug classification for pregnancy
bull B = Animal studies show no risk or if risk shown in animals controlled
trials in women showed no risk
FDA drug classification for pregnancy
bull C = Studies in animals with adverse effects and no human studies
OR no animal or human studies but benefits of use may outweigh potential harms
FDA drug classification for pregnancy
bull D = There is evidence of human fetal risk but benefits may outweigh risks
FDA drug classification for pregnancy
bull X = Contraindicated
Common Analgesics
bull paracetamol (B)bull Ibuprofen (BD) bull Oxycodone (BD) bull Hydrocodone and codeine
(CD)
avoid in third trimester
Analgesics
bull Paracetamol is the analgesic of choice for all stages of gestation
bull used to treat mild to moderate pain and fevers
bull short term usage is believed to be safebull avoid chronic and large doses of
paracetamol1048715
Analgesics - continuedbull Aspirin is nonteratogenic but may cause
maternal and fetal hemorrhagebull large and chronic doses during last trimester
may result in premature closure of ductus arteriosus fetal hypertension anemia and low birth weight
bull avoid ibuprofen in 3rd trimester because of possible adverse circulatory effects
bull short term use of codeine seems safebull avoid codeine late in gestation because of
possible fetal respiratory depression and withdrawal symptoms
Analgesics to Use During1st and 2nd Trimester
bull Category B (for best)bull Paracetamol Ibuprofenbull Naproxenbull Category C (use with caution)bull Paracetamol with codeine or
hydrocodonebull Paracetamol with oxycodone
Analgesics to Avoid During theThird Trimesterbull Causes delivery problemsbull Aspirin (C 3D)bull Ibuprofen (B3D)bull Naproxen (B3D)bull Causes neonatal respiratory
depression and opioid withdrawalbull Codeine (C3D)bull Hydrocodone (C3D)bull Oxycodone(C3D)
Sedation in Pregnancy
bull SedativesAnxiolytics (eg Diazepam ) are rated D and can cause oral clefts with prolonged exposure
bull Nitrous oxide should not be used in 1st trimester (If used in 2nd and 3rd do not go below 50 O2)
Common Antibioticsbull To treat oral abscess or cellulitis
ndash Penicillin (B) ndash Amoxicillin (B) ndash Cephalexin (B)ndash Erythromycin base (B) (Not estolate as it
cause cholestatic hepatitis)ndash Clindamycin (B)
Antibioticsbull penicillin V and amoxicillin is preferred drug
for mild to moderate infectionsbull widely used for many years with no ill effectsbull no studies show penicillin to be teratogenicbull amoxicillin extensively used without harming
the fetusbull Drug classes1048715 B penicillin cephalosporins erythromycin clindamycin Azithromycin D Tetracycline
Antibiotics To Use During Pregnancy
bull Penicillin Vbull Amoxicillinbull Erythromycin (base form)bull Cephalexin cephalosporinbull Clindamycinbull Metronidazole
Antibiotics to Avoid duringPregnancy
bull Doxycyclinebull Tetracyclinebull Erythromycin (estolate form)bull Vancomycin
The Problem With Tetracycline
bull Accumulates in bones and chelates calcium
bull Inhibits bone growthbull Discolors teeth
Other Antimicrobial Agentsbull OK to usebull Nystatin (B)bull Chlorhexidine rinse (B)bull Use with cautionbull Clotrimazole (C)bull Ketoconazole (C)bull Fluconazole (C)bull Do not usebull Doxycycline (D)
Local Anesthetic Use inPregnancy
bull Class Bbull Lidocaine (Xylocaine)bull Etidocainebull Prilocaine bull Class Cbull Procainebull Bupivicainebull Mepivicaine
Use of Local Anestheticsbull Lidocaine + vasoconstrictor most common
local anesthetic used in dentistrybull extensively used in pregnancy with no proven ill
effectsbull accidental intravascular injections of lidocaine
pass through the placenta but the concentrations are too low to harm fetus
bull prilocaine might cause methemoglobinemia
Ulcer healing drugsCimetidine bull FDA category B Famotidinebull FDA category BRanitidinebull FDA category Bbull not known to be harmful
Ulcer healing drugsOmeprazolebull FDA category BNot known to be
harmful Esomeprazolebull FDA category BLansoprazolebull FDA category BPantoprazolebull Avoid unless potential benefit
outweighs riskmdashfetotoxic in animals
Ulcer healing drugs
Misoprostolbull First second third trimesters Avoidmdash
potent uterine stimulant (has been used to induce abortion) and may be teratogenic
Ulcer healing drugs
Antacidsbull Almunium hydroxideMagnesium
hydroxidemdashFDA category B Calcium carbonatemdashFDA category C
SimetheconemdashFDA category C
Use of Nitrous Oxide Gas
bull used over 150 years bull safety is being debatedbull SHORT TERM exposure do not cause
birth defects or spontaneous abortionbull CHRONIC exposure may result in fetal
loss and infertilitybull literature suggests that nitrous oxide
should be avoided until more conclusive research is available
bull FDA Drug class not yet assigned
Common Preventives
bull Fluoridendash No increased risk during pregnancy
bull Xylitolndash No studies no harm reported
bull Chlorhexidinendash No increased risk during pregnancy
Are topical agents safe
bull Fluoridebull Toothpaste amp mouthrinse
bull Xylitol chewing gum bull Chlorhexidine (11 alcohol)bull No over the counter mouthrinses with
alcohol (Listerine 20 alcohol)
Pre-natal Fluoride
bull Daily 22 mg tablet of sodium fluoride during 3rd through 9th months
bull decreases caries rate in offspringbull Safe and effective
Glenn FB 1982
Is it safe to use mercury restorations
bull No evidence of harmful effect
bull Benefits outweigh risks
bull Canada Germany and New Zealand have some restrictions
bull Determine the best option
Referencesbull Wasylko L Matsui D Dykxhoorn SM Rieder MJ Weinberg
S A Review of Common Dental Treatments During Pregnancy J Canadian Dental Association 64434-439 1998
bull Little JW Donald AF Craig SM Rhodus NL Dental Management of the Medically Compromised Patient - 5th edition Mosby Toronto Pp434-442 1997
bull Livingston HM Dellinger TM Holder R Considerations in the management of the pregnant patient Special Care in Dentistry 185 pp183-188 1998
bull Larimore WL Petrie KA Drug use during pregnacy and lactation Primary Care Clinics in Office Practice 271 35-53 2000
bull Health Canada The Safety of DentalAmalgam Minister Of Supply and Services Canada 1996
REFERENCESbull 1 Weiss G Endocrinology of parturition J Clin
Endocrinol Metab 2000854421-5bull 2 Theunissen IM Parer JT Fluid and electrolytes in
pregnancy Clin Obstet Gynecol 1994373-15bull 3 Duvekot JJ Peeters LLH Renal hemodynamics and
volume homeostasis in pregnancy Obstet Gynecol Surv 199449830-9
bull 4 Barron WM Lindheimer MD Medical disorders during pregnancy 2nd ed St Louis Mosby 1995 p 129
bull 5 Thornburg KL Jacobson SL Giraud GD Morton MJ Hemodynamic changes in pregnancy Semin Perinatol 20002411-4
bull 6 Fiese R Herzog S Issues in dental and surgical management of the pregnant patient Oral Surg Oral Med Oral Pathol 198865292-7
bull 7 Martin C Varner MW Physiologic changes in pregnancysurgical implications Clin Obstet Gynecol 199437241-55
bull 8 Clark SL Cotton DB Lee W Bishop C Hill T Southwick J et al Central hemodynamic assessment of normal term pregnancy Am J Obstet Gynecol 19891611439-42
bull 9 Mabie WC Di Sessa TG Crocker LG Sibai BM Arheart KL A longitudinal study of cardiac output in normal human pregnancy Am J Obstet Gynecol 1994170849-56
bull 10 Clapp JF 3rd Capeless E Cardiovascular function before during and after the first and subsequent pregnancies Am J Cardiol 1997801469-73
bull 11 Duvekot JJ Peeters LL Maternal cardiovascular hemodynamic adaptation to pregnancy Obstet Gynecol Surv 199449(Suppl) S1-14
bull 12 Bhagwat AR Engel PJ Heart disease and pregnancy Cardiol Clin 199513163-78
bull 13 Lanni SM Tillinghast J Silver H Hemodynamic changes and baroreflex gain in the supine hypotensive syndrome Am J Obstet Gynecol 20021871636-41
bull 14 Little JW Falace DA Miller CS Rhodus NL Dental management of the medically compromised patient 6th ed St Louis Mosby 2002 p 303
bull 15 Garcia-Rio F Pino JM Gomez L Alvarez-Sala R Villasante C Villamor J Regulation of breathing and perception of dyspnea in healthy pregnant women Chest 1996110446-53
bull 16 McAuliffe F Kametas N Costello J Rafferty GF Greenough A Nicolaides K Respiratory function in singleton and twin pregnancy BJOG 2002109765-9
bull 17 Clapp JF 3rd Seaward BL Sleamaker RH Hiser J Maternal physiologic adaptations to early human pregnancy Am J Obstet Gynecol 19881591456-60
bull 18 OrsquoDay MP Cardio-respiratory physiological adaptation of pregnancy Semin Perinatol 199721268-75
bull 19 Contreras G Gutierrez M Beroiza T Fantin A Oddo H Villarroel L et al Ventilatory drive and respiratory muscle function in pregnancy Am Rev Respir Dis 1991144837-41
bull 20 Turner M Aziz SR Management of the pregnant oral and maxillofac
bull 21 Sifakis S Pharmakides G Anemia in pregnancy Ann N Y Acad Sci 2000900125-36
bull 22 Branch DW Physiologic adaptations of pregnancy Am J Reprod Immunol 199228120-2
bull 23 Burrows RF Kelton JG Incidentally detected thrombocytopenia in healthy mothers and their infants N Engl J Med 1988319 142-5
bull 24 Hanly JG Antiphospholipid syndrome an overview CMAJ 200324(168)1675-82
bull 25 Heilmann L von Tempelhoff GF Pollow K Antiphospholipid syndrome in obstetrics Clin Appl Thromb Hemost 20039 143-50
bull 26 Sherman P Flaxman SM Nausea and vomiting of pregnancy in an evolutionary perspective Am J Obstet Gynecol 2002 185(Suppl)s190-7
bull 27 Koch KL Gastrointestinal factors in nausea and vomiting of pregnancy Am J Obstet Gynecol 2002185(Suppl)s198-203
bull 28 Koch KL Frissora CL Nausea and vomiting during pregnancy Gastroenterol Clin N Am 200332201-34
bull 29 Baron TH Ramirez B Richter JE Gastrointestinal motility disorders during pregnancy Ann Intern Med 1993118 366-75
bull 30 Richter JE Gastroesophageal reflux disease during pregnancy Gastroenterol Clin N Am 200332235-61
bull 31 Marrero JM Goggin PM de Caestecker JS Pearce JM Maxwell JD Determinants of pregnancy heartburn Br J Obstet Gynaecol 199299731-4
bull 32 Hamaoui E Hamaoui M Nutritional assessment and support during pregnancy Gastroenterol Clin N Am 20033259-121
bull 33 King JC Physiology of pregnancy and nutrient metabolism Am J Clin Nutr 200071(suppl)1218s-25s
bull 34 Casanueva E Pfeffer F Fernandez-Gaxiola AC Gutierrez- Valenzuela V Rothenberg SJ Iron and folate status before pregnancy and anemia during pregnancy Ann Nutr Metab 2003 4760-3
bull 35 Chrsquong CL Morgan M Hainsworth I Kingham JG Prospective study of liver dysfunction in Southwest Wales Gut 200251 876-80
bull 36 Rahman TM Wendon J Severe hepatic dysfunction in pregnancy QJM 200295343-57
bull 37 Knox TA Olans LB Liver disease in pregnancy N Engl J Med 1996335569-76
bull 38 Saftlas AF Olson DR Franks AL Atrash H Pokras R Epidemiology of preeclampsia and eclampsia in the United States 1979e1986 Am J Obstet Gynecol 1990163460-5
bull 39 Walker JJ Pre-eclampsia Lancet 20003561260-5
bull 40 Davidson JM Renal disorders in pregnancy Curr Opin Obstet Gynecol 200113109-14
bull 41 Dafnis E Sabatini S The effect of pregnancy on renal function physiology and pathophysiologyAmJMedSci 1992303184-205
bull 42 Davison JM Shiells EA Philips PR Lindheimer MD Serial evaluation of vasopressin release and thirst in human pregnancy Role of human chorionic gonadotrophin in the osmoregulatory changes of gestation J Clin Invest 198881798-806
bull 43 Glinoer D de Nayer P Bourdoux P Lemone M Robyn C van Steirteghem A et al Regulation of maternal thyroid during pregnancy J Clin Endocrinol Metab 199071276-87
bull 44 Wilson SG Retallack RW Kent JC Worth GK Gutteridge DH Serum free 125-dihydroxyvitamin D and the free 125- dihydroxyvitamin D index during a longitudinal study of human pregnancy and lactation Clin Endocrinol 199032613-22
bull 45 Rasmussen N Frolich A Hornnes PJ Hegedus L Serum ionized calcium and intact parathyroid hormone levels during pregnancy and postpartum Br J Obstet Gynaecol 199097857-9
bull 46 Guyton AC Textbook of medical physiology 8th ed Philadelphia W B Saunders 1991 p 915e28
bull 47 Trainer PJ Corticosteroids and pregnancy Semin Reprod Med 200220375-80
bull 48 Soory M Hormonal factors in periodontal disease Dent Update 200027380-3
bull 49 Hugoson A Gingivitis in pregnant women A longitudinal clinical study Odontol Revy 19712265-84
bull 50 Neville BW Damm DD Allen CM Bouquot JE Oral amp Maxillofacial Pathology 3rd ed Philadelphia W B Saunders 2002 p 329-30 447-9
bull 51 Tilakaratne A Soory M Ranasinghe AW Corea SM Ekanayake SL de Silva M Periodontal disease status during pregnancy and 3 months post-partum in rural population of Sri-Lankan women J Clin Periodontol 200027787-92
bull 52 Laine M Tenovuo J Lehtonen OP Ojanatko-Harri A Vilja P Tuohimaa P Pregnancy e related changes in human whole saliva Arch Oral Biol 198833913-7
bull 53 Yuan K Wing LY Lin MT Pathogenetic roles of angiogenic factors in pyogenic granulomas in pregnancy are modulated by female sex hormones J Periodontol 200273701-8
bull 54 Evans RD Briggs PF Tooth-surface loss related to pregnancyinduced vomiting Prim Dent Care 1994124-6
bull 55 Salvolini E Di Giorgio R Curatola A Mazzanti L Fratto G Biochemical modifications of human whole saliva induced by pregnancy Br J Obstet Gynaec 1998105656-60
bull 56 Mauldin JG Newman RB Preterm birth risk assessment Semin Perinatol 200125215-22
bull 57 Heine RP McGregor JA Goodwin TM Artal R Hayashi RH Robertson PA et al Serial salivary estriol to detect an increased risk of preterm birth Obstet Gynecol 200096490-7
bull 58 Kauh YC Zachian TF Melasma Adv Exp Med Biol 1999455 491-9
bull 59 Wong RC Ellis CN Physiologic skin changes in pregnancy J Am Acad Dermatol 198410929-40
bull 60 Errickson CV Matus NR Skin disorders of pregnancy Am Fam Physician 199449605-10
bull 61 Lopez NJ Smith PC Gutierrez J Periodontal therapy may reduce the risk of preterm low birth weight in women with periodontal disease a randomized controlled trial J Periodontol 200273911-24
bull 62 McGaw T Periodontal disease and preterm delivery of lowbirth- weight infants J Can Dent Assoc 200268165-9
bull 63 Richards AG Dental x-ray protection Dent Clin North Am 1968631-41
bull 64 1990 Recommendations of the International Commission on Radiological Protection Ann ICRP 1991211-201
bull 65 Hall EJ Radiation the two-edged sword cancer risks at high and low doses Cancer J 20006343-50
bull 66 Diethelm L Xu H Diagnostic imaging of the lung during pregnancy Clin Obstet Gynecol 19963936-55
bull 67 Brent RL The effects of embryonic and fetal exposure to x-rays microwaves and ultrasound ClinObstetGynecol 198326484-510
bull 68 National Council on Radiation Protection NCRP report no128 1998 Bethesda Md Author
bull 69 Wasylko L Matsui D Dykxhoorn SM Reider MJ Weinberg S A review of common dental treatments during pregnancy implications for patients and dental personnel J Can Dent Assoc 199864434-9
bull 70 Freeman JP Brand JW Radiation doses of commonly used dental radiographic surveys Oral Surg Oral Med Oral Pathol 199477285-9
bull 71 Kircos LTAngin LL Lorton LOrder ofmagnitude dose reduction in intraoral radiography J Am Dent Assoc 1987114344-7
bull 72 Updegrave WJ Simplified and standardized intraoral radiography with reduced tissue irradiation J Am Dent Assoc 197285861-9
bull 73 Wood RE Harris AM van der Merwe EJ Nortje CJ The leaded apron revisited does it reduce gonadal radiation dose in dental radiology Oral Surg Oral Med Oral Pathol 199171642-6
bull 74 An update on radiographic practices information and recommendations ADA Council on Scientific Affairs J Am Dent Assoc 2001132234-8
bull 75 Rayburn WF Recommending medications during pregnancy an evidence based approach Clin Obstet Gynecol 2002451-5
bull 76 Rathmell JP Viscomi C Ashburn MA Management of nonobstetric pain during pregnancy and lactation Anesth Analg 1997851074-87
bull 77 Teratology society public affairs committee FDA classification of drugs for teratogenic risk Teratology 199449446-7
bull 78 Moore PA Selecting drugs for the pregnant dental patient J Am Dent Assoc 19981291281-6
bull 79 Haas DA An update on analgesics for the management of acute postoperative dental pain J Can Dent Assoc 200268476-82
bull 80 Haas DA Pynn BR Sands TD Drug use for the pregnant or lactating patient Gen Dent 20004854-60
bull 81 Committee on Drugs American Academy of Pediatrics The transfer of drugs and other chemicals into human milk Pediatrics 199493137-50
bull 82 Nielsen GL Sorensen HT Larsen H Pedersen L Risk of adverse birth outcome and miscarriage in pregnant users of nonsteroidal anti-inflammatory drugs population based observational study and case-control study BMJ 2001322266-70
bull 83 Janssen N Genta M The effects of immunosuppressive and anti-inflammatory medications on fertility pregnancy and lactation Arch Intern Med 200016610-9
bull 84 Ostensen M Nonsteroidal anti-inflammatory drugs during pregnancy Scand J Rheumatol Suppl 1998107128-32
bull 85 USPDI -Drug information for the health care professional 22nd ed Greenwood Village CO Micromedex 2002 p 152-79
bull 86 Denson DD Coyle DE Thompson GA Santos D Turner PA Myers JA et al Bupivacaine protein binding in the term parturient effects of lactic acidosis Clin Pharmacol Ther 198435702-9
bull 87 Dillon DE Wagner CL Wiest D Newman RB Drug therapy in the nursing mother Obstet Gynecol Clin North Am 199724 675-96
bull 88 Dashe JS Gilstrap LC Antibiotic use in pregnancy Obstet Gynecol Clin North Am 199724617-29
bull 89 American College of Rheumatology Ad hoc Committee on Clinical Guidelines Guidelines for monitoring drug therapy in rheumatoid arthritis Arthritis Rheum 199639723-31
bull 90 Ng PC The fetal and neonatal hypothalamic-pituitary-adrenal axis Arch Dis Child Fetal Neonatal Ed 200082F250-4
bull 91 Crowley P Antenatal corticosteroidsmdashcurrent thinking BJOG 2003110(Suppl 20)77-8
bull 92 ACOG committee opinion antenatal corticosteroid therapy for fetal maturation Obstet Gynecol 200299871-3
bull 93 Ost L Wettrell G Bjorkhem I Rane A Prednisolone excretion in human milk J Pediatr 19851061008-11
bull 94 Rowland AS Baird DD Shore DL Weinberg CR Savitz DA Wilcox AJ Nitrous oxide and spontaneous abortion in female dental assistants Am J Epidemiol 1995141531-8
bull 95 McGlothlin JD Jensen PA Fischbach TJ Hughes RT Jones JH Control of anesthetic gases in dental operatories Scand J Work Environ Health 199218(Suppl 2)103-5
bull ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY Volume 97 Number 6 Suresh and Radfar 681
bull 96 Rosen MA Nitrous oxide for relief of labor pain a systematic review Am J Obstet Gynecol 2002186(Suppl Nature)S110-6
bull 97 Sands TD Pynn BR Management considerations for the pregnant or nursing emergency patient Ont Dent 199875 17-9
bull 98 Daya S Recurrent spontaneous early pregnancy loss and low dose aspirin Minerva Ginecol 200355441-9
bull 99 Sinclair C Handbook of obstetrical emergencies 1st ed Philadelphia WB Saunders 1996 p 29-39 69
bull 100 Tarsitano BF Rollings RE The pregnant dental patient evaluation and management Gen Dent 199341226-34
bull 101 Livingston MH Dlllinger TM Holder R Consideration in the management of the pregnant patient SCD Special Care in Dentistry 199818183-8
Thank you
- A Review on the principle of Dental Management of the Pregnant patient
- Slide 2
- Questions that a dentist may ask
- Stages of Pregnancy
- Slide 5
- Slide 6
- Physiologic Changes in Pregnancy
- Systemic changes in pregnancy
- FLAT SUPINE POSITIONING
- SUPINE HYPOTENSION SYNDROME (Vena Cava Compression)
- Supine Hypotension Syndrome
- Slide 12
- Supine Hypotension Syndrome
- Prevention of Supine Hypotensive Syndrome
- Treatment of Supine Hypotensive Syndrome
- How should the pregnant woman be positioned
- Slide 17
- Slide 18
- Slide 19
- Slide 20
- Slide 21
- Slide 22
- Slide 23
- Pregnancy Related Oral Health Problems
- Oral Problems in Pregnancy
- Pregnancy Gingivitis Pathophysiology
- Pregnancy Gingivitis
- Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Gum Problems - Pregnancy Granuloma
- Slide 31
- Gum Changes - Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Candidiasis
- Pregnancy Myths
- Other Oral Conditions in Pregnancy
- Changes During Pregnancy that Affect Oral Health
- Saliva changes
- Increased Bacteria
- Slide 40
- Enamel erosion caused by frequent vomiting
- Treatment for Acid Exposure
- Oral Diseases Can Effect Pregnancy
- Periodontal Disease and Preterm Labor
- Periodontal Disease and Low Birth Weight
- Periodontal Disease and Preeclampsia
- Periodontitis and Pre-eclampsia
- Dental Considerations
- Treatment Timing
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Slide 52
- Use of Radiation on Pregnant Patient
- Radiographs during Pregnancy
- Risks of Dental X-Rays
- FDA drug classification for pregnancy
- Slide 57
- FDA drug classification for pregnancy
- Slide 59
- Slide 60
- Slide 61
- Common Analgesics
- Analgesics
- Analgesics - continued
- Analgesics to Use During 1st and 2nd Trimester
- Analgesics to Avoid During the Third Trimester
- Sedation in Pregnancy
- Common Antibiotics
- Antibiotics
- Antibiotics To Use During Pregnancy
- Antibiotics to Avoid during Pregnancy
- The Problem With Tetracycline
- Other Antimicrobial Agents
- Local Anesthetic Use in Pregnancy
- Use of Local Anesthetics
- Ulcer healing drugs
- Slide 77
- Slide 78
- Slide 79
- Use of Nitrous Oxide Gas
- Common Preventives
- Are topical agents safe
- Pre-natal Fluoride
- Is it safe to use mercury restorations
- References
- REFERENCES
- Slide 87
- Slide 88
- Slide 89
- Slide 90
- Slide 91
- Slide 92
- Slide 93
- Slide 94
- Slide 95
- Slide 96
- Slide 97
- Slide 98
- Thank you
-
Radiographs during Pregnancy
bull Take as needed with optimal methods for reducing secondary radiation and exposure time
bull Always use a lead apronbull Exposure to fetus (with apron use) is 00001
centiGray(rad)bull Daily cosmic radiation - 0004 centiGray (rad)
Risks of Dental X-Rays
bull X-ray only if necessary (ie root canal therapy trauma)
bull When x-rays are indicated radiation exposure is extremely low
bull Exposure can be limited byndash Lead apron shielding ndash Modern fast film ndash Avoiding retakes
FDA drug classification for pregnancybull Combines risk statements including
congenital anomalies fetal effects perinatal risks and therapeutic risk-benefit ratio
bull Untreated disease or condition may pose more serious risks to both mother and fetus than any theoretical risks from the medication
bull Category A thru D and X
FDA drug classification for pregnancy
bull A = Controlled Studies in women fail to demonstrate a risk to the fetus in the first trimester and the possibility of fetal harm appears remote
FDA drug classification for pregnancy
bull B = Animal studies show no risk or if risk shown in animals controlled
trials in women showed no risk
FDA drug classification for pregnancy
bull C = Studies in animals with adverse effects and no human studies
OR no animal or human studies but benefits of use may outweigh potential harms
FDA drug classification for pregnancy
bull D = There is evidence of human fetal risk but benefits may outweigh risks
FDA drug classification for pregnancy
bull X = Contraindicated
Common Analgesics
bull paracetamol (B)bull Ibuprofen (BD) bull Oxycodone (BD) bull Hydrocodone and codeine
(CD)
avoid in third trimester
Analgesics
bull Paracetamol is the analgesic of choice for all stages of gestation
bull used to treat mild to moderate pain and fevers
bull short term usage is believed to be safebull avoid chronic and large doses of
paracetamol1048715
Analgesics - continuedbull Aspirin is nonteratogenic but may cause
maternal and fetal hemorrhagebull large and chronic doses during last trimester
may result in premature closure of ductus arteriosus fetal hypertension anemia and low birth weight
bull avoid ibuprofen in 3rd trimester because of possible adverse circulatory effects
bull short term use of codeine seems safebull avoid codeine late in gestation because of
possible fetal respiratory depression and withdrawal symptoms
Analgesics to Use During1st and 2nd Trimester
bull Category B (for best)bull Paracetamol Ibuprofenbull Naproxenbull Category C (use with caution)bull Paracetamol with codeine or
hydrocodonebull Paracetamol with oxycodone
Analgesics to Avoid During theThird Trimesterbull Causes delivery problemsbull Aspirin (C 3D)bull Ibuprofen (B3D)bull Naproxen (B3D)bull Causes neonatal respiratory
depression and opioid withdrawalbull Codeine (C3D)bull Hydrocodone (C3D)bull Oxycodone(C3D)
Sedation in Pregnancy
bull SedativesAnxiolytics (eg Diazepam ) are rated D and can cause oral clefts with prolonged exposure
bull Nitrous oxide should not be used in 1st trimester (If used in 2nd and 3rd do not go below 50 O2)
Common Antibioticsbull To treat oral abscess or cellulitis
ndash Penicillin (B) ndash Amoxicillin (B) ndash Cephalexin (B)ndash Erythromycin base (B) (Not estolate as it
cause cholestatic hepatitis)ndash Clindamycin (B)
Antibioticsbull penicillin V and amoxicillin is preferred drug
for mild to moderate infectionsbull widely used for many years with no ill effectsbull no studies show penicillin to be teratogenicbull amoxicillin extensively used without harming
the fetusbull Drug classes1048715 B penicillin cephalosporins erythromycin clindamycin Azithromycin D Tetracycline
Antibiotics To Use During Pregnancy
bull Penicillin Vbull Amoxicillinbull Erythromycin (base form)bull Cephalexin cephalosporinbull Clindamycinbull Metronidazole
Antibiotics to Avoid duringPregnancy
bull Doxycyclinebull Tetracyclinebull Erythromycin (estolate form)bull Vancomycin
The Problem With Tetracycline
bull Accumulates in bones and chelates calcium
bull Inhibits bone growthbull Discolors teeth
Other Antimicrobial Agentsbull OK to usebull Nystatin (B)bull Chlorhexidine rinse (B)bull Use with cautionbull Clotrimazole (C)bull Ketoconazole (C)bull Fluconazole (C)bull Do not usebull Doxycycline (D)
Local Anesthetic Use inPregnancy
bull Class Bbull Lidocaine (Xylocaine)bull Etidocainebull Prilocaine bull Class Cbull Procainebull Bupivicainebull Mepivicaine
Use of Local Anestheticsbull Lidocaine + vasoconstrictor most common
local anesthetic used in dentistrybull extensively used in pregnancy with no proven ill
effectsbull accidental intravascular injections of lidocaine
pass through the placenta but the concentrations are too low to harm fetus
bull prilocaine might cause methemoglobinemia
Ulcer healing drugsCimetidine bull FDA category B Famotidinebull FDA category BRanitidinebull FDA category Bbull not known to be harmful
Ulcer healing drugsOmeprazolebull FDA category BNot known to be
harmful Esomeprazolebull FDA category BLansoprazolebull FDA category BPantoprazolebull Avoid unless potential benefit
outweighs riskmdashfetotoxic in animals
Ulcer healing drugs
Misoprostolbull First second third trimesters Avoidmdash
potent uterine stimulant (has been used to induce abortion) and may be teratogenic
Ulcer healing drugs
Antacidsbull Almunium hydroxideMagnesium
hydroxidemdashFDA category B Calcium carbonatemdashFDA category C
SimetheconemdashFDA category C
Use of Nitrous Oxide Gas
bull used over 150 years bull safety is being debatedbull SHORT TERM exposure do not cause
birth defects or spontaneous abortionbull CHRONIC exposure may result in fetal
loss and infertilitybull literature suggests that nitrous oxide
should be avoided until more conclusive research is available
bull FDA Drug class not yet assigned
Common Preventives
bull Fluoridendash No increased risk during pregnancy
bull Xylitolndash No studies no harm reported
bull Chlorhexidinendash No increased risk during pregnancy
Are topical agents safe
bull Fluoridebull Toothpaste amp mouthrinse
bull Xylitol chewing gum bull Chlorhexidine (11 alcohol)bull No over the counter mouthrinses with
alcohol (Listerine 20 alcohol)
Pre-natal Fluoride
bull Daily 22 mg tablet of sodium fluoride during 3rd through 9th months
bull decreases caries rate in offspringbull Safe and effective
Glenn FB 1982
Is it safe to use mercury restorations
bull No evidence of harmful effect
bull Benefits outweigh risks
bull Canada Germany and New Zealand have some restrictions
bull Determine the best option
Referencesbull Wasylko L Matsui D Dykxhoorn SM Rieder MJ Weinberg
S A Review of Common Dental Treatments During Pregnancy J Canadian Dental Association 64434-439 1998
bull Little JW Donald AF Craig SM Rhodus NL Dental Management of the Medically Compromised Patient - 5th edition Mosby Toronto Pp434-442 1997
bull Livingston HM Dellinger TM Holder R Considerations in the management of the pregnant patient Special Care in Dentistry 185 pp183-188 1998
bull Larimore WL Petrie KA Drug use during pregnacy and lactation Primary Care Clinics in Office Practice 271 35-53 2000
bull Health Canada The Safety of DentalAmalgam Minister Of Supply and Services Canada 1996
REFERENCESbull 1 Weiss G Endocrinology of parturition J Clin
Endocrinol Metab 2000854421-5bull 2 Theunissen IM Parer JT Fluid and electrolytes in
pregnancy Clin Obstet Gynecol 1994373-15bull 3 Duvekot JJ Peeters LLH Renal hemodynamics and
volume homeostasis in pregnancy Obstet Gynecol Surv 199449830-9
bull 4 Barron WM Lindheimer MD Medical disorders during pregnancy 2nd ed St Louis Mosby 1995 p 129
bull 5 Thornburg KL Jacobson SL Giraud GD Morton MJ Hemodynamic changes in pregnancy Semin Perinatol 20002411-4
bull 6 Fiese R Herzog S Issues in dental and surgical management of the pregnant patient Oral Surg Oral Med Oral Pathol 198865292-7
bull 7 Martin C Varner MW Physiologic changes in pregnancysurgical implications Clin Obstet Gynecol 199437241-55
bull 8 Clark SL Cotton DB Lee W Bishop C Hill T Southwick J et al Central hemodynamic assessment of normal term pregnancy Am J Obstet Gynecol 19891611439-42
bull 9 Mabie WC Di Sessa TG Crocker LG Sibai BM Arheart KL A longitudinal study of cardiac output in normal human pregnancy Am J Obstet Gynecol 1994170849-56
bull 10 Clapp JF 3rd Capeless E Cardiovascular function before during and after the first and subsequent pregnancies Am J Cardiol 1997801469-73
bull 11 Duvekot JJ Peeters LL Maternal cardiovascular hemodynamic adaptation to pregnancy Obstet Gynecol Surv 199449(Suppl) S1-14
bull 12 Bhagwat AR Engel PJ Heart disease and pregnancy Cardiol Clin 199513163-78
bull 13 Lanni SM Tillinghast J Silver H Hemodynamic changes and baroreflex gain in the supine hypotensive syndrome Am J Obstet Gynecol 20021871636-41
bull 14 Little JW Falace DA Miller CS Rhodus NL Dental management of the medically compromised patient 6th ed St Louis Mosby 2002 p 303
bull 15 Garcia-Rio F Pino JM Gomez L Alvarez-Sala R Villasante C Villamor J Regulation of breathing and perception of dyspnea in healthy pregnant women Chest 1996110446-53
bull 16 McAuliffe F Kametas N Costello J Rafferty GF Greenough A Nicolaides K Respiratory function in singleton and twin pregnancy BJOG 2002109765-9
bull 17 Clapp JF 3rd Seaward BL Sleamaker RH Hiser J Maternal physiologic adaptations to early human pregnancy Am J Obstet Gynecol 19881591456-60
bull 18 OrsquoDay MP Cardio-respiratory physiological adaptation of pregnancy Semin Perinatol 199721268-75
bull 19 Contreras G Gutierrez M Beroiza T Fantin A Oddo H Villarroel L et al Ventilatory drive and respiratory muscle function in pregnancy Am Rev Respir Dis 1991144837-41
bull 20 Turner M Aziz SR Management of the pregnant oral and maxillofac
bull 21 Sifakis S Pharmakides G Anemia in pregnancy Ann N Y Acad Sci 2000900125-36
bull 22 Branch DW Physiologic adaptations of pregnancy Am J Reprod Immunol 199228120-2
bull 23 Burrows RF Kelton JG Incidentally detected thrombocytopenia in healthy mothers and their infants N Engl J Med 1988319 142-5
bull 24 Hanly JG Antiphospholipid syndrome an overview CMAJ 200324(168)1675-82
bull 25 Heilmann L von Tempelhoff GF Pollow K Antiphospholipid syndrome in obstetrics Clin Appl Thromb Hemost 20039 143-50
bull 26 Sherman P Flaxman SM Nausea and vomiting of pregnancy in an evolutionary perspective Am J Obstet Gynecol 2002 185(Suppl)s190-7
bull 27 Koch KL Gastrointestinal factors in nausea and vomiting of pregnancy Am J Obstet Gynecol 2002185(Suppl)s198-203
bull 28 Koch KL Frissora CL Nausea and vomiting during pregnancy Gastroenterol Clin N Am 200332201-34
bull 29 Baron TH Ramirez B Richter JE Gastrointestinal motility disorders during pregnancy Ann Intern Med 1993118 366-75
bull 30 Richter JE Gastroesophageal reflux disease during pregnancy Gastroenterol Clin N Am 200332235-61
bull 31 Marrero JM Goggin PM de Caestecker JS Pearce JM Maxwell JD Determinants of pregnancy heartburn Br J Obstet Gynaecol 199299731-4
bull 32 Hamaoui E Hamaoui M Nutritional assessment and support during pregnancy Gastroenterol Clin N Am 20033259-121
bull 33 King JC Physiology of pregnancy and nutrient metabolism Am J Clin Nutr 200071(suppl)1218s-25s
bull 34 Casanueva E Pfeffer F Fernandez-Gaxiola AC Gutierrez- Valenzuela V Rothenberg SJ Iron and folate status before pregnancy and anemia during pregnancy Ann Nutr Metab 2003 4760-3
bull 35 Chrsquong CL Morgan M Hainsworth I Kingham JG Prospective study of liver dysfunction in Southwest Wales Gut 200251 876-80
bull 36 Rahman TM Wendon J Severe hepatic dysfunction in pregnancy QJM 200295343-57
bull 37 Knox TA Olans LB Liver disease in pregnancy N Engl J Med 1996335569-76
bull 38 Saftlas AF Olson DR Franks AL Atrash H Pokras R Epidemiology of preeclampsia and eclampsia in the United States 1979e1986 Am J Obstet Gynecol 1990163460-5
bull 39 Walker JJ Pre-eclampsia Lancet 20003561260-5
bull 40 Davidson JM Renal disorders in pregnancy Curr Opin Obstet Gynecol 200113109-14
bull 41 Dafnis E Sabatini S The effect of pregnancy on renal function physiology and pathophysiologyAmJMedSci 1992303184-205
bull 42 Davison JM Shiells EA Philips PR Lindheimer MD Serial evaluation of vasopressin release and thirst in human pregnancy Role of human chorionic gonadotrophin in the osmoregulatory changes of gestation J Clin Invest 198881798-806
bull 43 Glinoer D de Nayer P Bourdoux P Lemone M Robyn C van Steirteghem A et al Regulation of maternal thyroid during pregnancy J Clin Endocrinol Metab 199071276-87
bull 44 Wilson SG Retallack RW Kent JC Worth GK Gutteridge DH Serum free 125-dihydroxyvitamin D and the free 125- dihydroxyvitamin D index during a longitudinal study of human pregnancy and lactation Clin Endocrinol 199032613-22
bull 45 Rasmussen N Frolich A Hornnes PJ Hegedus L Serum ionized calcium and intact parathyroid hormone levels during pregnancy and postpartum Br J Obstet Gynaecol 199097857-9
bull 46 Guyton AC Textbook of medical physiology 8th ed Philadelphia W B Saunders 1991 p 915e28
bull 47 Trainer PJ Corticosteroids and pregnancy Semin Reprod Med 200220375-80
bull 48 Soory M Hormonal factors in periodontal disease Dent Update 200027380-3
bull 49 Hugoson A Gingivitis in pregnant women A longitudinal clinical study Odontol Revy 19712265-84
bull 50 Neville BW Damm DD Allen CM Bouquot JE Oral amp Maxillofacial Pathology 3rd ed Philadelphia W B Saunders 2002 p 329-30 447-9
bull 51 Tilakaratne A Soory M Ranasinghe AW Corea SM Ekanayake SL de Silva M Periodontal disease status during pregnancy and 3 months post-partum in rural population of Sri-Lankan women J Clin Periodontol 200027787-92
bull 52 Laine M Tenovuo J Lehtonen OP Ojanatko-Harri A Vilja P Tuohimaa P Pregnancy e related changes in human whole saliva Arch Oral Biol 198833913-7
bull 53 Yuan K Wing LY Lin MT Pathogenetic roles of angiogenic factors in pyogenic granulomas in pregnancy are modulated by female sex hormones J Periodontol 200273701-8
bull 54 Evans RD Briggs PF Tooth-surface loss related to pregnancyinduced vomiting Prim Dent Care 1994124-6
bull 55 Salvolini E Di Giorgio R Curatola A Mazzanti L Fratto G Biochemical modifications of human whole saliva induced by pregnancy Br J Obstet Gynaec 1998105656-60
bull 56 Mauldin JG Newman RB Preterm birth risk assessment Semin Perinatol 200125215-22
bull 57 Heine RP McGregor JA Goodwin TM Artal R Hayashi RH Robertson PA et al Serial salivary estriol to detect an increased risk of preterm birth Obstet Gynecol 200096490-7
bull 58 Kauh YC Zachian TF Melasma Adv Exp Med Biol 1999455 491-9
bull 59 Wong RC Ellis CN Physiologic skin changes in pregnancy J Am Acad Dermatol 198410929-40
bull 60 Errickson CV Matus NR Skin disorders of pregnancy Am Fam Physician 199449605-10
bull 61 Lopez NJ Smith PC Gutierrez J Periodontal therapy may reduce the risk of preterm low birth weight in women with periodontal disease a randomized controlled trial J Periodontol 200273911-24
bull 62 McGaw T Periodontal disease and preterm delivery of lowbirth- weight infants J Can Dent Assoc 200268165-9
bull 63 Richards AG Dental x-ray protection Dent Clin North Am 1968631-41
bull 64 1990 Recommendations of the International Commission on Radiological Protection Ann ICRP 1991211-201
bull 65 Hall EJ Radiation the two-edged sword cancer risks at high and low doses Cancer J 20006343-50
bull 66 Diethelm L Xu H Diagnostic imaging of the lung during pregnancy Clin Obstet Gynecol 19963936-55
bull 67 Brent RL The effects of embryonic and fetal exposure to x-rays microwaves and ultrasound ClinObstetGynecol 198326484-510
bull 68 National Council on Radiation Protection NCRP report no128 1998 Bethesda Md Author
bull 69 Wasylko L Matsui D Dykxhoorn SM Reider MJ Weinberg S A review of common dental treatments during pregnancy implications for patients and dental personnel J Can Dent Assoc 199864434-9
bull 70 Freeman JP Brand JW Radiation doses of commonly used dental radiographic surveys Oral Surg Oral Med Oral Pathol 199477285-9
bull 71 Kircos LTAngin LL Lorton LOrder ofmagnitude dose reduction in intraoral radiography J Am Dent Assoc 1987114344-7
bull 72 Updegrave WJ Simplified and standardized intraoral radiography with reduced tissue irradiation J Am Dent Assoc 197285861-9
bull 73 Wood RE Harris AM van der Merwe EJ Nortje CJ The leaded apron revisited does it reduce gonadal radiation dose in dental radiology Oral Surg Oral Med Oral Pathol 199171642-6
bull 74 An update on radiographic practices information and recommendations ADA Council on Scientific Affairs J Am Dent Assoc 2001132234-8
bull 75 Rayburn WF Recommending medications during pregnancy an evidence based approach Clin Obstet Gynecol 2002451-5
bull 76 Rathmell JP Viscomi C Ashburn MA Management of nonobstetric pain during pregnancy and lactation Anesth Analg 1997851074-87
bull 77 Teratology society public affairs committee FDA classification of drugs for teratogenic risk Teratology 199449446-7
bull 78 Moore PA Selecting drugs for the pregnant dental patient J Am Dent Assoc 19981291281-6
bull 79 Haas DA An update on analgesics for the management of acute postoperative dental pain J Can Dent Assoc 200268476-82
bull 80 Haas DA Pynn BR Sands TD Drug use for the pregnant or lactating patient Gen Dent 20004854-60
bull 81 Committee on Drugs American Academy of Pediatrics The transfer of drugs and other chemicals into human milk Pediatrics 199493137-50
bull 82 Nielsen GL Sorensen HT Larsen H Pedersen L Risk of adverse birth outcome and miscarriage in pregnant users of nonsteroidal anti-inflammatory drugs population based observational study and case-control study BMJ 2001322266-70
bull 83 Janssen N Genta M The effects of immunosuppressive and anti-inflammatory medications on fertility pregnancy and lactation Arch Intern Med 200016610-9
bull 84 Ostensen M Nonsteroidal anti-inflammatory drugs during pregnancy Scand J Rheumatol Suppl 1998107128-32
bull 85 USPDI -Drug information for the health care professional 22nd ed Greenwood Village CO Micromedex 2002 p 152-79
bull 86 Denson DD Coyle DE Thompson GA Santos D Turner PA Myers JA et al Bupivacaine protein binding in the term parturient effects of lactic acidosis Clin Pharmacol Ther 198435702-9
bull 87 Dillon DE Wagner CL Wiest D Newman RB Drug therapy in the nursing mother Obstet Gynecol Clin North Am 199724 675-96
bull 88 Dashe JS Gilstrap LC Antibiotic use in pregnancy Obstet Gynecol Clin North Am 199724617-29
bull 89 American College of Rheumatology Ad hoc Committee on Clinical Guidelines Guidelines for monitoring drug therapy in rheumatoid arthritis Arthritis Rheum 199639723-31
bull 90 Ng PC The fetal and neonatal hypothalamic-pituitary-adrenal axis Arch Dis Child Fetal Neonatal Ed 200082F250-4
bull 91 Crowley P Antenatal corticosteroidsmdashcurrent thinking BJOG 2003110(Suppl 20)77-8
bull 92 ACOG committee opinion antenatal corticosteroid therapy for fetal maturation Obstet Gynecol 200299871-3
bull 93 Ost L Wettrell G Bjorkhem I Rane A Prednisolone excretion in human milk J Pediatr 19851061008-11
bull 94 Rowland AS Baird DD Shore DL Weinberg CR Savitz DA Wilcox AJ Nitrous oxide and spontaneous abortion in female dental assistants Am J Epidemiol 1995141531-8
bull 95 McGlothlin JD Jensen PA Fischbach TJ Hughes RT Jones JH Control of anesthetic gases in dental operatories Scand J Work Environ Health 199218(Suppl 2)103-5
bull ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY Volume 97 Number 6 Suresh and Radfar 681
bull 96 Rosen MA Nitrous oxide for relief of labor pain a systematic review Am J Obstet Gynecol 2002186(Suppl Nature)S110-6
bull 97 Sands TD Pynn BR Management considerations for the pregnant or nursing emergency patient Ont Dent 199875 17-9
bull 98 Daya S Recurrent spontaneous early pregnancy loss and low dose aspirin Minerva Ginecol 200355441-9
bull 99 Sinclair C Handbook of obstetrical emergencies 1st ed Philadelphia WB Saunders 1996 p 29-39 69
bull 100 Tarsitano BF Rollings RE The pregnant dental patient evaluation and management Gen Dent 199341226-34
bull 101 Livingston MH Dlllinger TM Holder R Consideration in the management of the pregnant patient SCD Special Care in Dentistry 199818183-8
Thank you
- A Review on the principle of Dental Management of the Pregnant patient
- Slide 2
- Questions that a dentist may ask
- Stages of Pregnancy
- Slide 5
- Slide 6
- Physiologic Changes in Pregnancy
- Systemic changes in pregnancy
- FLAT SUPINE POSITIONING
- SUPINE HYPOTENSION SYNDROME (Vena Cava Compression)
- Supine Hypotension Syndrome
- Slide 12
- Supine Hypotension Syndrome
- Prevention of Supine Hypotensive Syndrome
- Treatment of Supine Hypotensive Syndrome
- How should the pregnant woman be positioned
- Slide 17
- Slide 18
- Slide 19
- Slide 20
- Slide 21
- Slide 22
- Slide 23
- Pregnancy Related Oral Health Problems
- Oral Problems in Pregnancy
- Pregnancy Gingivitis Pathophysiology
- Pregnancy Gingivitis
- Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Gum Problems - Pregnancy Granuloma
- Slide 31
- Gum Changes - Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Candidiasis
- Pregnancy Myths
- Other Oral Conditions in Pregnancy
- Changes During Pregnancy that Affect Oral Health
- Saliva changes
- Increased Bacteria
- Slide 40
- Enamel erosion caused by frequent vomiting
- Treatment for Acid Exposure
- Oral Diseases Can Effect Pregnancy
- Periodontal Disease and Preterm Labor
- Periodontal Disease and Low Birth Weight
- Periodontal Disease and Preeclampsia
- Periodontitis and Pre-eclampsia
- Dental Considerations
- Treatment Timing
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Slide 52
- Use of Radiation on Pregnant Patient
- Radiographs during Pregnancy
- Risks of Dental X-Rays
- FDA drug classification for pregnancy
- Slide 57
- FDA drug classification for pregnancy
- Slide 59
- Slide 60
- Slide 61
- Common Analgesics
- Analgesics
- Analgesics - continued
- Analgesics to Use During 1st and 2nd Trimester
- Analgesics to Avoid During the Third Trimester
- Sedation in Pregnancy
- Common Antibiotics
- Antibiotics
- Antibiotics To Use During Pregnancy
- Antibiotics to Avoid during Pregnancy
- The Problem With Tetracycline
- Other Antimicrobial Agents
- Local Anesthetic Use in Pregnancy
- Use of Local Anesthetics
- Ulcer healing drugs
- Slide 77
- Slide 78
- Slide 79
- Use of Nitrous Oxide Gas
- Common Preventives
- Are topical agents safe
- Pre-natal Fluoride
- Is it safe to use mercury restorations
- References
- REFERENCES
- Slide 87
- Slide 88
- Slide 89
- Slide 90
- Slide 91
- Slide 92
- Slide 93
- Slide 94
- Slide 95
- Slide 96
- Slide 97
- Slide 98
- Thank you
-
Risks of Dental X-Rays
bull X-ray only if necessary (ie root canal therapy trauma)
bull When x-rays are indicated radiation exposure is extremely low
bull Exposure can be limited byndash Lead apron shielding ndash Modern fast film ndash Avoiding retakes
FDA drug classification for pregnancybull Combines risk statements including
congenital anomalies fetal effects perinatal risks and therapeutic risk-benefit ratio
bull Untreated disease or condition may pose more serious risks to both mother and fetus than any theoretical risks from the medication
bull Category A thru D and X
FDA drug classification for pregnancy
bull A = Controlled Studies in women fail to demonstrate a risk to the fetus in the first trimester and the possibility of fetal harm appears remote
FDA drug classification for pregnancy
bull B = Animal studies show no risk or if risk shown in animals controlled
trials in women showed no risk
FDA drug classification for pregnancy
bull C = Studies in animals with adverse effects and no human studies
OR no animal or human studies but benefits of use may outweigh potential harms
FDA drug classification for pregnancy
bull D = There is evidence of human fetal risk but benefits may outweigh risks
FDA drug classification for pregnancy
bull X = Contraindicated
Common Analgesics
bull paracetamol (B)bull Ibuprofen (BD) bull Oxycodone (BD) bull Hydrocodone and codeine
(CD)
avoid in third trimester
Analgesics
bull Paracetamol is the analgesic of choice for all stages of gestation
bull used to treat mild to moderate pain and fevers
bull short term usage is believed to be safebull avoid chronic and large doses of
paracetamol1048715
Analgesics - continuedbull Aspirin is nonteratogenic but may cause
maternal and fetal hemorrhagebull large and chronic doses during last trimester
may result in premature closure of ductus arteriosus fetal hypertension anemia and low birth weight
bull avoid ibuprofen in 3rd trimester because of possible adverse circulatory effects
bull short term use of codeine seems safebull avoid codeine late in gestation because of
possible fetal respiratory depression and withdrawal symptoms
Analgesics to Use During1st and 2nd Trimester
bull Category B (for best)bull Paracetamol Ibuprofenbull Naproxenbull Category C (use with caution)bull Paracetamol with codeine or
hydrocodonebull Paracetamol with oxycodone
Analgesics to Avoid During theThird Trimesterbull Causes delivery problemsbull Aspirin (C 3D)bull Ibuprofen (B3D)bull Naproxen (B3D)bull Causes neonatal respiratory
depression and opioid withdrawalbull Codeine (C3D)bull Hydrocodone (C3D)bull Oxycodone(C3D)
Sedation in Pregnancy
bull SedativesAnxiolytics (eg Diazepam ) are rated D and can cause oral clefts with prolonged exposure
bull Nitrous oxide should not be used in 1st trimester (If used in 2nd and 3rd do not go below 50 O2)
Common Antibioticsbull To treat oral abscess or cellulitis
ndash Penicillin (B) ndash Amoxicillin (B) ndash Cephalexin (B)ndash Erythromycin base (B) (Not estolate as it
cause cholestatic hepatitis)ndash Clindamycin (B)
Antibioticsbull penicillin V and amoxicillin is preferred drug
for mild to moderate infectionsbull widely used for many years with no ill effectsbull no studies show penicillin to be teratogenicbull amoxicillin extensively used without harming
the fetusbull Drug classes1048715 B penicillin cephalosporins erythromycin clindamycin Azithromycin D Tetracycline
Antibiotics To Use During Pregnancy
bull Penicillin Vbull Amoxicillinbull Erythromycin (base form)bull Cephalexin cephalosporinbull Clindamycinbull Metronidazole
Antibiotics to Avoid duringPregnancy
bull Doxycyclinebull Tetracyclinebull Erythromycin (estolate form)bull Vancomycin
The Problem With Tetracycline
bull Accumulates in bones and chelates calcium
bull Inhibits bone growthbull Discolors teeth
Other Antimicrobial Agentsbull OK to usebull Nystatin (B)bull Chlorhexidine rinse (B)bull Use with cautionbull Clotrimazole (C)bull Ketoconazole (C)bull Fluconazole (C)bull Do not usebull Doxycycline (D)
Local Anesthetic Use inPregnancy
bull Class Bbull Lidocaine (Xylocaine)bull Etidocainebull Prilocaine bull Class Cbull Procainebull Bupivicainebull Mepivicaine
Use of Local Anestheticsbull Lidocaine + vasoconstrictor most common
local anesthetic used in dentistrybull extensively used in pregnancy with no proven ill
effectsbull accidental intravascular injections of lidocaine
pass through the placenta but the concentrations are too low to harm fetus
bull prilocaine might cause methemoglobinemia
Ulcer healing drugsCimetidine bull FDA category B Famotidinebull FDA category BRanitidinebull FDA category Bbull not known to be harmful
Ulcer healing drugsOmeprazolebull FDA category BNot known to be
harmful Esomeprazolebull FDA category BLansoprazolebull FDA category BPantoprazolebull Avoid unless potential benefit
outweighs riskmdashfetotoxic in animals
Ulcer healing drugs
Misoprostolbull First second third trimesters Avoidmdash
potent uterine stimulant (has been used to induce abortion) and may be teratogenic
Ulcer healing drugs
Antacidsbull Almunium hydroxideMagnesium
hydroxidemdashFDA category B Calcium carbonatemdashFDA category C
SimetheconemdashFDA category C
Use of Nitrous Oxide Gas
bull used over 150 years bull safety is being debatedbull SHORT TERM exposure do not cause
birth defects or spontaneous abortionbull CHRONIC exposure may result in fetal
loss and infertilitybull literature suggests that nitrous oxide
should be avoided until more conclusive research is available
bull FDA Drug class not yet assigned
Common Preventives
bull Fluoridendash No increased risk during pregnancy
bull Xylitolndash No studies no harm reported
bull Chlorhexidinendash No increased risk during pregnancy
Are topical agents safe
bull Fluoridebull Toothpaste amp mouthrinse
bull Xylitol chewing gum bull Chlorhexidine (11 alcohol)bull No over the counter mouthrinses with
alcohol (Listerine 20 alcohol)
Pre-natal Fluoride
bull Daily 22 mg tablet of sodium fluoride during 3rd through 9th months
bull decreases caries rate in offspringbull Safe and effective
Glenn FB 1982
Is it safe to use mercury restorations
bull No evidence of harmful effect
bull Benefits outweigh risks
bull Canada Germany and New Zealand have some restrictions
bull Determine the best option
Referencesbull Wasylko L Matsui D Dykxhoorn SM Rieder MJ Weinberg
S A Review of Common Dental Treatments During Pregnancy J Canadian Dental Association 64434-439 1998
bull Little JW Donald AF Craig SM Rhodus NL Dental Management of the Medically Compromised Patient - 5th edition Mosby Toronto Pp434-442 1997
bull Livingston HM Dellinger TM Holder R Considerations in the management of the pregnant patient Special Care in Dentistry 185 pp183-188 1998
bull Larimore WL Petrie KA Drug use during pregnacy and lactation Primary Care Clinics in Office Practice 271 35-53 2000
bull Health Canada The Safety of DentalAmalgam Minister Of Supply and Services Canada 1996
REFERENCESbull 1 Weiss G Endocrinology of parturition J Clin
Endocrinol Metab 2000854421-5bull 2 Theunissen IM Parer JT Fluid and electrolytes in
pregnancy Clin Obstet Gynecol 1994373-15bull 3 Duvekot JJ Peeters LLH Renal hemodynamics and
volume homeostasis in pregnancy Obstet Gynecol Surv 199449830-9
bull 4 Barron WM Lindheimer MD Medical disorders during pregnancy 2nd ed St Louis Mosby 1995 p 129
bull 5 Thornburg KL Jacobson SL Giraud GD Morton MJ Hemodynamic changes in pregnancy Semin Perinatol 20002411-4
bull 6 Fiese R Herzog S Issues in dental and surgical management of the pregnant patient Oral Surg Oral Med Oral Pathol 198865292-7
bull 7 Martin C Varner MW Physiologic changes in pregnancysurgical implications Clin Obstet Gynecol 199437241-55
bull 8 Clark SL Cotton DB Lee W Bishop C Hill T Southwick J et al Central hemodynamic assessment of normal term pregnancy Am J Obstet Gynecol 19891611439-42
bull 9 Mabie WC Di Sessa TG Crocker LG Sibai BM Arheart KL A longitudinal study of cardiac output in normal human pregnancy Am J Obstet Gynecol 1994170849-56
bull 10 Clapp JF 3rd Capeless E Cardiovascular function before during and after the first and subsequent pregnancies Am J Cardiol 1997801469-73
bull 11 Duvekot JJ Peeters LL Maternal cardiovascular hemodynamic adaptation to pregnancy Obstet Gynecol Surv 199449(Suppl) S1-14
bull 12 Bhagwat AR Engel PJ Heart disease and pregnancy Cardiol Clin 199513163-78
bull 13 Lanni SM Tillinghast J Silver H Hemodynamic changes and baroreflex gain in the supine hypotensive syndrome Am J Obstet Gynecol 20021871636-41
bull 14 Little JW Falace DA Miller CS Rhodus NL Dental management of the medically compromised patient 6th ed St Louis Mosby 2002 p 303
bull 15 Garcia-Rio F Pino JM Gomez L Alvarez-Sala R Villasante C Villamor J Regulation of breathing and perception of dyspnea in healthy pregnant women Chest 1996110446-53
bull 16 McAuliffe F Kametas N Costello J Rafferty GF Greenough A Nicolaides K Respiratory function in singleton and twin pregnancy BJOG 2002109765-9
bull 17 Clapp JF 3rd Seaward BL Sleamaker RH Hiser J Maternal physiologic adaptations to early human pregnancy Am J Obstet Gynecol 19881591456-60
bull 18 OrsquoDay MP Cardio-respiratory physiological adaptation of pregnancy Semin Perinatol 199721268-75
bull 19 Contreras G Gutierrez M Beroiza T Fantin A Oddo H Villarroel L et al Ventilatory drive and respiratory muscle function in pregnancy Am Rev Respir Dis 1991144837-41
bull 20 Turner M Aziz SR Management of the pregnant oral and maxillofac
bull 21 Sifakis S Pharmakides G Anemia in pregnancy Ann N Y Acad Sci 2000900125-36
bull 22 Branch DW Physiologic adaptations of pregnancy Am J Reprod Immunol 199228120-2
bull 23 Burrows RF Kelton JG Incidentally detected thrombocytopenia in healthy mothers and their infants N Engl J Med 1988319 142-5
bull 24 Hanly JG Antiphospholipid syndrome an overview CMAJ 200324(168)1675-82
bull 25 Heilmann L von Tempelhoff GF Pollow K Antiphospholipid syndrome in obstetrics Clin Appl Thromb Hemost 20039 143-50
bull 26 Sherman P Flaxman SM Nausea and vomiting of pregnancy in an evolutionary perspective Am J Obstet Gynecol 2002 185(Suppl)s190-7
bull 27 Koch KL Gastrointestinal factors in nausea and vomiting of pregnancy Am J Obstet Gynecol 2002185(Suppl)s198-203
bull 28 Koch KL Frissora CL Nausea and vomiting during pregnancy Gastroenterol Clin N Am 200332201-34
bull 29 Baron TH Ramirez B Richter JE Gastrointestinal motility disorders during pregnancy Ann Intern Med 1993118 366-75
bull 30 Richter JE Gastroesophageal reflux disease during pregnancy Gastroenterol Clin N Am 200332235-61
bull 31 Marrero JM Goggin PM de Caestecker JS Pearce JM Maxwell JD Determinants of pregnancy heartburn Br J Obstet Gynaecol 199299731-4
bull 32 Hamaoui E Hamaoui M Nutritional assessment and support during pregnancy Gastroenterol Clin N Am 20033259-121
bull 33 King JC Physiology of pregnancy and nutrient metabolism Am J Clin Nutr 200071(suppl)1218s-25s
bull 34 Casanueva E Pfeffer F Fernandez-Gaxiola AC Gutierrez- Valenzuela V Rothenberg SJ Iron and folate status before pregnancy and anemia during pregnancy Ann Nutr Metab 2003 4760-3
bull 35 Chrsquong CL Morgan M Hainsworth I Kingham JG Prospective study of liver dysfunction in Southwest Wales Gut 200251 876-80
bull 36 Rahman TM Wendon J Severe hepatic dysfunction in pregnancy QJM 200295343-57
bull 37 Knox TA Olans LB Liver disease in pregnancy N Engl J Med 1996335569-76
bull 38 Saftlas AF Olson DR Franks AL Atrash H Pokras R Epidemiology of preeclampsia and eclampsia in the United States 1979e1986 Am J Obstet Gynecol 1990163460-5
bull 39 Walker JJ Pre-eclampsia Lancet 20003561260-5
bull 40 Davidson JM Renal disorders in pregnancy Curr Opin Obstet Gynecol 200113109-14
bull 41 Dafnis E Sabatini S The effect of pregnancy on renal function physiology and pathophysiologyAmJMedSci 1992303184-205
bull 42 Davison JM Shiells EA Philips PR Lindheimer MD Serial evaluation of vasopressin release and thirst in human pregnancy Role of human chorionic gonadotrophin in the osmoregulatory changes of gestation J Clin Invest 198881798-806
bull 43 Glinoer D de Nayer P Bourdoux P Lemone M Robyn C van Steirteghem A et al Regulation of maternal thyroid during pregnancy J Clin Endocrinol Metab 199071276-87
bull 44 Wilson SG Retallack RW Kent JC Worth GK Gutteridge DH Serum free 125-dihydroxyvitamin D and the free 125- dihydroxyvitamin D index during a longitudinal study of human pregnancy and lactation Clin Endocrinol 199032613-22
bull 45 Rasmussen N Frolich A Hornnes PJ Hegedus L Serum ionized calcium and intact parathyroid hormone levels during pregnancy and postpartum Br J Obstet Gynaecol 199097857-9
bull 46 Guyton AC Textbook of medical physiology 8th ed Philadelphia W B Saunders 1991 p 915e28
bull 47 Trainer PJ Corticosteroids and pregnancy Semin Reprod Med 200220375-80
bull 48 Soory M Hormonal factors in periodontal disease Dent Update 200027380-3
bull 49 Hugoson A Gingivitis in pregnant women A longitudinal clinical study Odontol Revy 19712265-84
bull 50 Neville BW Damm DD Allen CM Bouquot JE Oral amp Maxillofacial Pathology 3rd ed Philadelphia W B Saunders 2002 p 329-30 447-9
bull 51 Tilakaratne A Soory M Ranasinghe AW Corea SM Ekanayake SL de Silva M Periodontal disease status during pregnancy and 3 months post-partum in rural population of Sri-Lankan women J Clin Periodontol 200027787-92
bull 52 Laine M Tenovuo J Lehtonen OP Ojanatko-Harri A Vilja P Tuohimaa P Pregnancy e related changes in human whole saliva Arch Oral Biol 198833913-7
bull 53 Yuan K Wing LY Lin MT Pathogenetic roles of angiogenic factors in pyogenic granulomas in pregnancy are modulated by female sex hormones J Periodontol 200273701-8
bull 54 Evans RD Briggs PF Tooth-surface loss related to pregnancyinduced vomiting Prim Dent Care 1994124-6
bull 55 Salvolini E Di Giorgio R Curatola A Mazzanti L Fratto G Biochemical modifications of human whole saliva induced by pregnancy Br J Obstet Gynaec 1998105656-60
bull 56 Mauldin JG Newman RB Preterm birth risk assessment Semin Perinatol 200125215-22
bull 57 Heine RP McGregor JA Goodwin TM Artal R Hayashi RH Robertson PA et al Serial salivary estriol to detect an increased risk of preterm birth Obstet Gynecol 200096490-7
bull 58 Kauh YC Zachian TF Melasma Adv Exp Med Biol 1999455 491-9
bull 59 Wong RC Ellis CN Physiologic skin changes in pregnancy J Am Acad Dermatol 198410929-40
bull 60 Errickson CV Matus NR Skin disorders of pregnancy Am Fam Physician 199449605-10
bull 61 Lopez NJ Smith PC Gutierrez J Periodontal therapy may reduce the risk of preterm low birth weight in women with periodontal disease a randomized controlled trial J Periodontol 200273911-24
bull 62 McGaw T Periodontal disease and preterm delivery of lowbirth- weight infants J Can Dent Assoc 200268165-9
bull 63 Richards AG Dental x-ray protection Dent Clin North Am 1968631-41
bull 64 1990 Recommendations of the International Commission on Radiological Protection Ann ICRP 1991211-201
bull 65 Hall EJ Radiation the two-edged sword cancer risks at high and low doses Cancer J 20006343-50
bull 66 Diethelm L Xu H Diagnostic imaging of the lung during pregnancy Clin Obstet Gynecol 19963936-55
bull 67 Brent RL The effects of embryonic and fetal exposure to x-rays microwaves and ultrasound ClinObstetGynecol 198326484-510
bull 68 National Council on Radiation Protection NCRP report no128 1998 Bethesda Md Author
bull 69 Wasylko L Matsui D Dykxhoorn SM Reider MJ Weinberg S A review of common dental treatments during pregnancy implications for patients and dental personnel J Can Dent Assoc 199864434-9
bull 70 Freeman JP Brand JW Radiation doses of commonly used dental radiographic surveys Oral Surg Oral Med Oral Pathol 199477285-9
bull 71 Kircos LTAngin LL Lorton LOrder ofmagnitude dose reduction in intraoral radiography J Am Dent Assoc 1987114344-7
bull 72 Updegrave WJ Simplified and standardized intraoral radiography with reduced tissue irradiation J Am Dent Assoc 197285861-9
bull 73 Wood RE Harris AM van der Merwe EJ Nortje CJ The leaded apron revisited does it reduce gonadal radiation dose in dental radiology Oral Surg Oral Med Oral Pathol 199171642-6
bull 74 An update on radiographic practices information and recommendations ADA Council on Scientific Affairs J Am Dent Assoc 2001132234-8
bull 75 Rayburn WF Recommending medications during pregnancy an evidence based approach Clin Obstet Gynecol 2002451-5
bull 76 Rathmell JP Viscomi C Ashburn MA Management of nonobstetric pain during pregnancy and lactation Anesth Analg 1997851074-87
bull 77 Teratology society public affairs committee FDA classification of drugs for teratogenic risk Teratology 199449446-7
bull 78 Moore PA Selecting drugs for the pregnant dental patient J Am Dent Assoc 19981291281-6
bull 79 Haas DA An update on analgesics for the management of acute postoperative dental pain J Can Dent Assoc 200268476-82
bull 80 Haas DA Pynn BR Sands TD Drug use for the pregnant or lactating patient Gen Dent 20004854-60
bull 81 Committee on Drugs American Academy of Pediatrics The transfer of drugs and other chemicals into human milk Pediatrics 199493137-50
bull 82 Nielsen GL Sorensen HT Larsen H Pedersen L Risk of adverse birth outcome and miscarriage in pregnant users of nonsteroidal anti-inflammatory drugs population based observational study and case-control study BMJ 2001322266-70
bull 83 Janssen N Genta M The effects of immunosuppressive and anti-inflammatory medications on fertility pregnancy and lactation Arch Intern Med 200016610-9
bull 84 Ostensen M Nonsteroidal anti-inflammatory drugs during pregnancy Scand J Rheumatol Suppl 1998107128-32
bull 85 USPDI -Drug information for the health care professional 22nd ed Greenwood Village CO Micromedex 2002 p 152-79
bull 86 Denson DD Coyle DE Thompson GA Santos D Turner PA Myers JA et al Bupivacaine protein binding in the term parturient effects of lactic acidosis Clin Pharmacol Ther 198435702-9
bull 87 Dillon DE Wagner CL Wiest D Newman RB Drug therapy in the nursing mother Obstet Gynecol Clin North Am 199724 675-96
bull 88 Dashe JS Gilstrap LC Antibiotic use in pregnancy Obstet Gynecol Clin North Am 199724617-29
bull 89 American College of Rheumatology Ad hoc Committee on Clinical Guidelines Guidelines for monitoring drug therapy in rheumatoid arthritis Arthritis Rheum 199639723-31
bull 90 Ng PC The fetal and neonatal hypothalamic-pituitary-adrenal axis Arch Dis Child Fetal Neonatal Ed 200082F250-4
bull 91 Crowley P Antenatal corticosteroidsmdashcurrent thinking BJOG 2003110(Suppl 20)77-8
bull 92 ACOG committee opinion antenatal corticosteroid therapy for fetal maturation Obstet Gynecol 200299871-3
bull 93 Ost L Wettrell G Bjorkhem I Rane A Prednisolone excretion in human milk J Pediatr 19851061008-11
bull 94 Rowland AS Baird DD Shore DL Weinberg CR Savitz DA Wilcox AJ Nitrous oxide and spontaneous abortion in female dental assistants Am J Epidemiol 1995141531-8
bull 95 McGlothlin JD Jensen PA Fischbach TJ Hughes RT Jones JH Control of anesthetic gases in dental operatories Scand J Work Environ Health 199218(Suppl 2)103-5
bull ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY Volume 97 Number 6 Suresh and Radfar 681
bull 96 Rosen MA Nitrous oxide for relief of labor pain a systematic review Am J Obstet Gynecol 2002186(Suppl Nature)S110-6
bull 97 Sands TD Pynn BR Management considerations for the pregnant or nursing emergency patient Ont Dent 199875 17-9
bull 98 Daya S Recurrent spontaneous early pregnancy loss and low dose aspirin Minerva Ginecol 200355441-9
bull 99 Sinclair C Handbook of obstetrical emergencies 1st ed Philadelphia WB Saunders 1996 p 29-39 69
bull 100 Tarsitano BF Rollings RE The pregnant dental patient evaluation and management Gen Dent 199341226-34
bull 101 Livingston MH Dlllinger TM Holder R Consideration in the management of the pregnant patient SCD Special Care in Dentistry 199818183-8
Thank you
- A Review on the principle of Dental Management of the Pregnant patient
- Slide 2
- Questions that a dentist may ask
- Stages of Pregnancy
- Slide 5
- Slide 6
- Physiologic Changes in Pregnancy
- Systemic changes in pregnancy
- FLAT SUPINE POSITIONING
- SUPINE HYPOTENSION SYNDROME (Vena Cava Compression)
- Supine Hypotension Syndrome
- Slide 12
- Supine Hypotension Syndrome
- Prevention of Supine Hypotensive Syndrome
- Treatment of Supine Hypotensive Syndrome
- How should the pregnant woman be positioned
- Slide 17
- Slide 18
- Slide 19
- Slide 20
- Slide 21
- Slide 22
- Slide 23
- Pregnancy Related Oral Health Problems
- Oral Problems in Pregnancy
- Pregnancy Gingivitis Pathophysiology
- Pregnancy Gingivitis
- Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Gum Problems - Pregnancy Granuloma
- Slide 31
- Gum Changes - Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Candidiasis
- Pregnancy Myths
- Other Oral Conditions in Pregnancy
- Changes During Pregnancy that Affect Oral Health
- Saliva changes
- Increased Bacteria
- Slide 40
- Enamel erosion caused by frequent vomiting
- Treatment for Acid Exposure
- Oral Diseases Can Effect Pregnancy
- Periodontal Disease and Preterm Labor
- Periodontal Disease and Low Birth Weight
- Periodontal Disease and Preeclampsia
- Periodontitis and Pre-eclampsia
- Dental Considerations
- Treatment Timing
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Slide 52
- Use of Radiation on Pregnant Patient
- Radiographs during Pregnancy
- Risks of Dental X-Rays
- FDA drug classification for pregnancy
- Slide 57
- FDA drug classification for pregnancy
- Slide 59
- Slide 60
- Slide 61
- Common Analgesics
- Analgesics
- Analgesics - continued
- Analgesics to Use During 1st and 2nd Trimester
- Analgesics to Avoid During the Third Trimester
- Sedation in Pregnancy
- Common Antibiotics
- Antibiotics
- Antibiotics To Use During Pregnancy
- Antibiotics to Avoid during Pregnancy
- The Problem With Tetracycline
- Other Antimicrobial Agents
- Local Anesthetic Use in Pregnancy
- Use of Local Anesthetics
- Ulcer healing drugs
- Slide 77
- Slide 78
- Slide 79
- Use of Nitrous Oxide Gas
- Common Preventives
- Are topical agents safe
- Pre-natal Fluoride
- Is it safe to use mercury restorations
- References
- REFERENCES
- Slide 87
- Slide 88
- Slide 89
- Slide 90
- Slide 91
- Slide 92
- Slide 93
- Slide 94
- Slide 95
- Slide 96
- Slide 97
- Slide 98
- Thank you
-
FDA drug classification for pregnancybull Combines risk statements including
congenital anomalies fetal effects perinatal risks and therapeutic risk-benefit ratio
bull Untreated disease or condition may pose more serious risks to both mother and fetus than any theoretical risks from the medication
bull Category A thru D and X
FDA drug classification for pregnancy
bull A = Controlled Studies in women fail to demonstrate a risk to the fetus in the first trimester and the possibility of fetal harm appears remote
FDA drug classification for pregnancy
bull B = Animal studies show no risk or if risk shown in animals controlled
trials in women showed no risk
FDA drug classification for pregnancy
bull C = Studies in animals with adverse effects and no human studies
OR no animal or human studies but benefits of use may outweigh potential harms
FDA drug classification for pregnancy
bull D = There is evidence of human fetal risk but benefits may outweigh risks
FDA drug classification for pregnancy
bull X = Contraindicated
Common Analgesics
bull paracetamol (B)bull Ibuprofen (BD) bull Oxycodone (BD) bull Hydrocodone and codeine
(CD)
avoid in third trimester
Analgesics
bull Paracetamol is the analgesic of choice for all stages of gestation
bull used to treat mild to moderate pain and fevers
bull short term usage is believed to be safebull avoid chronic and large doses of
paracetamol1048715
Analgesics - continuedbull Aspirin is nonteratogenic but may cause
maternal and fetal hemorrhagebull large and chronic doses during last trimester
may result in premature closure of ductus arteriosus fetal hypertension anemia and low birth weight
bull avoid ibuprofen in 3rd trimester because of possible adverse circulatory effects
bull short term use of codeine seems safebull avoid codeine late in gestation because of
possible fetal respiratory depression and withdrawal symptoms
Analgesics to Use During1st and 2nd Trimester
bull Category B (for best)bull Paracetamol Ibuprofenbull Naproxenbull Category C (use with caution)bull Paracetamol with codeine or
hydrocodonebull Paracetamol with oxycodone
Analgesics to Avoid During theThird Trimesterbull Causes delivery problemsbull Aspirin (C 3D)bull Ibuprofen (B3D)bull Naproxen (B3D)bull Causes neonatal respiratory
depression and opioid withdrawalbull Codeine (C3D)bull Hydrocodone (C3D)bull Oxycodone(C3D)
Sedation in Pregnancy
bull SedativesAnxiolytics (eg Diazepam ) are rated D and can cause oral clefts with prolonged exposure
bull Nitrous oxide should not be used in 1st trimester (If used in 2nd and 3rd do not go below 50 O2)
Common Antibioticsbull To treat oral abscess or cellulitis
ndash Penicillin (B) ndash Amoxicillin (B) ndash Cephalexin (B)ndash Erythromycin base (B) (Not estolate as it
cause cholestatic hepatitis)ndash Clindamycin (B)
Antibioticsbull penicillin V and amoxicillin is preferred drug
for mild to moderate infectionsbull widely used for many years with no ill effectsbull no studies show penicillin to be teratogenicbull amoxicillin extensively used without harming
the fetusbull Drug classes1048715 B penicillin cephalosporins erythromycin clindamycin Azithromycin D Tetracycline
Antibiotics To Use During Pregnancy
bull Penicillin Vbull Amoxicillinbull Erythromycin (base form)bull Cephalexin cephalosporinbull Clindamycinbull Metronidazole
Antibiotics to Avoid duringPregnancy
bull Doxycyclinebull Tetracyclinebull Erythromycin (estolate form)bull Vancomycin
The Problem With Tetracycline
bull Accumulates in bones and chelates calcium
bull Inhibits bone growthbull Discolors teeth
Other Antimicrobial Agentsbull OK to usebull Nystatin (B)bull Chlorhexidine rinse (B)bull Use with cautionbull Clotrimazole (C)bull Ketoconazole (C)bull Fluconazole (C)bull Do not usebull Doxycycline (D)
Local Anesthetic Use inPregnancy
bull Class Bbull Lidocaine (Xylocaine)bull Etidocainebull Prilocaine bull Class Cbull Procainebull Bupivicainebull Mepivicaine
Use of Local Anestheticsbull Lidocaine + vasoconstrictor most common
local anesthetic used in dentistrybull extensively used in pregnancy with no proven ill
effectsbull accidental intravascular injections of lidocaine
pass through the placenta but the concentrations are too low to harm fetus
bull prilocaine might cause methemoglobinemia
Ulcer healing drugsCimetidine bull FDA category B Famotidinebull FDA category BRanitidinebull FDA category Bbull not known to be harmful
Ulcer healing drugsOmeprazolebull FDA category BNot known to be
harmful Esomeprazolebull FDA category BLansoprazolebull FDA category BPantoprazolebull Avoid unless potential benefit
outweighs riskmdashfetotoxic in animals
Ulcer healing drugs
Misoprostolbull First second third trimesters Avoidmdash
potent uterine stimulant (has been used to induce abortion) and may be teratogenic
Ulcer healing drugs
Antacidsbull Almunium hydroxideMagnesium
hydroxidemdashFDA category B Calcium carbonatemdashFDA category C
SimetheconemdashFDA category C
Use of Nitrous Oxide Gas
bull used over 150 years bull safety is being debatedbull SHORT TERM exposure do not cause
birth defects or spontaneous abortionbull CHRONIC exposure may result in fetal
loss and infertilitybull literature suggests that nitrous oxide
should be avoided until more conclusive research is available
bull FDA Drug class not yet assigned
Common Preventives
bull Fluoridendash No increased risk during pregnancy
bull Xylitolndash No studies no harm reported
bull Chlorhexidinendash No increased risk during pregnancy
Are topical agents safe
bull Fluoridebull Toothpaste amp mouthrinse
bull Xylitol chewing gum bull Chlorhexidine (11 alcohol)bull No over the counter mouthrinses with
alcohol (Listerine 20 alcohol)
Pre-natal Fluoride
bull Daily 22 mg tablet of sodium fluoride during 3rd through 9th months
bull decreases caries rate in offspringbull Safe and effective
Glenn FB 1982
Is it safe to use mercury restorations
bull No evidence of harmful effect
bull Benefits outweigh risks
bull Canada Germany and New Zealand have some restrictions
bull Determine the best option
Referencesbull Wasylko L Matsui D Dykxhoorn SM Rieder MJ Weinberg
S A Review of Common Dental Treatments During Pregnancy J Canadian Dental Association 64434-439 1998
bull Little JW Donald AF Craig SM Rhodus NL Dental Management of the Medically Compromised Patient - 5th edition Mosby Toronto Pp434-442 1997
bull Livingston HM Dellinger TM Holder R Considerations in the management of the pregnant patient Special Care in Dentistry 185 pp183-188 1998
bull Larimore WL Petrie KA Drug use during pregnacy and lactation Primary Care Clinics in Office Practice 271 35-53 2000
bull Health Canada The Safety of DentalAmalgam Minister Of Supply and Services Canada 1996
REFERENCESbull 1 Weiss G Endocrinology of parturition J Clin
Endocrinol Metab 2000854421-5bull 2 Theunissen IM Parer JT Fluid and electrolytes in
pregnancy Clin Obstet Gynecol 1994373-15bull 3 Duvekot JJ Peeters LLH Renal hemodynamics and
volume homeostasis in pregnancy Obstet Gynecol Surv 199449830-9
bull 4 Barron WM Lindheimer MD Medical disorders during pregnancy 2nd ed St Louis Mosby 1995 p 129
bull 5 Thornburg KL Jacobson SL Giraud GD Morton MJ Hemodynamic changes in pregnancy Semin Perinatol 20002411-4
bull 6 Fiese R Herzog S Issues in dental and surgical management of the pregnant patient Oral Surg Oral Med Oral Pathol 198865292-7
bull 7 Martin C Varner MW Physiologic changes in pregnancysurgical implications Clin Obstet Gynecol 199437241-55
bull 8 Clark SL Cotton DB Lee W Bishop C Hill T Southwick J et al Central hemodynamic assessment of normal term pregnancy Am J Obstet Gynecol 19891611439-42
bull 9 Mabie WC Di Sessa TG Crocker LG Sibai BM Arheart KL A longitudinal study of cardiac output in normal human pregnancy Am J Obstet Gynecol 1994170849-56
bull 10 Clapp JF 3rd Capeless E Cardiovascular function before during and after the first and subsequent pregnancies Am J Cardiol 1997801469-73
bull 11 Duvekot JJ Peeters LL Maternal cardiovascular hemodynamic adaptation to pregnancy Obstet Gynecol Surv 199449(Suppl) S1-14
bull 12 Bhagwat AR Engel PJ Heart disease and pregnancy Cardiol Clin 199513163-78
bull 13 Lanni SM Tillinghast J Silver H Hemodynamic changes and baroreflex gain in the supine hypotensive syndrome Am J Obstet Gynecol 20021871636-41
bull 14 Little JW Falace DA Miller CS Rhodus NL Dental management of the medically compromised patient 6th ed St Louis Mosby 2002 p 303
bull 15 Garcia-Rio F Pino JM Gomez L Alvarez-Sala R Villasante C Villamor J Regulation of breathing and perception of dyspnea in healthy pregnant women Chest 1996110446-53
bull 16 McAuliffe F Kametas N Costello J Rafferty GF Greenough A Nicolaides K Respiratory function in singleton and twin pregnancy BJOG 2002109765-9
bull 17 Clapp JF 3rd Seaward BL Sleamaker RH Hiser J Maternal physiologic adaptations to early human pregnancy Am J Obstet Gynecol 19881591456-60
bull 18 OrsquoDay MP Cardio-respiratory physiological adaptation of pregnancy Semin Perinatol 199721268-75
bull 19 Contreras G Gutierrez M Beroiza T Fantin A Oddo H Villarroel L et al Ventilatory drive and respiratory muscle function in pregnancy Am Rev Respir Dis 1991144837-41
bull 20 Turner M Aziz SR Management of the pregnant oral and maxillofac
bull 21 Sifakis S Pharmakides G Anemia in pregnancy Ann N Y Acad Sci 2000900125-36
bull 22 Branch DW Physiologic adaptations of pregnancy Am J Reprod Immunol 199228120-2
bull 23 Burrows RF Kelton JG Incidentally detected thrombocytopenia in healthy mothers and their infants N Engl J Med 1988319 142-5
bull 24 Hanly JG Antiphospholipid syndrome an overview CMAJ 200324(168)1675-82
bull 25 Heilmann L von Tempelhoff GF Pollow K Antiphospholipid syndrome in obstetrics Clin Appl Thromb Hemost 20039 143-50
bull 26 Sherman P Flaxman SM Nausea and vomiting of pregnancy in an evolutionary perspective Am J Obstet Gynecol 2002 185(Suppl)s190-7
bull 27 Koch KL Gastrointestinal factors in nausea and vomiting of pregnancy Am J Obstet Gynecol 2002185(Suppl)s198-203
bull 28 Koch KL Frissora CL Nausea and vomiting during pregnancy Gastroenterol Clin N Am 200332201-34
bull 29 Baron TH Ramirez B Richter JE Gastrointestinal motility disorders during pregnancy Ann Intern Med 1993118 366-75
bull 30 Richter JE Gastroesophageal reflux disease during pregnancy Gastroenterol Clin N Am 200332235-61
bull 31 Marrero JM Goggin PM de Caestecker JS Pearce JM Maxwell JD Determinants of pregnancy heartburn Br J Obstet Gynaecol 199299731-4
bull 32 Hamaoui E Hamaoui M Nutritional assessment and support during pregnancy Gastroenterol Clin N Am 20033259-121
bull 33 King JC Physiology of pregnancy and nutrient metabolism Am J Clin Nutr 200071(suppl)1218s-25s
bull 34 Casanueva E Pfeffer F Fernandez-Gaxiola AC Gutierrez- Valenzuela V Rothenberg SJ Iron and folate status before pregnancy and anemia during pregnancy Ann Nutr Metab 2003 4760-3
bull 35 Chrsquong CL Morgan M Hainsworth I Kingham JG Prospective study of liver dysfunction in Southwest Wales Gut 200251 876-80
bull 36 Rahman TM Wendon J Severe hepatic dysfunction in pregnancy QJM 200295343-57
bull 37 Knox TA Olans LB Liver disease in pregnancy N Engl J Med 1996335569-76
bull 38 Saftlas AF Olson DR Franks AL Atrash H Pokras R Epidemiology of preeclampsia and eclampsia in the United States 1979e1986 Am J Obstet Gynecol 1990163460-5
bull 39 Walker JJ Pre-eclampsia Lancet 20003561260-5
bull 40 Davidson JM Renal disorders in pregnancy Curr Opin Obstet Gynecol 200113109-14
bull 41 Dafnis E Sabatini S The effect of pregnancy on renal function physiology and pathophysiologyAmJMedSci 1992303184-205
bull 42 Davison JM Shiells EA Philips PR Lindheimer MD Serial evaluation of vasopressin release and thirst in human pregnancy Role of human chorionic gonadotrophin in the osmoregulatory changes of gestation J Clin Invest 198881798-806
bull 43 Glinoer D de Nayer P Bourdoux P Lemone M Robyn C van Steirteghem A et al Regulation of maternal thyroid during pregnancy J Clin Endocrinol Metab 199071276-87
bull 44 Wilson SG Retallack RW Kent JC Worth GK Gutteridge DH Serum free 125-dihydroxyvitamin D and the free 125- dihydroxyvitamin D index during a longitudinal study of human pregnancy and lactation Clin Endocrinol 199032613-22
bull 45 Rasmussen N Frolich A Hornnes PJ Hegedus L Serum ionized calcium and intact parathyroid hormone levels during pregnancy and postpartum Br J Obstet Gynaecol 199097857-9
bull 46 Guyton AC Textbook of medical physiology 8th ed Philadelphia W B Saunders 1991 p 915e28
bull 47 Trainer PJ Corticosteroids and pregnancy Semin Reprod Med 200220375-80
bull 48 Soory M Hormonal factors in periodontal disease Dent Update 200027380-3
bull 49 Hugoson A Gingivitis in pregnant women A longitudinal clinical study Odontol Revy 19712265-84
bull 50 Neville BW Damm DD Allen CM Bouquot JE Oral amp Maxillofacial Pathology 3rd ed Philadelphia W B Saunders 2002 p 329-30 447-9
bull 51 Tilakaratne A Soory M Ranasinghe AW Corea SM Ekanayake SL de Silva M Periodontal disease status during pregnancy and 3 months post-partum in rural population of Sri-Lankan women J Clin Periodontol 200027787-92
bull 52 Laine M Tenovuo J Lehtonen OP Ojanatko-Harri A Vilja P Tuohimaa P Pregnancy e related changes in human whole saliva Arch Oral Biol 198833913-7
bull 53 Yuan K Wing LY Lin MT Pathogenetic roles of angiogenic factors in pyogenic granulomas in pregnancy are modulated by female sex hormones J Periodontol 200273701-8
bull 54 Evans RD Briggs PF Tooth-surface loss related to pregnancyinduced vomiting Prim Dent Care 1994124-6
bull 55 Salvolini E Di Giorgio R Curatola A Mazzanti L Fratto G Biochemical modifications of human whole saliva induced by pregnancy Br J Obstet Gynaec 1998105656-60
bull 56 Mauldin JG Newman RB Preterm birth risk assessment Semin Perinatol 200125215-22
bull 57 Heine RP McGregor JA Goodwin TM Artal R Hayashi RH Robertson PA et al Serial salivary estriol to detect an increased risk of preterm birth Obstet Gynecol 200096490-7
bull 58 Kauh YC Zachian TF Melasma Adv Exp Med Biol 1999455 491-9
bull 59 Wong RC Ellis CN Physiologic skin changes in pregnancy J Am Acad Dermatol 198410929-40
bull 60 Errickson CV Matus NR Skin disorders of pregnancy Am Fam Physician 199449605-10
bull 61 Lopez NJ Smith PC Gutierrez J Periodontal therapy may reduce the risk of preterm low birth weight in women with periodontal disease a randomized controlled trial J Periodontol 200273911-24
bull 62 McGaw T Periodontal disease and preterm delivery of lowbirth- weight infants J Can Dent Assoc 200268165-9
bull 63 Richards AG Dental x-ray protection Dent Clin North Am 1968631-41
bull 64 1990 Recommendations of the International Commission on Radiological Protection Ann ICRP 1991211-201
bull 65 Hall EJ Radiation the two-edged sword cancer risks at high and low doses Cancer J 20006343-50
bull 66 Diethelm L Xu H Diagnostic imaging of the lung during pregnancy Clin Obstet Gynecol 19963936-55
bull 67 Brent RL The effects of embryonic and fetal exposure to x-rays microwaves and ultrasound ClinObstetGynecol 198326484-510
bull 68 National Council on Radiation Protection NCRP report no128 1998 Bethesda Md Author
bull 69 Wasylko L Matsui D Dykxhoorn SM Reider MJ Weinberg S A review of common dental treatments during pregnancy implications for patients and dental personnel J Can Dent Assoc 199864434-9
bull 70 Freeman JP Brand JW Radiation doses of commonly used dental radiographic surveys Oral Surg Oral Med Oral Pathol 199477285-9
bull 71 Kircos LTAngin LL Lorton LOrder ofmagnitude dose reduction in intraoral radiography J Am Dent Assoc 1987114344-7
bull 72 Updegrave WJ Simplified and standardized intraoral radiography with reduced tissue irradiation J Am Dent Assoc 197285861-9
bull 73 Wood RE Harris AM van der Merwe EJ Nortje CJ The leaded apron revisited does it reduce gonadal radiation dose in dental radiology Oral Surg Oral Med Oral Pathol 199171642-6
bull 74 An update on radiographic practices information and recommendations ADA Council on Scientific Affairs J Am Dent Assoc 2001132234-8
bull 75 Rayburn WF Recommending medications during pregnancy an evidence based approach Clin Obstet Gynecol 2002451-5
bull 76 Rathmell JP Viscomi C Ashburn MA Management of nonobstetric pain during pregnancy and lactation Anesth Analg 1997851074-87
bull 77 Teratology society public affairs committee FDA classification of drugs for teratogenic risk Teratology 199449446-7
bull 78 Moore PA Selecting drugs for the pregnant dental patient J Am Dent Assoc 19981291281-6
bull 79 Haas DA An update on analgesics for the management of acute postoperative dental pain J Can Dent Assoc 200268476-82
bull 80 Haas DA Pynn BR Sands TD Drug use for the pregnant or lactating patient Gen Dent 20004854-60
bull 81 Committee on Drugs American Academy of Pediatrics The transfer of drugs and other chemicals into human milk Pediatrics 199493137-50
bull 82 Nielsen GL Sorensen HT Larsen H Pedersen L Risk of adverse birth outcome and miscarriage in pregnant users of nonsteroidal anti-inflammatory drugs population based observational study and case-control study BMJ 2001322266-70
bull 83 Janssen N Genta M The effects of immunosuppressive and anti-inflammatory medications on fertility pregnancy and lactation Arch Intern Med 200016610-9
bull 84 Ostensen M Nonsteroidal anti-inflammatory drugs during pregnancy Scand J Rheumatol Suppl 1998107128-32
bull 85 USPDI -Drug information for the health care professional 22nd ed Greenwood Village CO Micromedex 2002 p 152-79
bull 86 Denson DD Coyle DE Thompson GA Santos D Turner PA Myers JA et al Bupivacaine protein binding in the term parturient effects of lactic acidosis Clin Pharmacol Ther 198435702-9
bull 87 Dillon DE Wagner CL Wiest D Newman RB Drug therapy in the nursing mother Obstet Gynecol Clin North Am 199724 675-96
bull 88 Dashe JS Gilstrap LC Antibiotic use in pregnancy Obstet Gynecol Clin North Am 199724617-29
bull 89 American College of Rheumatology Ad hoc Committee on Clinical Guidelines Guidelines for monitoring drug therapy in rheumatoid arthritis Arthritis Rheum 199639723-31
bull 90 Ng PC The fetal and neonatal hypothalamic-pituitary-adrenal axis Arch Dis Child Fetal Neonatal Ed 200082F250-4
bull 91 Crowley P Antenatal corticosteroidsmdashcurrent thinking BJOG 2003110(Suppl 20)77-8
bull 92 ACOG committee opinion antenatal corticosteroid therapy for fetal maturation Obstet Gynecol 200299871-3
bull 93 Ost L Wettrell G Bjorkhem I Rane A Prednisolone excretion in human milk J Pediatr 19851061008-11
bull 94 Rowland AS Baird DD Shore DL Weinberg CR Savitz DA Wilcox AJ Nitrous oxide and spontaneous abortion in female dental assistants Am J Epidemiol 1995141531-8
bull 95 McGlothlin JD Jensen PA Fischbach TJ Hughes RT Jones JH Control of anesthetic gases in dental operatories Scand J Work Environ Health 199218(Suppl 2)103-5
bull ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY Volume 97 Number 6 Suresh and Radfar 681
bull 96 Rosen MA Nitrous oxide for relief of labor pain a systematic review Am J Obstet Gynecol 2002186(Suppl Nature)S110-6
bull 97 Sands TD Pynn BR Management considerations for the pregnant or nursing emergency patient Ont Dent 199875 17-9
bull 98 Daya S Recurrent spontaneous early pregnancy loss and low dose aspirin Minerva Ginecol 200355441-9
bull 99 Sinclair C Handbook of obstetrical emergencies 1st ed Philadelphia WB Saunders 1996 p 29-39 69
bull 100 Tarsitano BF Rollings RE The pregnant dental patient evaluation and management Gen Dent 199341226-34
bull 101 Livingston MH Dlllinger TM Holder R Consideration in the management of the pregnant patient SCD Special Care in Dentistry 199818183-8
Thank you
- A Review on the principle of Dental Management of the Pregnant patient
- Slide 2
- Questions that a dentist may ask
- Stages of Pregnancy
- Slide 5
- Slide 6
- Physiologic Changes in Pregnancy
- Systemic changes in pregnancy
- FLAT SUPINE POSITIONING
- SUPINE HYPOTENSION SYNDROME (Vena Cava Compression)
- Supine Hypotension Syndrome
- Slide 12
- Supine Hypotension Syndrome
- Prevention of Supine Hypotensive Syndrome
- Treatment of Supine Hypotensive Syndrome
- How should the pregnant woman be positioned
- Slide 17
- Slide 18
- Slide 19
- Slide 20
- Slide 21
- Slide 22
- Slide 23
- Pregnancy Related Oral Health Problems
- Oral Problems in Pregnancy
- Pregnancy Gingivitis Pathophysiology
- Pregnancy Gingivitis
- Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Gum Problems - Pregnancy Granuloma
- Slide 31
- Gum Changes - Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Candidiasis
- Pregnancy Myths
- Other Oral Conditions in Pregnancy
- Changes During Pregnancy that Affect Oral Health
- Saliva changes
- Increased Bacteria
- Slide 40
- Enamel erosion caused by frequent vomiting
- Treatment for Acid Exposure
- Oral Diseases Can Effect Pregnancy
- Periodontal Disease and Preterm Labor
- Periodontal Disease and Low Birth Weight
- Periodontal Disease and Preeclampsia
- Periodontitis and Pre-eclampsia
- Dental Considerations
- Treatment Timing
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Slide 52
- Use of Radiation on Pregnant Patient
- Radiographs during Pregnancy
- Risks of Dental X-Rays
- FDA drug classification for pregnancy
- Slide 57
- FDA drug classification for pregnancy
- Slide 59
- Slide 60
- Slide 61
- Common Analgesics
- Analgesics
- Analgesics - continued
- Analgesics to Use During 1st and 2nd Trimester
- Analgesics to Avoid During the Third Trimester
- Sedation in Pregnancy
- Common Antibiotics
- Antibiotics
- Antibiotics To Use During Pregnancy
- Antibiotics to Avoid during Pregnancy
- The Problem With Tetracycline
- Other Antimicrobial Agents
- Local Anesthetic Use in Pregnancy
- Use of Local Anesthetics
- Ulcer healing drugs
- Slide 77
- Slide 78
- Slide 79
- Use of Nitrous Oxide Gas
- Common Preventives
- Are topical agents safe
- Pre-natal Fluoride
- Is it safe to use mercury restorations
- References
- REFERENCES
- Slide 87
- Slide 88
- Slide 89
- Slide 90
- Slide 91
- Slide 92
- Slide 93
- Slide 94
- Slide 95
- Slide 96
- Slide 97
- Slide 98
- Thank you
-
FDA drug classification for pregnancy
bull A = Controlled Studies in women fail to demonstrate a risk to the fetus in the first trimester and the possibility of fetal harm appears remote
FDA drug classification for pregnancy
bull B = Animal studies show no risk or if risk shown in animals controlled
trials in women showed no risk
FDA drug classification for pregnancy
bull C = Studies in animals with adverse effects and no human studies
OR no animal or human studies but benefits of use may outweigh potential harms
FDA drug classification for pregnancy
bull D = There is evidence of human fetal risk but benefits may outweigh risks
FDA drug classification for pregnancy
bull X = Contraindicated
Common Analgesics
bull paracetamol (B)bull Ibuprofen (BD) bull Oxycodone (BD) bull Hydrocodone and codeine
(CD)
avoid in third trimester
Analgesics
bull Paracetamol is the analgesic of choice for all stages of gestation
bull used to treat mild to moderate pain and fevers
bull short term usage is believed to be safebull avoid chronic and large doses of
paracetamol1048715
Analgesics - continuedbull Aspirin is nonteratogenic but may cause
maternal and fetal hemorrhagebull large and chronic doses during last trimester
may result in premature closure of ductus arteriosus fetal hypertension anemia and low birth weight
bull avoid ibuprofen in 3rd trimester because of possible adverse circulatory effects
bull short term use of codeine seems safebull avoid codeine late in gestation because of
possible fetal respiratory depression and withdrawal symptoms
Analgesics to Use During1st and 2nd Trimester
bull Category B (for best)bull Paracetamol Ibuprofenbull Naproxenbull Category C (use with caution)bull Paracetamol with codeine or
hydrocodonebull Paracetamol with oxycodone
Analgesics to Avoid During theThird Trimesterbull Causes delivery problemsbull Aspirin (C 3D)bull Ibuprofen (B3D)bull Naproxen (B3D)bull Causes neonatal respiratory
depression and opioid withdrawalbull Codeine (C3D)bull Hydrocodone (C3D)bull Oxycodone(C3D)
Sedation in Pregnancy
bull SedativesAnxiolytics (eg Diazepam ) are rated D and can cause oral clefts with prolonged exposure
bull Nitrous oxide should not be used in 1st trimester (If used in 2nd and 3rd do not go below 50 O2)
Common Antibioticsbull To treat oral abscess or cellulitis
ndash Penicillin (B) ndash Amoxicillin (B) ndash Cephalexin (B)ndash Erythromycin base (B) (Not estolate as it
cause cholestatic hepatitis)ndash Clindamycin (B)
Antibioticsbull penicillin V and amoxicillin is preferred drug
for mild to moderate infectionsbull widely used for many years with no ill effectsbull no studies show penicillin to be teratogenicbull amoxicillin extensively used without harming
the fetusbull Drug classes1048715 B penicillin cephalosporins erythromycin clindamycin Azithromycin D Tetracycline
Antibiotics To Use During Pregnancy
bull Penicillin Vbull Amoxicillinbull Erythromycin (base form)bull Cephalexin cephalosporinbull Clindamycinbull Metronidazole
Antibiotics to Avoid duringPregnancy
bull Doxycyclinebull Tetracyclinebull Erythromycin (estolate form)bull Vancomycin
The Problem With Tetracycline
bull Accumulates in bones and chelates calcium
bull Inhibits bone growthbull Discolors teeth
Other Antimicrobial Agentsbull OK to usebull Nystatin (B)bull Chlorhexidine rinse (B)bull Use with cautionbull Clotrimazole (C)bull Ketoconazole (C)bull Fluconazole (C)bull Do not usebull Doxycycline (D)
Local Anesthetic Use inPregnancy
bull Class Bbull Lidocaine (Xylocaine)bull Etidocainebull Prilocaine bull Class Cbull Procainebull Bupivicainebull Mepivicaine
Use of Local Anestheticsbull Lidocaine + vasoconstrictor most common
local anesthetic used in dentistrybull extensively used in pregnancy with no proven ill
effectsbull accidental intravascular injections of lidocaine
pass through the placenta but the concentrations are too low to harm fetus
bull prilocaine might cause methemoglobinemia
Ulcer healing drugsCimetidine bull FDA category B Famotidinebull FDA category BRanitidinebull FDA category Bbull not known to be harmful
Ulcer healing drugsOmeprazolebull FDA category BNot known to be
harmful Esomeprazolebull FDA category BLansoprazolebull FDA category BPantoprazolebull Avoid unless potential benefit
outweighs riskmdashfetotoxic in animals
Ulcer healing drugs
Misoprostolbull First second third trimesters Avoidmdash
potent uterine stimulant (has been used to induce abortion) and may be teratogenic
Ulcer healing drugs
Antacidsbull Almunium hydroxideMagnesium
hydroxidemdashFDA category B Calcium carbonatemdashFDA category C
SimetheconemdashFDA category C
Use of Nitrous Oxide Gas
bull used over 150 years bull safety is being debatedbull SHORT TERM exposure do not cause
birth defects or spontaneous abortionbull CHRONIC exposure may result in fetal
loss and infertilitybull literature suggests that nitrous oxide
should be avoided until more conclusive research is available
bull FDA Drug class not yet assigned
Common Preventives
bull Fluoridendash No increased risk during pregnancy
bull Xylitolndash No studies no harm reported
bull Chlorhexidinendash No increased risk during pregnancy
Are topical agents safe
bull Fluoridebull Toothpaste amp mouthrinse
bull Xylitol chewing gum bull Chlorhexidine (11 alcohol)bull No over the counter mouthrinses with
alcohol (Listerine 20 alcohol)
Pre-natal Fluoride
bull Daily 22 mg tablet of sodium fluoride during 3rd through 9th months
bull decreases caries rate in offspringbull Safe and effective
Glenn FB 1982
Is it safe to use mercury restorations
bull No evidence of harmful effect
bull Benefits outweigh risks
bull Canada Germany and New Zealand have some restrictions
bull Determine the best option
Referencesbull Wasylko L Matsui D Dykxhoorn SM Rieder MJ Weinberg
S A Review of Common Dental Treatments During Pregnancy J Canadian Dental Association 64434-439 1998
bull Little JW Donald AF Craig SM Rhodus NL Dental Management of the Medically Compromised Patient - 5th edition Mosby Toronto Pp434-442 1997
bull Livingston HM Dellinger TM Holder R Considerations in the management of the pregnant patient Special Care in Dentistry 185 pp183-188 1998
bull Larimore WL Petrie KA Drug use during pregnacy and lactation Primary Care Clinics in Office Practice 271 35-53 2000
bull Health Canada The Safety of DentalAmalgam Minister Of Supply and Services Canada 1996
REFERENCESbull 1 Weiss G Endocrinology of parturition J Clin
Endocrinol Metab 2000854421-5bull 2 Theunissen IM Parer JT Fluid and electrolytes in
pregnancy Clin Obstet Gynecol 1994373-15bull 3 Duvekot JJ Peeters LLH Renal hemodynamics and
volume homeostasis in pregnancy Obstet Gynecol Surv 199449830-9
bull 4 Barron WM Lindheimer MD Medical disorders during pregnancy 2nd ed St Louis Mosby 1995 p 129
bull 5 Thornburg KL Jacobson SL Giraud GD Morton MJ Hemodynamic changes in pregnancy Semin Perinatol 20002411-4
bull 6 Fiese R Herzog S Issues in dental and surgical management of the pregnant patient Oral Surg Oral Med Oral Pathol 198865292-7
bull 7 Martin C Varner MW Physiologic changes in pregnancysurgical implications Clin Obstet Gynecol 199437241-55
bull 8 Clark SL Cotton DB Lee W Bishop C Hill T Southwick J et al Central hemodynamic assessment of normal term pregnancy Am J Obstet Gynecol 19891611439-42
bull 9 Mabie WC Di Sessa TG Crocker LG Sibai BM Arheart KL A longitudinal study of cardiac output in normal human pregnancy Am J Obstet Gynecol 1994170849-56
bull 10 Clapp JF 3rd Capeless E Cardiovascular function before during and after the first and subsequent pregnancies Am J Cardiol 1997801469-73
bull 11 Duvekot JJ Peeters LL Maternal cardiovascular hemodynamic adaptation to pregnancy Obstet Gynecol Surv 199449(Suppl) S1-14
bull 12 Bhagwat AR Engel PJ Heart disease and pregnancy Cardiol Clin 199513163-78
bull 13 Lanni SM Tillinghast J Silver H Hemodynamic changes and baroreflex gain in the supine hypotensive syndrome Am J Obstet Gynecol 20021871636-41
bull 14 Little JW Falace DA Miller CS Rhodus NL Dental management of the medically compromised patient 6th ed St Louis Mosby 2002 p 303
bull 15 Garcia-Rio F Pino JM Gomez L Alvarez-Sala R Villasante C Villamor J Regulation of breathing and perception of dyspnea in healthy pregnant women Chest 1996110446-53
bull 16 McAuliffe F Kametas N Costello J Rafferty GF Greenough A Nicolaides K Respiratory function in singleton and twin pregnancy BJOG 2002109765-9
bull 17 Clapp JF 3rd Seaward BL Sleamaker RH Hiser J Maternal physiologic adaptations to early human pregnancy Am J Obstet Gynecol 19881591456-60
bull 18 OrsquoDay MP Cardio-respiratory physiological adaptation of pregnancy Semin Perinatol 199721268-75
bull 19 Contreras G Gutierrez M Beroiza T Fantin A Oddo H Villarroel L et al Ventilatory drive and respiratory muscle function in pregnancy Am Rev Respir Dis 1991144837-41
bull 20 Turner M Aziz SR Management of the pregnant oral and maxillofac
bull 21 Sifakis S Pharmakides G Anemia in pregnancy Ann N Y Acad Sci 2000900125-36
bull 22 Branch DW Physiologic adaptations of pregnancy Am J Reprod Immunol 199228120-2
bull 23 Burrows RF Kelton JG Incidentally detected thrombocytopenia in healthy mothers and their infants N Engl J Med 1988319 142-5
bull 24 Hanly JG Antiphospholipid syndrome an overview CMAJ 200324(168)1675-82
bull 25 Heilmann L von Tempelhoff GF Pollow K Antiphospholipid syndrome in obstetrics Clin Appl Thromb Hemost 20039 143-50
bull 26 Sherman P Flaxman SM Nausea and vomiting of pregnancy in an evolutionary perspective Am J Obstet Gynecol 2002 185(Suppl)s190-7
bull 27 Koch KL Gastrointestinal factors in nausea and vomiting of pregnancy Am J Obstet Gynecol 2002185(Suppl)s198-203
bull 28 Koch KL Frissora CL Nausea and vomiting during pregnancy Gastroenterol Clin N Am 200332201-34
bull 29 Baron TH Ramirez B Richter JE Gastrointestinal motility disorders during pregnancy Ann Intern Med 1993118 366-75
bull 30 Richter JE Gastroesophageal reflux disease during pregnancy Gastroenterol Clin N Am 200332235-61
bull 31 Marrero JM Goggin PM de Caestecker JS Pearce JM Maxwell JD Determinants of pregnancy heartburn Br J Obstet Gynaecol 199299731-4
bull 32 Hamaoui E Hamaoui M Nutritional assessment and support during pregnancy Gastroenterol Clin N Am 20033259-121
bull 33 King JC Physiology of pregnancy and nutrient metabolism Am J Clin Nutr 200071(suppl)1218s-25s
bull 34 Casanueva E Pfeffer F Fernandez-Gaxiola AC Gutierrez- Valenzuela V Rothenberg SJ Iron and folate status before pregnancy and anemia during pregnancy Ann Nutr Metab 2003 4760-3
bull 35 Chrsquong CL Morgan M Hainsworth I Kingham JG Prospective study of liver dysfunction in Southwest Wales Gut 200251 876-80
bull 36 Rahman TM Wendon J Severe hepatic dysfunction in pregnancy QJM 200295343-57
bull 37 Knox TA Olans LB Liver disease in pregnancy N Engl J Med 1996335569-76
bull 38 Saftlas AF Olson DR Franks AL Atrash H Pokras R Epidemiology of preeclampsia and eclampsia in the United States 1979e1986 Am J Obstet Gynecol 1990163460-5
bull 39 Walker JJ Pre-eclampsia Lancet 20003561260-5
bull 40 Davidson JM Renal disorders in pregnancy Curr Opin Obstet Gynecol 200113109-14
bull 41 Dafnis E Sabatini S The effect of pregnancy on renal function physiology and pathophysiologyAmJMedSci 1992303184-205
bull 42 Davison JM Shiells EA Philips PR Lindheimer MD Serial evaluation of vasopressin release and thirst in human pregnancy Role of human chorionic gonadotrophin in the osmoregulatory changes of gestation J Clin Invest 198881798-806
bull 43 Glinoer D de Nayer P Bourdoux P Lemone M Robyn C van Steirteghem A et al Regulation of maternal thyroid during pregnancy J Clin Endocrinol Metab 199071276-87
bull 44 Wilson SG Retallack RW Kent JC Worth GK Gutteridge DH Serum free 125-dihydroxyvitamin D and the free 125- dihydroxyvitamin D index during a longitudinal study of human pregnancy and lactation Clin Endocrinol 199032613-22
bull 45 Rasmussen N Frolich A Hornnes PJ Hegedus L Serum ionized calcium and intact parathyroid hormone levels during pregnancy and postpartum Br J Obstet Gynaecol 199097857-9
bull 46 Guyton AC Textbook of medical physiology 8th ed Philadelphia W B Saunders 1991 p 915e28
bull 47 Trainer PJ Corticosteroids and pregnancy Semin Reprod Med 200220375-80
bull 48 Soory M Hormonal factors in periodontal disease Dent Update 200027380-3
bull 49 Hugoson A Gingivitis in pregnant women A longitudinal clinical study Odontol Revy 19712265-84
bull 50 Neville BW Damm DD Allen CM Bouquot JE Oral amp Maxillofacial Pathology 3rd ed Philadelphia W B Saunders 2002 p 329-30 447-9
bull 51 Tilakaratne A Soory M Ranasinghe AW Corea SM Ekanayake SL de Silva M Periodontal disease status during pregnancy and 3 months post-partum in rural population of Sri-Lankan women J Clin Periodontol 200027787-92
bull 52 Laine M Tenovuo J Lehtonen OP Ojanatko-Harri A Vilja P Tuohimaa P Pregnancy e related changes in human whole saliva Arch Oral Biol 198833913-7
bull 53 Yuan K Wing LY Lin MT Pathogenetic roles of angiogenic factors in pyogenic granulomas in pregnancy are modulated by female sex hormones J Periodontol 200273701-8
bull 54 Evans RD Briggs PF Tooth-surface loss related to pregnancyinduced vomiting Prim Dent Care 1994124-6
bull 55 Salvolini E Di Giorgio R Curatola A Mazzanti L Fratto G Biochemical modifications of human whole saliva induced by pregnancy Br J Obstet Gynaec 1998105656-60
bull 56 Mauldin JG Newman RB Preterm birth risk assessment Semin Perinatol 200125215-22
bull 57 Heine RP McGregor JA Goodwin TM Artal R Hayashi RH Robertson PA et al Serial salivary estriol to detect an increased risk of preterm birth Obstet Gynecol 200096490-7
bull 58 Kauh YC Zachian TF Melasma Adv Exp Med Biol 1999455 491-9
bull 59 Wong RC Ellis CN Physiologic skin changes in pregnancy J Am Acad Dermatol 198410929-40
bull 60 Errickson CV Matus NR Skin disorders of pregnancy Am Fam Physician 199449605-10
bull 61 Lopez NJ Smith PC Gutierrez J Periodontal therapy may reduce the risk of preterm low birth weight in women with periodontal disease a randomized controlled trial J Periodontol 200273911-24
bull 62 McGaw T Periodontal disease and preterm delivery of lowbirth- weight infants J Can Dent Assoc 200268165-9
bull 63 Richards AG Dental x-ray protection Dent Clin North Am 1968631-41
bull 64 1990 Recommendations of the International Commission on Radiological Protection Ann ICRP 1991211-201
bull 65 Hall EJ Radiation the two-edged sword cancer risks at high and low doses Cancer J 20006343-50
bull 66 Diethelm L Xu H Diagnostic imaging of the lung during pregnancy Clin Obstet Gynecol 19963936-55
bull 67 Brent RL The effects of embryonic and fetal exposure to x-rays microwaves and ultrasound ClinObstetGynecol 198326484-510
bull 68 National Council on Radiation Protection NCRP report no128 1998 Bethesda Md Author
bull 69 Wasylko L Matsui D Dykxhoorn SM Reider MJ Weinberg S A review of common dental treatments during pregnancy implications for patients and dental personnel J Can Dent Assoc 199864434-9
bull 70 Freeman JP Brand JW Radiation doses of commonly used dental radiographic surveys Oral Surg Oral Med Oral Pathol 199477285-9
bull 71 Kircos LTAngin LL Lorton LOrder ofmagnitude dose reduction in intraoral radiography J Am Dent Assoc 1987114344-7
bull 72 Updegrave WJ Simplified and standardized intraoral radiography with reduced tissue irradiation J Am Dent Assoc 197285861-9
bull 73 Wood RE Harris AM van der Merwe EJ Nortje CJ The leaded apron revisited does it reduce gonadal radiation dose in dental radiology Oral Surg Oral Med Oral Pathol 199171642-6
bull 74 An update on radiographic practices information and recommendations ADA Council on Scientific Affairs J Am Dent Assoc 2001132234-8
bull 75 Rayburn WF Recommending medications during pregnancy an evidence based approach Clin Obstet Gynecol 2002451-5
bull 76 Rathmell JP Viscomi C Ashburn MA Management of nonobstetric pain during pregnancy and lactation Anesth Analg 1997851074-87
bull 77 Teratology society public affairs committee FDA classification of drugs for teratogenic risk Teratology 199449446-7
bull 78 Moore PA Selecting drugs for the pregnant dental patient J Am Dent Assoc 19981291281-6
bull 79 Haas DA An update on analgesics for the management of acute postoperative dental pain J Can Dent Assoc 200268476-82
bull 80 Haas DA Pynn BR Sands TD Drug use for the pregnant or lactating patient Gen Dent 20004854-60
bull 81 Committee on Drugs American Academy of Pediatrics The transfer of drugs and other chemicals into human milk Pediatrics 199493137-50
bull 82 Nielsen GL Sorensen HT Larsen H Pedersen L Risk of adverse birth outcome and miscarriage in pregnant users of nonsteroidal anti-inflammatory drugs population based observational study and case-control study BMJ 2001322266-70
bull 83 Janssen N Genta M The effects of immunosuppressive and anti-inflammatory medications on fertility pregnancy and lactation Arch Intern Med 200016610-9
bull 84 Ostensen M Nonsteroidal anti-inflammatory drugs during pregnancy Scand J Rheumatol Suppl 1998107128-32
bull 85 USPDI -Drug information for the health care professional 22nd ed Greenwood Village CO Micromedex 2002 p 152-79
bull 86 Denson DD Coyle DE Thompson GA Santos D Turner PA Myers JA et al Bupivacaine protein binding in the term parturient effects of lactic acidosis Clin Pharmacol Ther 198435702-9
bull 87 Dillon DE Wagner CL Wiest D Newman RB Drug therapy in the nursing mother Obstet Gynecol Clin North Am 199724 675-96
bull 88 Dashe JS Gilstrap LC Antibiotic use in pregnancy Obstet Gynecol Clin North Am 199724617-29
bull 89 American College of Rheumatology Ad hoc Committee on Clinical Guidelines Guidelines for monitoring drug therapy in rheumatoid arthritis Arthritis Rheum 199639723-31
bull 90 Ng PC The fetal and neonatal hypothalamic-pituitary-adrenal axis Arch Dis Child Fetal Neonatal Ed 200082F250-4
bull 91 Crowley P Antenatal corticosteroidsmdashcurrent thinking BJOG 2003110(Suppl 20)77-8
bull 92 ACOG committee opinion antenatal corticosteroid therapy for fetal maturation Obstet Gynecol 200299871-3
bull 93 Ost L Wettrell G Bjorkhem I Rane A Prednisolone excretion in human milk J Pediatr 19851061008-11
bull 94 Rowland AS Baird DD Shore DL Weinberg CR Savitz DA Wilcox AJ Nitrous oxide and spontaneous abortion in female dental assistants Am J Epidemiol 1995141531-8
bull 95 McGlothlin JD Jensen PA Fischbach TJ Hughes RT Jones JH Control of anesthetic gases in dental operatories Scand J Work Environ Health 199218(Suppl 2)103-5
bull ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY Volume 97 Number 6 Suresh and Radfar 681
bull 96 Rosen MA Nitrous oxide for relief of labor pain a systematic review Am J Obstet Gynecol 2002186(Suppl Nature)S110-6
bull 97 Sands TD Pynn BR Management considerations for the pregnant or nursing emergency patient Ont Dent 199875 17-9
bull 98 Daya S Recurrent spontaneous early pregnancy loss and low dose aspirin Minerva Ginecol 200355441-9
bull 99 Sinclair C Handbook of obstetrical emergencies 1st ed Philadelphia WB Saunders 1996 p 29-39 69
bull 100 Tarsitano BF Rollings RE The pregnant dental patient evaluation and management Gen Dent 199341226-34
bull 101 Livingston MH Dlllinger TM Holder R Consideration in the management of the pregnant patient SCD Special Care in Dentistry 199818183-8
Thank you
- A Review on the principle of Dental Management of the Pregnant patient
- Slide 2
- Questions that a dentist may ask
- Stages of Pregnancy
- Slide 5
- Slide 6
- Physiologic Changes in Pregnancy
- Systemic changes in pregnancy
- FLAT SUPINE POSITIONING
- SUPINE HYPOTENSION SYNDROME (Vena Cava Compression)
- Supine Hypotension Syndrome
- Slide 12
- Supine Hypotension Syndrome
- Prevention of Supine Hypotensive Syndrome
- Treatment of Supine Hypotensive Syndrome
- How should the pregnant woman be positioned
- Slide 17
- Slide 18
- Slide 19
- Slide 20
- Slide 21
- Slide 22
- Slide 23
- Pregnancy Related Oral Health Problems
- Oral Problems in Pregnancy
- Pregnancy Gingivitis Pathophysiology
- Pregnancy Gingivitis
- Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Gum Problems - Pregnancy Granuloma
- Slide 31
- Gum Changes - Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Candidiasis
- Pregnancy Myths
- Other Oral Conditions in Pregnancy
- Changes During Pregnancy that Affect Oral Health
- Saliva changes
- Increased Bacteria
- Slide 40
- Enamel erosion caused by frequent vomiting
- Treatment for Acid Exposure
- Oral Diseases Can Effect Pregnancy
- Periodontal Disease and Preterm Labor
- Periodontal Disease and Low Birth Weight
- Periodontal Disease and Preeclampsia
- Periodontitis and Pre-eclampsia
- Dental Considerations
- Treatment Timing
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Slide 52
- Use of Radiation on Pregnant Patient
- Radiographs during Pregnancy
- Risks of Dental X-Rays
- FDA drug classification for pregnancy
- Slide 57
- FDA drug classification for pregnancy
- Slide 59
- Slide 60
- Slide 61
- Common Analgesics
- Analgesics
- Analgesics - continued
- Analgesics to Use During 1st and 2nd Trimester
- Analgesics to Avoid During the Third Trimester
- Sedation in Pregnancy
- Common Antibiotics
- Antibiotics
- Antibiotics To Use During Pregnancy
- Antibiotics to Avoid during Pregnancy
- The Problem With Tetracycline
- Other Antimicrobial Agents
- Local Anesthetic Use in Pregnancy
- Use of Local Anesthetics
- Ulcer healing drugs
- Slide 77
- Slide 78
- Slide 79
- Use of Nitrous Oxide Gas
- Common Preventives
- Are topical agents safe
- Pre-natal Fluoride
- Is it safe to use mercury restorations
- References
- REFERENCES
- Slide 87
- Slide 88
- Slide 89
- Slide 90
- Slide 91
- Slide 92
- Slide 93
- Slide 94
- Slide 95
- Slide 96
- Slide 97
- Slide 98
- Thank you
-
FDA drug classification for pregnancy
bull B = Animal studies show no risk or if risk shown in animals controlled
trials in women showed no risk
FDA drug classification for pregnancy
bull C = Studies in animals with adverse effects and no human studies
OR no animal or human studies but benefits of use may outweigh potential harms
FDA drug classification for pregnancy
bull D = There is evidence of human fetal risk but benefits may outweigh risks
FDA drug classification for pregnancy
bull X = Contraindicated
Common Analgesics
bull paracetamol (B)bull Ibuprofen (BD) bull Oxycodone (BD) bull Hydrocodone and codeine
(CD)
avoid in third trimester
Analgesics
bull Paracetamol is the analgesic of choice for all stages of gestation
bull used to treat mild to moderate pain and fevers
bull short term usage is believed to be safebull avoid chronic and large doses of
paracetamol1048715
Analgesics - continuedbull Aspirin is nonteratogenic but may cause
maternal and fetal hemorrhagebull large and chronic doses during last trimester
may result in premature closure of ductus arteriosus fetal hypertension anemia and low birth weight
bull avoid ibuprofen in 3rd trimester because of possible adverse circulatory effects
bull short term use of codeine seems safebull avoid codeine late in gestation because of
possible fetal respiratory depression and withdrawal symptoms
Analgesics to Use During1st and 2nd Trimester
bull Category B (for best)bull Paracetamol Ibuprofenbull Naproxenbull Category C (use with caution)bull Paracetamol with codeine or
hydrocodonebull Paracetamol with oxycodone
Analgesics to Avoid During theThird Trimesterbull Causes delivery problemsbull Aspirin (C 3D)bull Ibuprofen (B3D)bull Naproxen (B3D)bull Causes neonatal respiratory
depression and opioid withdrawalbull Codeine (C3D)bull Hydrocodone (C3D)bull Oxycodone(C3D)
Sedation in Pregnancy
bull SedativesAnxiolytics (eg Diazepam ) are rated D and can cause oral clefts with prolonged exposure
bull Nitrous oxide should not be used in 1st trimester (If used in 2nd and 3rd do not go below 50 O2)
Common Antibioticsbull To treat oral abscess or cellulitis
ndash Penicillin (B) ndash Amoxicillin (B) ndash Cephalexin (B)ndash Erythromycin base (B) (Not estolate as it
cause cholestatic hepatitis)ndash Clindamycin (B)
Antibioticsbull penicillin V and amoxicillin is preferred drug
for mild to moderate infectionsbull widely used for many years with no ill effectsbull no studies show penicillin to be teratogenicbull amoxicillin extensively used without harming
the fetusbull Drug classes1048715 B penicillin cephalosporins erythromycin clindamycin Azithromycin D Tetracycline
Antibiotics To Use During Pregnancy
bull Penicillin Vbull Amoxicillinbull Erythromycin (base form)bull Cephalexin cephalosporinbull Clindamycinbull Metronidazole
Antibiotics to Avoid duringPregnancy
bull Doxycyclinebull Tetracyclinebull Erythromycin (estolate form)bull Vancomycin
The Problem With Tetracycline
bull Accumulates in bones and chelates calcium
bull Inhibits bone growthbull Discolors teeth
Other Antimicrobial Agentsbull OK to usebull Nystatin (B)bull Chlorhexidine rinse (B)bull Use with cautionbull Clotrimazole (C)bull Ketoconazole (C)bull Fluconazole (C)bull Do not usebull Doxycycline (D)
Local Anesthetic Use inPregnancy
bull Class Bbull Lidocaine (Xylocaine)bull Etidocainebull Prilocaine bull Class Cbull Procainebull Bupivicainebull Mepivicaine
Use of Local Anestheticsbull Lidocaine + vasoconstrictor most common
local anesthetic used in dentistrybull extensively used in pregnancy with no proven ill
effectsbull accidental intravascular injections of lidocaine
pass through the placenta but the concentrations are too low to harm fetus
bull prilocaine might cause methemoglobinemia
Ulcer healing drugsCimetidine bull FDA category B Famotidinebull FDA category BRanitidinebull FDA category Bbull not known to be harmful
Ulcer healing drugsOmeprazolebull FDA category BNot known to be
harmful Esomeprazolebull FDA category BLansoprazolebull FDA category BPantoprazolebull Avoid unless potential benefit
outweighs riskmdashfetotoxic in animals
Ulcer healing drugs
Misoprostolbull First second third trimesters Avoidmdash
potent uterine stimulant (has been used to induce abortion) and may be teratogenic
Ulcer healing drugs
Antacidsbull Almunium hydroxideMagnesium
hydroxidemdashFDA category B Calcium carbonatemdashFDA category C
SimetheconemdashFDA category C
Use of Nitrous Oxide Gas
bull used over 150 years bull safety is being debatedbull SHORT TERM exposure do not cause
birth defects or spontaneous abortionbull CHRONIC exposure may result in fetal
loss and infertilitybull literature suggests that nitrous oxide
should be avoided until more conclusive research is available
bull FDA Drug class not yet assigned
Common Preventives
bull Fluoridendash No increased risk during pregnancy
bull Xylitolndash No studies no harm reported
bull Chlorhexidinendash No increased risk during pregnancy
Are topical agents safe
bull Fluoridebull Toothpaste amp mouthrinse
bull Xylitol chewing gum bull Chlorhexidine (11 alcohol)bull No over the counter mouthrinses with
alcohol (Listerine 20 alcohol)
Pre-natal Fluoride
bull Daily 22 mg tablet of sodium fluoride during 3rd through 9th months
bull decreases caries rate in offspringbull Safe and effective
Glenn FB 1982
Is it safe to use mercury restorations
bull No evidence of harmful effect
bull Benefits outweigh risks
bull Canada Germany and New Zealand have some restrictions
bull Determine the best option
Referencesbull Wasylko L Matsui D Dykxhoorn SM Rieder MJ Weinberg
S A Review of Common Dental Treatments During Pregnancy J Canadian Dental Association 64434-439 1998
bull Little JW Donald AF Craig SM Rhodus NL Dental Management of the Medically Compromised Patient - 5th edition Mosby Toronto Pp434-442 1997
bull Livingston HM Dellinger TM Holder R Considerations in the management of the pregnant patient Special Care in Dentistry 185 pp183-188 1998
bull Larimore WL Petrie KA Drug use during pregnacy and lactation Primary Care Clinics in Office Practice 271 35-53 2000
bull Health Canada The Safety of DentalAmalgam Minister Of Supply and Services Canada 1996
REFERENCESbull 1 Weiss G Endocrinology of parturition J Clin
Endocrinol Metab 2000854421-5bull 2 Theunissen IM Parer JT Fluid and electrolytes in
pregnancy Clin Obstet Gynecol 1994373-15bull 3 Duvekot JJ Peeters LLH Renal hemodynamics and
volume homeostasis in pregnancy Obstet Gynecol Surv 199449830-9
bull 4 Barron WM Lindheimer MD Medical disorders during pregnancy 2nd ed St Louis Mosby 1995 p 129
bull 5 Thornburg KL Jacobson SL Giraud GD Morton MJ Hemodynamic changes in pregnancy Semin Perinatol 20002411-4
bull 6 Fiese R Herzog S Issues in dental and surgical management of the pregnant patient Oral Surg Oral Med Oral Pathol 198865292-7
bull 7 Martin C Varner MW Physiologic changes in pregnancysurgical implications Clin Obstet Gynecol 199437241-55
bull 8 Clark SL Cotton DB Lee W Bishop C Hill T Southwick J et al Central hemodynamic assessment of normal term pregnancy Am J Obstet Gynecol 19891611439-42
bull 9 Mabie WC Di Sessa TG Crocker LG Sibai BM Arheart KL A longitudinal study of cardiac output in normal human pregnancy Am J Obstet Gynecol 1994170849-56
bull 10 Clapp JF 3rd Capeless E Cardiovascular function before during and after the first and subsequent pregnancies Am J Cardiol 1997801469-73
bull 11 Duvekot JJ Peeters LL Maternal cardiovascular hemodynamic adaptation to pregnancy Obstet Gynecol Surv 199449(Suppl) S1-14
bull 12 Bhagwat AR Engel PJ Heart disease and pregnancy Cardiol Clin 199513163-78
bull 13 Lanni SM Tillinghast J Silver H Hemodynamic changes and baroreflex gain in the supine hypotensive syndrome Am J Obstet Gynecol 20021871636-41
bull 14 Little JW Falace DA Miller CS Rhodus NL Dental management of the medically compromised patient 6th ed St Louis Mosby 2002 p 303
bull 15 Garcia-Rio F Pino JM Gomez L Alvarez-Sala R Villasante C Villamor J Regulation of breathing and perception of dyspnea in healthy pregnant women Chest 1996110446-53
bull 16 McAuliffe F Kametas N Costello J Rafferty GF Greenough A Nicolaides K Respiratory function in singleton and twin pregnancy BJOG 2002109765-9
bull 17 Clapp JF 3rd Seaward BL Sleamaker RH Hiser J Maternal physiologic adaptations to early human pregnancy Am J Obstet Gynecol 19881591456-60
bull 18 OrsquoDay MP Cardio-respiratory physiological adaptation of pregnancy Semin Perinatol 199721268-75
bull 19 Contreras G Gutierrez M Beroiza T Fantin A Oddo H Villarroel L et al Ventilatory drive and respiratory muscle function in pregnancy Am Rev Respir Dis 1991144837-41
bull 20 Turner M Aziz SR Management of the pregnant oral and maxillofac
bull 21 Sifakis S Pharmakides G Anemia in pregnancy Ann N Y Acad Sci 2000900125-36
bull 22 Branch DW Physiologic adaptations of pregnancy Am J Reprod Immunol 199228120-2
bull 23 Burrows RF Kelton JG Incidentally detected thrombocytopenia in healthy mothers and their infants N Engl J Med 1988319 142-5
bull 24 Hanly JG Antiphospholipid syndrome an overview CMAJ 200324(168)1675-82
bull 25 Heilmann L von Tempelhoff GF Pollow K Antiphospholipid syndrome in obstetrics Clin Appl Thromb Hemost 20039 143-50
bull 26 Sherman P Flaxman SM Nausea and vomiting of pregnancy in an evolutionary perspective Am J Obstet Gynecol 2002 185(Suppl)s190-7
bull 27 Koch KL Gastrointestinal factors in nausea and vomiting of pregnancy Am J Obstet Gynecol 2002185(Suppl)s198-203
bull 28 Koch KL Frissora CL Nausea and vomiting during pregnancy Gastroenterol Clin N Am 200332201-34
bull 29 Baron TH Ramirez B Richter JE Gastrointestinal motility disorders during pregnancy Ann Intern Med 1993118 366-75
bull 30 Richter JE Gastroesophageal reflux disease during pregnancy Gastroenterol Clin N Am 200332235-61
bull 31 Marrero JM Goggin PM de Caestecker JS Pearce JM Maxwell JD Determinants of pregnancy heartburn Br J Obstet Gynaecol 199299731-4
bull 32 Hamaoui E Hamaoui M Nutritional assessment and support during pregnancy Gastroenterol Clin N Am 20033259-121
bull 33 King JC Physiology of pregnancy and nutrient metabolism Am J Clin Nutr 200071(suppl)1218s-25s
bull 34 Casanueva E Pfeffer F Fernandez-Gaxiola AC Gutierrez- Valenzuela V Rothenberg SJ Iron and folate status before pregnancy and anemia during pregnancy Ann Nutr Metab 2003 4760-3
bull 35 Chrsquong CL Morgan M Hainsworth I Kingham JG Prospective study of liver dysfunction in Southwest Wales Gut 200251 876-80
bull 36 Rahman TM Wendon J Severe hepatic dysfunction in pregnancy QJM 200295343-57
bull 37 Knox TA Olans LB Liver disease in pregnancy N Engl J Med 1996335569-76
bull 38 Saftlas AF Olson DR Franks AL Atrash H Pokras R Epidemiology of preeclampsia and eclampsia in the United States 1979e1986 Am J Obstet Gynecol 1990163460-5
bull 39 Walker JJ Pre-eclampsia Lancet 20003561260-5
bull 40 Davidson JM Renal disorders in pregnancy Curr Opin Obstet Gynecol 200113109-14
bull 41 Dafnis E Sabatini S The effect of pregnancy on renal function physiology and pathophysiologyAmJMedSci 1992303184-205
bull 42 Davison JM Shiells EA Philips PR Lindheimer MD Serial evaluation of vasopressin release and thirst in human pregnancy Role of human chorionic gonadotrophin in the osmoregulatory changes of gestation J Clin Invest 198881798-806
bull 43 Glinoer D de Nayer P Bourdoux P Lemone M Robyn C van Steirteghem A et al Regulation of maternal thyroid during pregnancy J Clin Endocrinol Metab 199071276-87
bull 44 Wilson SG Retallack RW Kent JC Worth GK Gutteridge DH Serum free 125-dihydroxyvitamin D and the free 125- dihydroxyvitamin D index during a longitudinal study of human pregnancy and lactation Clin Endocrinol 199032613-22
bull 45 Rasmussen N Frolich A Hornnes PJ Hegedus L Serum ionized calcium and intact parathyroid hormone levels during pregnancy and postpartum Br J Obstet Gynaecol 199097857-9
bull 46 Guyton AC Textbook of medical physiology 8th ed Philadelphia W B Saunders 1991 p 915e28
bull 47 Trainer PJ Corticosteroids and pregnancy Semin Reprod Med 200220375-80
bull 48 Soory M Hormonal factors in periodontal disease Dent Update 200027380-3
bull 49 Hugoson A Gingivitis in pregnant women A longitudinal clinical study Odontol Revy 19712265-84
bull 50 Neville BW Damm DD Allen CM Bouquot JE Oral amp Maxillofacial Pathology 3rd ed Philadelphia W B Saunders 2002 p 329-30 447-9
bull 51 Tilakaratne A Soory M Ranasinghe AW Corea SM Ekanayake SL de Silva M Periodontal disease status during pregnancy and 3 months post-partum in rural population of Sri-Lankan women J Clin Periodontol 200027787-92
bull 52 Laine M Tenovuo J Lehtonen OP Ojanatko-Harri A Vilja P Tuohimaa P Pregnancy e related changes in human whole saliva Arch Oral Biol 198833913-7
bull 53 Yuan K Wing LY Lin MT Pathogenetic roles of angiogenic factors in pyogenic granulomas in pregnancy are modulated by female sex hormones J Periodontol 200273701-8
bull 54 Evans RD Briggs PF Tooth-surface loss related to pregnancyinduced vomiting Prim Dent Care 1994124-6
bull 55 Salvolini E Di Giorgio R Curatola A Mazzanti L Fratto G Biochemical modifications of human whole saliva induced by pregnancy Br J Obstet Gynaec 1998105656-60
bull 56 Mauldin JG Newman RB Preterm birth risk assessment Semin Perinatol 200125215-22
bull 57 Heine RP McGregor JA Goodwin TM Artal R Hayashi RH Robertson PA et al Serial salivary estriol to detect an increased risk of preterm birth Obstet Gynecol 200096490-7
bull 58 Kauh YC Zachian TF Melasma Adv Exp Med Biol 1999455 491-9
bull 59 Wong RC Ellis CN Physiologic skin changes in pregnancy J Am Acad Dermatol 198410929-40
bull 60 Errickson CV Matus NR Skin disorders of pregnancy Am Fam Physician 199449605-10
bull 61 Lopez NJ Smith PC Gutierrez J Periodontal therapy may reduce the risk of preterm low birth weight in women with periodontal disease a randomized controlled trial J Periodontol 200273911-24
bull 62 McGaw T Periodontal disease and preterm delivery of lowbirth- weight infants J Can Dent Assoc 200268165-9
bull 63 Richards AG Dental x-ray protection Dent Clin North Am 1968631-41
bull 64 1990 Recommendations of the International Commission on Radiological Protection Ann ICRP 1991211-201
bull 65 Hall EJ Radiation the two-edged sword cancer risks at high and low doses Cancer J 20006343-50
bull 66 Diethelm L Xu H Diagnostic imaging of the lung during pregnancy Clin Obstet Gynecol 19963936-55
bull 67 Brent RL The effects of embryonic and fetal exposure to x-rays microwaves and ultrasound ClinObstetGynecol 198326484-510
bull 68 National Council on Radiation Protection NCRP report no128 1998 Bethesda Md Author
bull 69 Wasylko L Matsui D Dykxhoorn SM Reider MJ Weinberg S A review of common dental treatments during pregnancy implications for patients and dental personnel J Can Dent Assoc 199864434-9
bull 70 Freeman JP Brand JW Radiation doses of commonly used dental radiographic surveys Oral Surg Oral Med Oral Pathol 199477285-9
bull 71 Kircos LTAngin LL Lorton LOrder ofmagnitude dose reduction in intraoral radiography J Am Dent Assoc 1987114344-7
bull 72 Updegrave WJ Simplified and standardized intraoral radiography with reduced tissue irradiation J Am Dent Assoc 197285861-9
bull 73 Wood RE Harris AM van der Merwe EJ Nortje CJ The leaded apron revisited does it reduce gonadal radiation dose in dental radiology Oral Surg Oral Med Oral Pathol 199171642-6
bull 74 An update on radiographic practices information and recommendations ADA Council on Scientific Affairs J Am Dent Assoc 2001132234-8
bull 75 Rayburn WF Recommending medications during pregnancy an evidence based approach Clin Obstet Gynecol 2002451-5
bull 76 Rathmell JP Viscomi C Ashburn MA Management of nonobstetric pain during pregnancy and lactation Anesth Analg 1997851074-87
bull 77 Teratology society public affairs committee FDA classification of drugs for teratogenic risk Teratology 199449446-7
bull 78 Moore PA Selecting drugs for the pregnant dental patient J Am Dent Assoc 19981291281-6
bull 79 Haas DA An update on analgesics for the management of acute postoperative dental pain J Can Dent Assoc 200268476-82
bull 80 Haas DA Pynn BR Sands TD Drug use for the pregnant or lactating patient Gen Dent 20004854-60
bull 81 Committee on Drugs American Academy of Pediatrics The transfer of drugs and other chemicals into human milk Pediatrics 199493137-50
bull 82 Nielsen GL Sorensen HT Larsen H Pedersen L Risk of adverse birth outcome and miscarriage in pregnant users of nonsteroidal anti-inflammatory drugs population based observational study and case-control study BMJ 2001322266-70
bull 83 Janssen N Genta M The effects of immunosuppressive and anti-inflammatory medications on fertility pregnancy and lactation Arch Intern Med 200016610-9
bull 84 Ostensen M Nonsteroidal anti-inflammatory drugs during pregnancy Scand J Rheumatol Suppl 1998107128-32
bull 85 USPDI -Drug information for the health care professional 22nd ed Greenwood Village CO Micromedex 2002 p 152-79
bull 86 Denson DD Coyle DE Thompson GA Santos D Turner PA Myers JA et al Bupivacaine protein binding in the term parturient effects of lactic acidosis Clin Pharmacol Ther 198435702-9
bull 87 Dillon DE Wagner CL Wiest D Newman RB Drug therapy in the nursing mother Obstet Gynecol Clin North Am 199724 675-96
bull 88 Dashe JS Gilstrap LC Antibiotic use in pregnancy Obstet Gynecol Clin North Am 199724617-29
bull 89 American College of Rheumatology Ad hoc Committee on Clinical Guidelines Guidelines for monitoring drug therapy in rheumatoid arthritis Arthritis Rheum 199639723-31
bull 90 Ng PC The fetal and neonatal hypothalamic-pituitary-adrenal axis Arch Dis Child Fetal Neonatal Ed 200082F250-4
bull 91 Crowley P Antenatal corticosteroidsmdashcurrent thinking BJOG 2003110(Suppl 20)77-8
bull 92 ACOG committee opinion antenatal corticosteroid therapy for fetal maturation Obstet Gynecol 200299871-3
bull 93 Ost L Wettrell G Bjorkhem I Rane A Prednisolone excretion in human milk J Pediatr 19851061008-11
bull 94 Rowland AS Baird DD Shore DL Weinberg CR Savitz DA Wilcox AJ Nitrous oxide and spontaneous abortion in female dental assistants Am J Epidemiol 1995141531-8
bull 95 McGlothlin JD Jensen PA Fischbach TJ Hughes RT Jones JH Control of anesthetic gases in dental operatories Scand J Work Environ Health 199218(Suppl 2)103-5
bull ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY Volume 97 Number 6 Suresh and Radfar 681
bull 96 Rosen MA Nitrous oxide for relief of labor pain a systematic review Am J Obstet Gynecol 2002186(Suppl Nature)S110-6
bull 97 Sands TD Pynn BR Management considerations for the pregnant or nursing emergency patient Ont Dent 199875 17-9
bull 98 Daya S Recurrent spontaneous early pregnancy loss and low dose aspirin Minerva Ginecol 200355441-9
bull 99 Sinclair C Handbook of obstetrical emergencies 1st ed Philadelphia WB Saunders 1996 p 29-39 69
bull 100 Tarsitano BF Rollings RE The pregnant dental patient evaluation and management Gen Dent 199341226-34
bull 101 Livingston MH Dlllinger TM Holder R Consideration in the management of the pregnant patient SCD Special Care in Dentistry 199818183-8
Thank you
- A Review on the principle of Dental Management of the Pregnant patient
- Slide 2
- Questions that a dentist may ask
- Stages of Pregnancy
- Slide 5
- Slide 6
- Physiologic Changes in Pregnancy
- Systemic changes in pregnancy
- FLAT SUPINE POSITIONING
- SUPINE HYPOTENSION SYNDROME (Vena Cava Compression)
- Supine Hypotension Syndrome
- Slide 12
- Supine Hypotension Syndrome
- Prevention of Supine Hypotensive Syndrome
- Treatment of Supine Hypotensive Syndrome
- How should the pregnant woman be positioned
- Slide 17
- Slide 18
- Slide 19
- Slide 20
- Slide 21
- Slide 22
- Slide 23
- Pregnancy Related Oral Health Problems
- Oral Problems in Pregnancy
- Pregnancy Gingivitis Pathophysiology
- Pregnancy Gingivitis
- Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Gum Problems - Pregnancy Granuloma
- Slide 31
- Gum Changes - Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Candidiasis
- Pregnancy Myths
- Other Oral Conditions in Pregnancy
- Changes During Pregnancy that Affect Oral Health
- Saliva changes
- Increased Bacteria
- Slide 40
- Enamel erosion caused by frequent vomiting
- Treatment for Acid Exposure
- Oral Diseases Can Effect Pregnancy
- Periodontal Disease and Preterm Labor
- Periodontal Disease and Low Birth Weight
- Periodontal Disease and Preeclampsia
- Periodontitis and Pre-eclampsia
- Dental Considerations
- Treatment Timing
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Slide 52
- Use of Radiation on Pregnant Patient
- Radiographs during Pregnancy
- Risks of Dental X-Rays
- FDA drug classification for pregnancy
- Slide 57
- FDA drug classification for pregnancy
- Slide 59
- Slide 60
- Slide 61
- Common Analgesics
- Analgesics
- Analgesics - continued
- Analgesics to Use During 1st and 2nd Trimester
- Analgesics to Avoid During the Third Trimester
- Sedation in Pregnancy
- Common Antibiotics
- Antibiotics
- Antibiotics To Use During Pregnancy
- Antibiotics to Avoid during Pregnancy
- The Problem With Tetracycline
- Other Antimicrobial Agents
- Local Anesthetic Use in Pregnancy
- Use of Local Anesthetics
- Ulcer healing drugs
- Slide 77
- Slide 78
- Slide 79
- Use of Nitrous Oxide Gas
- Common Preventives
- Are topical agents safe
- Pre-natal Fluoride
- Is it safe to use mercury restorations
- References
- REFERENCES
- Slide 87
- Slide 88
- Slide 89
- Slide 90
- Slide 91
- Slide 92
- Slide 93
- Slide 94
- Slide 95
- Slide 96
- Slide 97
- Slide 98
- Thank you
-
FDA drug classification for pregnancy
bull C = Studies in animals with adverse effects and no human studies
OR no animal or human studies but benefits of use may outweigh potential harms
FDA drug classification for pregnancy
bull D = There is evidence of human fetal risk but benefits may outweigh risks
FDA drug classification for pregnancy
bull X = Contraindicated
Common Analgesics
bull paracetamol (B)bull Ibuprofen (BD) bull Oxycodone (BD) bull Hydrocodone and codeine
(CD)
avoid in third trimester
Analgesics
bull Paracetamol is the analgesic of choice for all stages of gestation
bull used to treat mild to moderate pain and fevers
bull short term usage is believed to be safebull avoid chronic and large doses of
paracetamol1048715
Analgesics - continuedbull Aspirin is nonteratogenic but may cause
maternal and fetal hemorrhagebull large and chronic doses during last trimester
may result in premature closure of ductus arteriosus fetal hypertension anemia and low birth weight
bull avoid ibuprofen in 3rd trimester because of possible adverse circulatory effects
bull short term use of codeine seems safebull avoid codeine late in gestation because of
possible fetal respiratory depression and withdrawal symptoms
Analgesics to Use During1st and 2nd Trimester
bull Category B (for best)bull Paracetamol Ibuprofenbull Naproxenbull Category C (use with caution)bull Paracetamol with codeine or
hydrocodonebull Paracetamol with oxycodone
Analgesics to Avoid During theThird Trimesterbull Causes delivery problemsbull Aspirin (C 3D)bull Ibuprofen (B3D)bull Naproxen (B3D)bull Causes neonatal respiratory
depression and opioid withdrawalbull Codeine (C3D)bull Hydrocodone (C3D)bull Oxycodone(C3D)
Sedation in Pregnancy
bull SedativesAnxiolytics (eg Diazepam ) are rated D and can cause oral clefts with prolonged exposure
bull Nitrous oxide should not be used in 1st trimester (If used in 2nd and 3rd do not go below 50 O2)
Common Antibioticsbull To treat oral abscess or cellulitis
ndash Penicillin (B) ndash Amoxicillin (B) ndash Cephalexin (B)ndash Erythromycin base (B) (Not estolate as it
cause cholestatic hepatitis)ndash Clindamycin (B)
Antibioticsbull penicillin V and amoxicillin is preferred drug
for mild to moderate infectionsbull widely used for many years with no ill effectsbull no studies show penicillin to be teratogenicbull amoxicillin extensively used without harming
the fetusbull Drug classes1048715 B penicillin cephalosporins erythromycin clindamycin Azithromycin D Tetracycline
Antibiotics To Use During Pregnancy
bull Penicillin Vbull Amoxicillinbull Erythromycin (base form)bull Cephalexin cephalosporinbull Clindamycinbull Metronidazole
Antibiotics to Avoid duringPregnancy
bull Doxycyclinebull Tetracyclinebull Erythromycin (estolate form)bull Vancomycin
The Problem With Tetracycline
bull Accumulates in bones and chelates calcium
bull Inhibits bone growthbull Discolors teeth
Other Antimicrobial Agentsbull OK to usebull Nystatin (B)bull Chlorhexidine rinse (B)bull Use with cautionbull Clotrimazole (C)bull Ketoconazole (C)bull Fluconazole (C)bull Do not usebull Doxycycline (D)
Local Anesthetic Use inPregnancy
bull Class Bbull Lidocaine (Xylocaine)bull Etidocainebull Prilocaine bull Class Cbull Procainebull Bupivicainebull Mepivicaine
Use of Local Anestheticsbull Lidocaine + vasoconstrictor most common
local anesthetic used in dentistrybull extensively used in pregnancy with no proven ill
effectsbull accidental intravascular injections of lidocaine
pass through the placenta but the concentrations are too low to harm fetus
bull prilocaine might cause methemoglobinemia
Ulcer healing drugsCimetidine bull FDA category B Famotidinebull FDA category BRanitidinebull FDA category Bbull not known to be harmful
Ulcer healing drugsOmeprazolebull FDA category BNot known to be
harmful Esomeprazolebull FDA category BLansoprazolebull FDA category BPantoprazolebull Avoid unless potential benefit
outweighs riskmdashfetotoxic in animals
Ulcer healing drugs
Misoprostolbull First second third trimesters Avoidmdash
potent uterine stimulant (has been used to induce abortion) and may be teratogenic
Ulcer healing drugs
Antacidsbull Almunium hydroxideMagnesium
hydroxidemdashFDA category B Calcium carbonatemdashFDA category C
SimetheconemdashFDA category C
Use of Nitrous Oxide Gas
bull used over 150 years bull safety is being debatedbull SHORT TERM exposure do not cause
birth defects or spontaneous abortionbull CHRONIC exposure may result in fetal
loss and infertilitybull literature suggests that nitrous oxide
should be avoided until more conclusive research is available
bull FDA Drug class not yet assigned
Common Preventives
bull Fluoridendash No increased risk during pregnancy
bull Xylitolndash No studies no harm reported
bull Chlorhexidinendash No increased risk during pregnancy
Are topical agents safe
bull Fluoridebull Toothpaste amp mouthrinse
bull Xylitol chewing gum bull Chlorhexidine (11 alcohol)bull No over the counter mouthrinses with
alcohol (Listerine 20 alcohol)
Pre-natal Fluoride
bull Daily 22 mg tablet of sodium fluoride during 3rd through 9th months
bull decreases caries rate in offspringbull Safe and effective
Glenn FB 1982
Is it safe to use mercury restorations
bull No evidence of harmful effect
bull Benefits outweigh risks
bull Canada Germany and New Zealand have some restrictions
bull Determine the best option
Referencesbull Wasylko L Matsui D Dykxhoorn SM Rieder MJ Weinberg
S A Review of Common Dental Treatments During Pregnancy J Canadian Dental Association 64434-439 1998
bull Little JW Donald AF Craig SM Rhodus NL Dental Management of the Medically Compromised Patient - 5th edition Mosby Toronto Pp434-442 1997
bull Livingston HM Dellinger TM Holder R Considerations in the management of the pregnant patient Special Care in Dentistry 185 pp183-188 1998
bull Larimore WL Petrie KA Drug use during pregnacy and lactation Primary Care Clinics in Office Practice 271 35-53 2000
bull Health Canada The Safety of DentalAmalgam Minister Of Supply and Services Canada 1996
REFERENCESbull 1 Weiss G Endocrinology of parturition J Clin
Endocrinol Metab 2000854421-5bull 2 Theunissen IM Parer JT Fluid and electrolytes in
pregnancy Clin Obstet Gynecol 1994373-15bull 3 Duvekot JJ Peeters LLH Renal hemodynamics and
volume homeostasis in pregnancy Obstet Gynecol Surv 199449830-9
bull 4 Barron WM Lindheimer MD Medical disorders during pregnancy 2nd ed St Louis Mosby 1995 p 129
bull 5 Thornburg KL Jacobson SL Giraud GD Morton MJ Hemodynamic changes in pregnancy Semin Perinatol 20002411-4
bull 6 Fiese R Herzog S Issues in dental and surgical management of the pregnant patient Oral Surg Oral Med Oral Pathol 198865292-7
bull 7 Martin C Varner MW Physiologic changes in pregnancysurgical implications Clin Obstet Gynecol 199437241-55
bull 8 Clark SL Cotton DB Lee W Bishop C Hill T Southwick J et al Central hemodynamic assessment of normal term pregnancy Am J Obstet Gynecol 19891611439-42
bull 9 Mabie WC Di Sessa TG Crocker LG Sibai BM Arheart KL A longitudinal study of cardiac output in normal human pregnancy Am J Obstet Gynecol 1994170849-56
bull 10 Clapp JF 3rd Capeless E Cardiovascular function before during and after the first and subsequent pregnancies Am J Cardiol 1997801469-73
bull 11 Duvekot JJ Peeters LL Maternal cardiovascular hemodynamic adaptation to pregnancy Obstet Gynecol Surv 199449(Suppl) S1-14
bull 12 Bhagwat AR Engel PJ Heart disease and pregnancy Cardiol Clin 199513163-78
bull 13 Lanni SM Tillinghast J Silver H Hemodynamic changes and baroreflex gain in the supine hypotensive syndrome Am J Obstet Gynecol 20021871636-41
bull 14 Little JW Falace DA Miller CS Rhodus NL Dental management of the medically compromised patient 6th ed St Louis Mosby 2002 p 303
bull 15 Garcia-Rio F Pino JM Gomez L Alvarez-Sala R Villasante C Villamor J Regulation of breathing and perception of dyspnea in healthy pregnant women Chest 1996110446-53
bull 16 McAuliffe F Kametas N Costello J Rafferty GF Greenough A Nicolaides K Respiratory function in singleton and twin pregnancy BJOG 2002109765-9
bull 17 Clapp JF 3rd Seaward BL Sleamaker RH Hiser J Maternal physiologic adaptations to early human pregnancy Am J Obstet Gynecol 19881591456-60
bull 18 OrsquoDay MP Cardio-respiratory physiological adaptation of pregnancy Semin Perinatol 199721268-75
bull 19 Contreras G Gutierrez M Beroiza T Fantin A Oddo H Villarroel L et al Ventilatory drive and respiratory muscle function in pregnancy Am Rev Respir Dis 1991144837-41
bull 20 Turner M Aziz SR Management of the pregnant oral and maxillofac
bull 21 Sifakis S Pharmakides G Anemia in pregnancy Ann N Y Acad Sci 2000900125-36
bull 22 Branch DW Physiologic adaptations of pregnancy Am J Reprod Immunol 199228120-2
bull 23 Burrows RF Kelton JG Incidentally detected thrombocytopenia in healthy mothers and their infants N Engl J Med 1988319 142-5
bull 24 Hanly JG Antiphospholipid syndrome an overview CMAJ 200324(168)1675-82
bull 25 Heilmann L von Tempelhoff GF Pollow K Antiphospholipid syndrome in obstetrics Clin Appl Thromb Hemost 20039 143-50
bull 26 Sherman P Flaxman SM Nausea and vomiting of pregnancy in an evolutionary perspective Am J Obstet Gynecol 2002 185(Suppl)s190-7
bull 27 Koch KL Gastrointestinal factors in nausea and vomiting of pregnancy Am J Obstet Gynecol 2002185(Suppl)s198-203
bull 28 Koch KL Frissora CL Nausea and vomiting during pregnancy Gastroenterol Clin N Am 200332201-34
bull 29 Baron TH Ramirez B Richter JE Gastrointestinal motility disorders during pregnancy Ann Intern Med 1993118 366-75
bull 30 Richter JE Gastroesophageal reflux disease during pregnancy Gastroenterol Clin N Am 200332235-61
bull 31 Marrero JM Goggin PM de Caestecker JS Pearce JM Maxwell JD Determinants of pregnancy heartburn Br J Obstet Gynaecol 199299731-4
bull 32 Hamaoui E Hamaoui M Nutritional assessment and support during pregnancy Gastroenterol Clin N Am 20033259-121
bull 33 King JC Physiology of pregnancy and nutrient metabolism Am J Clin Nutr 200071(suppl)1218s-25s
bull 34 Casanueva E Pfeffer F Fernandez-Gaxiola AC Gutierrez- Valenzuela V Rothenberg SJ Iron and folate status before pregnancy and anemia during pregnancy Ann Nutr Metab 2003 4760-3
bull 35 Chrsquong CL Morgan M Hainsworth I Kingham JG Prospective study of liver dysfunction in Southwest Wales Gut 200251 876-80
bull 36 Rahman TM Wendon J Severe hepatic dysfunction in pregnancy QJM 200295343-57
bull 37 Knox TA Olans LB Liver disease in pregnancy N Engl J Med 1996335569-76
bull 38 Saftlas AF Olson DR Franks AL Atrash H Pokras R Epidemiology of preeclampsia and eclampsia in the United States 1979e1986 Am J Obstet Gynecol 1990163460-5
bull 39 Walker JJ Pre-eclampsia Lancet 20003561260-5
bull 40 Davidson JM Renal disorders in pregnancy Curr Opin Obstet Gynecol 200113109-14
bull 41 Dafnis E Sabatini S The effect of pregnancy on renal function physiology and pathophysiologyAmJMedSci 1992303184-205
bull 42 Davison JM Shiells EA Philips PR Lindheimer MD Serial evaluation of vasopressin release and thirst in human pregnancy Role of human chorionic gonadotrophin in the osmoregulatory changes of gestation J Clin Invest 198881798-806
bull 43 Glinoer D de Nayer P Bourdoux P Lemone M Robyn C van Steirteghem A et al Regulation of maternal thyroid during pregnancy J Clin Endocrinol Metab 199071276-87
bull 44 Wilson SG Retallack RW Kent JC Worth GK Gutteridge DH Serum free 125-dihydroxyvitamin D and the free 125- dihydroxyvitamin D index during a longitudinal study of human pregnancy and lactation Clin Endocrinol 199032613-22
bull 45 Rasmussen N Frolich A Hornnes PJ Hegedus L Serum ionized calcium and intact parathyroid hormone levels during pregnancy and postpartum Br J Obstet Gynaecol 199097857-9
bull 46 Guyton AC Textbook of medical physiology 8th ed Philadelphia W B Saunders 1991 p 915e28
bull 47 Trainer PJ Corticosteroids and pregnancy Semin Reprod Med 200220375-80
bull 48 Soory M Hormonal factors in periodontal disease Dent Update 200027380-3
bull 49 Hugoson A Gingivitis in pregnant women A longitudinal clinical study Odontol Revy 19712265-84
bull 50 Neville BW Damm DD Allen CM Bouquot JE Oral amp Maxillofacial Pathology 3rd ed Philadelphia W B Saunders 2002 p 329-30 447-9
bull 51 Tilakaratne A Soory M Ranasinghe AW Corea SM Ekanayake SL de Silva M Periodontal disease status during pregnancy and 3 months post-partum in rural population of Sri-Lankan women J Clin Periodontol 200027787-92
bull 52 Laine M Tenovuo J Lehtonen OP Ojanatko-Harri A Vilja P Tuohimaa P Pregnancy e related changes in human whole saliva Arch Oral Biol 198833913-7
bull 53 Yuan K Wing LY Lin MT Pathogenetic roles of angiogenic factors in pyogenic granulomas in pregnancy are modulated by female sex hormones J Periodontol 200273701-8
bull 54 Evans RD Briggs PF Tooth-surface loss related to pregnancyinduced vomiting Prim Dent Care 1994124-6
bull 55 Salvolini E Di Giorgio R Curatola A Mazzanti L Fratto G Biochemical modifications of human whole saliva induced by pregnancy Br J Obstet Gynaec 1998105656-60
bull 56 Mauldin JG Newman RB Preterm birth risk assessment Semin Perinatol 200125215-22
bull 57 Heine RP McGregor JA Goodwin TM Artal R Hayashi RH Robertson PA et al Serial salivary estriol to detect an increased risk of preterm birth Obstet Gynecol 200096490-7
bull 58 Kauh YC Zachian TF Melasma Adv Exp Med Biol 1999455 491-9
bull 59 Wong RC Ellis CN Physiologic skin changes in pregnancy J Am Acad Dermatol 198410929-40
bull 60 Errickson CV Matus NR Skin disorders of pregnancy Am Fam Physician 199449605-10
bull 61 Lopez NJ Smith PC Gutierrez J Periodontal therapy may reduce the risk of preterm low birth weight in women with periodontal disease a randomized controlled trial J Periodontol 200273911-24
bull 62 McGaw T Periodontal disease and preterm delivery of lowbirth- weight infants J Can Dent Assoc 200268165-9
bull 63 Richards AG Dental x-ray protection Dent Clin North Am 1968631-41
bull 64 1990 Recommendations of the International Commission on Radiological Protection Ann ICRP 1991211-201
bull 65 Hall EJ Radiation the two-edged sword cancer risks at high and low doses Cancer J 20006343-50
bull 66 Diethelm L Xu H Diagnostic imaging of the lung during pregnancy Clin Obstet Gynecol 19963936-55
bull 67 Brent RL The effects of embryonic and fetal exposure to x-rays microwaves and ultrasound ClinObstetGynecol 198326484-510
bull 68 National Council on Radiation Protection NCRP report no128 1998 Bethesda Md Author
bull 69 Wasylko L Matsui D Dykxhoorn SM Reider MJ Weinberg S A review of common dental treatments during pregnancy implications for patients and dental personnel J Can Dent Assoc 199864434-9
bull 70 Freeman JP Brand JW Radiation doses of commonly used dental radiographic surveys Oral Surg Oral Med Oral Pathol 199477285-9
bull 71 Kircos LTAngin LL Lorton LOrder ofmagnitude dose reduction in intraoral radiography J Am Dent Assoc 1987114344-7
bull 72 Updegrave WJ Simplified and standardized intraoral radiography with reduced tissue irradiation J Am Dent Assoc 197285861-9
bull 73 Wood RE Harris AM van der Merwe EJ Nortje CJ The leaded apron revisited does it reduce gonadal radiation dose in dental radiology Oral Surg Oral Med Oral Pathol 199171642-6
bull 74 An update on radiographic practices information and recommendations ADA Council on Scientific Affairs J Am Dent Assoc 2001132234-8
bull 75 Rayburn WF Recommending medications during pregnancy an evidence based approach Clin Obstet Gynecol 2002451-5
bull 76 Rathmell JP Viscomi C Ashburn MA Management of nonobstetric pain during pregnancy and lactation Anesth Analg 1997851074-87
bull 77 Teratology society public affairs committee FDA classification of drugs for teratogenic risk Teratology 199449446-7
bull 78 Moore PA Selecting drugs for the pregnant dental patient J Am Dent Assoc 19981291281-6
bull 79 Haas DA An update on analgesics for the management of acute postoperative dental pain J Can Dent Assoc 200268476-82
bull 80 Haas DA Pynn BR Sands TD Drug use for the pregnant or lactating patient Gen Dent 20004854-60
bull 81 Committee on Drugs American Academy of Pediatrics The transfer of drugs and other chemicals into human milk Pediatrics 199493137-50
bull 82 Nielsen GL Sorensen HT Larsen H Pedersen L Risk of adverse birth outcome and miscarriage in pregnant users of nonsteroidal anti-inflammatory drugs population based observational study and case-control study BMJ 2001322266-70
bull 83 Janssen N Genta M The effects of immunosuppressive and anti-inflammatory medications on fertility pregnancy and lactation Arch Intern Med 200016610-9
bull 84 Ostensen M Nonsteroidal anti-inflammatory drugs during pregnancy Scand J Rheumatol Suppl 1998107128-32
bull 85 USPDI -Drug information for the health care professional 22nd ed Greenwood Village CO Micromedex 2002 p 152-79
bull 86 Denson DD Coyle DE Thompson GA Santos D Turner PA Myers JA et al Bupivacaine protein binding in the term parturient effects of lactic acidosis Clin Pharmacol Ther 198435702-9
bull 87 Dillon DE Wagner CL Wiest D Newman RB Drug therapy in the nursing mother Obstet Gynecol Clin North Am 199724 675-96
bull 88 Dashe JS Gilstrap LC Antibiotic use in pregnancy Obstet Gynecol Clin North Am 199724617-29
bull 89 American College of Rheumatology Ad hoc Committee on Clinical Guidelines Guidelines for monitoring drug therapy in rheumatoid arthritis Arthritis Rheum 199639723-31
bull 90 Ng PC The fetal and neonatal hypothalamic-pituitary-adrenal axis Arch Dis Child Fetal Neonatal Ed 200082F250-4
bull 91 Crowley P Antenatal corticosteroidsmdashcurrent thinking BJOG 2003110(Suppl 20)77-8
bull 92 ACOG committee opinion antenatal corticosteroid therapy for fetal maturation Obstet Gynecol 200299871-3
bull 93 Ost L Wettrell G Bjorkhem I Rane A Prednisolone excretion in human milk J Pediatr 19851061008-11
bull 94 Rowland AS Baird DD Shore DL Weinberg CR Savitz DA Wilcox AJ Nitrous oxide and spontaneous abortion in female dental assistants Am J Epidemiol 1995141531-8
bull 95 McGlothlin JD Jensen PA Fischbach TJ Hughes RT Jones JH Control of anesthetic gases in dental operatories Scand J Work Environ Health 199218(Suppl 2)103-5
bull ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY Volume 97 Number 6 Suresh and Radfar 681
bull 96 Rosen MA Nitrous oxide for relief of labor pain a systematic review Am J Obstet Gynecol 2002186(Suppl Nature)S110-6
bull 97 Sands TD Pynn BR Management considerations for the pregnant or nursing emergency patient Ont Dent 199875 17-9
bull 98 Daya S Recurrent spontaneous early pregnancy loss and low dose aspirin Minerva Ginecol 200355441-9
bull 99 Sinclair C Handbook of obstetrical emergencies 1st ed Philadelphia WB Saunders 1996 p 29-39 69
bull 100 Tarsitano BF Rollings RE The pregnant dental patient evaluation and management Gen Dent 199341226-34
bull 101 Livingston MH Dlllinger TM Holder R Consideration in the management of the pregnant patient SCD Special Care in Dentistry 199818183-8
Thank you
- A Review on the principle of Dental Management of the Pregnant patient
- Slide 2
- Questions that a dentist may ask
- Stages of Pregnancy
- Slide 5
- Slide 6
- Physiologic Changes in Pregnancy
- Systemic changes in pregnancy
- FLAT SUPINE POSITIONING
- SUPINE HYPOTENSION SYNDROME (Vena Cava Compression)
- Supine Hypotension Syndrome
- Slide 12
- Supine Hypotension Syndrome
- Prevention of Supine Hypotensive Syndrome
- Treatment of Supine Hypotensive Syndrome
- How should the pregnant woman be positioned
- Slide 17
- Slide 18
- Slide 19
- Slide 20
- Slide 21
- Slide 22
- Slide 23
- Pregnancy Related Oral Health Problems
- Oral Problems in Pregnancy
- Pregnancy Gingivitis Pathophysiology
- Pregnancy Gingivitis
- Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Gum Problems - Pregnancy Granuloma
- Slide 31
- Gum Changes - Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Candidiasis
- Pregnancy Myths
- Other Oral Conditions in Pregnancy
- Changes During Pregnancy that Affect Oral Health
- Saliva changes
- Increased Bacteria
- Slide 40
- Enamel erosion caused by frequent vomiting
- Treatment for Acid Exposure
- Oral Diseases Can Effect Pregnancy
- Periodontal Disease and Preterm Labor
- Periodontal Disease and Low Birth Weight
- Periodontal Disease and Preeclampsia
- Periodontitis and Pre-eclampsia
- Dental Considerations
- Treatment Timing
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Slide 52
- Use of Radiation on Pregnant Patient
- Radiographs during Pregnancy
- Risks of Dental X-Rays
- FDA drug classification for pregnancy
- Slide 57
- FDA drug classification for pregnancy
- Slide 59
- Slide 60
- Slide 61
- Common Analgesics
- Analgesics
- Analgesics - continued
- Analgesics to Use During 1st and 2nd Trimester
- Analgesics to Avoid During the Third Trimester
- Sedation in Pregnancy
- Common Antibiotics
- Antibiotics
- Antibiotics To Use During Pregnancy
- Antibiotics to Avoid during Pregnancy
- The Problem With Tetracycline
- Other Antimicrobial Agents
- Local Anesthetic Use in Pregnancy
- Use of Local Anesthetics
- Ulcer healing drugs
- Slide 77
- Slide 78
- Slide 79
- Use of Nitrous Oxide Gas
- Common Preventives
- Are topical agents safe
- Pre-natal Fluoride
- Is it safe to use mercury restorations
- References
- REFERENCES
- Slide 87
- Slide 88
- Slide 89
- Slide 90
- Slide 91
- Slide 92
- Slide 93
- Slide 94
- Slide 95
- Slide 96
- Slide 97
- Slide 98
- Thank you
-
FDA drug classification for pregnancy
bull D = There is evidence of human fetal risk but benefits may outweigh risks
FDA drug classification for pregnancy
bull X = Contraindicated
Common Analgesics
bull paracetamol (B)bull Ibuprofen (BD) bull Oxycodone (BD) bull Hydrocodone and codeine
(CD)
avoid in third trimester
Analgesics
bull Paracetamol is the analgesic of choice for all stages of gestation
bull used to treat mild to moderate pain and fevers
bull short term usage is believed to be safebull avoid chronic and large doses of
paracetamol1048715
Analgesics - continuedbull Aspirin is nonteratogenic but may cause
maternal and fetal hemorrhagebull large and chronic doses during last trimester
may result in premature closure of ductus arteriosus fetal hypertension anemia and low birth weight
bull avoid ibuprofen in 3rd trimester because of possible adverse circulatory effects
bull short term use of codeine seems safebull avoid codeine late in gestation because of
possible fetal respiratory depression and withdrawal symptoms
Analgesics to Use During1st and 2nd Trimester
bull Category B (for best)bull Paracetamol Ibuprofenbull Naproxenbull Category C (use with caution)bull Paracetamol with codeine or
hydrocodonebull Paracetamol with oxycodone
Analgesics to Avoid During theThird Trimesterbull Causes delivery problemsbull Aspirin (C 3D)bull Ibuprofen (B3D)bull Naproxen (B3D)bull Causes neonatal respiratory
depression and opioid withdrawalbull Codeine (C3D)bull Hydrocodone (C3D)bull Oxycodone(C3D)
Sedation in Pregnancy
bull SedativesAnxiolytics (eg Diazepam ) are rated D and can cause oral clefts with prolonged exposure
bull Nitrous oxide should not be used in 1st trimester (If used in 2nd and 3rd do not go below 50 O2)
Common Antibioticsbull To treat oral abscess or cellulitis
ndash Penicillin (B) ndash Amoxicillin (B) ndash Cephalexin (B)ndash Erythromycin base (B) (Not estolate as it
cause cholestatic hepatitis)ndash Clindamycin (B)
Antibioticsbull penicillin V and amoxicillin is preferred drug
for mild to moderate infectionsbull widely used for many years with no ill effectsbull no studies show penicillin to be teratogenicbull amoxicillin extensively used without harming
the fetusbull Drug classes1048715 B penicillin cephalosporins erythromycin clindamycin Azithromycin D Tetracycline
Antibiotics To Use During Pregnancy
bull Penicillin Vbull Amoxicillinbull Erythromycin (base form)bull Cephalexin cephalosporinbull Clindamycinbull Metronidazole
Antibiotics to Avoid duringPregnancy
bull Doxycyclinebull Tetracyclinebull Erythromycin (estolate form)bull Vancomycin
The Problem With Tetracycline
bull Accumulates in bones and chelates calcium
bull Inhibits bone growthbull Discolors teeth
Other Antimicrobial Agentsbull OK to usebull Nystatin (B)bull Chlorhexidine rinse (B)bull Use with cautionbull Clotrimazole (C)bull Ketoconazole (C)bull Fluconazole (C)bull Do not usebull Doxycycline (D)
Local Anesthetic Use inPregnancy
bull Class Bbull Lidocaine (Xylocaine)bull Etidocainebull Prilocaine bull Class Cbull Procainebull Bupivicainebull Mepivicaine
Use of Local Anestheticsbull Lidocaine + vasoconstrictor most common
local anesthetic used in dentistrybull extensively used in pregnancy with no proven ill
effectsbull accidental intravascular injections of lidocaine
pass through the placenta but the concentrations are too low to harm fetus
bull prilocaine might cause methemoglobinemia
Ulcer healing drugsCimetidine bull FDA category B Famotidinebull FDA category BRanitidinebull FDA category Bbull not known to be harmful
Ulcer healing drugsOmeprazolebull FDA category BNot known to be
harmful Esomeprazolebull FDA category BLansoprazolebull FDA category BPantoprazolebull Avoid unless potential benefit
outweighs riskmdashfetotoxic in animals
Ulcer healing drugs
Misoprostolbull First second third trimesters Avoidmdash
potent uterine stimulant (has been used to induce abortion) and may be teratogenic
Ulcer healing drugs
Antacidsbull Almunium hydroxideMagnesium
hydroxidemdashFDA category B Calcium carbonatemdashFDA category C
SimetheconemdashFDA category C
Use of Nitrous Oxide Gas
bull used over 150 years bull safety is being debatedbull SHORT TERM exposure do not cause
birth defects or spontaneous abortionbull CHRONIC exposure may result in fetal
loss and infertilitybull literature suggests that nitrous oxide
should be avoided until more conclusive research is available
bull FDA Drug class not yet assigned
Common Preventives
bull Fluoridendash No increased risk during pregnancy
bull Xylitolndash No studies no harm reported
bull Chlorhexidinendash No increased risk during pregnancy
Are topical agents safe
bull Fluoridebull Toothpaste amp mouthrinse
bull Xylitol chewing gum bull Chlorhexidine (11 alcohol)bull No over the counter mouthrinses with
alcohol (Listerine 20 alcohol)
Pre-natal Fluoride
bull Daily 22 mg tablet of sodium fluoride during 3rd through 9th months
bull decreases caries rate in offspringbull Safe and effective
Glenn FB 1982
Is it safe to use mercury restorations
bull No evidence of harmful effect
bull Benefits outweigh risks
bull Canada Germany and New Zealand have some restrictions
bull Determine the best option
Referencesbull Wasylko L Matsui D Dykxhoorn SM Rieder MJ Weinberg
S A Review of Common Dental Treatments During Pregnancy J Canadian Dental Association 64434-439 1998
bull Little JW Donald AF Craig SM Rhodus NL Dental Management of the Medically Compromised Patient - 5th edition Mosby Toronto Pp434-442 1997
bull Livingston HM Dellinger TM Holder R Considerations in the management of the pregnant patient Special Care in Dentistry 185 pp183-188 1998
bull Larimore WL Petrie KA Drug use during pregnacy and lactation Primary Care Clinics in Office Practice 271 35-53 2000
bull Health Canada The Safety of DentalAmalgam Minister Of Supply and Services Canada 1996
REFERENCESbull 1 Weiss G Endocrinology of parturition J Clin
Endocrinol Metab 2000854421-5bull 2 Theunissen IM Parer JT Fluid and electrolytes in
pregnancy Clin Obstet Gynecol 1994373-15bull 3 Duvekot JJ Peeters LLH Renal hemodynamics and
volume homeostasis in pregnancy Obstet Gynecol Surv 199449830-9
bull 4 Barron WM Lindheimer MD Medical disorders during pregnancy 2nd ed St Louis Mosby 1995 p 129
bull 5 Thornburg KL Jacobson SL Giraud GD Morton MJ Hemodynamic changes in pregnancy Semin Perinatol 20002411-4
bull 6 Fiese R Herzog S Issues in dental and surgical management of the pregnant patient Oral Surg Oral Med Oral Pathol 198865292-7
bull 7 Martin C Varner MW Physiologic changes in pregnancysurgical implications Clin Obstet Gynecol 199437241-55
bull 8 Clark SL Cotton DB Lee W Bishop C Hill T Southwick J et al Central hemodynamic assessment of normal term pregnancy Am J Obstet Gynecol 19891611439-42
bull 9 Mabie WC Di Sessa TG Crocker LG Sibai BM Arheart KL A longitudinal study of cardiac output in normal human pregnancy Am J Obstet Gynecol 1994170849-56
bull 10 Clapp JF 3rd Capeless E Cardiovascular function before during and after the first and subsequent pregnancies Am J Cardiol 1997801469-73
bull 11 Duvekot JJ Peeters LL Maternal cardiovascular hemodynamic adaptation to pregnancy Obstet Gynecol Surv 199449(Suppl) S1-14
bull 12 Bhagwat AR Engel PJ Heart disease and pregnancy Cardiol Clin 199513163-78
bull 13 Lanni SM Tillinghast J Silver H Hemodynamic changes and baroreflex gain in the supine hypotensive syndrome Am J Obstet Gynecol 20021871636-41
bull 14 Little JW Falace DA Miller CS Rhodus NL Dental management of the medically compromised patient 6th ed St Louis Mosby 2002 p 303
bull 15 Garcia-Rio F Pino JM Gomez L Alvarez-Sala R Villasante C Villamor J Regulation of breathing and perception of dyspnea in healthy pregnant women Chest 1996110446-53
bull 16 McAuliffe F Kametas N Costello J Rafferty GF Greenough A Nicolaides K Respiratory function in singleton and twin pregnancy BJOG 2002109765-9
bull 17 Clapp JF 3rd Seaward BL Sleamaker RH Hiser J Maternal physiologic adaptations to early human pregnancy Am J Obstet Gynecol 19881591456-60
bull 18 OrsquoDay MP Cardio-respiratory physiological adaptation of pregnancy Semin Perinatol 199721268-75
bull 19 Contreras G Gutierrez M Beroiza T Fantin A Oddo H Villarroel L et al Ventilatory drive and respiratory muscle function in pregnancy Am Rev Respir Dis 1991144837-41
bull 20 Turner M Aziz SR Management of the pregnant oral and maxillofac
bull 21 Sifakis S Pharmakides G Anemia in pregnancy Ann N Y Acad Sci 2000900125-36
bull 22 Branch DW Physiologic adaptations of pregnancy Am J Reprod Immunol 199228120-2
bull 23 Burrows RF Kelton JG Incidentally detected thrombocytopenia in healthy mothers and their infants N Engl J Med 1988319 142-5
bull 24 Hanly JG Antiphospholipid syndrome an overview CMAJ 200324(168)1675-82
bull 25 Heilmann L von Tempelhoff GF Pollow K Antiphospholipid syndrome in obstetrics Clin Appl Thromb Hemost 20039 143-50
bull 26 Sherman P Flaxman SM Nausea and vomiting of pregnancy in an evolutionary perspective Am J Obstet Gynecol 2002 185(Suppl)s190-7
bull 27 Koch KL Gastrointestinal factors in nausea and vomiting of pregnancy Am J Obstet Gynecol 2002185(Suppl)s198-203
bull 28 Koch KL Frissora CL Nausea and vomiting during pregnancy Gastroenterol Clin N Am 200332201-34
bull 29 Baron TH Ramirez B Richter JE Gastrointestinal motility disorders during pregnancy Ann Intern Med 1993118 366-75
bull 30 Richter JE Gastroesophageal reflux disease during pregnancy Gastroenterol Clin N Am 200332235-61
bull 31 Marrero JM Goggin PM de Caestecker JS Pearce JM Maxwell JD Determinants of pregnancy heartburn Br J Obstet Gynaecol 199299731-4
bull 32 Hamaoui E Hamaoui M Nutritional assessment and support during pregnancy Gastroenterol Clin N Am 20033259-121
bull 33 King JC Physiology of pregnancy and nutrient metabolism Am J Clin Nutr 200071(suppl)1218s-25s
bull 34 Casanueva E Pfeffer F Fernandez-Gaxiola AC Gutierrez- Valenzuela V Rothenberg SJ Iron and folate status before pregnancy and anemia during pregnancy Ann Nutr Metab 2003 4760-3
bull 35 Chrsquong CL Morgan M Hainsworth I Kingham JG Prospective study of liver dysfunction in Southwest Wales Gut 200251 876-80
bull 36 Rahman TM Wendon J Severe hepatic dysfunction in pregnancy QJM 200295343-57
bull 37 Knox TA Olans LB Liver disease in pregnancy N Engl J Med 1996335569-76
bull 38 Saftlas AF Olson DR Franks AL Atrash H Pokras R Epidemiology of preeclampsia and eclampsia in the United States 1979e1986 Am J Obstet Gynecol 1990163460-5
bull 39 Walker JJ Pre-eclampsia Lancet 20003561260-5
bull 40 Davidson JM Renal disorders in pregnancy Curr Opin Obstet Gynecol 200113109-14
bull 41 Dafnis E Sabatini S The effect of pregnancy on renal function physiology and pathophysiologyAmJMedSci 1992303184-205
bull 42 Davison JM Shiells EA Philips PR Lindheimer MD Serial evaluation of vasopressin release and thirst in human pregnancy Role of human chorionic gonadotrophin in the osmoregulatory changes of gestation J Clin Invest 198881798-806
bull 43 Glinoer D de Nayer P Bourdoux P Lemone M Robyn C van Steirteghem A et al Regulation of maternal thyroid during pregnancy J Clin Endocrinol Metab 199071276-87
bull 44 Wilson SG Retallack RW Kent JC Worth GK Gutteridge DH Serum free 125-dihydroxyvitamin D and the free 125- dihydroxyvitamin D index during a longitudinal study of human pregnancy and lactation Clin Endocrinol 199032613-22
bull 45 Rasmussen N Frolich A Hornnes PJ Hegedus L Serum ionized calcium and intact parathyroid hormone levels during pregnancy and postpartum Br J Obstet Gynaecol 199097857-9
bull 46 Guyton AC Textbook of medical physiology 8th ed Philadelphia W B Saunders 1991 p 915e28
bull 47 Trainer PJ Corticosteroids and pregnancy Semin Reprod Med 200220375-80
bull 48 Soory M Hormonal factors in periodontal disease Dent Update 200027380-3
bull 49 Hugoson A Gingivitis in pregnant women A longitudinal clinical study Odontol Revy 19712265-84
bull 50 Neville BW Damm DD Allen CM Bouquot JE Oral amp Maxillofacial Pathology 3rd ed Philadelphia W B Saunders 2002 p 329-30 447-9
bull 51 Tilakaratne A Soory M Ranasinghe AW Corea SM Ekanayake SL de Silva M Periodontal disease status during pregnancy and 3 months post-partum in rural population of Sri-Lankan women J Clin Periodontol 200027787-92
bull 52 Laine M Tenovuo J Lehtonen OP Ojanatko-Harri A Vilja P Tuohimaa P Pregnancy e related changes in human whole saliva Arch Oral Biol 198833913-7
bull 53 Yuan K Wing LY Lin MT Pathogenetic roles of angiogenic factors in pyogenic granulomas in pregnancy are modulated by female sex hormones J Periodontol 200273701-8
bull 54 Evans RD Briggs PF Tooth-surface loss related to pregnancyinduced vomiting Prim Dent Care 1994124-6
bull 55 Salvolini E Di Giorgio R Curatola A Mazzanti L Fratto G Biochemical modifications of human whole saliva induced by pregnancy Br J Obstet Gynaec 1998105656-60
bull 56 Mauldin JG Newman RB Preterm birth risk assessment Semin Perinatol 200125215-22
bull 57 Heine RP McGregor JA Goodwin TM Artal R Hayashi RH Robertson PA et al Serial salivary estriol to detect an increased risk of preterm birth Obstet Gynecol 200096490-7
bull 58 Kauh YC Zachian TF Melasma Adv Exp Med Biol 1999455 491-9
bull 59 Wong RC Ellis CN Physiologic skin changes in pregnancy J Am Acad Dermatol 198410929-40
bull 60 Errickson CV Matus NR Skin disorders of pregnancy Am Fam Physician 199449605-10
bull 61 Lopez NJ Smith PC Gutierrez J Periodontal therapy may reduce the risk of preterm low birth weight in women with periodontal disease a randomized controlled trial J Periodontol 200273911-24
bull 62 McGaw T Periodontal disease and preterm delivery of lowbirth- weight infants J Can Dent Assoc 200268165-9
bull 63 Richards AG Dental x-ray protection Dent Clin North Am 1968631-41
bull 64 1990 Recommendations of the International Commission on Radiological Protection Ann ICRP 1991211-201
bull 65 Hall EJ Radiation the two-edged sword cancer risks at high and low doses Cancer J 20006343-50
bull 66 Diethelm L Xu H Diagnostic imaging of the lung during pregnancy Clin Obstet Gynecol 19963936-55
bull 67 Brent RL The effects of embryonic and fetal exposure to x-rays microwaves and ultrasound ClinObstetGynecol 198326484-510
bull 68 National Council on Radiation Protection NCRP report no128 1998 Bethesda Md Author
bull 69 Wasylko L Matsui D Dykxhoorn SM Reider MJ Weinberg S A review of common dental treatments during pregnancy implications for patients and dental personnel J Can Dent Assoc 199864434-9
bull 70 Freeman JP Brand JW Radiation doses of commonly used dental radiographic surveys Oral Surg Oral Med Oral Pathol 199477285-9
bull 71 Kircos LTAngin LL Lorton LOrder ofmagnitude dose reduction in intraoral radiography J Am Dent Assoc 1987114344-7
bull 72 Updegrave WJ Simplified and standardized intraoral radiography with reduced tissue irradiation J Am Dent Assoc 197285861-9
bull 73 Wood RE Harris AM van der Merwe EJ Nortje CJ The leaded apron revisited does it reduce gonadal radiation dose in dental radiology Oral Surg Oral Med Oral Pathol 199171642-6
bull 74 An update on radiographic practices information and recommendations ADA Council on Scientific Affairs J Am Dent Assoc 2001132234-8
bull 75 Rayburn WF Recommending medications during pregnancy an evidence based approach Clin Obstet Gynecol 2002451-5
bull 76 Rathmell JP Viscomi C Ashburn MA Management of nonobstetric pain during pregnancy and lactation Anesth Analg 1997851074-87
bull 77 Teratology society public affairs committee FDA classification of drugs for teratogenic risk Teratology 199449446-7
bull 78 Moore PA Selecting drugs for the pregnant dental patient J Am Dent Assoc 19981291281-6
bull 79 Haas DA An update on analgesics for the management of acute postoperative dental pain J Can Dent Assoc 200268476-82
bull 80 Haas DA Pynn BR Sands TD Drug use for the pregnant or lactating patient Gen Dent 20004854-60
bull 81 Committee on Drugs American Academy of Pediatrics The transfer of drugs and other chemicals into human milk Pediatrics 199493137-50
bull 82 Nielsen GL Sorensen HT Larsen H Pedersen L Risk of adverse birth outcome and miscarriage in pregnant users of nonsteroidal anti-inflammatory drugs population based observational study and case-control study BMJ 2001322266-70
bull 83 Janssen N Genta M The effects of immunosuppressive and anti-inflammatory medications on fertility pregnancy and lactation Arch Intern Med 200016610-9
bull 84 Ostensen M Nonsteroidal anti-inflammatory drugs during pregnancy Scand J Rheumatol Suppl 1998107128-32
bull 85 USPDI -Drug information for the health care professional 22nd ed Greenwood Village CO Micromedex 2002 p 152-79
bull 86 Denson DD Coyle DE Thompson GA Santos D Turner PA Myers JA et al Bupivacaine protein binding in the term parturient effects of lactic acidosis Clin Pharmacol Ther 198435702-9
bull 87 Dillon DE Wagner CL Wiest D Newman RB Drug therapy in the nursing mother Obstet Gynecol Clin North Am 199724 675-96
bull 88 Dashe JS Gilstrap LC Antibiotic use in pregnancy Obstet Gynecol Clin North Am 199724617-29
bull 89 American College of Rheumatology Ad hoc Committee on Clinical Guidelines Guidelines for monitoring drug therapy in rheumatoid arthritis Arthritis Rheum 199639723-31
bull 90 Ng PC The fetal and neonatal hypothalamic-pituitary-adrenal axis Arch Dis Child Fetal Neonatal Ed 200082F250-4
bull 91 Crowley P Antenatal corticosteroidsmdashcurrent thinking BJOG 2003110(Suppl 20)77-8
bull 92 ACOG committee opinion antenatal corticosteroid therapy for fetal maturation Obstet Gynecol 200299871-3
bull 93 Ost L Wettrell G Bjorkhem I Rane A Prednisolone excretion in human milk J Pediatr 19851061008-11
bull 94 Rowland AS Baird DD Shore DL Weinberg CR Savitz DA Wilcox AJ Nitrous oxide and spontaneous abortion in female dental assistants Am J Epidemiol 1995141531-8
bull 95 McGlothlin JD Jensen PA Fischbach TJ Hughes RT Jones JH Control of anesthetic gases in dental operatories Scand J Work Environ Health 199218(Suppl 2)103-5
bull ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY Volume 97 Number 6 Suresh and Radfar 681
bull 96 Rosen MA Nitrous oxide for relief of labor pain a systematic review Am J Obstet Gynecol 2002186(Suppl Nature)S110-6
bull 97 Sands TD Pynn BR Management considerations for the pregnant or nursing emergency patient Ont Dent 199875 17-9
bull 98 Daya S Recurrent spontaneous early pregnancy loss and low dose aspirin Minerva Ginecol 200355441-9
bull 99 Sinclair C Handbook of obstetrical emergencies 1st ed Philadelphia WB Saunders 1996 p 29-39 69
bull 100 Tarsitano BF Rollings RE The pregnant dental patient evaluation and management Gen Dent 199341226-34
bull 101 Livingston MH Dlllinger TM Holder R Consideration in the management of the pregnant patient SCD Special Care in Dentistry 199818183-8
Thank you
- A Review on the principle of Dental Management of the Pregnant patient
- Slide 2
- Questions that a dentist may ask
- Stages of Pregnancy
- Slide 5
- Slide 6
- Physiologic Changes in Pregnancy
- Systemic changes in pregnancy
- FLAT SUPINE POSITIONING
- SUPINE HYPOTENSION SYNDROME (Vena Cava Compression)
- Supine Hypotension Syndrome
- Slide 12
- Supine Hypotension Syndrome
- Prevention of Supine Hypotensive Syndrome
- Treatment of Supine Hypotensive Syndrome
- How should the pregnant woman be positioned
- Slide 17
- Slide 18
- Slide 19
- Slide 20
- Slide 21
- Slide 22
- Slide 23
- Pregnancy Related Oral Health Problems
- Oral Problems in Pregnancy
- Pregnancy Gingivitis Pathophysiology
- Pregnancy Gingivitis
- Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Gum Problems - Pregnancy Granuloma
- Slide 31
- Gum Changes - Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Candidiasis
- Pregnancy Myths
- Other Oral Conditions in Pregnancy
- Changes During Pregnancy that Affect Oral Health
- Saliva changes
- Increased Bacteria
- Slide 40
- Enamel erosion caused by frequent vomiting
- Treatment for Acid Exposure
- Oral Diseases Can Effect Pregnancy
- Periodontal Disease and Preterm Labor
- Periodontal Disease and Low Birth Weight
- Periodontal Disease and Preeclampsia
- Periodontitis and Pre-eclampsia
- Dental Considerations
- Treatment Timing
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Slide 52
- Use of Radiation on Pregnant Patient
- Radiographs during Pregnancy
- Risks of Dental X-Rays
- FDA drug classification for pregnancy
- Slide 57
- FDA drug classification for pregnancy
- Slide 59
- Slide 60
- Slide 61
- Common Analgesics
- Analgesics
- Analgesics - continued
- Analgesics to Use During 1st and 2nd Trimester
- Analgesics to Avoid During the Third Trimester
- Sedation in Pregnancy
- Common Antibiotics
- Antibiotics
- Antibiotics To Use During Pregnancy
- Antibiotics to Avoid during Pregnancy
- The Problem With Tetracycline
- Other Antimicrobial Agents
- Local Anesthetic Use in Pregnancy
- Use of Local Anesthetics
- Ulcer healing drugs
- Slide 77
- Slide 78
- Slide 79
- Use of Nitrous Oxide Gas
- Common Preventives
- Are topical agents safe
- Pre-natal Fluoride
- Is it safe to use mercury restorations
- References
- REFERENCES
- Slide 87
- Slide 88
- Slide 89
- Slide 90
- Slide 91
- Slide 92
- Slide 93
- Slide 94
- Slide 95
- Slide 96
- Slide 97
- Slide 98
- Thank you
-
FDA drug classification for pregnancy
bull X = Contraindicated
Common Analgesics
bull paracetamol (B)bull Ibuprofen (BD) bull Oxycodone (BD) bull Hydrocodone and codeine
(CD)
avoid in third trimester
Analgesics
bull Paracetamol is the analgesic of choice for all stages of gestation
bull used to treat mild to moderate pain and fevers
bull short term usage is believed to be safebull avoid chronic and large doses of
paracetamol1048715
Analgesics - continuedbull Aspirin is nonteratogenic but may cause
maternal and fetal hemorrhagebull large and chronic doses during last trimester
may result in premature closure of ductus arteriosus fetal hypertension anemia and low birth weight
bull avoid ibuprofen in 3rd trimester because of possible adverse circulatory effects
bull short term use of codeine seems safebull avoid codeine late in gestation because of
possible fetal respiratory depression and withdrawal symptoms
Analgesics to Use During1st and 2nd Trimester
bull Category B (for best)bull Paracetamol Ibuprofenbull Naproxenbull Category C (use with caution)bull Paracetamol with codeine or
hydrocodonebull Paracetamol with oxycodone
Analgesics to Avoid During theThird Trimesterbull Causes delivery problemsbull Aspirin (C 3D)bull Ibuprofen (B3D)bull Naproxen (B3D)bull Causes neonatal respiratory
depression and opioid withdrawalbull Codeine (C3D)bull Hydrocodone (C3D)bull Oxycodone(C3D)
Sedation in Pregnancy
bull SedativesAnxiolytics (eg Diazepam ) are rated D and can cause oral clefts with prolonged exposure
bull Nitrous oxide should not be used in 1st trimester (If used in 2nd and 3rd do not go below 50 O2)
Common Antibioticsbull To treat oral abscess or cellulitis
ndash Penicillin (B) ndash Amoxicillin (B) ndash Cephalexin (B)ndash Erythromycin base (B) (Not estolate as it
cause cholestatic hepatitis)ndash Clindamycin (B)
Antibioticsbull penicillin V and amoxicillin is preferred drug
for mild to moderate infectionsbull widely used for many years with no ill effectsbull no studies show penicillin to be teratogenicbull amoxicillin extensively used without harming
the fetusbull Drug classes1048715 B penicillin cephalosporins erythromycin clindamycin Azithromycin D Tetracycline
Antibiotics To Use During Pregnancy
bull Penicillin Vbull Amoxicillinbull Erythromycin (base form)bull Cephalexin cephalosporinbull Clindamycinbull Metronidazole
Antibiotics to Avoid duringPregnancy
bull Doxycyclinebull Tetracyclinebull Erythromycin (estolate form)bull Vancomycin
The Problem With Tetracycline
bull Accumulates in bones and chelates calcium
bull Inhibits bone growthbull Discolors teeth
Other Antimicrobial Agentsbull OK to usebull Nystatin (B)bull Chlorhexidine rinse (B)bull Use with cautionbull Clotrimazole (C)bull Ketoconazole (C)bull Fluconazole (C)bull Do not usebull Doxycycline (D)
Local Anesthetic Use inPregnancy
bull Class Bbull Lidocaine (Xylocaine)bull Etidocainebull Prilocaine bull Class Cbull Procainebull Bupivicainebull Mepivicaine
Use of Local Anestheticsbull Lidocaine + vasoconstrictor most common
local anesthetic used in dentistrybull extensively used in pregnancy with no proven ill
effectsbull accidental intravascular injections of lidocaine
pass through the placenta but the concentrations are too low to harm fetus
bull prilocaine might cause methemoglobinemia
Ulcer healing drugsCimetidine bull FDA category B Famotidinebull FDA category BRanitidinebull FDA category Bbull not known to be harmful
Ulcer healing drugsOmeprazolebull FDA category BNot known to be
harmful Esomeprazolebull FDA category BLansoprazolebull FDA category BPantoprazolebull Avoid unless potential benefit
outweighs riskmdashfetotoxic in animals
Ulcer healing drugs
Misoprostolbull First second third trimesters Avoidmdash
potent uterine stimulant (has been used to induce abortion) and may be teratogenic
Ulcer healing drugs
Antacidsbull Almunium hydroxideMagnesium
hydroxidemdashFDA category B Calcium carbonatemdashFDA category C
SimetheconemdashFDA category C
Use of Nitrous Oxide Gas
bull used over 150 years bull safety is being debatedbull SHORT TERM exposure do not cause
birth defects or spontaneous abortionbull CHRONIC exposure may result in fetal
loss and infertilitybull literature suggests that nitrous oxide
should be avoided until more conclusive research is available
bull FDA Drug class not yet assigned
Common Preventives
bull Fluoridendash No increased risk during pregnancy
bull Xylitolndash No studies no harm reported
bull Chlorhexidinendash No increased risk during pregnancy
Are topical agents safe
bull Fluoridebull Toothpaste amp mouthrinse
bull Xylitol chewing gum bull Chlorhexidine (11 alcohol)bull No over the counter mouthrinses with
alcohol (Listerine 20 alcohol)
Pre-natal Fluoride
bull Daily 22 mg tablet of sodium fluoride during 3rd through 9th months
bull decreases caries rate in offspringbull Safe and effective
Glenn FB 1982
Is it safe to use mercury restorations
bull No evidence of harmful effect
bull Benefits outweigh risks
bull Canada Germany and New Zealand have some restrictions
bull Determine the best option
Referencesbull Wasylko L Matsui D Dykxhoorn SM Rieder MJ Weinberg
S A Review of Common Dental Treatments During Pregnancy J Canadian Dental Association 64434-439 1998
bull Little JW Donald AF Craig SM Rhodus NL Dental Management of the Medically Compromised Patient - 5th edition Mosby Toronto Pp434-442 1997
bull Livingston HM Dellinger TM Holder R Considerations in the management of the pregnant patient Special Care in Dentistry 185 pp183-188 1998
bull Larimore WL Petrie KA Drug use during pregnacy and lactation Primary Care Clinics in Office Practice 271 35-53 2000
bull Health Canada The Safety of DentalAmalgam Minister Of Supply and Services Canada 1996
REFERENCESbull 1 Weiss G Endocrinology of parturition J Clin
Endocrinol Metab 2000854421-5bull 2 Theunissen IM Parer JT Fluid and electrolytes in
pregnancy Clin Obstet Gynecol 1994373-15bull 3 Duvekot JJ Peeters LLH Renal hemodynamics and
volume homeostasis in pregnancy Obstet Gynecol Surv 199449830-9
bull 4 Barron WM Lindheimer MD Medical disorders during pregnancy 2nd ed St Louis Mosby 1995 p 129
bull 5 Thornburg KL Jacobson SL Giraud GD Morton MJ Hemodynamic changes in pregnancy Semin Perinatol 20002411-4
bull 6 Fiese R Herzog S Issues in dental and surgical management of the pregnant patient Oral Surg Oral Med Oral Pathol 198865292-7
bull 7 Martin C Varner MW Physiologic changes in pregnancysurgical implications Clin Obstet Gynecol 199437241-55
bull 8 Clark SL Cotton DB Lee W Bishop C Hill T Southwick J et al Central hemodynamic assessment of normal term pregnancy Am J Obstet Gynecol 19891611439-42
bull 9 Mabie WC Di Sessa TG Crocker LG Sibai BM Arheart KL A longitudinal study of cardiac output in normal human pregnancy Am J Obstet Gynecol 1994170849-56
bull 10 Clapp JF 3rd Capeless E Cardiovascular function before during and after the first and subsequent pregnancies Am J Cardiol 1997801469-73
bull 11 Duvekot JJ Peeters LL Maternal cardiovascular hemodynamic adaptation to pregnancy Obstet Gynecol Surv 199449(Suppl) S1-14
bull 12 Bhagwat AR Engel PJ Heart disease and pregnancy Cardiol Clin 199513163-78
bull 13 Lanni SM Tillinghast J Silver H Hemodynamic changes and baroreflex gain in the supine hypotensive syndrome Am J Obstet Gynecol 20021871636-41
bull 14 Little JW Falace DA Miller CS Rhodus NL Dental management of the medically compromised patient 6th ed St Louis Mosby 2002 p 303
bull 15 Garcia-Rio F Pino JM Gomez L Alvarez-Sala R Villasante C Villamor J Regulation of breathing and perception of dyspnea in healthy pregnant women Chest 1996110446-53
bull 16 McAuliffe F Kametas N Costello J Rafferty GF Greenough A Nicolaides K Respiratory function in singleton and twin pregnancy BJOG 2002109765-9
bull 17 Clapp JF 3rd Seaward BL Sleamaker RH Hiser J Maternal physiologic adaptations to early human pregnancy Am J Obstet Gynecol 19881591456-60
bull 18 OrsquoDay MP Cardio-respiratory physiological adaptation of pregnancy Semin Perinatol 199721268-75
bull 19 Contreras G Gutierrez M Beroiza T Fantin A Oddo H Villarroel L et al Ventilatory drive and respiratory muscle function in pregnancy Am Rev Respir Dis 1991144837-41
bull 20 Turner M Aziz SR Management of the pregnant oral and maxillofac
bull 21 Sifakis S Pharmakides G Anemia in pregnancy Ann N Y Acad Sci 2000900125-36
bull 22 Branch DW Physiologic adaptations of pregnancy Am J Reprod Immunol 199228120-2
bull 23 Burrows RF Kelton JG Incidentally detected thrombocytopenia in healthy mothers and their infants N Engl J Med 1988319 142-5
bull 24 Hanly JG Antiphospholipid syndrome an overview CMAJ 200324(168)1675-82
bull 25 Heilmann L von Tempelhoff GF Pollow K Antiphospholipid syndrome in obstetrics Clin Appl Thromb Hemost 20039 143-50
bull 26 Sherman P Flaxman SM Nausea and vomiting of pregnancy in an evolutionary perspective Am J Obstet Gynecol 2002 185(Suppl)s190-7
bull 27 Koch KL Gastrointestinal factors in nausea and vomiting of pregnancy Am J Obstet Gynecol 2002185(Suppl)s198-203
bull 28 Koch KL Frissora CL Nausea and vomiting during pregnancy Gastroenterol Clin N Am 200332201-34
bull 29 Baron TH Ramirez B Richter JE Gastrointestinal motility disorders during pregnancy Ann Intern Med 1993118 366-75
bull 30 Richter JE Gastroesophageal reflux disease during pregnancy Gastroenterol Clin N Am 200332235-61
bull 31 Marrero JM Goggin PM de Caestecker JS Pearce JM Maxwell JD Determinants of pregnancy heartburn Br J Obstet Gynaecol 199299731-4
bull 32 Hamaoui E Hamaoui M Nutritional assessment and support during pregnancy Gastroenterol Clin N Am 20033259-121
bull 33 King JC Physiology of pregnancy and nutrient metabolism Am J Clin Nutr 200071(suppl)1218s-25s
bull 34 Casanueva E Pfeffer F Fernandez-Gaxiola AC Gutierrez- Valenzuela V Rothenberg SJ Iron and folate status before pregnancy and anemia during pregnancy Ann Nutr Metab 2003 4760-3
bull 35 Chrsquong CL Morgan M Hainsworth I Kingham JG Prospective study of liver dysfunction in Southwest Wales Gut 200251 876-80
bull 36 Rahman TM Wendon J Severe hepatic dysfunction in pregnancy QJM 200295343-57
bull 37 Knox TA Olans LB Liver disease in pregnancy N Engl J Med 1996335569-76
bull 38 Saftlas AF Olson DR Franks AL Atrash H Pokras R Epidemiology of preeclampsia and eclampsia in the United States 1979e1986 Am J Obstet Gynecol 1990163460-5
bull 39 Walker JJ Pre-eclampsia Lancet 20003561260-5
bull 40 Davidson JM Renal disorders in pregnancy Curr Opin Obstet Gynecol 200113109-14
bull 41 Dafnis E Sabatini S The effect of pregnancy on renal function physiology and pathophysiologyAmJMedSci 1992303184-205
bull 42 Davison JM Shiells EA Philips PR Lindheimer MD Serial evaluation of vasopressin release and thirst in human pregnancy Role of human chorionic gonadotrophin in the osmoregulatory changes of gestation J Clin Invest 198881798-806
bull 43 Glinoer D de Nayer P Bourdoux P Lemone M Robyn C van Steirteghem A et al Regulation of maternal thyroid during pregnancy J Clin Endocrinol Metab 199071276-87
bull 44 Wilson SG Retallack RW Kent JC Worth GK Gutteridge DH Serum free 125-dihydroxyvitamin D and the free 125- dihydroxyvitamin D index during a longitudinal study of human pregnancy and lactation Clin Endocrinol 199032613-22
bull 45 Rasmussen N Frolich A Hornnes PJ Hegedus L Serum ionized calcium and intact parathyroid hormone levels during pregnancy and postpartum Br J Obstet Gynaecol 199097857-9
bull 46 Guyton AC Textbook of medical physiology 8th ed Philadelphia W B Saunders 1991 p 915e28
bull 47 Trainer PJ Corticosteroids and pregnancy Semin Reprod Med 200220375-80
bull 48 Soory M Hormonal factors in periodontal disease Dent Update 200027380-3
bull 49 Hugoson A Gingivitis in pregnant women A longitudinal clinical study Odontol Revy 19712265-84
bull 50 Neville BW Damm DD Allen CM Bouquot JE Oral amp Maxillofacial Pathology 3rd ed Philadelphia W B Saunders 2002 p 329-30 447-9
bull 51 Tilakaratne A Soory M Ranasinghe AW Corea SM Ekanayake SL de Silva M Periodontal disease status during pregnancy and 3 months post-partum in rural population of Sri-Lankan women J Clin Periodontol 200027787-92
bull 52 Laine M Tenovuo J Lehtonen OP Ojanatko-Harri A Vilja P Tuohimaa P Pregnancy e related changes in human whole saliva Arch Oral Biol 198833913-7
bull 53 Yuan K Wing LY Lin MT Pathogenetic roles of angiogenic factors in pyogenic granulomas in pregnancy are modulated by female sex hormones J Periodontol 200273701-8
bull 54 Evans RD Briggs PF Tooth-surface loss related to pregnancyinduced vomiting Prim Dent Care 1994124-6
bull 55 Salvolini E Di Giorgio R Curatola A Mazzanti L Fratto G Biochemical modifications of human whole saliva induced by pregnancy Br J Obstet Gynaec 1998105656-60
bull 56 Mauldin JG Newman RB Preterm birth risk assessment Semin Perinatol 200125215-22
bull 57 Heine RP McGregor JA Goodwin TM Artal R Hayashi RH Robertson PA et al Serial salivary estriol to detect an increased risk of preterm birth Obstet Gynecol 200096490-7
bull 58 Kauh YC Zachian TF Melasma Adv Exp Med Biol 1999455 491-9
bull 59 Wong RC Ellis CN Physiologic skin changes in pregnancy J Am Acad Dermatol 198410929-40
bull 60 Errickson CV Matus NR Skin disorders of pregnancy Am Fam Physician 199449605-10
bull 61 Lopez NJ Smith PC Gutierrez J Periodontal therapy may reduce the risk of preterm low birth weight in women with periodontal disease a randomized controlled trial J Periodontol 200273911-24
bull 62 McGaw T Periodontal disease and preterm delivery of lowbirth- weight infants J Can Dent Assoc 200268165-9
bull 63 Richards AG Dental x-ray protection Dent Clin North Am 1968631-41
bull 64 1990 Recommendations of the International Commission on Radiological Protection Ann ICRP 1991211-201
bull 65 Hall EJ Radiation the two-edged sword cancer risks at high and low doses Cancer J 20006343-50
bull 66 Diethelm L Xu H Diagnostic imaging of the lung during pregnancy Clin Obstet Gynecol 19963936-55
bull 67 Brent RL The effects of embryonic and fetal exposure to x-rays microwaves and ultrasound ClinObstetGynecol 198326484-510
bull 68 National Council on Radiation Protection NCRP report no128 1998 Bethesda Md Author
bull 69 Wasylko L Matsui D Dykxhoorn SM Reider MJ Weinberg S A review of common dental treatments during pregnancy implications for patients and dental personnel J Can Dent Assoc 199864434-9
bull 70 Freeman JP Brand JW Radiation doses of commonly used dental radiographic surveys Oral Surg Oral Med Oral Pathol 199477285-9
bull 71 Kircos LTAngin LL Lorton LOrder ofmagnitude dose reduction in intraoral radiography J Am Dent Assoc 1987114344-7
bull 72 Updegrave WJ Simplified and standardized intraoral radiography with reduced tissue irradiation J Am Dent Assoc 197285861-9
bull 73 Wood RE Harris AM van der Merwe EJ Nortje CJ The leaded apron revisited does it reduce gonadal radiation dose in dental radiology Oral Surg Oral Med Oral Pathol 199171642-6
bull 74 An update on radiographic practices information and recommendations ADA Council on Scientific Affairs J Am Dent Assoc 2001132234-8
bull 75 Rayburn WF Recommending medications during pregnancy an evidence based approach Clin Obstet Gynecol 2002451-5
bull 76 Rathmell JP Viscomi C Ashburn MA Management of nonobstetric pain during pregnancy and lactation Anesth Analg 1997851074-87
bull 77 Teratology society public affairs committee FDA classification of drugs for teratogenic risk Teratology 199449446-7
bull 78 Moore PA Selecting drugs for the pregnant dental patient J Am Dent Assoc 19981291281-6
bull 79 Haas DA An update on analgesics for the management of acute postoperative dental pain J Can Dent Assoc 200268476-82
bull 80 Haas DA Pynn BR Sands TD Drug use for the pregnant or lactating patient Gen Dent 20004854-60
bull 81 Committee on Drugs American Academy of Pediatrics The transfer of drugs and other chemicals into human milk Pediatrics 199493137-50
bull 82 Nielsen GL Sorensen HT Larsen H Pedersen L Risk of adverse birth outcome and miscarriage in pregnant users of nonsteroidal anti-inflammatory drugs population based observational study and case-control study BMJ 2001322266-70
bull 83 Janssen N Genta M The effects of immunosuppressive and anti-inflammatory medications on fertility pregnancy and lactation Arch Intern Med 200016610-9
bull 84 Ostensen M Nonsteroidal anti-inflammatory drugs during pregnancy Scand J Rheumatol Suppl 1998107128-32
bull 85 USPDI -Drug information for the health care professional 22nd ed Greenwood Village CO Micromedex 2002 p 152-79
bull 86 Denson DD Coyle DE Thompson GA Santos D Turner PA Myers JA et al Bupivacaine protein binding in the term parturient effects of lactic acidosis Clin Pharmacol Ther 198435702-9
bull 87 Dillon DE Wagner CL Wiest D Newman RB Drug therapy in the nursing mother Obstet Gynecol Clin North Am 199724 675-96
bull 88 Dashe JS Gilstrap LC Antibiotic use in pregnancy Obstet Gynecol Clin North Am 199724617-29
bull 89 American College of Rheumatology Ad hoc Committee on Clinical Guidelines Guidelines for monitoring drug therapy in rheumatoid arthritis Arthritis Rheum 199639723-31
bull 90 Ng PC The fetal and neonatal hypothalamic-pituitary-adrenal axis Arch Dis Child Fetal Neonatal Ed 200082F250-4
bull 91 Crowley P Antenatal corticosteroidsmdashcurrent thinking BJOG 2003110(Suppl 20)77-8
bull 92 ACOG committee opinion antenatal corticosteroid therapy for fetal maturation Obstet Gynecol 200299871-3
bull 93 Ost L Wettrell G Bjorkhem I Rane A Prednisolone excretion in human milk J Pediatr 19851061008-11
bull 94 Rowland AS Baird DD Shore DL Weinberg CR Savitz DA Wilcox AJ Nitrous oxide and spontaneous abortion in female dental assistants Am J Epidemiol 1995141531-8
bull 95 McGlothlin JD Jensen PA Fischbach TJ Hughes RT Jones JH Control of anesthetic gases in dental operatories Scand J Work Environ Health 199218(Suppl 2)103-5
bull ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY Volume 97 Number 6 Suresh and Radfar 681
bull 96 Rosen MA Nitrous oxide for relief of labor pain a systematic review Am J Obstet Gynecol 2002186(Suppl Nature)S110-6
bull 97 Sands TD Pynn BR Management considerations for the pregnant or nursing emergency patient Ont Dent 199875 17-9
bull 98 Daya S Recurrent spontaneous early pregnancy loss and low dose aspirin Minerva Ginecol 200355441-9
bull 99 Sinclair C Handbook of obstetrical emergencies 1st ed Philadelphia WB Saunders 1996 p 29-39 69
bull 100 Tarsitano BF Rollings RE The pregnant dental patient evaluation and management Gen Dent 199341226-34
bull 101 Livingston MH Dlllinger TM Holder R Consideration in the management of the pregnant patient SCD Special Care in Dentistry 199818183-8
Thank you
- A Review on the principle of Dental Management of the Pregnant patient
- Slide 2
- Questions that a dentist may ask
- Stages of Pregnancy
- Slide 5
- Slide 6
- Physiologic Changes in Pregnancy
- Systemic changes in pregnancy
- FLAT SUPINE POSITIONING
- SUPINE HYPOTENSION SYNDROME (Vena Cava Compression)
- Supine Hypotension Syndrome
- Slide 12
- Supine Hypotension Syndrome
- Prevention of Supine Hypotensive Syndrome
- Treatment of Supine Hypotensive Syndrome
- How should the pregnant woman be positioned
- Slide 17
- Slide 18
- Slide 19
- Slide 20
- Slide 21
- Slide 22
- Slide 23
- Pregnancy Related Oral Health Problems
- Oral Problems in Pregnancy
- Pregnancy Gingivitis Pathophysiology
- Pregnancy Gingivitis
- Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Gum Problems - Pregnancy Granuloma
- Slide 31
- Gum Changes - Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Candidiasis
- Pregnancy Myths
- Other Oral Conditions in Pregnancy
- Changes During Pregnancy that Affect Oral Health
- Saliva changes
- Increased Bacteria
- Slide 40
- Enamel erosion caused by frequent vomiting
- Treatment for Acid Exposure
- Oral Diseases Can Effect Pregnancy
- Periodontal Disease and Preterm Labor
- Periodontal Disease and Low Birth Weight
- Periodontal Disease and Preeclampsia
- Periodontitis and Pre-eclampsia
- Dental Considerations
- Treatment Timing
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Slide 52
- Use of Radiation on Pregnant Patient
- Radiographs during Pregnancy
- Risks of Dental X-Rays
- FDA drug classification for pregnancy
- Slide 57
- FDA drug classification for pregnancy
- Slide 59
- Slide 60
- Slide 61
- Common Analgesics
- Analgesics
- Analgesics - continued
- Analgesics to Use During 1st and 2nd Trimester
- Analgesics to Avoid During the Third Trimester
- Sedation in Pregnancy
- Common Antibiotics
- Antibiotics
- Antibiotics To Use During Pregnancy
- Antibiotics to Avoid during Pregnancy
- The Problem With Tetracycline
- Other Antimicrobial Agents
- Local Anesthetic Use in Pregnancy
- Use of Local Anesthetics
- Ulcer healing drugs
- Slide 77
- Slide 78
- Slide 79
- Use of Nitrous Oxide Gas
- Common Preventives
- Are topical agents safe
- Pre-natal Fluoride
- Is it safe to use mercury restorations
- References
- REFERENCES
- Slide 87
- Slide 88
- Slide 89
- Slide 90
- Slide 91
- Slide 92
- Slide 93
- Slide 94
- Slide 95
- Slide 96
- Slide 97
- Slide 98
- Thank you
-
Common Analgesics
bull paracetamol (B)bull Ibuprofen (BD) bull Oxycodone (BD) bull Hydrocodone and codeine
(CD)
avoid in third trimester
Analgesics
bull Paracetamol is the analgesic of choice for all stages of gestation
bull used to treat mild to moderate pain and fevers
bull short term usage is believed to be safebull avoid chronic and large doses of
paracetamol1048715
Analgesics - continuedbull Aspirin is nonteratogenic but may cause
maternal and fetal hemorrhagebull large and chronic doses during last trimester
may result in premature closure of ductus arteriosus fetal hypertension anemia and low birth weight
bull avoid ibuprofen in 3rd trimester because of possible adverse circulatory effects
bull short term use of codeine seems safebull avoid codeine late in gestation because of
possible fetal respiratory depression and withdrawal symptoms
Analgesics to Use During1st and 2nd Trimester
bull Category B (for best)bull Paracetamol Ibuprofenbull Naproxenbull Category C (use with caution)bull Paracetamol with codeine or
hydrocodonebull Paracetamol with oxycodone
Analgesics to Avoid During theThird Trimesterbull Causes delivery problemsbull Aspirin (C 3D)bull Ibuprofen (B3D)bull Naproxen (B3D)bull Causes neonatal respiratory
depression and opioid withdrawalbull Codeine (C3D)bull Hydrocodone (C3D)bull Oxycodone(C3D)
Sedation in Pregnancy
bull SedativesAnxiolytics (eg Diazepam ) are rated D and can cause oral clefts with prolonged exposure
bull Nitrous oxide should not be used in 1st trimester (If used in 2nd and 3rd do not go below 50 O2)
Common Antibioticsbull To treat oral abscess or cellulitis
ndash Penicillin (B) ndash Amoxicillin (B) ndash Cephalexin (B)ndash Erythromycin base (B) (Not estolate as it
cause cholestatic hepatitis)ndash Clindamycin (B)
Antibioticsbull penicillin V and amoxicillin is preferred drug
for mild to moderate infectionsbull widely used for many years with no ill effectsbull no studies show penicillin to be teratogenicbull amoxicillin extensively used without harming
the fetusbull Drug classes1048715 B penicillin cephalosporins erythromycin clindamycin Azithromycin D Tetracycline
Antibiotics To Use During Pregnancy
bull Penicillin Vbull Amoxicillinbull Erythromycin (base form)bull Cephalexin cephalosporinbull Clindamycinbull Metronidazole
Antibiotics to Avoid duringPregnancy
bull Doxycyclinebull Tetracyclinebull Erythromycin (estolate form)bull Vancomycin
The Problem With Tetracycline
bull Accumulates in bones and chelates calcium
bull Inhibits bone growthbull Discolors teeth
Other Antimicrobial Agentsbull OK to usebull Nystatin (B)bull Chlorhexidine rinse (B)bull Use with cautionbull Clotrimazole (C)bull Ketoconazole (C)bull Fluconazole (C)bull Do not usebull Doxycycline (D)
Local Anesthetic Use inPregnancy
bull Class Bbull Lidocaine (Xylocaine)bull Etidocainebull Prilocaine bull Class Cbull Procainebull Bupivicainebull Mepivicaine
Use of Local Anestheticsbull Lidocaine + vasoconstrictor most common
local anesthetic used in dentistrybull extensively used in pregnancy with no proven ill
effectsbull accidental intravascular injections of lidocaine
pass through the placenta but the concentrations are too low to harm fetus
bull prilocaine might cause methemoglobinemia
Ulcer healing drugsCimetidine bull FDA category B Famotidinebull FDA category BRanitidinebull FDA category Bbull not known to be harmful
Ulcer healing drugsOmeprazolebull FDA category BNot known to be
harmful Esomeprazolebull FDA category BLansoprazolebull FDA category BPantoprazolebull Avoid unless potential benefit
outweighs riskmdashfetotoxic in animals
Ulcer healing drugs
Misoprostolbull First second third trimesters Avoidmdash
potent uterine stimulant (has been used to induce abortion) and may be teratogenic
Ulcer healing drugs
Antacidsbull Almunium hydroxideMagnesium
hydroxidemdashFDA category B Calcium carbonatemdashFDA category C
SimetheconemdashFDA category C
Use of Nitrous Oxide Gas
bull used over 150 years bull safety is being debatedbull SHORT TERM exposure do not cause
birth defects or spontaneous abortionbull CHRONIC exposure may result in fetal
loss and infertilitybull literature suggests that nitrous oxide
should be avoided until more conclusive research is available
bull FDA Drug class not yet assigned
Common Preventives
bull Fluoridendash No increased risk during pregnancy
bull Xylitolndash No studies no harm reported
bull Chlorhexidinendash No increased risk during pregnancy
Are topical agents safe
bull Fluoridebull Toothpaste amp mouthrinse
bull Xylitol chewing gum bull Chlorhexidine (11 alcohol)bull No over the counter mouthrinses with
alcohol (Listerine 20 alcohol)
Pre-natal Fluoride
bull Daily 22 mg tablet of sodium fluoride during 3rd through 9th months
bull decreases caries rate in offspringbull Safe and effective
Glenn FB 1982
Is it safe to use mercury restorations
bull No evidence of harmful effect
bull Benefits outweigh risks
bull Canada Germany and New Zealand have some restrictions
bull Determine the best option
Referencesbull Wasylko L Matsui D Dykxhoorn SM Rieder MJ Weinberg
S A Review of Common Dental Treatments During Pregnancy J Canadian Dental Association 64434-439 1998
bull Little JW Donald AF Craig SM Rhodus NL Dental Management of the Medically Compromised Patient - 5th edition Mosby Toronto Pp434-442 1997
bull Livingston HM Dellinger TM Holder R Considerations in the management of the pregnant patient Special Care in Dentistry 185 pp183-188 1998
bull Larimore WL Petrie KA Drug use during pregnacy and lactation Primary Care Clinics in Office Practice 271 35-53 2000
bull Health Canada The Safety of DentalAmalgam Minister Of Supply and Services Canada 1996
REFERENCESbull 1 Weiss G Endocrinology of parturition J Clin
Endocrinol Metab 2000854421-5bull 2 Theunissen IM Parer JT Fluid and electrolytes in
pregnancy Clin Obstet Gynecol 1994373-15bull 3 Duvekot JJ Peeters LLH Renal hemodynamics and
volume homeostasis in pregnancy Obstet Gynecol Surv 199449830-9
bull 4 Barron WM Lindheimer MD Medical disorders during pregnancy 2nd ed St Louis Mosby 1995 p 129
bull 5 Thornburg KL Jacobson SL Giraud GD Morton MJ Hemodynamic changes in pregnancy Semin Perinatol 20002411-4
bull 6 Fiese R Herzog S Issues in dental and surgical management of the pregnant patient Oral Surg Oral Med Oral Pathol 198865292-7
bull 7 Martin C Varner MW Physiologic changes in pregnancysurgical implications Clin Obstet Gynecol 199437241-55
bull 8 Clark SL Cotton DB Lee W Bishop C Hill T Southwick J et al Central hemodynamic assessment of normal term pregnancy Am J Obstet Gynecol 19891611439-42
bull 9 Mabie WC Di Sessa TG Crocker LG Sibai BM Arheart KL A longitudinal study of cardiac output in normal human pregnancy Am J Obstet Gynecol 1994170849-56
bull 10 Clapp JF 3rd Capeless E Cardiovascular function before during and after the first and subsequent pregnancies Am J Cardiol 1997801469-73
bull 11 Duvekot JJ Peeters LL Maternal cardiovascular hemodynamic adaptation to pregnancy Obstet Gynecol Surv 199449(Suppl) S1-14
bull 12 Bhagwat AR Engel PJ Heart disease and pregnancy Cardiol Clin 199513163-78
bull 13 Lanni SM Tillinghast J Silver H Hemodynamic changes and baroreflex gain in the supine hypotensive syndrome Am J Obstet Gynecol 20021871636-41
bull 14 Little JW Falace DA Miller CS Rhodus NL Dental management of the medically compromised patient 6th ed St Louis Mosby 2002 p 303
bull 15 Garcia-Rio F Pino JM Gomez L Alvarez-Sala R Villasante C Villamor J Regulation of breathing and perception of dyspnea in healthy pregnant women Chest 1996110446-53
bull 16 McAuliffe F Kametas N Costello J Rafferty GF Greenough A Nicolaides K Respiratory function in singleton and twin pregnancy BJOG 2002109765-9
bull 17 Clapp JF 3rd Seaward BL Sleamaker RH Hiser J Maternal physiologic adaptations to early human pregnancy Am J Obstet Gynecol 19881591456-60
bull 18 OrsquoDay MP Cardio-respiratory physiological adaptation of pregnancy Semin Perinatol 199721268-75
bull 19 Contreras G Gutierrez M Beroiza T Fantin A Oddo H Villarroel L et al Ventilatory drive and respiratory muscle function in pregnancy Am Rev Respir Dis 1991144837-41
bull 20 Turner M Aziz SR Management of the pregnant oral and maxillofac
bull 21 Sifakis S Pharmakides G Anemia in pregnancy Ann N Y Acad Sci 2000900125-36
bull 22 Branch DW Physiologic adaptations of pregnancy Am J Reprod Immunol 199228120-2
bull 23 Burrows RF Kelton JG Incidentally detected thrombocytopenia in healthy mothers and their infants N Engl J Med 1988319 142-5
bull 24 Hanly JG Antiphospholipid syndrome an overview CMAJ 200324(168)1675-82
bull 25 Heilmann L von Tempelhoff GF Pollow K Antiphospholipid syndrome in obstetrics Clin Appl Thromb Hemost 20039 143-50
bull 26 Sherman P Flaxman SM Nausea and vomiting of pregnancy in an evolutionary perspective Am J Obstet Gynecol 2002 185(Suppl)s190-7
bull 27 Koch KL Gastrointestinal factors in nausea and vomiting of pregnancy Am J Obstet Gynecol 2002185(Suppl)s198-203
bull 28 Koch KL Frissora CL Nausea and vomiting during pregnancy Gastroenterol Clin N Am 200332201-34
bull 29 Baron TH Ramirez B Richter JE Gastrointestinal motility disorders during pregnancy Ann Intern Med 1993118 366-75
bull 30 Richter JE Gastroesophageal reflux disease during pregnancy Gastroenterol Clin N Am 200332235-61
bull 31 Marrero JM Goggin PM de Caestecker JS Pearce JM Maxwell JD Determinants of pregnancy heartburn Br J Obstet Gynaecol 199299731-4
bull 32 Hamaoui E Hamaoui M Nutritional assessment and support during pregnancy Gastroenterol Clin N Am 20033259-121
bull 33 King JC Physiology of pregnancy and nutrient metabolism Am J Clin Nutr 200071(suppl)1218s-25s
bull 34 Casanueva E Pfeffer F Fernandez-Gaxiola AC Gutierrez- Valenzuela V Rothenberg SJ Iron and folate status before pregnancy and anemia during pregnancy Ann Nutr Metab 2003 4760-3
bull 35 Chrsquong CL Morgan M Hainsworth I Kingham JG Prospective study of liver dysfunction in Southwest Wales Gut 200251 876-80
bull 36 Rahman TM Wendon J Severe hepatic dysfunction in pregnancy QJM 200295343-57
bull 37 Knox TA Olans LB Liver disease in pregnancy N Engl J Med 1996335569-76
bull 38 Saftlas AF Olson DR Franks AL Atrash H Pokras R Epidemiology of preeclampsia and eclampsia in the United States 1979e1986 Am J Obstet Gynecol 1990163460-5
bull 39 Walker JJ Pre-eclampsia Lancet 20003561260-5
bull 40 Davidson JM Renal disorders in pregnancy Curr Opin Obstet Gynecol 200113109-14
bull 41 Dafnis E Sabatini S The effect of pregnancy on renal function physiology and pathophysiologyAmJMedSci 1992303184-205
bull 42 Davison JM Shiells EA Philips PR Lindheimer MD Serial evaluation of vasopressin release and thirst in human pregnancy Role of human chorionic gonadotrophin in the osmoregulatory changes of gestation J Clin Invest 198881798-806
bull 43 Glinoer D de Nayer P Bourdoux P Lemone M Robyn C van Steirteghem A et al Regulation of maternal thyroid during pregnancy J Clin Endocrinol Metab 199071276-87
bull 44 Wilson SG Retallack RW Kent JC Worth GK Gutteridge DH Serum free 125-dihydroxyvitamin D and the free 125- dihydroxyvitamin D index during a longitudinal study of human pregnancy and lactation Clin Endocrinol 199032613-22
bull 45 Rasmussen N Frolich A Hornnes PJ Hegedus L Serum ionized calcium and intact parathyroid hormone levels during pregnancy and postpartum Br J Obstet Gynaecol 199097857-9
bull 46 Guyton AC Textbook of medical physiology 8th ed Philadelphia W B Saunders 1991 p 915e28
bull 47 Trainer PJ Corticosteroids and pregnancy Semin Reprod Med 200220375-80
bull 48 Soory M Hormonal factors in periodontal disease Dent Update 200027380-3
bull 49 Hugoson A Gingivitis in pregnant women A longitudinal clinical study Odontol Revy 19712265-84
bull 50 Neville BW Damm DD Allen CM Bouquot JE Oral amp Maxillofacial Pathology 3rd ed Philadelphia W B Saunders 2002 p 329-30 447-9
bull 51 Tilakaratne A Soory M Ranasinghe AW Corea SM Ekanayake SL de Silva M Periodontal disease status during pregnancy and 3 months post-partum in rural population of Sri-Lankan women J Clin Periodontol 200027787-92
bull 52 Laine M Tenovuo J Lehtonen OP Ojanatko-Harri A Vilja P Tuohimaa P Pregnancy e related changes in human whole saliva Arch Oral Biol 198833913-7
bull 53 Yuan K Wing LY Lin MT Pathogenetic roles of angiogenic factors in pyogenic granulomas in pregnancy are modulated by female sex hormones J Periodontol 200273701-8
bull 54 Evans RD Briggs PF Tooth-surface loss related to pregnancyinduced vomiting Prim Dent Care 1994124-6
bull 55 Salvolini E Di Giorgio R Curatola A Mazzanti L Fratto G Biochemical modifications of human whole saliva induced by pregnancy Br J Obstet Gynaec 1998105656-60
bull 56 Mauldin JG Newman RB Preterm birth risk assessment Semin Perinatol 200125215-22
bull 57 Heine RP McGregor JA Goodwin TM Artal R Hayashi RH Robertson PA et al Serial salivary estriol to detect an increased risk of preterm birth Obstet Gynecol 200096490-7
bull 58 Kauh YC Zachian TF Melasma Adv Exp Med Biol 1999455 491-9
bull 59 Wong RC Ellis CN Physiologic skin changes in pregnancy J Am Acad Dermatol 198410929-40
bull 60 Errickson CV Matus NR Skin disorders of pregnancy Am Fam Physician 199449605-10
bull 61 Lopez NJ Smith PC Gutierrez J Periodontal therapy may reduce the risk of preterm low birth weight in women with periodontal disease a randomized controlled trial J Periodontol 200273911-24
bull 62 McGaw T Periodontal disease and preterm delivery of lowbirth- weight infants J Can Dent Assoc 200268165-9
bull 63 Richards AG Dental x-ray protection Dent Clin North Am 1968631-41
bull 64 1990 Recommendations of the International Commission on Radiological Protection Ann ICRP 1991211-201
bull 65 Hall EJ Radiation the two-edged sword cancer risks at high and low doses Cancer J 20006343-50
bull 66 Diethelm L Xu H Diagnostic imaging of the lung during pregnancy Clin Obstet Gynecol 19963936-55
bull 67 Brent RL The effects of embryonic and fetal exposure to x-rays microwaves and ultrasound ClinObstetGynecol 198326484-510
bull 68 National Council on Radiation Protection NCRP report no128 1998 Bethesda Md Author
bull 69 Wasylko L Matsui D Dykxhoorn SM Reider MJ Weinberg S A review of common dental treatments during pregnancy implications for patients and dental personnel J Can Dent Assoc 199864434-9
bull 70 Freeman JP Brand JW Radiation doses of commonly used dental radiographic surveys Oral Surg Oral Med Oral Pathol 199477285-9
bull 71 Kircos LTAngin LL Lorton LOrder ofmagnitude dose reduction in intraoral radiography J Am Dent Assoc 1987114344-7
bull 72 Updegrave WJ Simplified and standardized intraoral radiography with reduced tissue irradiation J Am Dent Assoc 197285861-9
bull 73 Wood RE Harris AM van der Merwe EJ Nortje CJ The leaded apron revisited does it reduce gonadal radiation dose in dental radiology Oral Surg Oral Med Oral Pathol 199171642-6
bull 74 An update on radiographic practices information and recommendations ADA Council on Scientific Affairs J Am Dent Assoc 2001132234-8
bull 75 Rayburn WF Recommending medications during pregnancy an evidence based approach Clin Obstet Gynecol 2002451-5
bull 76 Rathmell JP Viscomi C Ashburn MA Management of nonobstetric pain during pregnancy and lactation Anesth Analg 1997851074-87
bull 77 Teratology society public affairs committee FDA classification of drugs for teratogenic risk Teratology 199449446-7
bull 78 Moore PA Selecting drugs for the pregnant dental patient J Am Dent Assoc 19981291281-6
bull 79 Haas DA An update on analgesics for the management of acute postoperative dental pain J Can Dent Assoc 200268476-82
bull 80 Haas DA Pynn BR Sands TD Drug use for the pregnant or lactating patient Gen Dent 20004854-60
bull 81 Committee on Drugs American Academy of Pediatrics The transfer of drugs and other chemicals into human milk Pediatrics 199493137-50
bull 82 Nielsen GL Sorensen HT Larsen H Pedersen L Risk of adverse birth outcome and miscarriage in pregnant users of nonsteroidal anti-inflammatory drugs population based observational study and case-control study BMJ 2001322266-70
bull 83 Janssen N Genta M The effects of immunosuppressive and anti-inflammatory medications on fertility pregnancy and lactation Arch Intern Med 200016610-9
bull 84 Ostensen M Nonsteroidal anti-inflammatory drugs during pregnancy Scand J Rheumatol Suppl 1998107128-32
bull 85 USPDI -Drug information for the health care professional 22nd ed Greenwood Village CO Micromedex 2002 p 152-79
bull 86 Denson DD Coyle DE Thompson GA Santos D Turner PA Myers JA et al Bupivacaine protein binding in the term parturient effects of lactic acidosis Clin Pharmacol Ther 198435702-9
bull 87 Dillon DE Wagner CL Wiest D Newman RB Drug therapy in the nursing mother Obstet Gynecol Clin North Am 199724 675-96
bull 88 Dashe JS Gilstrap LC Antibiotic use in pregnancy Obstet Gynecol Clin North Am 199724617-29
bull 89 American College of Rheumatology Ad hoc Committee on Clinical Guidelines Guidelines for monitoring drug therapy in rheumatoid arthritis Arthritis Rheum 199639723-31
bull 90 Ng PC The fetal and neonatal hypothalamic-pituitary-adrenal axis Arch Dis Child Fetal Neonatal Ed 200082F250-4
bull 91 Crowley P Antenatal corticosteroidsmdashcurrent thinking BJOG 2003110(Suppl 20)77-8
bull 92 ACOG committee opinion antenatal corticosteroid therapy for fetal maturation Obstet Gynecol 200299871-3
bull 93 Ost L Wettrell G Bjorkhem I Rane A Prednisolone excretion in human milk J Pediatr 19851061008-11
bull 94 Rowland AS Baird DD Shore DL Weinberg CR Savitz DA Wilcox AJ Nitrous oxide and spontaneous abortion in female dental assistants Am J Epidemiol 1995141531-8
bull 95 McGlothlin JD Jensen PA Fischbach TJ Hughes RT Jones JH Control of anesthetic gases in dental operatories Scand J Work Environ Health 199218(Suppl 2)103-5
bull ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY Volume 97 Number 6 Suresh and Radfar 681
bull 96 Rosen MA Nitrous oxide for relief of labor pain a systematic review Am J Obstet Gynecol 2002186(Suppl Nature)S110-6
bull 97 Sands TD Pynn BR Management considerations for the pregnant or nursing emergency patient Ont Dent 199875 17-9
bull 98 Daya S Recurrent spontaneous early pregnancy loss and low dose aspirin Minerva Ginecol 200355441-9
bull 99 Sinclair C Handbook of obstetrical emergencies 1st ed Philadelphia WB Saunders 1996 p 29-39 69
bull 100 Tarsitano BF Rollings RE The pregnant dental patient evaluation and management Gen Dent 199341226-34
bull 101 Livingston MH Dlllinger TM Holder R Consideration in the management of the pregnant patient SCD Special Care in Dentistry 199818183-8
Thank you
- A Review on the principle of Dental Management of the Pregnant patient
- Slide 2
- Questions that a dentist may ask
- Stages of Pregnancy
- Slide 5
- Slide 6
- Physiologic Changes in Pregnancy
- Systemic changes in pregnancy
- FLAT SUPINE POSITIONING
- SUPINE HYPOTENSION SYNDROME (Vena Cava Compression)
- Supine Hypotension Syndrome
- Slide 12
- Supine Hypotension Syndrome
- Prevention of Supine Hypotensive Syndrome
- Treatment of Supine Hypotensive Syndrome
- How should the pregnant woman be positioned
- Slide 17
- Slide 18
- Slide 19
- Slide 20
- Slide 21
- Slide 22
- Slide 23
- Pregnancy Related Oral Health Problems
- Oral Problems in Pregnancy
- Pregnancy Gingivitis Pathophysiology
- Pregnancy Gingivitis
- Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Gum Problems - Pregnancy Granuloma
- Slide 31
- Gum Changes - Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Candidiasis
- Pregnancy Myths
- Other Oral Conditions in Pregnancy
- Changes During Pregnancy that Affect Oral Health
- Saliva changes
- Increased Bacteria
- Slide 40
- Enamel erosion caused by frequent vomiting
- Treatment for Acid Exposure
- Oral Diseases Can Effect Pregnancy
- Periodontal Disease and Preterm Labor
- Periodontal Disease and Low Birth Weight
- Periodontal Disease and Preeclampsia
- Periodontitis and Pre-eclampsia
- Dental Considerations
- Treatment Timing
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Slide 52
- Use of Radiation on Pregnant Patient
- Radiographs during Pregnancy
- Risks of Dental X-Rays
- FDA drug classification for pregnancy
- Slide 57
- FDA drug classification for pregnancy
- Slide 59
- Slide 60
- Slide 61
- Common Analgesics
- Analgesics
- Analgesics - continued
- Analgesics to Use During 1st and 2nd Trimester
- Analgesics to Avoid During the Third Trimester
- Sedation in Pregnancy
- Common Antibiotics
- Antibiotics
- Antibiotics To Use During Pregnancy
- Antibiotics to Avoid during Pregnancy
- The Problem With Tetracycline
- Other Antimicrobial Agents
- Local Anesthetic Use in Pregnancy
- Use of Local Anesthetics
- Ulcer healing drugs
- Slide 77
- Slide 78
- Slide 79
- Use of Nitrous Oxide Gas
- Common Preventives
- Are topical agents safe
- Pre-natal Fluoride
- Is it safe to use mercury restorations
- References
- REFERENCES
- Slide 87
- Slide 88
- Slide 89
- Slide 90
- Slide 91
- Slide 92
- Slide 93
- Slide 94
- Slide 95
- Slide 96
- Slide 97
- Slide 98
- Thank you
-
Analgesics
bull Paracetamol is the analgesic of choice for all stages of gestation
bull used to treat mild to moderate pain and fevers
bull short term usage is believed to be safebull avoid chronic and large doses of
paracetamol1048715
Analgesics - continuedbull Aspirin is nonteratogenic but may cause
maternal and fetal hemorrhagebull large and chronic doses during last trimester
may result in premature closure of ductus arteriosus fetal hypertension anemia and low birth weight
bull avoid ibuprofen in 3rd trimester because of possible adverse circulatory effects
bull short term use of codeine seems safebull avoid codeine late in gestation because of
possible fetal respiratory depression and withdrawal symptoms
Analgesics to Use During1st and 2nd Trimester
bull Category B (for best)bull Paracetamol Ibuprofenbull Naproxenbull Category C (use with caution)bull Paracetamol with codeine or
hydrocodonebull Paracetamol with oxycodone
Analgesics to Avoid During theThird Trimesterbull Causes delivery problemsbull Aspirin (C 3D)bull Ibuprofen (B3D)bull Naproxen (B3D)bull Causes neonatal respiratory
depression and opioid withdrawalbull Codeine (C3D)bull Hydrocodone (C3D)bull Oxycodone(C3D)
Sedation in Pregnancy
bull SedativesAnxiolytics (eg Diazepam ) are rated D and can cause oral clefts with prolonged exposure
bull Nitrous oxide should not be used in 1st trimester (If used in 2nd and 3rd do not go below 50 O2)
Common Antibioticsbull To treat oral abscess or cellulitis
ndash Penicillin (B) ndash Amoxicillin (B) ndash Cephalexin (B)ndash Erythromycin base (B) (Not estolate as it
cause cholestatic hepatitis)ndash Clindamycin (B)
Antibioticsbull penicillin V and amoxicillin is preferred drug
for mild to moderate infectionsbull widely used for many years with no ill effectsbull no studies show penicillin to be teratogenicbull amoxicillin extensively used without harming
the fetusbull Drug classes1048715 B penicillin cephalosporins erythromycin clindamycin Azithromycin D Tetracycline
Antibiotics To Use During Pregnancy
bull Penicillin Vbull Amoxicillinbull Erythromycin (base form)bull Cephalexin cephalosporinbull Clindamycinbull Metronidazole
Antibiotics to Avoid duringPregnancy
bull Doxycyclinebull Tetracyclinebull Erythromycin (estolate form)bull Vancomycin
The Problem With Tetracycline
bull Accumulates in bones and chelates calcium
bull Inhibits bone growthbull Discolors teeth
Other Antimicrobial Agentsbull OK to usebull Nystatin (B)bull Chlorhexidine rinse (B)bull Use with cautionbull Clotrimazole (C)bull Ketoconazole (C)bull Fluconazole (C)bull Do not usebull Doxycycline (D)
Local Anesthetic Use inPregnancy
bull Class Bbull Lidocaine (Xylocaine)bull Etidocainebull Prilocaine bull Class Cbull Procainebull Bupivicainebull Mepivicaine
Use of Local Anestheticsbull Lidocaine + vasoconstrictor most common
local anesthetic used in dentistrybull extensively used in pregnancy with no proven ill
effectsbull accidental intravascular injections of lidocaine
pass through the placenta but the concentrations are too low to harm fetus
bull prilocaine might cause methemoglobinemia
Ulcer healing drugsCimetidine bull FDA category B Famotidinebull FDA category BRanitidinebull FDA category Bbull not known to be harmful
Ulcer healing drugsOmeprazolebull FDA category BNot known to be
harmful Esomeprazolebull FDA category BLansoprazolebull FDA category BPantoprazolebull Avoid unless potential benefit
outweighs riskmdashfetotoxic in animals
Ulcer healing drugs
Misoprostolbull First second third trimesters Avoidmdash
potent uterine stimulant (has been used to induce abortion) and may be teratogenic
Ulcer healing drugs
Antacidsbull Almunium hydroxideMagnesium
hydroxidemdashFDA category B Calcium carbonatemdashFDA category C
SimetheconemdashFDA category C
Use of Nitrous Oxide Gas
bull used over 150 years bull safety is being debatedbull SHORT TERM exposure do not cause
birth defects or spontaneous abortionbull CHRONIC exposure may result in fetal
loss and infertilitybull literature suggests that nitrous oxide
should be avoided until more conclusive research is available
bull FDA Drug class not yet assigned
Common Preventives
bull Fluoridendash No increased risk during pregnancy
bull Xylitolndash No studies no harm reported
bull Chlorhexidinendash No increased risk during pregnancy
Are topical agents safe
bull Fluoridebull Toothpaste amp mouthrinse
bull Xylitol chewing gum bull Chlorhexidine (11 alcohol)bull No over the counter mouthrinses with
alcohol (Listerine 20 alcohol)
Pre-natal Fluoride
bull Daily 22 mg tablet of sodium fluoride during 3rd through 9th months
bull decreases caries rate in offspringbull Safe and effective
Glenn FB 1982
Is it safe to use mercury restorations
bull No evidence of harmful effect
bull Benefits outweigh risks
bull Canada Germany and New Zealand have some restrictions
bull Determine the best option
Referencesbull Wasylko L Matsui D Dykxhoorn SM Rieder MJ Weinberg
S A Review of Common Dental Treatments During Pregnancy J Canadian Dental Association 64434-439 1998
bull Little JW Donald AF Craig SM Rhodus NL Dental Management of the Medically Compromised Patient - 5th edition Mosby Toronto Pp434-442 1997
bull Livingston HM Dellinger TM Holder R Considerations in the management of the pregnant patient Special Care in Dentistry 185 pp183-188 1998
bull Larimore WL Petrie KA Drug use during pregnacy and lactation Primary Care Clinics in Office Practice 271 35-53 2000
bull Health Canada The Safety of DentalAmalgam Minister Of Supply and Services Canada 1996
REFERENCESbull 1 Weiss G Endocrinology of parturition J Clin
Endocrinol Metab 2000854421-5bull 2 Theunissen IM Parer JT Fluid and electrolytes in
pregnancy Clin Obstet Gynecol 1994373-15bull 3 Duvekot JJ Peeters LLH Renal hemodynamics and
volume homeostasis in pregnancy Obstet Gynecol Surv 199449830-9
bull 4 Barron WM Lindheimer MD Medical disorders during pregnancy 2nd ed St Louis Mosby 1995 p 129
bull 5 Thornburg KL Jacobson SL Giraud GD Morton MJ Hemodynamic changes in pregnancy Semin Perinatol 20002411-4
bull 6 Fiese R Herzog S Issues in dental and surgical management of the pregnant patient Oral Surg Oral Med Oral Pathol 198865292-7
bull 7 Martin C Varner MW Physiologic changes in pregnancysurgical implications Clin Obstet Gynecol 199437241-55
bull 8 Clark SL Cotton DB Lee W Bishop C Hill T Southwick J et al Central hemodynamic assessment of normal term pregnancy Am J Obstet Gynecol 19891611439-42
bull 9 Mabie WC Di Sessa TG Crocker LG Sibai BM Arheart KL A longitudinal study of cardiac output in normal human pregnancy Am J Obstet Gynecol 1994170849-56
bull 10 Clapp JF 3rd Capeless E Cardiovascular function before during and after the first and subsequent pregnancies Am J Cardiol 1997801469-73
bull 11 Duvekot JJ Peeters LL Maternal cardiovascular hemodynamic adaptation to pregnancy Obstet Gynecol Surv 199449(Suppl) S1-14
bull 12 Bhagwat AR Engel PJ Heart disease and pregnancy Cardiol Clin 199513163-78
bull 13 Lanni SM Tillinghast J Silver H Hemodynamic changes and baroreflex gain in the supine hypotensive syndrome Am J Obstet Gynecol 20021871636-41
bull 14 Little JW Falace DA Miller CS Rhodus NL Dental management of the medically compromised patient 6th ed St Louis Mosby 2002 p 303
bull 15 Garcia-Rio F Pino JM Gomez L Alvarez-Sala R Villasante C Villamor J Regulation of breathing and perception of dyspnea in healthy pregnant women Chest 1996110446-53
bull 16 McAuliffe F Kametas N Costello J Rafferty GF Greenough A Nicolaides K Respiratory function in singleton and twin pregnancy BJOG 2002109765-9
bull 17 Clapp JF 3rd Seaward BL Sleamaker RH Hiser J Maternal physiologic adaptations to early human pregnancy Am J Obstet Gynecol 19881591456-60
bull 18 OrsquoDay MP Cardio-respiratory physiological adaptation of pregnancy Semin Perinatol 199721268-75
bull 19 Contreras G Gutierrez M Beroiza T Fantin A Oddo H Villarroel L et al Ventilatory drive and respiratory muscle function in pregnancy Am Rev Respir Dis 1991144837-41
bull 20 Turner M Aziz SR Management of the pregnant oral and maxillofac
bull 21 Sifakis S Pharmakides G Anemia in pregnancy Ann N Y Acad Sci 2000900125-36
bull 22 Branch DW Physiologic adaptations of pregnancy Am J Reprod Immunol 199228120-2
bull 23 Burrows RF Kelton JG Incidentally detected thrombocytopenia in healthy mothers and their infants N Engl J Med 1988319 142-5
bull 24 Hanly JG Antiphospholipid syndrome an overview CMAJ 200324(168)1675-82
bull 25 Heilmann L von Tempelhoff GF Pollow K Antiphospholipid syndrome in obstetrics Clin Appl Thromb Hemost 20039 143-50
bull 26 Sherman P Flaxman SM Nausea and vomiting of pregnancy in an evolutionary perspective Am J Obstet Gynecol 2002 185(Suppl)s190-7
bull 27 Koch KL Gastrointestinal factors in nausea and vomiting of pregnancy Am J Obstet Gynecol 2002185(Suppl)s198-203
bull 28 Koch KL Frissora CL Nausea and vomiting during pregnancy Gastroenterol Clin N Am 200332201-34
bull 29 Baron TH Ramirez B Richter JE Gastrointestinal motility disorders during pregnancy Ann Intern Med 1993118 366-75
bull 30 Richter JE Gastroesophageal reflux disease during pregnancy Gastroenterol Clin N Am 200332235-61
bull 31 Marrero JM Goggin PM de Caestecker JS Pearce JM Maxwell JD Determinants of pregnancy heartburn Br J Obstet Gynaecol 199299731-4
bull 32 Hamaoui E Hamaoui M Nutritional assessment and support during pregnancy Gastroenterol Clin N Am 20033259-121
bull 33 King JC Physiology of pregnancy and nutrient metabolism Am J Clin Nutr 200071(suppl)1218s-25s
bull 34 Casanueva E Pfeffer F Fernandez-Gaxiola AC Gutierrez- Valenzuela V Rothenberg SJ Iron and folate status before pregnancy and anemia during pregnancy Ann Nutr Metab 2003 4760-3
bull 35 Chrsquong CL Morgan M Hainsworth I Kingham JG Prospective study of liver dysfunction in Southwest Wales Gut 200251 876-80
bull 36 Rahman TM Wendon J Severe hepatic dysfunction in pregnancy QJM 200295343-57
bull 37 Knox TA Olans LB Liver disease in pregnancy N Engl J Med 1996335569-76
bull 38 Saftlas AF Olson DR Franks AL Atrash H Pokras R Epidemiology of preeclampsia and eclampsia in the United States 1979e1986 Am J Obstet Gynecol 1990163460-5
bull 39 Walker JJ Pre-eclampsia Lancet 20003561260-5
bull 40 Davidson JM Renal disorders in pregnancy Curr Opin Obstet Gynecol 200113109-14
bull 41 Dafnis E Sabatini S The effect of pregnancy on renal function physiology and pathophysiologyAmJMedSci 1992303184-205
bull 42 Davison JM Shiells EA Philips PR Lindheimer MD Serial evaluation of vasopressin release and thirst in human pregnancy Role of human chorionic gonadotrophin in the osmoregulatory changes of gestation J Clin Invest 198881798-806
bull 43 Glinoer D de Nayer P Bourdoux P Lemone M Robyn C van Steirteghem A et al Regulation of maternal thyroid during pregnancy J Clin Endocrinol Metab 199071276-87
bull 44 Wilson SG Retallack RW Kent JC Worth GK Gutteridge DH Serum free 125-dihydroxyvitamin D and the free 125- dihydroxyvitamin D index during a longitudinal study of human pregnancy and lactation Clin Endocrinol 199032613-22
bull 45 Rasmussen N Frolich A Hornnes PJ Hegedus L Serum ionized calcium and intact parathyroid hormone levels during pregnancy and postpartum Br J Obstet Gynaecol 199097857-9
bull 46 Guyton AC Textbook of medical physiology 8th ed Philadelphia W B Saunders 1991 p 915e28
bull 47 Trainer PJ Corticosteroids and pregnancy Semin Reprod Med 200220375-80
bull 48 Soory M Hormonal factors in periodontal disease Dent Update 200027380-3
bull 49 Hugoson A Gingivitis in pregnant women A longitudinal clinical study Odontol Revy 19712265-84
bull 50 Neville BW Damm DD Allen CM Bouquot JE Oral amp Maxillofacial Pathology 3rd ed Philadelphia W B Saunders 2002 p 329-30 447-9
bull 51 Tilakaratne A Soory M Ranasinghe AW Corea SM Ekanayake SL de Silva M Periodontal disease status during pregnancy and 3 months post-partum in rural population of Sri-Lankan women J Clin Periodontol 200027787-92
bull 52 Laine M Tenovuo J Lehtonen OP Ojanatko-Harri A Vilja P Tuohimaa P Pregnancy e related changes in human whole saliva Arch Oral Biol 198833913-7
bull 53 Yuan K Wing LY Lin MT Pathogenetic roles of angiogenic factors in pyogenic granulomas in pregnancy are modulated by female sex hormones J Periodontol 200273701-8
bull 54 Evans RD Briggs PF Tooth-surface loss related to pregnancyinduced vomiting Prim Dent Care 1994124-6
bull 55 Salvolini E Di Giorgio R Curatola A Mazzanti L Fratto G Biochemical modifications of human whole saliva induced by pregnancy Br J Obstet Gynaec 1998105656-60
bull 56 Mauldin JG Newman RB Preterm birth risk assessment Semin Perinatol 200125215-22
bull 57 Heine RP McGregor JA Goodwin TM Artal R Hayashi RH Robertson PA et al Serial salivary estriol to detect an increased risk of preterm birth Obstet Gynecol 200096490-7
bull 58 Kauh YC Zachian TF Melasma Adv Exp Med Biol 1999455 491-9
bull 59 Wong RC Ellis CN Physiologic skin changes in pregnancy J Am Acad Dermatol 198410929-40
bull 60 Errickson CV Matus NR Skin disorders of pregnancy Am Fam Physician 199449605-10
bull 61 Lopez NJ Smith PC Gutierrez J Periodontal therapy may reduce the risk of preterm low birth weight in women with periodontal disease a randomized controlled trial J Periodontol 200273911-24
bull 62 McGaw T Periodontal disease and preterm delivery of lowbirth- weight infants J Can Dent Assoc 200268165-9
bull 63 Richards AG Dental x-ray protection Dent Clin North Am 1968631-41
bull 64 1990 Recommendations of the International Commission on Radiological Protection Ann ICRP 1991211-201
bull 65 Hall EJ Radiation the two-edged sword cancer risks at high and low doses Cancer J 20006343-50
bull 66 Diethelm L Xu H Diagnostic imaging of the lung during pregnancy Clin Obstet Gynecol 19963936-55
bull 67 Brent RL The effects of embryonic and fetal exposure to x-rays microwaves and ultrasound ClinObstetGynecol 198326484-510
bull 68 National Council on Radiation Protection NCRP report no128 1998 Bethesda Md Author
bull 69 Wasylko L Matsui D Dykxhoorn SM Reider MJ Weinberg S A review of common dental treatments during pregnancy implications for patients and dental personnel J Can Dent Assoc 199864434-9
bull 70 Freeman JP Brand JW Radiation doses of commonly used dental radiographic surveys Oral Surg Oral Med Oral Pathol 199477285-9
bull 71 Kircos LTAngin LL Lorton LOrder ofmagnitude dose reduction in intraoral radiography J Am Dent Assoc 1987114344-7
bull 72 Updegrave WJ Simplified and standardized intraoral radiography with reduced tissue irradiation J Am Dent Assoc 197285861-9
bull 73 Wood RE Harris AM van der Merwe EJ Nortje CJ The leaded apron revisited does it reduce gonadal radiation dose in dental radiology Oral Surg Oral Med Oral Pathol 199171642-6
bull 74 An update on radiographic practices information and recommendations ADA Council on Scientific Affairs J Am Dent Assoc 2001132234-8
bull 75 Rayburn WF Recommending medications during pregnancy an evidence based approach Clin Obstet Gynecol 2002451-5
bull 76 Rathmell JP Viscomi C Ashburn MA Management of nonobstetric pain during pregnancy and lactation Anesth Analg 1997851074-87
bull 77 Teratology society public affairs committee FDA classification of drugs for teratogenic risk Teratology 199449446-7
bull 78 Moore PA Selecting drugs for the pregnant dental patient J Am Dent Assoc 19981291281-6
bull 79 Haas DA An update on analgesics for the management of acute postoperative dental pain J Can Dent Assoc 200268476-82
bull 80 Haas DA Pynn BR Sands TD Drug use for the pregnant or lactating patient Gen Dent 20004854-60
bull 81 Committee on Drugs American Academy of Pediatrics The transfer of drugs and other chemicals into human milk Pediatrics 199493137-50
bull 82 Nielsen GL Sorensen HT Larsen H Pedersen L Risk of adverse birth outcome and miscarriage in pregnant users of nonsteroidal anti-inflammatory drugs population based observational study and case-control study BMJ 2001322266-70
bull 83 Janssen N Genta M The effects of immunosuppressive and anti-inflammatory medications on fertility pregnancy and lactation Arch Intern Med 200016610-9
bull 84 Ostensen M Nonsteroidal anti-inflammatory drugs during pregnancy Scand J Rheumatol Suppl 1998107128-32
bull 85 USPDI -Drug information for the health care professional 22nd ed Greenwood Village CO Micromedex 2002 p 152-79
bull 86 Denson DD Coyle DE Thompson GA Santos D Turner PA Myers JA et al Bupivacaine protein binding in the term parturient effects of lactic acidosis Clin Pharmacol Ther 198435702-9
bull 87 Dillon DE Wagner CL Wiest D Newman RB Drug therapy in the nursing mother Obstet Gynecol Clin North Am 199724 675-96
bull 88 Dashe JS Gilstrap LC Antibiotic use in pregnancy Obstet Gynecol Clin North Am 199724617-29
bull 89 American College of Rheumatology Ad hoc Committee on Clinical Guidelines Guidelines for monitoring drug therapy in rheumatoid arthritis Arthritis Rheum 199639723-31
bull 90 Ng PC The fetal and neonatal hypothalamic-pituitary-adrenal axis Arch Dis Child Fetal Neonatal Ed 200082F250-4
bull 91 Crowley P Antenatal corticosteroidsmdashcurrent thinking BJOG 2003110(Suppl 20)77-8
bull 92 ACOG committee opinion antenatal corticosteroid therapy for fetal maturation Obstet Gynecol 200299871-3
bull 93 Ost L Wettrell G Bjorkhem I Rane A Prednisolone excretion in human milk J Pediatr 19851061008-11
bull 94 Rowland AS Baird DD Shore DL Weinberg CR Savitz DA Wilcox AJ Nitrous oxide and spontaneous abortion in female dental assistants Am J Epidemiol 1995141531-8
bull 95 McGlothlin JD Jensen PA Fischbach TJ Hughes RT Jones JH Control of anesthetic gases in dental operatories Scand J Work Environ Health 199218(Suppl 2)103-5
bull ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY Volume 97 Number 6 Suresh and Radfar 681
bull 96 Rosen MA Nitrous oxide for relief of labor pain a systematic review Am J Obstet Gynecol 2002186(Suppl Nature)S110-6
bull 97 Sands TD Pynn BR Management considerations for the pregnant or nursing emergency patient Ont Dent 199875 17-9
bull 98 Daya S Recurrent spontaneous early pregnancy loss and low dose aspirin Minerva Ginecol 200355441-9
bull 99 Sinclair C Handbook of obstetrical emergencies 1st ed Philadelphia WB Saunders 1996 p 29-39 69
bull 100 Tarsitano BF Rollings RE The pregnant dental patient evaluation and management Gen Dent 199341226-34
bull 101 Livingston MH Dlllinger TM Holder R Consideration in the management of the pregnant patient SCD Special Care in Dentistry 199818183-8
Thank you
- A Review on the principle of Dental Management of the Pregnant patient
- Slide 2
- Questions that a dentist may ask
- Stages of Pregnancy
- Slide 5
- Slide 6
- Physiologic Changes in Pregnancy
- Systemic changes in pregnancy
- FLAT SUPINE POSITIONING
- SUPINE HYPOTENSION SYNDROME (Vena Cava Compression)
- Supine Hypotension Syndrome
- Slide 12
- Supine Hypotension Syndrome
- Prevention of Supine Hypotensive Syndrome
- Treatment of Supine Hypotensive Syndrome
- How should the pregnant woman be positioned
- Slide 17
- Slide 18
- Slide 19
- Slide 20
- Slide 21
- Slide 22
- Slide 23
- Pregnancy Related Oral Health Problems
- Oral Problems in Pregnancy
- Pregnancy Gingivitis Pathophysiology
- Pregnancy Gingivitis
- Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Gum Problems - Pregnancy Granuloma
- Slide 31
- Gum Changes - Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Candidiasis
- Pregnancy Myths
- Other Oral Conditions in Pregnancy
- Changes During Pregnancy that Affect Oral Health
- Saliva changes
- Increased Bacteria
- Slide 40
- Enamel erosion caused by frequent vomiting
- Treatment for Acid Exposure
- Oral Diseases Can Effect Pregnancy
- Periodontal Disease and Preterm Labor
- Periodontal Disease and Low Birth Weight
- Periodontal Disease and Preeclampsia
- Periodontitis and Pre-eclampsia
- Dental Considerations
- Treatment Timing
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Slide 52
- Use of Radiation on Pregnant Patient
- Radiographs during Pregnancy
- Risks of Dental X-Rays
- FDA drug classification for pregnancy
- Slide 57
- FDA drug classification for pregnancy
- Slide 59
- Slide 60
- Slide 61
- Common Analgesics
- Analgesics
- Analgesics - continued
- Analgesics to Use During 1st and 2nd Trimester
- Analgesics to Avoid During the Third Trimester
- Sedation in Pregnancy
- Common Antibiotics
- Antibiotics
- Antibiotics To Use During Pregnancy
- Antibiotics to Avoid during Pregnancy
- The Problem With Tetracycline
- Other Antimicrobial Agents
- Local Anesthetic Use in Pregnancy
- Use of Local Anesthetics
- Ulcer healing drugs
- Slide 77
- Slide 78
- Slide 79
- Use of Nitrous Oxide Gas
- Common Preventives
- Are topical agents safe
- Pre-natal Fluoride
- Is it safe to use mercury restorations
- References
- REFERENCES
- Slide 87
- Slide 88
- Slide 89
- Slide 90
- Slide 91
- Slide 92
- Slide 93
- Slide 94
- Slide 95
- Slide 96
- Slide 97
- Slide 98
- Thank you
-
Analgesics - continuedbull Aspirin is nonteratogenic but may cause
maternal and fetal hemorrhagebull large and chronic doses during last trimester
may result in premature closure of ductus arteriosus fetal hypertension anemia and low birth weight
bull avoid ibuprofen in 3rd trimester because of possible adverse circulatory effects
bull short term use of codeine seems safebull avoid codeine late in gestation because of
possible fetal respiratory depression and withdrawal symptoms
Analgesics to Use During1st and 2nd Trimester
bull Category B (for best)bull Paracetamol Ibuprofenbull Naproxenbull Category C (use with caution)bull Paracetamol with codeine or
hydrocodonebull Paracetamol with oxycodone
Analgesics to Avoid During theThird Trimesterbull Causes delivery problemsbull Aspirin (C 3D)bull Ibuprofen (B3D)bull Naproxen (B3D)bull Causes neonatal respiratory
depression and opioid withdrawalbull Codeine (C3D)bull Hydrocodone (C3D)bull Oxycodone(C3D)
Sedation in Pregnancy
bull SedativesAnxiolytics (eg Diazepam ) are rated D and can cause oral clefts with prolonged exposure
bull Nitrous oxide should not be used in 1st trimester (If used in 2nd and 3rd do not go below 50 O2)
Common Antibioticsbull To treat oral abscess or cellulitis
ndash Penicillin (B) ndash Amoxicillin (B) ndash Cephalexin (B)ndash Erythromycin base (B) (Not estolate as it
cause cholestatic hepatitis)ndash Clindamycin (B)
Antibioticsbull penicillin V and amoxicillin is preferred drug
for mild to moderate infectionsbull widely used for many years with no ill effectsbull no studies show penicillin to be teratogenicbull amoxicillin extensively used without harming
the fetusbull Drug classes1048715 B penicillin cephalosporins erythromycin clindamycin Azithromycin D Tetracycline
Antibiotics To Use During Pregnancy
bull Penicillin Vbull Amoxicillinbull Erythromycin (base form)bull Cephalexin cephalosporinbull Clindamycinbull Metronidazole
Antibiotics to Avoid duringPregnancy
bull Doxycyclinebull Tetracyclinebull Erythromycin (estolate form)bull Vancomycin
The Problem With Tetracycline
bull Accumulates in bones and chelates calcium
bull Inhibits bone growthbull Discolors teeth
Other Antimicrobial Agentsbull OK to usebull Nystatin (B)bull Chlorhexidine rinse (B)bull Use with cautionbull Clotrimazole (C)bull Ketoconazole (C)bull Fluconazole (C)bull Do not usebull Doxycycline (D)
Local Anesthetic Use inPregnancy
bull Class Bbull Lidocaine (Xylocaine)bull Etidocainebull Prilocaine bull Class Cbull Procainebull Bupivicainebull Mepivicaine
Use of Local Anestheticsbull Lidocaine + vasoconstrictor most common
local anesthetic used in dentistrybull extensively used in pregnancy with no proven ill
effectsbull accidental intravascular injections of lidocaine
pass through the placenta but the concentrations are too low to harm fetus
bull prilocaine might cause methemoglobinemia
Ulcer healing drugsCimetidine bull FDA category B Famotidinebull FDA category BRanitidinebull FDA category Bbull not known to be harmful
Ulcer healing drugsOmeprazolebull FDA category BNot known to be
harmful Esomeprazolebull FDA category BLansoprazolebull FDA category BPantoprazolebull Avoid unless potential benefit
outweighs riskmdashfetotoxic in animals
Ulcer healing drugs
Misoprostolbull First second third trimesters Avoidmdash
potent uterine stimulant (has been used to induce abortion) and may be teratogenic
Ulcer healing drugs
Antacidsbull Almunium hydroxideMagnesium
hydroxidemdashFDA category B Calcium carbonatemdashFDA category C
SimetheconemdashFDA category C
Use of Nitrous Oxide Gas
bull used over 150 years bull safety is being debatedbull SHORT TERM exposure do not cause
birth defects or spontaneous abortionbull CHRONIC exposure may result in fetal
loss and infertilitybull literature suggests that nitrous oxide
should be avoided until more conclusive research is available
bull FDA Drug class not yet assigned
Common Preventives
bull Fluoridendash No increased risk during pregnancy
bull Xylitolndash No studies no harm reported
bull Chlorhexidinendash No increased risk during pregnancy
Are topical agents safe
bull Fluoridebull Toothpaste amp mouthrinse
bull Xylitol chewing gum bull Chlorhexidine (11 alcohol)bull No over the counter mouthrinses with
alcohol (Listerine 20 alcohol)
Pre-natal Fluoride
bull Daily 22 mg tablet of sodium fluoride during 3rd through 9th months
bull decreases caries rate in offspringbull Safe and effective
Glenn FB 1982
Is it safe to use mercury restorations
bull No evidence of harmful effect
bull Benefits outweigh risks
bull Canada Germany and New Zealand have some restrictions
bull Determine the best option
Referencesbull Wasylko L Matsui D Dykxhoorn SM Rieder MJ Weinberg
S A Review of Common Dental Treatments During Pregnancy J Canadian Dental Association 64434-439 1998
bull Little JW Donald AF Craig SM Rhodus NL Dental Management of the Medically Compromised Patient - 5th edition Mosby Toronto Pp434-442 1997
bull Livingston HM Dellinger TM Holder R Considerations in the management of the pregnant patient Special Care in Dentistry 185 pp183-188 1998
bull Larimore WL Petrie KA Drug use during pregnacy and lactation Primary Care Clinics in Office Practice 271 35-53 2000
bull Health Canada The Safety of DentalAmalgam Minister Of Supply and Services Canada 1996
REFERENCESbull 1 Weiss G Endocrinology of parturition J Clin
Endocrinol Metab 2000854421-5bull 2 Theunissen IM Parer JT Fluid and electrolytes in
pregnancy Clin Obstet Gynecol 1994373-15bull 3 Duvekot JJ Peeters LLH Renal hemodynamics and
volume homeostasis in pregnancy Obstet Gynecol Surv 199449830-9
bull 4 Barron WM Lindheimer MD Medical disorders during pregnancy 2nd ed St Louis Mosby 1995 p 129
bull 5 Thornburg KL Jacobson SL Giraud GD Morton MJ Hemodynamic changes in pregnancy Semin Perinatol 20002411-4
bull 6 Fiese R Herzog S Issues in dental and surgical management of the pregnant patient Oral Surg Oral Med Oral Pathol 198865292-7
bull 7 Martin C Varner MW Physiologic changes in pregnancysurgical implications Clin Obstet Gynecol 199437241-55
bull 8 Clark SL Cotton DB Lee W Bishop C Hill T Southwick J et al Central hemodynamic assessment of normal term pregnancy Am J Obstet Gynecol 19891611439-42
bull 9 Mabie WC Di Sessa TG Crocker LG Sibai BM Arheart KL A longitudinal study of cardiac output in normal human pregnancy Am J Obstet Gynecol 1994170849-56
bull 10 Clapp JF 3rd Capeless E Cardiovascular function before during and after the first and subsequent pregnancies Am J Cardiol 1997801469-73
bull 11 Duvekot JJ Peeters LL Maternal cardiovascular hemodynamic adaptation to pregnancy Obstet Gynecol Surv 199449(Suppl) S1-14
bull 12 Bhagwat AR Engel PJ Heart disease and pregnancy Cardiol Clin 199513163-78
bull 13 Lanni SM Tillinghast J Silver H Hemodynamic changes and baroreflex gain in the supine hypotensive syndrome Am J Obstet Gynecol 20021871636-41
bull 14 Little JW Falace DA Miller CS Rhodus NL Dental management of the medically compromised patient 6th ed St Louis Mosby 2002 p 303
bull 15 Garcia-Rio F Pino JM Gomez L Alvarez-Sala R Villasante C Villamor J Regulation of breathing and perception of dyspnea in healthy pregnant women Chest 1996110446-53
bull 16 McAuliffe F Kametas N Costello J Rafferty GF Greenough A Nicolaides K Respiratory function in singleton and twin pregnancy BJOG 2002109765-9
bull 17 Clapp JF 3rd Seaward BL Sleamaker RH Hiser J Maternal physiologic adaptations to early human pregnancy Am J Obstet Gynecol 19881591456-60
bull 18 OrsquoDay MP Cardio-respiratory physiological adaptation of pregnancy Semin Perinatol 199721268-75
bull 19 Contreras G Gutierrez M Beroiza T Fantin A Oddo H Villarroel L et al Ventilatory drive and respiratory muscle function in pregnancy Am Rev Respir Dis 1991144837-41
bull 20 Turner M Aziz SR Management of the pregnant oral and maxillofac
bull 21 Sifakis S Pharmakides G Anemia in pregnancy Ann N Y Acad Sci 2000900125-36
bull 22 Branch DW Physiologic adaptations of pregnancy Am J Reprod Immunol 199228120-2
bull 23 Burrows RF Kelton JG Incidentally detected thrombocytopenia in healthy mothers and their infants N Engl J Med 1988319 142-5
bull 24 Hanly JG Antiphospholipid syndrome an overview CMAJ 200324(168)1675-82
bull 25 Heilmann L von Tempelhoff GF Pollow K Antiphospholipid syndrome in obstetrics Clin Appl Thromb Hemost 20039 143-50
bull 26 Sherman P Flaxman SM Nausea and vomiting of pregnancy in an evolutionary perspective Am J Obstet Gynecol 2002 185(Suppl)s190-7
bull 27 Koch KL Gastrointestinal factors in nausea and vomiting of pregnancy Am J Obstet Gynecol 2002185(Suppl)s198-203
bull 28 Koch KL Frissora CL Nausea and vomiting during pregnancy Gastroenterol Clin N Am 200332201-34
bull 29 Baron TH Ramirez B Richter JE Gastrointestinal motility disorders during pregnancy Ann Intern Med 1993118 366-75
bull 30 Richter JE Gastroesophageal reflux disease during pregnancy Gastroenterol Clin N Am 200332235-61
bull 31 Marrero JM Goggin PM de Caestecker JS Pearce JM Maxwell JD Determinants of pregnancy heartburn Br J Obstet Gynaecol 199299731-4
bull 32 Hamaoui E Hamaoui M Nutritional assessment and support during pregnancy Gastroenterol Clin N Am 20033259-121
bull 33 King JC Physiology of pregnancy and nutrient metabolism Am J Clin Nutr 200071(suppl)1218s-25s
bull 34 Casanueva E Pfeffer F Fernandez-Gaxiola AC Gutierrez- Valenzuela V Rothenberg SJ Iron and folate status before pregnancy and anemia during pregnancy Ann Nutr Metab 2003 4760-3
bull 35 Chrsquong CL Morgan M Hainsworth I Kingham JG Prospective study of liver dysfunction in Southwest Wales Gut 200251 876-80
bull 36 Rahman TM Wendon J Severe hepatic dysfunction in pregnancy QJM 200295343-57
bull 37 Knox TA Olans LB Liver disease in pregnancy N Engl J Med 1996335569-76
bull 38 Saftlas AF Olson DR Franks AL Atrash H Pokras R Epidemiology of preeclampsia and eclampsia in the United States 1979e1986 Am J Obstet Gynecol 1990163460-5
bull 39 Walker JJ Pre-eclampsia Lancet 20003561260-5
bull 40 Davidson JM Renal disorders in pregnancy Curr Opin Obstet Gynecol 200113109-14
bull 41 Dafnis E Sabatini S The effect of pregnancy on renal function physiology and pathophysiologyAmJMedSci 1992303184-205
bull 42 Davison JM Shiells EA Philips PR Lindheimer MD Serial evaluation of vasopressin release and thirst in human pregnancy Role of human chorionic gonadotrophin in the osmoregulatory changes of gestation J Clin Invest 198881798-806
bull 43 Glinoer D de Nayer P Bourdoux P Lemone M Robyn C van Steirteghem A et al Regulation of maternal thyroid during pregnancy J Clin Endocrinol Metab 199071276-87
bull 44 Wilson SG Retallack RW Kent JC Worth GK Gutteridge DH Serum free 125-dihydroxyvitamin D and the free 125- dihydroxyvitamin D index during a longitudinal study of human pregnancy and lactation Clin Endocrinol 199032613-22
bull 45 Rasmussen N Frolich A Hornnes PJ Hegedus L Serum ionized calcium and intact parathyroid hormone levels during pregnancy and postpartum Br J Obstet Gynaecol 199097857-9
bull 46 Guyton AC Textbook of medical physiology 8th ed Philadelphia W B Saunders 1991 p 915e28
bull 47 Trainer PJ Corticosteroids and pregnancy Semin Reprod Med 200220375-80
bull 48 Soory M Hormonal factors in periodontal disease Dent Update 200027380-3
bull 49 Hugoson A Gingivitis in pregnant women A longitudinal clinical study Odontol Revy 19712265-84
bull 50 Neville BW Damm DD Allen CM Bouquot JE Oral amp Maxillofacial Pathology 3rd ed Philadelphia W B Saunders 2002 p 329-30 447-9
bull 51 Tilakaratne A Soory M Ranasinghe AW Corea SM Ekanayake SL de Silva M Periodontal disease status during pregnancy and 3 months post-partum in rural population of Sri-Lankan women J Clin Periodontol 200027787-92
bull 52 Laine M Tenovuo J Lehtonen OP Ojanatko-Harri A Vilja P Tuohimaa P Pregnancy e related changes in human whole saliva Arch Oral Biol 198833913-7
bull 53 Yuan K Wing LY Lin MT Pathogenetic roles of angiogenic factors in pyogenic granulomas in pregnancy are modulated by female sex hormones J Periodontol 200273701-8
bull 54 Evans RD Briggs PF Tooth-surface loss related to pregnancyinduced vomiting Prim Dent Care 1994124-6
bull 55 Salvolini E Di Giorgio R Curatola A Mazzanti L Fratto G Biochemical modifications of human whole saliva induced by pregnancy Br J Obstet Gynaec 1998105656-60
bull 56 Mauldin JG Newman RB Preterm birth risk assessment Semin Perinatol 200125215-22
bull 57 Heine RP McGregor JA Goodwin TM Artal R Hayashi RH Robertson PA et al Serial salivary estriol to detect an increased risk of preterm birth Obstet Gynecol 200096490-7
bull 58 Kauh YC Zachian TF Melasma Adv Exp Med Biol 1999455 491-9
bull 59 Wong RC Ellis CN Physiologic skin changes in pregnancy J Am Acad Dermatol 198410929-40
bull 60 Errickson CV Matus NR Skin disorders of pregnancy Am Fam Physician 199449605-10
bull 61 Lopez NJ Smith PC Gutierrez J Periodontal therapy may reduce the risk of preterm low birth weight in women with periodontal disease a randomized controlled trial J Periodontol 200273911-24
bull 62 McGaw T Periodontal disease and preterm delivery of lowbirth- weight infants J Can Dent Assoc 200268165-9
bull 63 Richards AG Dental x-ray protection Dent Clin North Am 1968631-41
bull 64 1990 Recommendations of the International Commission on Radiological Protection Ann ICRP 1991211-201
bull 65 Hall EJ Radiation the two-edged sword cancer risks at high and low doses Cancer J 20006343-50
bull 66 Diethelm L Xu H Diagnostic imaging of the lung during pregnancy Clin Obstet Gynecol 19963936-55
bull 67 Brent RL The effects of embryonic and fetal exposure to x-rays microwaves and ultrasound ClinObstetGynecol 198326484-510
bull 68 National Council on Radiation Protection NCRP report no128 1998 Bethesda Md Author
bull 69 Wasylko L Matsui D Dykxhoorn SM Reider MJ Weinberg S A review of common dental treatments during pregnancy implications for patients and dental personnel J Can Dent Assoc 199864434-9
bull 70 Freeman JP Brand JW Radiation doses of commonly used dental radiographic surveys Oral Surg Oral Med Oral Pathol 199477285-9
bull 71 Kircos LTAngin LL Lorton LOrder ofmagnitude dose reduction in intraoral radiography J Am Dent Assoc 1987114344-7
bull 72 Updegrave WJ Simplified and standardized intraoral radiography with reduced tissue irradiation J Am Dent Assoc 197285861-9
bull 73 Wood RE Harris AM van der Merwe EJ Nortje CJ The leaded apron revisited does it reduce gonadal radiation dose in dental radiology Oral Surg Oral Med Oral Pathol 199171642-6
bull 74 An update on radiographic practices information and recommendations ADA Council on Scientific Affairs J Am Dent Assoc 2001132234-8
bull 75 Rayburn WF Recommending medications during pregnancy an evidence based approach Clin Obstet Gynecol 2002451-5
bull 76 Rathmell JP Viscomi C Ashburn MA Management of nonobstetric pain during pregnancy and lactation Anesth Analg 1997851074-87
bull 77 Teratology society public affairs committee FDA classification of drugs for teratogenic risk Teratology 199449446-7
bull 78 Moore PA Selecting drugs for the pregnant dental patient J Am Dent Assoc 19981291281-6
bull 79 Haas DA An update on analgesics for the management of acute postoperative dental pain J Can Dent Assoc 200268476-82
bull 80 Haas DA Pynn BR Sands TD Drug use for the pregnant or lactating patient Gen Dent 20004854-60
bull 81 Committee on Drugs American Academy of Pediatrics The transfer of drugs and other chemicals into human milk Pediatrics 199493137-50
bull 82 Nielsen GL Sorensen HT Larsen H Pedersen L Risk of adverse birth outcome and miscarriage in pregnant users of nonsteroidal anti-inflammatory drugs population based observational study and case-control study BMJ 2001322266-70
bull 83 Janssen N Genta M The effects of immunosuppressive and anti-inflammatory medications on fertility pregnancy and lactation Arch Intern Med 200016610-9
bull 84 Ostensen M Nonsteroidal anti-inflammatory drugs during pregnancy Scand J Rheumatol Suppl 1998107128-32
bull 85 USPDI -Drug information for the health care professional 22nd ed Greenwood Village CO Micromedex 2002 p 152-79
bull 86 Denson DD Coyle DE Thompson GA Santos D Turner PA Myers JA et al Bupivacaine protein binding in the term parturient effects of lactic acidosis Clin Pharmacol Ther 198435702-9
bull 87 Dillon DE Wagner CL Wiest D Newman RB Drug therapy in the nursing mother Obstet Gynecol Clin North Am 199724 675-96
bull 88 Dashe JS Gilstrap LC Antibiotic use in pregnancy Obstet Gynecol Clin North Am 199724617-29
bull 89 American College of Rheumatology Ad hoc Committee on Clinical Guidelines Guidelines for monitoring drug therapy in rheumatoid arthritis Arthritis Rheum 199639723-31
bull 90 Ng PC The fetal and neonatal hypothalamic-pituitary-adrenal axis Arch Dis Child Fetal Neonatal Ed 200082F250-4
bull 91 Crowley P Antenatal corticosteroidsmdashcurrent thinking BJOG 2003110(Suppl 20)77-8
bull 92 ACOG committee opinion antenatal corticosteroid therapy for fetal maturation Obstet Gynecol 200299871-3
bull 93 Ost L Wettrell G Bjorkhem I Rane A Prednisolone excretion in human milk J Pediatr 19851061008-11
bull 94 Rowland AS Baird DD Shore DL Weinberg CR Savitz DA Wilcox AJ Nitrous oxide and spontaneous abortion in female dental assistants Am J Epidemiol 1995141531-8
bull 95 McGlothlin JD Jensen PA Fischbach TJ Hughes RT Jones JH Control of anesthetic gases in dental operatories Scand J Work Environ Health 199218(Suppl 2)103-5
bull ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY Volume 97 Number 6 Suresh and Radfar 681
bull 96 Rosen MA Nitrous oxide for relief of labor pain a systematic review Am J Obstet Gynecol 2002186(Suppl Nature)S110-6
bull 97 Sands TD Pynn BR Management considerations for the pregnant or nursing emergency patient Ont Dent 199875 17-9
bull 98 Daya S Recurrent spontaneous early pregnancy loss and low dose aspirin Minerva Ginecol 200355441-9
bull 99 Sinclair C Handbook of obstetrical emergencies 1st ed Philadelphia WB Saunders 1996 p 29-39 69
bull 100 Tarsitano BF Rollings RE The pregnant dental patient evaluation and management Gen Dent 199341226-34
bull 101 Livingston MH Dlllinger TM Holder R Consideration in the management of the pregnant patient SCD Special Care in Dentistry 199818183-8
Thank you
- A Review on the principle of Dental Management of the Pregnant patient
- Slide 2
- Questions that a dentist may ask
- Stages of Pregnancy
- Slide 5
- Slide 6
- Physiologic Changes in Pregnancy
- Systemic changes in pregnancy
- FLAT SUPINE POSITIONING
- SUPINE HYPOTENSION SYNDROME (Vena Cava Compression)
- Supine Hypotension Syndrome
- Slide 12
- Supine Hypotension Syndrome
- Prevention of Supine Hypotensive Syndrome
- Treatment of Supine Hypotensive Syndrome
- How should the pregnant woman be positioned
- Slide 17
- Slide 18
- Slide 19
- Slide 20
- Slide 21
- Slide 22
- Slide 23
- Pregnancy Related Oral Health Problems
- Oral Problems in Pregnancy
- Pregnancy Gingivitis Pathophysiology
- Pregnancy Gingivitis
- Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Gum Problems - Pregnancy Granuloma
- Slide 31
- Gum Changes - Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Candidiasis
- Pregnancy Myths
- Other Oral Conditions in Pregnancy
- Changes During Pregnancy that Affect Oral Health
- Saliva changes
- Increased Bacteria
- Slide 40
- Enamel erosion caused by frequent vomiting
- Treatment for Acid Exposure
- Oral Diseases Can Effect Pregnancy
- Periodontal Disease and Preterm Labor
- Periodontal Disease and Low Birth Weight
- Periodontal Disease and Preeclampsia
- Periodontitis and Pre-eclampsia
- Dental Considerations
- Treatment Timing
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Slide 52
- Use of Radiation on Pregnant Patient
- Radiographs during Pregnancy
- Risks of Dental X-Rays
- FDA drug classification for pregnancy
- Slide 57
- FDA drug classification for pregnancy
- Slide 59
- Slide 60
- Slide 61
- Common Analgesics
- Analgesics
- Analgesics - continued
- Analgesics to Use During 1st and 2nd Trimester
- Analgesics to Avoid During the Third Trimester
- Sedation in Pregnancy
- Common Antibiotics
- Antibiotics
- Antibiotics To Use During Pregnancy
- Antibiotics to Avoid during Pregnancy
- The Problem With Tetracycline
- Other Antimicrobial Agents
- Local Anesthetic Use in Pregnancy
- Use of Local Anesthetics
- Ulcer healing drugs
- Slide 77
- Slide 78
- Slide 79
- Use of Nitrous Oxide Gas
- Common Preventives
- Are topical agents safe
- Pre-natal Fluoride
- Is it safe to use mercury restorations
- References
- REFERENCES
- Slide 87
- Slide 88
- Slide 89
- Slide 90
- Slide 91
- Slide 92
- Slide 93
- Slide 94
- Slide 95
- Slide 96
- Slide 97
- Slide 98
- Thank you
-
Analgesics to Use During1st and 2nd Trimester
bull Category B (for best)bull Paracetamol Ibuprofenbull Naproxenbull Category C (use with caution)bull Paracetamol with codeine or
hydrocodonebull Paracetamol with oxycodone
Analgesics to Avoid During theThird Trimesterbull Causes delivery problemsbull Aspirin (C 3D)bull Ibuprofen (B3D)bull Naproxen (B3D)bull Causes neonatal respiratory
depression and opioid withdrawalbull Codeine (C3D)bull Hydrocodone (C3D)bull Oxycodone(C3D)
Sedation in Pregnancy
bull SedativesAnxiolytics (eg Diazepam ) are rated D and can cause oral clefts with prolonged exposure
bull Nitrous oxide should not be used in 1st trimester (If used in 2nd and 3rd do not go below 50 O2)
Common Antibioticsbull To treat oral abscess or cellulitis
ndash Penicillin (B) ndash Amoxicillin (B) ndash Cephalexin (B)ndash Erythromycin base (B) (Not estolate as it
cause cholestatic hepatitis)ndash Clindamycin (B)
Antibioticsbull penicillin V and amoxicillin is preferred drug
for mild to moderate infectionsbull widely used for many years with no ill effectsbull no studies show penicillin to be teratogenicbull amoxicillin extensively used without harming
the fetusbull Drug classes1048715 B penicillin cephalosporins erythromycin clindamycin Azithromycin D Tetracycline
Antibiotics To Use During Pregnancy
bull Penicillin Vbull Amoxicillinbull Erythromycin (base form)bull Cephalexin cephalosporinbull Clindamycinbull Metronidazole
Antibiotics to Avoid duringPregnancy
bull Doxycyclinebull Tetracyclinebull Erythromycin (estolate form)bull Vancomycin
The Problem With Tetracycline
bull Accumulates in bones and chelates calcium
bull Inhibits bone growthbull Discolors teeth
Other Antimicrobial Agentsbull OK to usebull Nystatin (B)bull Chlorhexidine rinse (B)bull Use with cautionbull Clotrimazole (C)bull Ketoconazole (C)bull Fluconazole (C)bull Do not usebull Doxycycline (D)
Local Anesthetic Use inPregnancy
bull Class Bbull Lidocaine (Xylocaine)bull Etidocainebull Prilocaine bull Class Cbull Procainebull Bupivicainebull Mepivicaine
Use of Local Anestheticsbull Lidocaine + vasoconstrictor most common
local anesthetic used in dentistrybull extensively used in pregnancy with no proven ill
effectsbull accidental intravascular injections of lidocaine
pass through the placenta but the concentrations are too low to harm fetus
bull prilocaine might cause methemoglobinemia
Ulcer healing drugsCimetidine bull FDA category B Famotidinebull FDA category BRanitidinebull FDA category Bbull not known to be harmful
Ulcer healing drugsOmeprazolebull FDA category BNot known to be
harmful Esomeprazolebull FDA category BLansoprazolebull FDA category BPantoprazolebull Avoid unless potential benefit
outweighs riskmdashfetotoxic in animals
Ulcer healing drugs
Misoprostolbull First second third trimesters Avoidmdash
potent uterine stimulant (has been used to induce abortion) and may be teratogenic
Ulcer healing drugs
Antacidsbull Almunium hydroxideMagnesium
hydroxidemdashFDA category B Calcium carbonatemdashFDA category C
SimetheconemdashFDA category C
Use of Nitrous Oxide Gas
bull used over 150 years bull safety is being debatedbull SHORT TERM exposure do not cause
birth defects or spontaneous abortionbull CHRONIC exposure may result in fetal
loss and infertilitybull literature suggests that nitrous oxide
should be avoided until more conclusive research is available
bull FDA Drug class not yet assigned
Common Preventives
bull Fluoridendash No increased risk during pregnancy
bull Xylitolndash No studies no harm reported
bull Chlorhexidinendash No increased risk during pregnancy
Are topical agents safe
bull Fluoridebull Toothpaste amp mouthrinse
bull Xylitol chewing gum bull Chlorhexidine (11 alcohol)bull No over the counter mouthrinses with
alcohol (Listerine 20 alcohol)
Pre-natal Fluoride
bull Daily 22 mg tablet of sodium fluoride during 3rd through 9th months
bull decreases caries rate in offspringbull Safe and effective
Glenn FB 1982
Is it safe to use mercury restorations
bull No evidence of harmful effect
bull Benefits outweigh risks
bull Canada Germany and New Zealand have some restrictions
bull Determine the best option
Referencesbull Wasylko L Matsui D Dykxhoorn SM Rieder MJ Weinberg
S A Review of Common Dental Treatments During Pregnancy J Canadian Dental Association 64434-439 1998
bull Little JW Donald AF Craig SM Rhodus NL Dental Management of the Medically Compromised Patient - 5th edition Mosby Toronto Pp434-442 1997
bull Livingston HM Dellinger TM Holder R Considerations in the management of the pregnant patient Special Care in Dentistry 185 pp183-188 1998
bull Larimore WL Petrie KA Drug use during pregnacy and lactation Primary Care Clinics in Office Practice 271 35-53 2000
bull Health Canada The Safety of DentalAmalgam Minister Of Supply and Services Canada 1996
REFERENCESbull 1 Weiss G Endocrinology of parturition J Clin
Endocrinol Metab 2000854421-5bull 2 Theunissen IM Parer JT Fluid and electrolytes in
pregnancy Clin Obstet Gynecol 1994373-15bull 3 Duvekot JJ Peeters LLH Renal hemodynamics and
volume homeostasis in pregnancy Obstet Gynecol Surv 199449830-9
bull 4 Barron WM Lindheimer MD Medical disorders during pregnancy 2nd ed St Louis Mosby 1995 p 129
bull 5 Thornburg KL Jacobson SL Giraud GD Morton MJ Hemodynamic changes in pregnancy Semin Perinatol 20002411-4
bull 6 Fiese R Herzog S Issues in dental and surgical management of the pregnant patient Oral Surg Oral Med Oral Pathol 198865292-7
bull 7 Martin C Varner MW Physiologic changes in pregnancysurgical implications Clin Obstet Gynecol 199437241-55
bull 8 Clark SL Cotton DB Lee W Bishop C Hill T Southwick J et al Central hemodynamic assessment of normal term pregnancy Am J Obstet Gynecol 19891611439-42
bull 9 Mabie WC Di Sessa TG Crocker LG Sibai BM Arheart KL A longitudinal study of cardiac output in normal human pregnancy Am J Obstet Gynecol 1994170849-56
bull 10 Clapp JF 3rd Capeless E Cardiovascular function before during and after the first and subsequent pregnancies Am J Cardiol 1997801469-73
bull 11 Duvekot JJ Peeters LL Maternal cardiovascular hemodynamic adaptation to pregnancy Obstet Gynecol Surv 199449(Suppl) S1-14
bull 12 Bhagwat AR Engel PJ Heart disease and pregnancy Cardiol Clin 199513163-78
bull 13 Lanni SM Tillinghast J Silver H Hemodynamic changes and baroreflex gain in the supine hypotensive syndrome Am J Obstet Gynecol 20021871636-41
bull 14 Little JW Falace DA Miller CS Rhodus NL Dental management of the medically compromised patient 6th ed St Louis Mosby 2002 p 303
bull 15 Garcia-Rio F Pino JM Gomez L Alvarez-Sala R Villasante C Villamor J Regulation of breathing and perception of dyspnea in healthy pregnant women Chest 1996110446-53
bull 16 McAuliffe F Kametas N Costello J Rafferty GF Greenough A Nicolaides K Respiratory function in singleton and twin pregnancy BJOG 2002109765-9
bull 17 Clapp JF 3rd Seaward BL Sleamaker RH Hiser J Maternal physiologic adaptations to early human pregnancy Am J Obstet Gynecol 19881591456-60
bull 18 OrsquoDay MP Cardio-respiratory physiological adaptation of pregnancy Semin Perinatol 199721268-75
bull 19 Contreras G Gutierrez M Beroiza T Fantin A Oddo H Villarroel L et al Ventilatory drive and respiratory muscle function in pregnancy Am Rev Respir Dis 1991144837-41
bull 20 Turner M Aziz SR Management of the pregnant oral and maxillofac
bull 21 Sifakis S Pharmakides G Anemia in pregnancy Ann N Y Acad Sci 2000900125-36
bull 22 Branch DW Physiologic adaptations of pregnancy Am J Reprod Immunol 199228120-2
bull 23 Burrows RF Kelton JG Incidentally detected thrombocytopenia in healthy mothers and their infants N Engl J Med 1988319 142-5
bull 24 Hanly JG Antiphospholipid syndrome an overview CMAJ 200324(168)1675-82
bull 25 Heilmann L von Tempelhoff GF Pollow K Antiphospholipid syndrome in obstetrics Clin Appl Thromb Hemost 20039 143-50
bull 26 Sherman P Flaxman SM Nausea and vomiting of pregnancy in an evolutionary perspective Am J Obstet Gynecol 2002 185(Suppl)s190-7
bull 27 Koch KL Gastrointestinal factors in nausea and vomiting of pregnancy Am J Obstet Gynecol 2002185(Suppl)s198-203
bull 28 Koch KL Frissora CL Nausea and vomiting during pregnancy Gastroenterol Clin N Am 200332201-34
bull 29 Baron TH Ramirez B Richter JE Gastrointestinal motility disorders during pregnancy Ann Intern Med 1993118 366-75
bull 30 Richter JE Gastroesophageal reflux disease during pregnancy Gastroenterol Clin N Am 200332235-61
bull 31 Marrero JM Goggin PM de Caestecker JS Pearce JM Maxwell JD Determinants of pregnancy heartburn Br J Obstet Gynaecol 199299731-4
bull 32 Hamaoui E Hamaoui M Nutritional assessment and support during pregnancy Gastroenterol Clin N Am 20033259-121
bull 33 King JC Physiology of pregnancy and nutrient metabolism Am J Clin Nutr 200071(suppl)1218s-25s
bull 34 Casanueva E Pfeffer F Fernandez-Gaxiola AC Gutierrez- Valenzuela V Rothenberg SJ Iron and folate status before pregnancy and anemia during pregnancy Ann Nutr Metab 2003 4760-3
bull 35 Chrsquong CL Morgan M Hainsworth I Kingham JG Prospective study of liver dysfunction in Southwest Wales Gut 200251 876-80
bull 36 Rahman TM Wendon J Severe hepatic dysfunction in pregnancy QJM 200295343-57
bull 37 Knox TA Olans LB Liver disease in pregnancy N Engl J Med 1996335569-76
bull 38 Saftlas AF Olson DR Franks AL Atrash H Pokras R Epidemiology of preeclampsia and eclampsia in the United States 1979e1986 Am J Obstet Gynecol 1990163460-5
bull 39 Walker JJ Pre-eclampsia Lancet 20003561260-5
bull 40 Davidson JM Renal disorders in pregnancy Curr Opin Obstet Gynecol 200113109-14
bull 41 Dafnis E Sabatini S The effect of pregnancy on renal function physiology and pathophysiologyAmJMedSci 1992303184-205
bull 42 Davison JM Shiells EA Philips PR Lindheimer MD Serial evaluation of vasopressin release and thirst in human pregnancy Role of human chorionic gonadotrophin in the osmoregulatory changes of gestation J Clin Invest 198881798-806
bull 43 Glinoer D de Nayer P Bourdoux P Lemone M Robyn C van Steirteghem A et al Regulation of maternal thyroid during pregnancy J Clin Endocrinol Metab 199071276-87
bull 44 Wilson SG Retallack RW Kent JC Worth GK Gutteridge DH Serum free 125-dihydroxyvitamin D and the free 125- dihydroxyvitamin D index during a longitudinal study of human pregnancy and lactation Clin Endocrinol 199032613-22
bull 45 Rasmussen N Frolich A Hornnes PJ Hegedus L Serum ionized calcium and intact parathyroid hormone levels during pregnancy and postpartum Br J Obstet Gynaecol 199097857-9
bull 46 Guyton AC Textbook of medical physiology 8th ed Philadelphia W B Saunders 1991 p 915e28
bull 47 Trainer PJ Corticosteroids and pregnancy Semin Reprod Med 200220375-80
bull 48 Soory M Hormonal factors in periodontal disease Dent Update 200027380-3
bull 49 Hugoson A Gingivitis in pregnant women A longitudinal clinical study Odontol Revy 19712265-84
bull 50 Neville BW Damm DD Allen CM Bouquot JE Oral amp Maxillofacial Pathology 3rd ed Philadelphia W B Saunders 2002 p 329-30 447-9
bull 51 Tilakaratne A Soory M Ranasinghe AW Corea SM Ekanayake SL de Silva M Periodontal disease status during pregnancy and 3 months post-partum in rural population of Sri-Lankan women J Clin Periodontol 200027787-92
bull 52 Laine M Tenovuo J Lehtonen OP Ojanatko-Harri A Vilja P Tuohimaa P Pregnancy e related changes in human whole saliva Arch Oral Biol 198833913-7
bull 53 Yuan K Wing LY Lin MT Pathogenetic roles of angiogenic factors in pyogenic granulomas in pregnancy are modulated by female sex hormones J Periodontol 200273701-8
bull 54 Evans RD Briggs PF Tooth-surface loss related to pregnancyinduced vomiting Prim Dent Care 1994124-6
bull 55 Salvolini E Di Giorgio R Curatola A Mazzanti L Fratto G Biochemical modifications of human whole saliva induced by pregnancy Br J Obstet Gynaec 1998105656-60
bull 56 Mauldin JG Newman RB Preterm birth risk assessment Semin Perinatol 200125215-22
bull 57 Heine RP McGregor JA Goodwin TM Artal R Hayashi RH Robertson PA et al Serial salivary estriol to detect an increased risk of preterm birth Obstet Gynecol 200096490-7
bull 58 Kauh YC Zachian TF Melasma Adv Exp Med Biol 1999455 491-9
bull 59 Wong RC Ellis CN Physiologic skin changes in pregnancy J Am Acad Dermatol 198410929-40
bull 60 Errickson CV Matus NR Skin disorders of pregnancy Am Fam Physician 199449605-10
bull 61 Lopez NJ Smith PC Gutierrez J Periodontal therapy may reduce the risk of preterm low birth weight in women with periodontal disease a randomized controlled trial J Periodontol 200273911-24
bull 62 McGaw T Periodontal disease and preterm delivery of lowbirth- weight infants J Can Dent Assoc 200268165-9
bull 63 Richards AG Dental x-ray protection Dent Clin North Am 1968631-41
bull 64 1990 Recommendations of the International Commission on Radiological Protection Ann ICRP 1991211-201
bull 65 Hall EJ Radiation the two-edged sword cancer risks at high and low doses Cancer J 20006343-50
bull 66 Diethelm L Xu H Diagnostic imaging of the lung during pregnancy Clin Obstet Gynecol 19963936-55
bull 67 Brent RL The effects of embryonic and fetal exposure to x-rays microwaves and ultrasound ClinObstetGynecol 198326484-510
bull 68 National Council on Radiation Protection NCRP report no128 1998 Bethesda Md Author
bull 69 Wasylko L Matsui D Dykxhoorn SM Reider MJ Weinberg S A review of common dental treatments during pregnancy implications for patients and dental personnel J Can Dent Assoc 199864434-9
bull 70 Freeman JP Brand JW Radiation doses of commonly used dental radiographic surveys Oral Surg Oral Med Oral Pathol 199477285-9
bull 71 Kircos LTAngin LL Lorton LOrder ofmagnitude dose reduction in intraoral radiography J Am Dent Assoc 1987114344-7
bull 72 Updegrave WJ Simplified and standardized intraoral radiography with reduced tissue irradiation J Am Dent Assoc 197285861-9
bull 73 Wood RE Harris AM van der Merwe EJ Nortje CJ The leaded apron revisited does it reduce gonadal radiation dose in dental radiology Oral Surg Oral Med Oral Pathol 199171642-6
bull 74 An update on radiographic practices information and recommendations ADA Council on Scientific Affairs J Am Dent Assoc 2001132234-8
bull 75 Rayburn WF Recommending medications during pregnancy an evidence based approach Clin Obstet Gynecol 2002451-5
bull 76 Rathmell JP Viscomi C Ashburn MA Management of nonobstetric pain during pregnancy and lactation Anesth Analg 1997851074-87
bull 77 Teratology society public affairs committee FDA classification of drugs for teratogenic risk Teratology 199449446-7
bull 78 Moore PA Selecting drugs for the pregnant dental patient J Am Dent Assoc 19981291281-6
bull 79 Haas DA An update on analgesics for the management of acute postoperative dental pain J Can Dent Assoc 200268476-82
bull 80 Haas DA Pynn BR Sands TD Drug use for the pregnant or lactating patient Gen Dent 20004854-60
bull 81 Committee on Drugs American Academy of Pediatrics The transfer of drugs and other chemicals into human milk Pediatrics 199493137-50
bull 82 Nielsen GL Sorensen HT Larsen H Pedersen L Risk of adverse birth outcome and miscarriage in pregnant users of nonsteroidal anti-inflammatory drugs population based observational study and case-control study BMJ 2001322266-70
bull 83 Janssen N Genta M The effects of immunosuppressive and anti-inflammatory medications on fertility pregnancy and lactation Arch Intern Med 200016610-9
bull 84 Ostensen M Nonsteroidal anti-inflammatory drugs during pregnancy Scand J Rheumatol Suppl 1998107128-32
bull 85 USPDI -Drug information for the health care professional 22nd ed Greenwood Village CO Micromedex 2002 p 152-79
bull 86 Denson DD Coyle DE Thompson GA Santos D Turner PA Myers JA et al Bupivacaine protein binding in the term parturient effects of lactic acidosis Clin Pharmacol Ther 198435702-9
bull 87 Dillon DE Wagner CL Wiest D Newman RB Drug therapy in the nursing mother Obstet Gynecol Clin North Am 199724 675-96
bull 88 Dashe JS Gilstrap LC Antibiotic use in pregnancy Obstet Gynecol Clin North Am 199724617-29
bull 89 American College of Rheumatology Ad hoc Committee on Clinical Guidelines Guidelines for monitoring drug therapy in rheumatoid arthritis Arthritis Rheum 199639723-31
bull 90 Ng PC The fetal and neonatal hypothalamic-pituitary-adrenal axis Arch Dis Child Fetal Neonatal Ed 200082F250-4
bull 91 Crowley P Antenatal corticosteroidsmdashcurrent thinking BJOG 2003110(Suppl 20)77-8
bull 92 ACOG committee opinion antenatal corticosteroid therapy for fetal maturation Obstet Gynecol 200299871-3
bull 93 Ost L Wettrell G Bjorkhem I Rane A Prednisolone excretion in human milk J Pediatr 19851061008-11
bull 94 Rowland AS Baird DD Shore DL Weinberg CR Savitz DA Wilcox AJ Nitrous oxide and spontaneous abortion in female dental assistants Am J Epidemiol 1995141531-8
bull 95 McGlothlin JD Jensen PA Fischbach TJ Hughes RT Jones JH Control of anesthetic gases in dental operatories Scand J Work Environ Health 199218(Suppl 2)103-5
bull ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY Volume 97 Number 6 Suresh and Radfar 681
bull 96 Rosen MA Nitrous oxide for relief of labor pain a systematic review Am J Obstet Gynecol 2002186(Suppl Nature)S110-6
bull 97 Sands TD Pynn BR Management considerations for the pregnant or nursing emergency patient Ont Dent 199875 17-9
bull 98 Daya S Recurrent spontaneous early pregnancy loss and low dose aspirin Minerva Ginecol 200355441-9
bull 99 Sinclair C Handbook of obstetrical emergencies 1st ed Philadelphia WB Saunders 1996 p 29-39 69
bull 100 Tarsitano BF Rollings RE The pregnant dental patient evaluation and management Gen Dent 199341226-34
bull 101 Livingston MH Dlllinger TM Holder R Consideration in the management of the pregnant patient SCD Special Care in Dentistry 199818183-8
Thank you
- A Review on the principle of Dental Management of the Pregnant patient
- Slide 2
- Questions that a dentist may ask
- Stages of Pregnancy
- Slide 5
- Slide 6
- Physiologic Changes in Pregnancy
- Systemic changes in pregnancy
- FLAT SUPINE POSITIONING
- SUPINE HYPOTENSION SYNDROME (Vena Cava Compression)
- Supine Hypotension Syndrome
- Slide 12
- Supine Hypotension Syndrome
- Prevention of Supine Hypotensive Syndrome
- Treatment of Supine Hypotensive Syndrome
- How should the pregnant woman be positioned
- Slide 17
- Slide 18
- Slide 19
- Slide 20
- Slide 21
- Slide 22
- Slide 23
- Pregnancy Related Oral Health Problems
- Oral Problems in Pregnancy
- Pregnancy Gingivitis Pathophysiology
- Pregnancy Gingivitis
- Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Gum Problems - Pregnancy Granuloma
- Slide 31
- Gum Changes - Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Candidiasis
- Pregnancy Myths
- Other Oral Conditions in Pregnancy
- Changes During Pregnancy that Affect Oral Health
- Saliva changes
- Increased Bacteria
- Slide 40
- Enamel erosion caused by frequent vomiting
- Treatment for Acid Exposure
- Oral Diseases Can Effect Pregnancy
- Periodontal Disease and Preterm Labor
- Periodontal Disease and Low Birth Weight
- Periodontal Disease and Preeclampsia
- Periodontitis and Pre-eclampsia
- Dental Considerations
- Treatment Timing
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Slide 52
- Use of Radiation on Pregnant Patient
- Radiographs during Pregnancy
- Risks of Dental X-Rays
- FDA drug classification for pregnancy
- Slide 57
- FDA drug classification for pregnancy
- Slide 59
- Slide 60
- Slide 61
- Common Analgesics
- Analgesics
- Analgesics - continued
- Analgesics to Use During 1st and 2nd Trimester
- Analgesics to Avoid During the Third Trimester
- Sedation in Pregnancy
- Common Antibiotics
- Antibiotics
- Antibiotics To Use During Pregnancy
- Antibiotics to Avoid during Pregnancy
- The Problem With Tetracycline
- Other Antimicrobial Agents
- Local Anesthetic Use in Pregnancy
- Use of Local Anesthetics
- Ulcer healing drugs
- Slide 77
- Slide 78
- Slide 79
- Use of Nitrous Oxide Gas
- Common Preventives
- Are topical agents safe
- Pre-natal Fluoride
- Is it safe to use mercury restorations
- References
- REFERENCES
- Slide 87
- Slide 88
- Slide 89
- Slide 90
- Slide 91
- Slide 92
- Slide 93
- Slide 94
- Slide 95
- Slide 96
- Slide 97
- Slide 98
- Thank you
-
Analgesics to Avoid During theThird Trimesterbull Causes delivery problemsbull Aspirin (C 3D)bull Ibuprofen (B3D)bull Naproxen (B3D)bull Causes neonatal respiratory
depression and opioid withdrawalbull Codeine (C3D)bull Hydrocodone (C3D)bull Oxycodone(C3D)
Sedation in Pregnancy
bull SedativesAnxiolytics (eg Diazepam ) are rated D and can cause oral clefts with prolonged exposure
bull Nitrous oxide should not be used in 1st trimester (If used in 2nd and 3rd do not go below 50 O2)
Common Antibioticsbull To treat oral abscess or cellulitis
ndash Penicillin (B) ndash Amoxicillin (B) ndash Cephalexin (B)ndash Erythromycin base (B) (Not estolate as it
cause cholestatic hepatitis)ndash Clindamycin (B)
Antibioticsbull penicillin V and amoxicillin is preferred drug
for mild to moderate infectionsbull widely used for many years with no ill effectsbull no studies show penicillin to be teratogenicbull amoxicillin extensively used without harming
the fetusbull Drug classes1048715 B penicillin cephalosporins erythromycin clindamycin Azithromycin D Tetracycline
Antibiotics To Use During Pregnancy
bull Penicillin Vbull Amoxicillinbull Erythromycin (base form)bull Cephalexin cephalosporinbull Clindamycinbull Metronidazole
Antibiotics to Avoid duringPregnancy
bull Doxycyclinebull Tetracyclinebull Erythromycin (estolate form)bull Vancomycin
The Problem With Tetracycline
bull Accumulates in bones and chelates calcium
bull Inhibits bone growthbull Discolors teeth
Other Antimicrobial Agentsbull OK to usebull Nystatin (B)bull Chlorhexidine rinse (B)bull Use with cautionbull Clotrimazole (C)bull Ketoconazole (C)bull Fluconazole (C)bull Do not usebull Doxycycline (D)
Local Anesthetic Use inPregnancy
bull Class Bbull Lidocaine (Xylocaine)bull Etidocainebull Prilocaine bull Class Cbull Procainebull Bupivicainebull Mepivicaine
Use of Local Anestheticsbull Lidocaine + vasoconstrictor most common
local anesthetic used in dentistrybull extensively used in pregnancy with no proven ill
effectsbull accidental intravascular injections of lidocaine
pass through the placenta but the concentrations are too low to harm fetus
bull prilocaine might cause methemoglobinemia
Ulcer healing drugsCimetidine bull FDA category B Famotidinebull FDA category BRanitidinebull FDA category Bbull not known to be harmful
Ulcer healing drugsOmeprazolebull FDA category BNot known to be
harmful Esomeprazolebull FDA category BLansoprazolebull FDA category BPantoprazolebull Avoid unless potential benefit
outweighs riskmdashfetotoxic in animals
Ulcer healing drugs
Misoprostolbull First second third trimesters Avoidmdash
potent uterine stimulant (has been used to induce abortion) and may be teratogenic
Ulcer healing drugs
Antacidsbull Almunium hydroxideMagnesium
hydroxidemdashFDA category B Calcium carbonatemdashFDA category C
SimetheconemdashFDA category C
Use of Nitrous Oxide Gas
bull used over 150 years bull safety is being debatedbull SHORT TERM exposure do not cause
birth defects or spontaneous abortionbull CHRONIC exposure may result in fetal
loss and infertilitybull literature suggests that nitrous oxide
should be avoided until more conclusive research is available
bull FDA Drug class not yet assigned
Common Preventives
bull Fluoridendash No increased risk during pregnancy
bull Xylitolndash No studies no harm reported
bull Chlorhexidinendash No increased risk during pregnancy
Are topical agents safe
bull Fluoridebull Toothpaste amp mouthrinse
bull Xylitol chewing gum bull Chlorhexidine (11 alcohol)bull No over the counter mouthrinses with
alcohol (Listerine 20 alcohol)
Pre-natal Fluoride
bull Daily 22 mg tablet of sodium fluoride during 3rd through 9th months
bull decreases caries rate in offspringbull Safe and effective
Glenn FB 1982
Is it safe to use mercury restorations
bull No evidence of harmful effect
bull Benefits outweigh risks
bull Canada Germany and New Zealand have some restrictions
bull Determine the best option
Referencesbull Wasylko L Matsui D Dykxhoorn SM Rieder MJ Weinberg
S A Review of Common Dental Treatments During Pregnancy J Canadian Dental Association 64434-439 1998
bull Little JW Donald AF Craig SM Rhodus NL Dental Management of the Medically Compromised Patient - 5th edition Mosby Toronto Pp434-442 1997
bull Livingston HM Dellinger TM Holder R Considerations in the management of the pregnant patient Special Care in Dentistry 185 pp183-188 1998
bull Larimore WL Petrie KA Drug use during pregnacy and lactation Primary Care Clinics in Office Practice 271 35-53 2000
bull Health Canada The Safety of DentalAmalgam Minister Of Supply and Services Canada 1996
REFERENCESbull 1 Weiss G Endocrinology of parturition J Clin
Endocrinol Metab 2000854421-5bull 2 Theunissen IM Parer JT Fluid and electrolytes in
pregnancy Clin Obstet Gynecol 1994373-15bull 3 Duvekot JJ Peeters LLH Renal hemodynamics and
volume homeostasis in pregnancy Obstet Gynecol Surv 199449830-9
bull 4 Barron WM Lindheimer MD Medical disorders during pregnancy 2nd ed St Louis Mosby 1995 p 129
bull 5 Thornburg KL Jacobson SL Giraud GD Morton MJ Hemodynamic changes in pregnancy Semin Perinatol 20002411-4
bull 6 Fiese R Herzog S Issues in dental and surgical management of the pregnant patient Oral Surg Oral Med Oral Pathol 198865292-7
bull 7 Martin C Varner MW Physiologic changes in pregnancysurgical implications Clin Obstet Gynecol 199437241-55
bull 8 Clark SL Cotton DB Lee W Bishop C Hill T Southwick J et al Central hemodynamic assessment of normal term pregnancy Am J Obstet Gynecol 19891611439-42
bull 9 Mabie WC Di Sessa TG Crocker LG Sibai BM Arheart KL A longitudinal study of cardiac output in normal human pregnancy Am J Obstet Gynecol 1994170849-56
bull 10 Clapp JF 3rd Capeless E Cardiovascular function before during and after the first and subsequent pregnancies Am J Cardiol 1997801469-73
bull 11 Duvekot JJ Peeters LL Maternal cardiovascular hemodynamic adaptation to pregnancy Obstet Gynecol Surv 199449(Suppl) S1-14
bull 12 Bhagwat AR Engel PJ Heart disease and pregnancy Cardiol Clin 199513163-78
bull 13 Lanni SM Tillinghast J Silver H Hemodynamic changes and baroreflex gain in the supine hypotensive syndrome Am J Obstet Gynecol 20021871636-41
bull 14 Little JW Falace DA Miller CS Rhodus NL Dental management of the medically compromised patient 6th ed St Louis Mosby 2002 p 303
bull 15 Garcia-Rio F Pino JM Gomez L Alvarez-Sala R Villasante C Villamor J Regulation of breathing and perception of dyspnea in healthy pregnant women Chest 1996110446-53
bull 16 McAuliffe F Kametas N Costello J Rafferty GF Greenough A Nicolaides K Respiratory function in singleton and twin pregnancy BJOG 2002109765-9
bull 17 Clapp JF 3rd Seaward BL Sleamaker RH Hiser J Maternal physiologic adaptations to early human pregnancy Am J Obstet Gynecol 19881591456-60
bull 18 OrsquoDay MP Cardio-respiratory physiological adaptation of pregnancy Semin Perinatol 199721268-75
bull 19 Contreras G Gutierrez M Beroiza T Fantin A Oddo H Villarroel L et al Ventilatory drive and respiratory muscle function in pregnancy Am Rev Respir Dis 1991144837-41
bull 20 Turner M Aziz SR Management of the pregnant oral and maxillofac
bull 21 Sifakis S Pharmakides G Anemia in pregnancy Ann N Y Acad Sci 2000900125-36
bull 22 Branch DW Physiologic adaptations of pregnancy Am J Reprod Immunol 199228120-2
bull 23 Burrows RF Kelton JG Incidentally detected thrombocytopenia in healthy mothers and their infants N Engl J Med 1988319 142-5
bull 24 Hanly JG Antiphospholipid syndrome an overview CMAJ 200324(168)1675-82
bull 25 Heilmann L von Tempelhoff GF Pollow K Antiphospholipid syndrome in obstetrics Clin Appl Thromb Hemost 20039 143-50
bull 26 Sherman P Flaxman SM Nausea and vomiting of pregnancy in an evolutionary perspective Am J Obstet Gynecol 2002 185(Suppl)s190-7
bull 27 Koch KL Gastrointestinal factors in nausea and vomiting of pregnancy Am J Obstet Gynecol 2002185(Suppl)s198-203
bull 28 Koch KL Frissora CL Nausea and vomiting during pregnancy Gastroenterol Clin N Am 200332201-34
bull 29 Baron TH Ramirez B Richter JE Gastrointestinal motility disorders during pregnancy Ann Intern Med 1993118 366-75
bull 30 Richter JE Gastroesophageal reflux disease during pregnancy Gastroenterol Clin N Am 200332235-61
bull 31 Marrero JM Goggin PM de Caestecker JS Pearce JM Maxwell JD Determinants of pregnancy heartburn Br J Obstet Gynaecol 199299731-4
bull 32 Hamaoui E Hamaoui M Nutritional assessment and support during pregnancy Gastroenterol Clin N Am 20033259-121
bull 33 King JC Physiology of pregnancy and nutrient metabolism Am J Clin Nutr 200071(suppl)1218s-25s
bull 34 Casanueva E Pfeffer F Fernandez-Gaxiola AC Gutierrez- Valenzuela V Rothenberg SJ Iron and folate status before pregnancy and anemia during pregnancy Ann Nutr Metab 2003 4760-3
bull 35 Chrsquong CL Morgan M Hainsworth I Kingham JG Prospective study of liver dysfunction in Southwest Wales Gut 200251 876-80
bull 36 Rahman TM Wendon J Severe hepatic dysfunction in pregnancy QJM 200295343-57
bull 37 Knox TA Olans LB Liver disease in pregnancy N Engl J Med 1996335569-76
bull 38 Saftlas AF Olson DR Franks AL Atrash H Pokras R Epidemiology of preeclampsia and eclampsia in the United States 1979e1986 Am J Obstet Gynecol 1990163460-5
bull 39 Walker JJ Pre-eclampsia Lancet 20003561260-5
bull 40 Davidson JM Renal disorders in pregnancy Curr Opin Obstet Gynecol 200113109-14
bull 41 Dafnis E Sabatini S The effect of pregnancy on renal function physiology and pathophysiologyAmJMedSci 1992303184-205
bull 42 Davison JM Shiells EA Philips PR Lindheimer MD Serial evaluation of vasopressin release and thirst in human pregnancy Role of human chorionic gonadotrophin in the osmoregulatory changes of gestation J Clin Invest 198881798-806
bull 43 Glinoer D de Nayer P Bourdoux P Lemone M Robyn C van Steirteghem A et al Regulation of maternal thyroid during pregnancy J Clin Endocrinol Metab 199071276-87
bull 44 Wilson SG Retallack RW Kent JC Worth GK Gutteridge DH Serum free 125-dihydroxyvitamin D and the free 125- dihydroxyvitamin D index during a longitudinal study of human pregnancy and lactation Clin Endocrinol 199032613-22
bull 45 Rasmussen N Frolich A Hornnes PJ Hegedus L Serum ionized calcium and intact parathyroid hormone levels during pregnancy and postpartum Br J Obstet Gynaecol 199097857-9
bull 46 Guyton AC Textbook of medical physiology 8th ed Philadelphia W B Saunders 1991 p 915e28
bull 47 Trainer PJ Corticosteroids and pregnancy Semin Reprod Med 200220375-80
bull 48 Soory M Hormonal factors in periodontal disease Dent Update 200027380-3
bull 49 Hugoson A Gingivitis in pregnant women A longitudinal clinical study Odontol Revy 19712265-84
bull 50 Neville BW Damm DD Allen CM Bouquot JE Oral amp Maxillofacial Pathology 3rd ed Philadelphia W B Saunders 2002 p 329-30 447-9
bull 51 Tilakaratne A Soory M Ranasinghe AW Corea SM Ekanayake SL de Silva M Periodontal disease status during pregnancy and 3 months post-partum in rural population of Sri-Lankan women J Clin Periodontol 200027787-92
bull 52 Laine M Tenovuo J Lehtonen OP Ojanatko-Harri A Vilja P Tuohimaa P Pregnancy e related changes in human whole saliva Arch Oral Biol 198833913-7
bull 53 Yuan K Wing LY Lin MT Pathogenetic roles of angiogenic factors in pyogenic granulomas in pregnancy are modulated by female sex hormones J Periodontol 200273701-8
bull 54 Evans RD Briggs PF Tooth-surface loss related to pregnancyinduced vomiting Prim Dent Care 1994124-6
bull 55 Salvolini E Di Giorgio R Curatola A Mazzanti L Fratto G Biochemical modifications of human whole saliva induced by pregnancy Br J Obstet Gynaec 1998105656-60
bull 56 Mauldin JG Newman RB Preterm birth risk assessment Semin Perinatol 200125215-22
bull 57 Heine RP McGregor JA Goodwin TM Artal R Hayashi RH Robertson PA et al Serial salivary estriol to detect an increased risk of preterm birth Obstet Gynecol 200096490-7
bull 58 Kauh YC Zachian TF Melasma Adv Exp Med Biol 1999455 491-9
bull 59 Wong RC Ellis CN Physiologic skin changes in pregnancy J Am Acad Dermatol 198410929-40
bull 60 Errickson CV Matus NR Skin disorders of pregnancy Am Fam Physician 199449605-10
bull 61 Lopez NJ Smith PC Gutierrez J Periodontal therapy may reduce the risk of preterm low birth weight in women with periodontal disease a randomized controlled trial J Periodontol 200273911-24
bull 62 McGaw T Periodontal disease and preterm delivery of lowbirth- weight infants J Can Dent Assoc 200268165-9
bull 63 Richards AG Dental x-ray protection Dent Clin North Am 1968631-41
bull 64 1990 Recommendations of the International Commission on Radiological Protection Ann ICRP 1991211-201
bull 65 Hall EJ Radiation the two-edged sword cancer risks at high and low doses Cancer J 20006343-50
bull 66 Diethelm L Xu H Diagnostic imaging of the lung during pregnancy Clin Obstet Gynecol 19963936-55
bull 67 Brent RL The effects of embryonic and fetal exposure to x-rays microwaves and ultrasound ClinObstetGynecol 198326484-510
bull 68 National Council on Radiation Protection NCRP report no128 1998 Bethesda Md Author
bull 69 Wasylko L Matsui D Dykxhoorn SM Reider MJ Weinberg S A review of common dental treatments during pregnancy implications for patients and dental personnel J Can Dent Assoc 199864434-9
bull 70 Freeman JP Brand JW Radiation doses of commonly used dental radiographic surveys Oral Surg Oral Med Oral Pathol 199477285-9
bull 71 Kircos LTAngin LL Lorton LOrder ofmagnitude dose reduction in intraoral radiography J Am Dent Assoc 1987114344-7
bull 72 Updegrave WJ Simplified and standardized intraoral radiography with reduced tissue irradiation J Am Dent Assoc 197285861-9
bull 73 Wood RE Harris AM van der Merwe EJ Nortje CJ The leaded apron revisited does it reduce gonadal radiation dose in dental radiology Oral Surg Oral Med Oral Pathol 199171642-6
bull 74 An update on radiographic practices information and recommendations ADA Council on Scientific Affairs J Am Dent Assoc 2001132234-8
bull 75 Rayburn WF Recommending medications during pregnancy an evidence based approach Clin Obstet Gynecol 2002451-5
bull 76 Rathmell JP Viscomi C Ashburn MA Management of nonobstetric pain during pregnancy and lactation Anesth Analg 1997851074-87
bull 77 Teratology society public affairs committee FDA classification of drugs for teratogenic risk Teratology 199449446-7
bull 78 Moore PA Selecting drugs for the pregnant dental patient J Am Dent Assoc 19981291281-6
bull 79 Haas DA An update on analgesics for the management of acute postoperative dental pain J Can Dent Assoc 200268476-82
bull 80 Haas DA Pynn BR Sands TD Drug use for the pregnant or lactating patient Gen Dent 20004854-60
bull 81 Committee on Drugs American Academy of Pediatrics The transfer of drugs and other chemicals into human milk Pediatrics 199493137-50
bull 82 Nielsen GL Sorensen HT Larsen H Pedersen L Risk of adverse birth outcome and miscarriage in pregnant users of nonsteroidal anti-inflammatory drugs population based observational study and case-control study BMJ 2001322266-70
bull 83 Janssen N Genta M The effects of immunosuppressive and anti-inflammatory medications on fertility pregnancy and lactation Arch Intern Med 200016610-9
bull 84 Ostensen M Nonsteroidal anti-inflammatory drugs during pregnancy Scand J Rheumatol Suppl 1998107128-32
bull 85 USPDI -Drug information for the health care professional 22nd ed Greenwood Village CO Micromedex 2002 p 152-79
bull 86 Denson DD Coyle DE Thompson GA Santos D Turner PA Myers JA et al Bupivacaine protein binding in the term parturient effects of lactic acidosis Clin Pharmacol Ther 198435702-9
bull 87 Dillon DE Wagner CL Wiest D Newman RB Drug therapy in the nursing mother Obstet Gynecol Clin North Am 199724 675-96
bull 88 Dashe JS Gilstrap LC Antibiotic use in pregnancy Obstet Gynecol Clin North Am 199724617-29
bull 89 American College of Rheumatology Ad hoc Committee on Clinical Guidelines Guidelines for monitoring drug therapy in rheumatoid arthritis Arthritis Rheum 199639723-31
bull 90 Ng PC The fetal and neonatal hypothalamic-pituitary-adrenal axis Arch Dis Child Fetal Neonatal Ed 200082F250-4
bull 91 Crowley P Antenatal corticosteroidsmdashcurrent thinking BJOG 2003110(Suppl 20)77-8
bull 92 ACOG committee opinion antenatal corticosteroid therapy for fetal maturation Obstet Gynecol 200299871-3
bull 93 Ost L Wettrell G Bjorkhem I Rane A Prednisolone excretion in human milk J Pediatr 19851061008-11
bull 94 Rowland AS Baird DD Shore DL Weinberg CR Savitz DA Wilcox AJ Nitrous oxide and spontaneous abortion in female dental assistants Am J Epidemiol 1995141531-8
bull 95 McGlothlin JD Jensen PA Fischbach TJ Hughes RT Jones JH Control of anesthetic gases in dental operatories Scand J Work Environ Health 199218(Suppl 2)103-5
bull ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY Volume 97 Number 6 Suresh and Radfar 681
bull 96 Rosen MA Nitrous oxide for relief of labor pain a systematic review Am J Obstet Gynecol 2002186(Suppl Nature)S110-6
bull 97 Sands TD Pynn BR Management considerations for the pregnant or nursing emergency patient Ont Dent 199875 17-9
bull 98 Daya S Recurrent spontaneous early pregnancy loss and low dose aspirin Minerva Ginecol 200355441-9
bull 99 Sinclair C Handbook of obstetrical emergencies 1st ed Philadelphia WB Saunders 1996 p 29-39 69
bull 100 Tarsitano BF Rollings RE The pregnant dental patient evaluation and management Gen Dent 199341226-34
bull 101 Livingston MH Dlllinger TM Holder R Consideration in the management of the pregnant patient SCD Special Care in Dentistry 199818183-8
Thank you
- A Review on the principle of Dental Management of the Pregnant patient
- Slide 2
- Questions that a dentist may ask
- Stages of Pregnancy
- Slide 5
- Slide 6
- Physiologic Changes in Pregnancy
- Systemic changes in pregnancy
- FLAT SUPINE POSITIONING
- SUPINE HYPOTENSION SYNDROME (Vena Cava Compression)
- Supine Hypotension Syndrome
- Slide 12
- Supine Hypotension Syndrome
- Prevention of Supine Hypotensive Syndrome
- Treatment of Supine Hypotensive Syndrome
- How should the pregnant woman be positioned
- Slide 17
- Slide 18
- Slide 19
- Slide 20
- Slide 21
- Slide 22
- Slide 23
- Pregnancy Related Oral Health Problems
- Oral Problems in Pregnancy
- Pregnancy Gingivitis Pathophysiology
- Pregnancy Gingivitis
- Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Gum Problems - Pregnancy Granuloma
- Slide 31
- Gum Changes - Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Candidiasis
- Pregnancy Myths
- Other Oral Conditions in Pregnancy
- Changes During Pregnancy that Affect Oral Health
- Saliva changes
- Increased Bacteria
- Slide 40
- Enamel erosion caused by frequent vomiting
- Treatment for Acid Exposure
- Oral Diseases Can Effect Pregnancy
- Periodontal Disease and Preterm Labor
- Periodontal Disease and Low Birth Weight
- Periodontal Disease and Preeclampsia
- Periodontitis and Pre-eclampsia
- Dental Considerations
- Treatment Timing
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Slide 52
- Use of Radiation on Pregnant Patient
- Radiographs during Pregnancy
- Risks of Dental X-Rays
- FDA drug classification for pregnancy
- Slide 57
- FDA drug classification for pregnancy
- Slide 59
- Slide 60
- Slide 61
- Common Analgesics
- Analgesics
- Analgesics - continued
- Analgesics to Use During 1st and 2nd Trimester
- Analgesics to Avoid During the Third Trimester
- Sedation in Pregnancy
- Common Antibiotics
- Antibiotics
- Antibiotics To Use During Pregnancy
- Antibiotics to Avoid during Pregnancy
- The Problem With Tetracycline
- Other Antimicrobial Agents
- Local Anesthetic Use in Pregnancy
- Use of Local Anesthetics
- Ulcer healing drugs
- Slide 77
- Slide 78
- Slide 79
- Use of Nitrous Oxide Gas
- Common Preventives
- Are topical agents safe
- Pre-natal Fluoride
- Is it safe to use mercury restorations
- References
- REFERENCES
- Slide 87
- Slide 88
- Slide 89
- Slide 90
- Slide 91
- Slide 92
- Slide 93
- Slide 94
- Slide 95
- Slide 96
- Slide 97
- Slide 98
- Thank you
-
Sedation in Pregnancy
bull SedativesAnxiolytics (eg Diazepam ) are rated D and can cause oral clefts with prolonged exposure
bull Nitrous oxide should not be used in 1st trimester (If used in 2nd and 3rd do not go below 50 O2)
Common Antibioticsbull To treat oral abscess or cellulitis
ndash Penicillin (B) ndash Amoxicillin (B) ndash Cephalexin (B)ndash Erythromycin base (B) (Not estolate as it
cause cholestatic hepatitis)ndash Clindamycin (B)
Antibioticsbull penicillin V and amoxicillin is preferred drug
for mild to moderate infectionsbull widely used for many years with no ill effectsbull no studies show penicillin to be teratogenicbull amoxicillin extensively used without harming
the fetusbull Drug classes1048715 B penicillin cephalosporins erythromycin clindamycin Azithromycin D Tetracycline
Antibiotics To Use During Pregnancy
bull Penicillin Vbull Amoxicillinbull Erythromycin (base form)bull Cephalexin cephalosporinbull Clindamycinbull Metronidazole
Antibiotics to Avoid duringPregnancy
bull Doxycyclinebull Tetracyclinebull Erythromycin (estolate form)bull Vancomycin
The Problem With Tetracycline
bull Accumulates in bones and chelates calcium
bull Inhibits bone growthbull Discolors teeth
Other Antimicrobial Agentsbull OK to usebull Nystatin (B)bull Chlorhexidine rinse (B)bull Use with cautionbull Clotrimazole (C)bull Ketoconazole (C)bull Fluconazole (C)bull Do not usebull Doxycycline (D)
Local Anesthetic Use inPregnancy
bull Class Bbull Lidocaine (Xylocaine)bull Etidocainebull Prilocaine bull Class Cbull Procainebull Bupivicainebull Mepivicaine
Use of Local Anestheticsbull Lidocaine + vasoconstrictor most common
local anesthetic used in dentistrybull extensively used in pregnancy with no proven ill
effectsbull accidental intravascular injections of lidocaine
pass through the placenta but the concentrations are too low to harm fetus
bull prilocaine might cause methemoglobinemia
Ulcer healing drugsCimetidine bull FDA category B Famotidinebull FDA category BRanitidinebull FDA category Bbull not known to be harmful
Ulcer healing drugsOmeprazolebull FDA category BNot known to be
harmful Esomeprazolebull FDA category BLansoprazolebull FDA category BPantoprazolebull Avoid unless potential benefit
outweighs riskmdashfetotoxic in animals
Ulcer healing drugs
Misoprostolbull First second third trimesters Avoidmdash
potent uterine stimulant (has been used to induce abortion) and may be teratogenic
Ulcer healing drugs
Antacidsbull Almunium hydroxideMagnesium
hydroxidemdashFDA category B Calcium carbonatemdashFDA category C
SimetheconemdashFDA category C
Use of Nitrous Oxide Gas
bull used over 150 years bull safety is being debatedbull SHORT TERM exposure do not cause
birth defects or spontaneous abortionbull CHRONIC exposure may result in fetal
loss and infertilitybull literature suggests that nitrous oxide
should be avoided until more conclusive research is available
bull FDA Drug class not yet assigned
Common Preventives
bull Fluoridendash No increased risk during pregnancy
bull Xylitolndash No studies no harm reported
bull Chlorhexidinendash No increased risk during pregnancy
Are topical agents safe
bull Fluoridebull Toothpaste amp mouthrinse
bull Xylitol chewing gum bull Chlorhexidine (11 alcohol)bull No over the counter mouthrinses with
alcohol (Listerine 20 alcohol)
Pre-natal Fluoride
bull Daily 22 mg tablet of sodium fluoride during 3rd through 9th months
bull decreases caries rate in offspringbull Safe and effective
Glenn FB 1982
Is it safe to use mercury restorations
bull No evidence of harmful effect
bull Benefits outweigh risks
bull Canada Germany and New Zealand have some restrictions
bull Determine the best option
Referencesbull Wasylko L Matsui D Dykxhoorn SM Rieder MJ Weinberg
S A Review of Common Dental Treatments During Pregnancy J Canadian Dental Association 64434-439 1998
bull Little JW Donald AF Craig SM Rhodus NL Dental Management of the Medically Compromised Patient - 5th edition Mosby Toronto Pp434-442 1997
bull Livingston HM Dellinger TM Holder R Considerations in the management of the pregnant patient Special Care in Dentistry 185 pp183-188 1998
bull Larimore WL Petrie KA Drug use during pregnacy and lactation Primary Care Clinics in Office Practice 271 35-53 2000
bull Health Canada The Safety of DentalAmalgam Minister Of Supply and Services Canada 1996
REFERENCESbull 1 Weiss G Endocrinology of parturition J Clin
Endocrinol Metab 2000854421-5bull 2 Theunissen IM Parer JT Fluid and electrolytes in
pregnancy Clin Obstet Gynecol 1994373-15bull 3 Duvekot JJ Peeters LLH Renal hemodynamics and
volume homeostasis in pregnancy Obstet Gynecol Surv 199449830-9
bull 4 Barron WM Lindheimer MD Medical disorders during pregnancy 2nd ed St Louis Mosby 1995 p 129
bull 5 Thornburg KL Jacobson SL Giraud GD Morton MJ Hemodynamic changes in pregnancy Semin Perinatol 20002411-4
bull 6 Fiese R Herzog S Issues in dental and surgical management of the pregnant patient Oral Surg Oral Med Oral Pathol 198865292-7
bull 7 Martin C Varner MW Physiologic changes in pregnancysurgical implications Clin Obstet Gynecol 199437241-55
bull 8 Clark SL Cotton DB Lee W Bishop C Hill T Southwick J et al Central hemodynamic assessment of normal term pregnancy Am J Obstet Gynecol 19891611439-42
bull 9 Mabie WC Di Sessa TG Crocker LG Sibai BM Arheart KL A longitudinal study of cardiac output in normal human pregnancy Am J Obstet Gynecol 1994170849-56
bull 10 Clapp JF 3rd Capeless E Cardiovascular function before during and after the first and subsequent pregnancies Am J Cardiol 1997801469-73
bull 11 Duvekot JJ Peeters LL Maternal cardiovascular hemodynamic adaptation to pregnancy Obstet Gynecol Surv 199449(Suppl) S1-14
bull 12 Bhagwat AR Engel PJ Heart disease and pregnancy Cardiol Clin 199513163-78
bull 13 Lanni SM Tillinghast J Silver H Hemodynamic changes and baroreflex gain in the supine hypotensive syndrome Am J Obstet Gynecol 20021871636-41
bull 14 Little JW Falace DA Miller CS Rhodus NL Dental management of the medically compromised patient 6th ed St Louis Mosby 2002 p 303
bull 15 Garcia-Rio F Pino JM Gomez L Alvarez-Sala R Villasante C Villamor J Regulation of breathing and perception of dyspnea in healthy pregnant women Chest 1996110446-53
bull 16 McAuliffe F Kametas N Costello J Rafferty GF Greenough A Nicolaides K Respiratory function in singleton and twin pregnancy BJOG 2002109765-9
bull 17 Clapp JF 3rd Seaward BL Sleamaker RH Hiser J Maternal physiologic adaptations to early human pregnancy Am J Obstet Gynecol 19881591456-60
bull 18 OrsquoDay MP Cardio-respiratory physiological adaptation of pregnancy Semin Perinatol 199721268-75
bull 19 Contreras G Gutierrez M Beroiza T Fantin A Oddo H Villarroel L et al Ventilatory drive and respiratory muscle function in pregnancy Am Rev Respir Dis 1991144837-41
bull 20 Turner M Aziz SR Management of the pregnant oral and maxillofac
bull 21 Sifakis S Pharmakides G Anemia in pregnancy Ann N Y Acad Sci 2000900125-36
bull 22 Branch DW Physiologic adaptations of pregnancy Am J Reprod Immunol 199228120-2
bull 23 Burrows RF Kelton JG Incidentally detected thrombocytopenia in healthy mothers and their infants N Engl J Med 1988319 142-5
bull 24 Hanly JG Antiphospholipid syndrome an overview CMAJ 200324(168)1675-82
bull 25 Heilmann L von Tempelhoff GF Pollow K Antiphospholipid syndrome in obstetrics Clin Appl Thromb Hemost 20039 143-50
bull 26 Sherman P Flaxman SM Nausea and vomiting of pregnancy in an evolutionary perspective Am J Obstet Gynecol 2002 185(Suppl)s190-7
bull 27 Koch KL Gastrointestinal factors in nausea and vomiting of pregnancy Am J Obstet Gynecol 2002185(Suppl)s198-203
bull 28 Koch KL Frissora CL Nausea and vomiting during pregnancy Gastroenterol Clin N Am 200332201-34
bull 29 Baron TH Ramirez B Richter JE Gastrointestinal motility disorders during pregnancy Ann Intern Med 1993118 366-75
bull 30 Richter JE Gastroesophageal reflux disease during pregnancy Gastroenterol Clin N Am 200332235-61
bull 31 Marrero JM Goggin PM de Caestecker JS Pearce JM Maxwell JD Determinants of pregnancy heartburn Br J Obstet Gynaecol 199299731-4
bull 32 Hamaoui E Hamaoui M Nutritional assessment and support during pregnancy Gastroenterol Clin N Am 20033259-121
bull 33 King JC Physiology of pregnancy and nutrient metabolism Am J Clin Nutr 200071(suppl)1218s-25s
bull 34 Casanueva E Pfeffer F Fernandez-Gaxiola AC Gutierrez- Valenzuela V Rothenberg SJ Iron and folate status before pregnancy and anemia during pregnancy Ann Nutr Metab 2003 4760-3
bull 35 Chrsquong CL Morgan M Hainsworth I Kingham JG Prospective study of liver dysfunction in Southwest Wales Gut 200251 876-80
bull 36 Rahman TM Wendon J Severe hepatic dysfunction in pregnancy QJM 200295343-57
bull 37 Knox TA Olans LB Liver disease in pregnancy N Engl J Med 1996335569-76
bull 38 Saftlas AF Olson DR Franks AL Atrash H Pokras R Epidemiology of preeclampsia and eclampsia in the United States 1979e1986 Am J Obstet Gynecol 1990163460-5
bull 39 Walker JJ Pre-eclampsia Lancet 20003561260-5
bull 40 Davidson JM Renal disorders in pregnancy Curr Opin Obstet Gynecol 200113109-14
bull 41 Dafnis E Sabatini S The effect of pregnancy on renal function physiology and pathophysiologyAmJMedSci 1992303184-205
bull 42 Davison JM Shiells EA Philips PR Lindheimer MD Serial evaluation of vasopressin release and thirst in human pregnancy Role of human chorionic gonadotrophin in the osmoregulatory changes of gestation J Clin Invest 198881798-806
bull 43 Glinoer D de Nayer P Bourdoux P Lemone M Robyn C van Steirteghem A et al Regulation of maternal thyroid during pregnancy J Clin Endocrinol Metab 199071276-87
bull 44 Wilson SG Retallack RW Kent JC Worth GK Gutteridge DH Serum free 125-dihydroxyvitamin D and the free 125- dihydroxyvitamin D index during a longitudinal study of human pregnancy and lactation Clin Endocrinol 199032613-22
bull 45 Rasmussen N Frolich A Hornnes PJ Hegedus L Serum ionized calcium and intact parathyroid hormone levels during pregnancy and postpartum Br J Obstet Gynaecol 199097857-9
bull 46 Guyton AC Textbook of medical physiology 8th ed Philadelphia W B Saunders 1991 p 915e28
bull 47 Trainer PJ Corticosteroids and pregnancy Semin Reprod Med 200220375-80
bull 48 Soory M Hormonal factors in periodontal disease Dent Update 200027380-3
bull 49 Hugoson A Gingivitis in pregnant women A longitudinal clinical study Odontol Revy 19712265-84
bull 50 Neville BW Damm DD Allen CM Bouquot JE Oral amp Maxillofacial Pathology 3rd ed Philadelphia W B Saunders 2002 p 329-30 447-9
bull 51 Tilakaratne A Soory M Ranasinghe AW Corea SM Ekanayake SL de Silva M Periodontal disease status during pregnancy and 3 months post-partum in rural population of Sri-Lankan women J Clin Periodontol 200027787-92
bull 52 Laine M Tenovuo J Lehtonen OP Ojanatko-Harri A Vilja P Tuohimaa P Pregnancy e related changes in human whole saliva Arch Oral Biol 198833913-7
bull 53 Yuan K Wing LY Lin MT Pathogenetic roles of angiogenic factors in pyogenic granulomas in pregnancy are modulated by female sex hormones J Periodontol 200273701-8
bull 54 Evans RD Briggs PF Tooth-surface loss related to pregnancyinduced vomiting Prim Dent Care 1994124-6
bull 55 Salvolini E Di Giorgio R Curatola A Mazzanti L Fratto G Biochemical modifications of human whole saliva induced by pregnancy Br J Obstet Gynaec 1998105656-60
bull 56 Mauldin JG Newman RB Preterm birth risk assessment Semin Perinatol 200125215-22
bull 57 Heine RP McGregor JA Goodwin TM Artal R Hayashi RH Robertson PA et al Serial salivary estriol to detect an increased risk of preterm birth Obstet Gynecol 200096490-7
bull 58 Kauh YC Zachian TF Melasma Adv Exp Med Biol 1999455 491-9
bull 59 Wong RC Ellis CN Physiologic skin changes in pregnancy J Am Acad Dermatol 198410929-40
bull 60 Errickson CV Matus NR Skin disorders of pregnancy Am Fam Physician 199449605-10
bull 61 Lopez NJ Smith PC Gutierrez J Periodontal therapy may reduce the risk of preterm low birth weight in women with periodontal disease a randomized controlled trial J Periodontol 200273911-24
bull 62 McGaw T Periodontal disease and preterm delivery of lowbirth- weight infants J Can Dent Assoc 200268165-9
bull 63 Richards AG Dental x-ray protection Dent Clin North Am 1968631-41
bull 64 1990 Recommendations of the International Commission on Radiological Protection Ann ICRP 1991211-201
bull 65 Hall EJ Radiation the two-edged sword cancer risks at high and low doses Cancer J 20006343-50
bull 66 Diethelm L Xu H Diagnostic imaging of the lung during pregnancy Clin Obstet Gynecol 19963936-55
bull 67 Brent RL The effects of embryonic and fetal exposure to x-rays microwaves and ultrasound ClinObstetGynecol 198326484-510
bull 68 National Council on Radiation Protection NCRP report no128 1998 Bethesda Md Author
bull 69 Wasylko L Matsui D Dykxhoorn SM Reider MJ Weinberg S A review of common dental treatments during pregnancy implications for patients and dental personnel J Can Dent Assoc 199864434-9
bull 70 Freeman JP Brand JW Radiation doses of commonly used dental radiographic surveys Oral Surg Oral Med Oral Pathol 199477285-9
bull 71 Kircos LTAngin LL Lorton LOrder ofmagnitude dose reduction in intraoral radiography J Am Dent Assoc 1987114344-7
bull 72 Updegrave WJ Simplified and standardized intraoral radiography with reduced tissue irradiation J Am Dent Assoc 197285861-9
bull 73 Wood RE Harris AM van der Merwe EJ Nortje CJ The leaded apron revisited does it reduce gonadal radiation dose in dental radiology Oral Surg Oral Med Oral Pathol 199171642-6
bull 74 An update on radiographic practices information and recommendations ADA Council on Scientific Affairs J Am Dent Assoc 2001132234-8
bull 75 Rayburn WF Recommending medications during pregnancy an evidence based approach Clin Obstet Gynecol 2002451-5
bull 76 Rathmell JP Viscomi C Ashburn MA Management of nonobstetric pain during pregnancy and lactation Anesth Analg 1997851074-87
bull 77 Teratology society public affairs committee FDA classification of drugs for teratogenic risk Teratology 199449446-7
bull 78 Moore PA Selecting drugs for the pregnant dental patient J Am Dent Assoc 19981291281-6
bull 79 Haas DA An update on analgesics for the management of acute postoperative dental pain J Can Dent Assoc 200268476-82
bull 80 Haas DA Pynn BR Sands TD Drug use for the pregnant or lactating patient Gen Dent 20004854-60
bull 81 Committee on Drugs American Academy of Pediatrics The transfer of drugs and other chemicals into human milk Pediatrics 199493137-50
bull 82 Nielsen GL Sorensen HT Larsen H Pedersen L Risk of adverse birth outcome and miscarriage in pregnant users of nonsteroidal anti-inflammatory drugs population based observational study and case-control study BMJ 2001322266-70
bull 83 Janssen N Genta M The effects of immunosuppressive and anti-inflammatory medications on fertility pregnancy and lactation Arch Intern Med 200016610-9
bull 84 Ostensen M Nonsteroidal anti-inflammatory drugs during pregnancy Scand J Rheumatol Suppl 1998107128-32
bull 85 USPDI -Drug information for the health care professional 22nd ed Greenwood Village CO Micromedex 2002 p 152-79
bull 86 Denson DD Coyle DE Thompson GA Santos D Turner PA Myers JA et al Bupivacaine protein binding in the term parturient effects of lactic acidosis Clin Pharmacol Ther 198435702-9
bull 87 Dillon DE Wagner CL Wiest D Newman RB Drug therapy in the nursing mother Obstet Gynecol Clin North Am 199724 675-96
bull 88 Dashe JS Gilstrap LC Antibiotic use in pregnancy Obstet Gynecol Clin North Am 199724617-29
bull 89 American College of Rheumatology Ad hoc Committee on Clinical Guidelines Guidelines for monitoring drug therapy in rheumatoid arthritis Arthritis Rheum 199639723-31
bull 90 Ng PC The fetal and neonatal hypothalamic-pituitary-adrenal axis Arch Dis Child Fetal Neonatal Ed 200082F250-4
bull 91 Crowley P Antenatal corticosteroidsmdashcurrent thinking BJOG 2003110(Suppl 20)77-8
bull 92 ACOG committee opinion antenatal corticosteroid therapy for fetal maturation Obstet Gynecol 200299871-3
bull 93 Ost L Wettrell G Bjorkhem I Rane A Prednisolone excretion in human milk J Pediatr 19851061008-11
bull 94 Rowland AS Baird DD Shore DL Weinberg CR Savitz DA Wilcox AJ Nitrous oxide and spontaneous abortion in female dental assistants Am J Epidemiol 1995141531-8
bull 95 McGlothlin JD Jensen PA Fischbach TJ Hughes RT Jones JH Control of anesthetic gases in dental operatories Scand J Work Environ Health 199218(Suppl 2)103-5
bull ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY Volume 97 Number 6 Suresh and Radfar 681
bull 96 Rosen MA Nitrous oxide for relief of labor pain a systematic review Am J Obstet Gynecol 2002186(Suppl Nature)S110-6
bull 97 Sands TD Pynn BR Management considerations for the pregnant or nursing emergency patient Ont Dent 199875 17-9
bull 98 Daya S Recurrent spontaneous early pregnancy loss and low dose aspirin Minerva Ginecol 200355441-9
bull 99 Sinclair C Handbook of obstetrical emergencies 1st ed Philadelphia WB Saunders 1996 p 29-39 69
bull 100 Tarsitano BF Rollings RE The pregnant dental patient evaluation and management Gen Dent 199341226-34
bull 101 Livingston MH Dlllinger TM Holder R Consideration in the management of the pregnant patient SCD Special Care in Dentistry 199818183-8
Thank you
- A Review on the principle of Dental Management of the Pregnant patient
- Slide 2
- Questions that a dentist may ask
- Stages of Pregnancy
- Slide 5
- Slide 6
- Physiologic Changes in Pregnancy
- Systemic changes in pregnancy
- FLAT SUPINE POSITIONING
- SUPINE HYPOTENSION SYNDROME (Vena Cava Compression)
- Supine Hypotension Syndrome
- Slide 12
- Supine Hypotension Syndrome
- Prevention of Supine Hypotensive Syndrome
- Treatment of Supine Hypotensive Syndrome
- How should the pregnant woman be positioned
- Slide 17
- Slide 18
- Slide 19
- Slide 20
- Slide 21
- Slide 22
- Slide 23
- Pregnancy Related Oral Health Problems
- Oral Problems in Pregnancy
- Pregnancy Gingivitis Pathophysiology
- Pregnancy Gingivitis
- Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Gum Problems - Pregnancy Granuloma
- Slide 31
- Gum Changes - Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Candidiasis
- Pregnancy Myths
- Other Oral Conditions in Pregnancy
- Changes During Pregnancy that Affect Oral Health
- Saliva changes
- Increased Bacteria
- Slide 40
- Enamel erosion caused by frequent vomiting
- Treatment for Acid Exposure
- Oral Diseases Can Effect Pregnancy
- Periodontal Disease and Preterm Labor
- Periodontal Disease and Low Birth Weight
- Periodontal Disease and Preeclampsia
- Periodontitis and Pre-eclampsia
- Dental Considerations
- Treatment Timing
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Slide 52
- Use of Radiation on Pregnant Patient
- Radiographs during Pregnancy
- Risks of Dental X-Rays
- FDA drug classification for pregnancy
- Slide 57
- FDA drug classification for pregnancy
- Slide 59
- Slide 60
- Slide 61
- Common Analgesics
- Analgesics
- Analgesics - continued
- Analgesics to Use During 1st and 2nd Trimester
- Analgesics to Avoid During the Third Trimester
- Sedation in Pregnancy
- Common Antibiotics
- Antibiotics
- Antibiotics To Use During Pregnancy
- Antibiotics to Avoid during Pregnancy
- The Problem With Tetracycline
- Other Antimicrobial Agents
- Local Anesthetic Use in Pregnancy
- Use of Local Anesthetics
- Ulcer healing drugs
- Slide 77
- Slide 78
- Slide 79
- Use of Nitrous Oxide Gas
- Common Preventives
- Are topical agents safe
- Pre-natal Fluoride
- Is it safe to use mercury restorations
- References
- REFERENCES
- Slide 87
- Slide 88
- Slide 89
- Slide 90
- Slide 91
- Slide 92
- Slide 93
- Slide 94
- Slide 95
- Slide 96
- Slide 97
- Slide 98
- Thank you
-
Common Antibioticsbull To treat oral abscess or cellulitis
ndash Penicillin (B) ndash Amoxicillin (B) ndash Cephalexin (B)ndash Erythromycin base (B) (Not estolate as it
cause cholestatic hepatitis)ndash Clindamycin (B)
Antibioticsbull penicillin V and amoxicillin is preferred drug
for mild to moderate infectionsbull widely used for many years with no ill effectsbull no studies show penicillin to be teratogenicbull amoxicillin extensively used without harming
the fetusbull Drug classes1048715 B penicillin cephalosporins erythromycin clindamycin Azithromycin D Tetracycline
Antibiotics To Use During Pregnancy
bull Penicillin Vbull Amoxicillinbull Erythromycin (base form)bull Cephalexin cephalosporinbull Clindamycinbull Metronidazole
Antibiotics to Avoid duringPregnancy
bull Doxycyclinebull Tetracyclinebull Erythromycin (estolate form)bull Vancomycin
The Problem With Tetracycline
bull Accumulates in bones and chelates calcium
bull Inhibits bone growthbull Discolors teeth
Other Antimicrobial Agentsbull OK to usebull Nystatin (B)bull Chlorhexidine rinse (B)bull Use with cautionbull Clotrimazole (C)bull Ketoconazole (C)bull Fluconazole (C)bull Do not usebull Doxycycline (D)
Local Anesthetic Use inPregnancy
bull Class Bbull Lidocaine (Xylocaine)bull Etidocainebull Prilocaine bull Class Cbull Procainebull Bupivicainebull Mepivicaine
Use of Local Anestheticsbull Lidocaine + vasoconstrictor most common
local anesthetic used in dentistrybull extensively used in pregnancy with no proven ill
effectsbull accidental intravascular injections of lidocaine
pass through the placenta but the concentrations are too low to harm fetus
bull prilocaine might cause methemoglobinemia
Ulcer healing drugsCimetidine bull FDA category B Famotidinebull FDA category BRanitidinebull FDA category Bbull not known to be harmful
Ulcer healing drugsOmeprazolebull FDA category BNot known to be
harmful Esomeprazolebull FDA category BLansoprazolebull FDA category BPantoprazolebull Avoid unless potential benefit
outweighs riskmdashfetotoxic in animals
Ulcer healing drugs
Misoprostolbull First second third trimesters Avoidmdash
potent uterine stimulant (has been used to induce abortion) and may be teratogenic
Ulcer healing drugs
Antacidsbull Almunium hydroxideMagnesium
hydroxidemdashFDA category B Calcium carbonatemdashFDA category C
SimetheconemdashFDA category C
Use of Nitrous Oxide Gas
bull used over 150 years bull safety is being debatedbull SHORT TERM exposure do not cause
birth defects or spontaneous abortionbull CHRONIC exposure may result in fetal
loss and infertilitybull literature suggests that nitrous oxide
should be avoided until more conclusive research is available
bull FDA Drug class not yet assigned
Common Preventives
bull Fluoridendash No increased risk during pregnancy
bull Xylitolndash No studies no harm reported
bull Chlorhexidinendash No increased risk during pregnancy
Are topical agents safe
bull Fluoridebull Toothpaste amp mouthrinse
bull Xylitol chewing gum bull Chlorhexidine (11 alcohol)bull No over the counter mouthrinses with
alcohol (Listerine 20 alcohol)
Pre-natal Fluoride
bull Daily 22 mg tablet of sodium fluoride during 3rd through 9th months
bull decreases caries rate in offspringbull Safe and effective
Glenn FB 1982
Is it safe to use mercury restorations
bull No evidence of harmful effect
bull Benefits outweigh risks
bull Canada Germany and New Zealand have some restrictions
bull Determine the best option
Referencesbull Wasylko L Matsui D Dykxhoorn SM Rieder MJ Weinberg
S A Review of Common Dental Treatments During Pregnancy J Canadian Dental Association 64434-439 1998
bull Little JW Donald AF Craig SM Rhodus NL Dental Management of the Medically Compromised Patient - 5th edition Mosby Toronto Pp434-442 1997
bull Livingston HM Dellinger TM Holder R Considerations in the management of the pregnant patient Special Care in Dentistry 185 pp183-188 1998
bull Larimore WL Petrie KA Drug use during pregnacy and lactation Primary Care Clinics in Office Practice 271 35-53 2000
bull Health Canada The Safety of DentalAmalgam Minister Of Supply and Services Canada 1996
REFERENCESbull 1 Weiss G Endocrinology of parturition J Clin
Endocrinol Metab 2000854421-5bull 2 Theunissen IM Parer JT Fluid and electrolytes in
pregnancy Clin Obstet Gynecol 1994373-15bull 3 Duvekot JJ Peeters LLH Renal hemodynamics and
volume homeostasis in pregnancy Obstet Gynecol Surv 199449830-9
bull 4 Barron WM Lindheimer MD Medical disorders during pregnancy 2nd ed St Louis Mosby 1995 p 129
bull 5 Thornburg KL Jacobson SL Giraud GD Morton MJ Hemodynamic changes in pregnancy Semin Perinatol 20002411-4
bull 6 Fiese R Herzog S Issues in dental and surgical management of the pregnant patient Oral Surg Oral Med Oral Pathol 198865292-7
bull 7 Martin C Varner MW Physiologic changes in pregnancysurgical implications Clin Obstet Gynecol 199437241-55
bull 8 Clark SL Cotton DB Lee W Bishop C Hill T Southwick J et al Central hemodynamic assessment of normal term pregnancy Am J Obstet Gynecol 19891611439-42
bull 9 Mabie WC Di Sessa TG Crocker LG Sibai BM Arheart KL A longitudinal study of cardiac output in normal human pregnancy Am J Obstet Gynecol 1994170849-56
bull 10 Clapp JF 3rd Capeless E Cardiovascular function before during and after the first and subsequent pregnancies Am J Cardiol 1997801469-73
bull 11 Duvekot JJ Peeters LL Maternal cardiovascular hemodynamic adaptation to pregnancy Obstet Gynecol Surv 199449(Suppl) S1-14
bull 12 Bhagwat AR Engel PJ Heart disease and pregnancy Cardiol Clin 199513163-78
bull 13 Lanni SM Tillinghast J Silver H Hemodynamic changes and baroreflex gain in the supine hypotensive syndrome Am J Obstet Gynecol 20021871636-41
bull 14 Little JW Falace DA Miller CS Rhodus NL Dental management of the medically compromised patient 6th ed St Louis Mosby 2002 p 303
bull 15 Garcia-Rio F Pino JM Gomez L Alvarez-Sala R Villasante C Villamor J Regulation of breathing and perception of dyspnea in healthy pregnant women Chest 1996110446-53
bull 16 McAuliffe F Kametas N Costello J Rafferty GF Greenough A Nicolaides K Respiratory function in singleton and twin pregnancy BJOG 2002109765-9
bull 17 Clapp JF 3rd Seaward BL Sleamaker RH Hiser J Maternal physiologic adaptations to early human pregnancy Am J Obstet Gynecol 19881591456-60
bull 18 OrsquoDay MP Cardio-respiratory physiological adaptation of pregnancy Semin Perinatol 199721268-75
bull 19 Contreras G Gutierrez M Beroiza T Fantin A Oddo H Villarroel L et al Ventilatory drive and respiratory muscle function in pregnancy Am Rev Respir Dis 1991144837-41
bull 20 Turner M Aziz SR Management of the pregnant oral and maxillofac
bull 21 Sifakis S Pharmakides G Anemia in pregnancy Ann N Y Acad Sci 2000900125-36
bull 22 Branch DW Physiologic adaptations of pregnancy Am J Reprod Immunol 199228120-2
bull 23 Burrows RF Kelton JG Incidentally detected thrombocytopenia in healthy mothers and their infants N Engl J Med 1988319 142-5
bull 24 Hanly JG Antiphospholipid syndrome an overview CMAJ 200324(168)1675-82
bull 25 Heilmann L von Tempelhoff GF Pollow K Antiphospholipid syndrome in obstetrics Clin Appl Thromb Hemost 20039 143-50
bull 26 Sherman P Flaxman SM Nausea and vomiting of pregnancy in an evolutionary perspective Am J Obstet Gynecol 2002 185(Suppl)s190-7
bull 27 Koch KL Gastrointestinal factors in nausea and vomiting of pregnancy Am J Obstet Gynecol 2002185(Suppl)s198-203
bull 28 Koch KL Frissora CL Nausea and vomiting during pregnancy Gastroenterol Clin N Am 200332201-34
bull 29 Baron TH Ramirez B Richter JE Gastrointestinal motility disorders during pregnancy Ann Intern Med 1993118 366-75
bull 30 Richter JE Gastroesophageal reflux disease during pregnancy Gastroenterol Clin N Am 200332235-61
bull 31 Marrero JM Goggin PM de Caestecker JS Pearce JM Maxwell JD Determinants of pregnancy heartburn Br J Obstet Gynaecol 199299731-4
bull 32 Hamaoui E Hamaoui M Nutritional assessment and support during pregnancy Gastroenterol Clin N Am 20033259-121
bull 33 King JC Physiology of pregnancy and nutrient metabolism Am J Clin Nutr 200071(suppl)1218s-25s
bull 34 Casanueva E Pfeffer F Fernandez-Gaxiola AC Gutierrez- Valenzuela V Rothenberg SJ Iron and folate status before pregnancy and anemia during pregnancy Ann Nutr Metab 2003 4760-3
bull 35 Chrsquong CL Morgan M Hainsworth I Kingham JG Prospective study of liver dysfunction in Southwest Wales Gut 200251 876-80
bull 36 Rahman TM Wendon J Severe hepatic dysfunction in pregnancy QJM 200295343-57
bull 37 Knox TA Olans LB Liver disease in pregnancy N Engl J Med 1996335569-76
bull 38 Saftlas AF Olson DR Franks AL Atrash H Pokras R Epidemiology of preeclampsia and eclampsia in the United States 1979e1986 Am J Obstet Gynecol 1990163460-5
bull 39 Walker JJ Pre-eclampsia Lancet 20003561260-5
bull 40 Davidson JM Renal disorders in pregnancy Curr Opin Obstet Gynecol 200113109-14
bull 41 Dafnis E Sabatini S The effect of pregnancy on renal function physiology and pathophysiologyAmJMedSci 1992303184-205
bull 42 Davison JM Shiells EA Philips PR Lindheimer MD Serial evaluation of vasopressin release and thirst in human pregnancy Role of human chorionic gonadotrophin in the osmoregulatory changes of gestation J Clin Invest 198881798-806
bull 43 Glinoer D de Nayer P Bourdoux P Lemone M Robyn C van Steirteghem A et al Regulation of maternal thyroid during pregnancy J Clin Endocrinol Metab 199071276-87
bull 44 Wilson SG Retallack RW Kent JC Worth GK Gutteridge DH Serum free 125-dihydroxyvitamin D and the free 125- dihydroxyvitamin D index during a longitudinal study of human pregnancy and lactation Clin Endocrinol 199032613-22
bull 45 Rasmussen N Frolich A Hornnes PJ Hegedus L Serum ionized calcium and intact parathyroid hormone levels during pregnancy and postpartum Br J Obstet Gynaecol 199097857-9
bull 46 Guyton AC Textbook of medical physiology 8th ed Philadelphia W B Saunders 1991 p 915e28
bull 47 Trainer PJ Corticosteroids and pregnancy Semin Reprod Med 200220375-80
bull 48 Soory M Hormonal factors in periodontal disease Dent Update 200027380-3
bull 49 Hugoson A Gingivitis in pregnant women A longitudinal clinical study Odontol Revy 19712265-84
bull 50 Neville BW Damm DD Allen CM Bouquot JE Oral amp Maxillofacial Pathology 3rd ed Philadelphia W B Saunders 2002 p 329-30 447-9
bull 51 Tilakaratne A Soory M Ranasinghe AW Corea SM Ekanayake SL de Silva M Periodontal disease status during pregnancy and 3 months post-partum in rural population of Sri-Lankan women J Clin Periodontol 200027787-92
bull 52 Laine M Tenovuo J Lehtonen OP Ojanatko-Harri A Vilja P Tuohimaa P Pregnancy e related changes in human whole saliva Arch Oral Biol 198833913-7
bull 53 Yuan K Wing LY Lin MT Pathogenetic roles of angiogenic factors in pyogenic granulomas in pregnancy are modulated by female sex hormones J Periodontol 200273701-8
bull 54 Evans RD Briggs PF Tooth-surface loss related to pregnancyinduced vomiting Prim Dent Care 1994124-6
bull 55 Salvolini E Di Giorgio R Curatola A Mazzanti L Fratto G Biochemical modifications of human whole saliva induced by pregnancy Br J Obstet Gynaec 1998105656-60
bull 56 Mauldin JG Newman RB Preterm birth risk assessment Semin Perinatol 200125215-22
bull 57 Heine RP McGregor JA Goodwin TM Artal R Hayashi RH Robertson PA et al Serial salivary estriol to detect an increased risk of preterm birth Obstet Gynecol 200096490-7
bull 58 Kauh YC Zachian TF Melasma Adv Exp Med Biol 1999455 491-9
bull 59 Wong RC Ellis CN Physiologic skin changes in pregnancy J Am Acad Dermatol 198410929-40
bull 60 Errickson CV Matus NR Skin disorders of pregnancy Am Fam Physician 199449605-10
bull 61 Lopez NJ Smith PC Gutierrez J Periodontal therapy may reduce the risk of preterm low birth weight in women with periodontal disease a randomized controlled trial J Periodontol 200273911-24
bull 62 McGaw T Periodontal disease and preterm delivery of lowbirth- weight infants J Can Dent Assoc 200268165-9
bull 63 Richards AG Dental x-ray protection Dent Clin North Am 1968631-41
bull 64 1990 Recommendations of the International Commission on Radiological Protection Ann ICRP 1991211-201
bull 65 Hall EJ Radiation the two-edged sword cancer risks at high and low doses Cancer J 20006343-50
bull 66 Diethelm L Xu H Diagnostic imaging of the lung during pregnancy Clin Obstet Gynecol 19963936-55
bull 67 Brent RL The effects of embryonic and fetal exposure to x-rays microwaves and ultrasound ClinObstetGynecol 198326484-510
bull 68 National Council on Radiation Protection NCRP report no128 1998 Bethesda Md Author
bull 69 Wasylko L Matsui D Dykxhoorn SM Reider MJ Weinberg S A review of common dental treatments during pregnancy implications for patients and dental personnel J Can Dent Assoc 199864434-9
bull 70 Freeman JP Brand JW Radiation doses of commonly used dental radiographic surveys Oral Surg Oral Med Oral Pathol 199477285-9
bull 71 Kircos LTAngin LL Lorton LOrder ofmagnitude dose reduction in intraoral radiography J Am Dent Assoc 1987114344-7
bull 72 Updegrave WJ Simplified and standardized intraoral radiography with reduced tissue irradiation J Am Dent Assoc 197285861-9
bull 73 Wood RE Harris AM van der Merwe EJ Nortje CJ The leaded apron revisited does it reduce gonadal radiation dose in dental radiology Oral Surg Oral Med Oral Pathol 199171642-6
bull 74 An update on radiographic practices information and recommendations ADA Council on Scientific Affairs J Am Dent Assoc 2001132234-8
bull 75 Rayburn WF Recommending medications during pregnancy an evidence based approach Clin Obstet Gynecol 2002451-5
bull 76 Rathmell JP Viscomi C Ashburn MA Management of nonobstetric pain during pregnancy and lactation Anesth Analg 1997851074-87
bull 77 Teratology society public affairs committee FDA classification of drugs for teratogenic risk Teratology 199449446-7
bull 78 Moore PA Selecting drugs for the pregnant dental patient J Am Dent Assoc 19981291281-6
bull 79 Haas DA An update on analgesics for the management of acute postoperative dental pain J Can Dent Assoc 200268476-82
bull 80 Haas DA Pynn BR Sands TD Drug use for the pregnant or lactating patient Gen Dent 20004854-60
bull 81 Committee on Drugs American Academy of Pediatrics The transfer of drugs and other chemicals into human milk Pediatrics 199493137-50
bull 82 Nielsen GL Sorensen HT Larsen H Pedersen L Risk of adverse birth outcome and miscarriage in pregnant users of nonsteroidal anti-inflammatory drugs population based observational study and case-control study BMJ 2001322266-70
bull 83 Janssen N Genta M The effects of immunosuppressive and anti-inflammatory medications on fertility pregnancy and lactation Arch Intern Med 200016610-9
bull 84 Ostensen M Nonsteroidal anti-inflammatory drugs during pregnancy Scand J Rheumatol Suppl 1998107128-32
bull 85 USPDI -Drug information for the health care professional 22nd ed Greenwood Village CO Micromedex 2002 p 152-79
bull 86 Denson DD Coyle DE Thompson GA Santos D Turner PA Myers JA et al Bupivacaine protein binding in the term parturient effects of lactic acidosis Clin Pharmacol Ther 198435702-9
bull 87 Dillon DE Wagner CL Wiest D Newman RB Drug therapy in the nursing mother Obstet Gynecol Clin North Am 199724 675-96
bull 88 Dashe JS Gilstrap LC Antibiotic use in pregnancy Obstet Gynecol Clin North Am 199724617-29
bull 89 American College of Rheumatology Ad hoc Committee on Clinical Guidelines Guidelines for monitoring drug therapy in rheumatoid arthritis Arthritis Rheum 199639723-31
bull 90 Ng PC The fetal and neonatal hypothalamic-pituitary-adrenal axis Arch Dis Child Fetal Neonatal Ed 200082F250-4
bull 91 Crowley P Antenatal corticosteroidsmdashcurrent thinking BJOG 2003110(Suppl 20)77-8
bull 92 ACOG committee opinion antenatal corticosteroid therapy for fetal maturation Obstet Gynecol 200299871-3
bull 93 Ost L Wettrell G Bjorkhem I Rane A Prednisolone excretion in human milk J Pediatr 19851061008-11
bull 94 Rowland AS Baird DD Shore DL Weinberg CR Savitz DA Wilcox AJ Nitrous oxide and spontaneous abortion in female dental assistants Am J Epidemiol 1995141531-8
bull 95 McGlothlin JD Jensen PA Fischbach TJ Hughes RT Jones JH Control of anesthetic gases in dental operatories Scand J Work Environ Health 199218(Suppl 2)103-5
bull ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY Volume 97 Number 6 Suresh and Radfar 681
bull 96 Rosen MA Nitrous oxide for relief of labor pain a systematic review Am J Obstet Gynecol 2002186(Suppl Nature)S110-6
bull 97 Sands TD Pynn BR Management considerations for the pregnant or nursing emergency patient Ont Dent 199875 17-9
bull 98 Daya S Recurrent spontaneous early pregnancy loss and low dose aspirin Minerva Ginecol 200355441-9
bull 99 Sinclair C Handbook of obstetrical emergencies 1st ed Philadelphia WB Saunders 1996 p 29-39 69
bull 100 Tarsitano BF Rollings RE The pregnant dental patient evaluation and management Gen Dent 199341226-34
bull 101 Livingston MH Dlllinger TM Holder R Consideration in the management of the pregnant patient SCD Special Care in Dentistry 199818183-8
Thank you
- A Review on the principle of Dental Management of the Pregnant patient
- Slide 2
- Questions that a dentist may ask
- Stages of Pregnancy
- Slide 5
- Slide 6
- Physiologic Changes in Pregnancy
- Systemic changes in pregnancy
- FLAT SUPINE POSITIONING
- SUPINE HYPOTENSION SYNDROME (Vena Cava Compression)
- Supine Hypotension Syndrome
- Slide 12
- Supine Hypotension Syndrome
- Prevention of Supine Hypotensive Syndrome
- Treatment of Supine Hypotensive Syndrome
- How should the pregnant woman be positioned
- Slide 17
- Slide 18
- Slide 19
- Slide 20
- Slide 21
- Slide 22
- Slide 23
- Pregnancy Related Oral Health Problems
- Oral Problems in Pregnancy
- Pregnancy Gingivitis Pathophysiology
- Pregnancy Gingivitis
- Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Gum Problems - Pregnancy Granuloma
- Slide 31
- Gum Changes - Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Candidiasis
- Pregnancy Myths
- Other Oral Conditions in Pregnancy
- Changes During Pregnancy that Affect Oral Health
- Saliva changes
- Increased Bacteria
- Slide 40
- Enamel erosion caused by frequent vomiting
- Treatment for Acid Exposure
- Oral Diseases Can Effect Pregnancy
- Periodontal Disease and Preterm Labor
- Periodontal Disease and Low Birth Weight
- Periodontal Disease and Preeclampsia
- Periodontitis and Pre-eclampsia
- Dental Considerations
- Treatment Timing
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Slide 52
- Use of Radiation on Pregnant Patient
- Radiographs during Pregnancy
- Risks of Dental X-Rays
- FDA drug classification for pregnancy
- Slide 57
- FDA drug classification for pregnancy
- Slide 59
- Slide 60
- Slide 61
- Common Analgesics
- Analgesics
- Analgesics - continued
- Analgesics to Use During 1st and 2nd Trimester
- Analgesics to Avoid During the Third Trimester
- Sedation in Pregnancy
- Common Antibiotics
- Antibiotics
- Antibiotics To Use During Pregnancy
- Antibiotics to Avoid during Pregnancy
- The Problem With Tetracycline
- Other Antimicrobial Agents
- Local Anesthetic Use in Pregnancy
- Use of Local Anesthetics
- Ulcer healing drugs
- Slide 77
- Slide 78
- Slide 79
- Use of Nitrous Oxide Gas
- Common Preventives
- Are topical agents safe
- Pre-natal Fluoride
- Is it safe to use mercury restorations
- References
- REFERENCES
- Slide 87
- Slide 88
- Slide 89
- Slide 90
- Slide 91
- Slide 92
- Slide 93
- Slide 94
- Slide 95
- Slide 96
- Slide 97
- Slide 98
- Thank you
-
Antibioticsbull penicillin V and amoxicillin is preferred drug
for mild to moderate infectionsbull widely used for many years with no ill effectsbull no studies show penicillin to be teratogenicbull amoxicillin extensively used without harming
the fetusbull Drug classes1048715 B penicillin cephalosporins erythromycin clindamycin Azithromycin D Tetracycline
Antibiotics To Use During Pregnancy
bull Penicillin Vbull Amoxicillinbull Erythromycin (base form)bull Cephalexin cephalosporinbull Clindamycinbull Metronidazole
Antibiotics to Avoid duringPregnancy
bull Doxycyclinebull Tetracyclinebull Erythromycin (estolate form)bull Vancomycin
The Problem With Tetracycline
bull Accumulates in bones and chelates calcium
bull Inhibits bone growthbull Discolors teeth
Other Antimicrobial Agentsbull OK to usebull Nystatin (B)bull Chlorhexidine rinse (B)bull Use with cautionbull Clotrimazole (C)bull Ketoconazole (C)bull Fluconazole (C)bull Do not usebull Doxycycline (D)
Local Anesthetic Use inPregnancy
bull Class Bbull Lidocaine (Xylocaine)bull Etidocainebull Prilocaine bull Class Cbull Procainebull Bupivicainebull Mepivicaine
Use of Local Anestheticsbull Lidocaine + vasoconstrictor most common
local anesthetic used in dentistrybull extensively used in pregnancy with no proven ill
effectsbull accidental intravascular injections of lidocaine
pass through the placenta but the concentrations are too low to harm fetus
bull prilocaine might cause methemoglobinemia
Ulcer healing drugsCimetidine bull FDA category B Famotidinebull FDA category BRanitidinebull FDA category Bbull not known to be harmful
Ulcer healing drugsOmeprazolebull FDA category BNot known to be
harmful Esomeprazolebull FDA category BLansoprazolebull FDA category BPantoprazolebull Avoid unless potential benefit
outweighs riskmdashfetotoxic in animals
Ulcer healing drugs
Misoprostolbull First second third trimesters Avoidmdash
potent uterine stimulant (has been used to induce abortion) and may be teratogenic
Ulcer healing drugs
Antacidsbull Almunium hydroxideMagnesium
hydroxidemdashFDA category B Calcium carbonatemdashFDA category C
SimetheconemdashFDA category C
Use of Nitrous Oxide Gas
bull used over 150 years bull safety is being debatedbull SHORT TERM exposure do not cause
birth defects or spontaneous abortionbull CHRONIC exposure may result in fetal
loss and infertilitybull literature suggests that nitrous oxide
should be avoided until more conclusive research is available
bull FDA Drug class not yet assigned
Common Preventives
bull Fluoridendash No increased risk during pregnancy
bull Xylitolndash No studies no harm reported
bull Chlorhexidinendash No increased risk during pregnancy
Are topical agents safe
bull Fluoridebull Toothpaste amp mouthrinse
bull Xylitol chewing gum bull Chlorhexidine (11 alcohol)bull No over the counter mouthrinses with
alcohol (Listerine 20 alcohol)
Pre-natal Fluoride
bull Daily 22 mg tablet of sodium fluoride during 3rd through 9th months
bull decreases caries rate in offspringbull Safe and effective
Glenn FB 1982
Is it safe to use mercury restorations
bull No evidence of harmful effect
bull Benefits outweigh risks
bull Canada Germany and New Zealand have some restrictions
bull Determine the best option
Referencesbull Wasylko L Matsui D Dykxhoorn SM Rieder MJ Weinberg
S A Review of Common Dental Treatments During Pregnancy J Canadian Dental Association 64434-439 1998
bull Little JW Donald AF Craig SM Rhodus NL Dental Management of the Medically Compromised Patient - 5th edition Mosby Toronto Pp434-442 1997
bull Livingston HM Dellinger TM Holder R Considerations in the management of the pregnant patient Special Care in Dentistry 185 pp183-188 1998
bull Larimore WL Petrie KA Drug use during pregnacy and lactation Primary Care Clinics in Office Practice 271 35-53 2000
bull Health Canada The Safety of DentalAmalgam Minister Of Supply and Services Canada 1996
REFERENCESbull 1 Weiss G Endocrinology of parturition J Clin
Endocrinol Metab 2000854421-5bull 2 Theunissen IM Parer JT Fluid and electrolytes in
pregnancy Clin Obstet Gynecol 1994373-15bull 3 Duvekot JJ Peeters LLH Renal hemodynamics and
volume homeostasis in pregnancy Obstet Gynecol Surv 199449830-9
bull 4 Barron WM Lindheimer MD Medical disorders during pregnancy 2nd ed St Louis Mosby 1995 p 129
bull 5 Thornburg KL Jacobson SL Giraud GD Morton MJ Hemodynamic changes in pregnancy Semin Perinatol 20002411-4
bull 6 Fiese R Herzog S Issues in dental and surgical management of the pregnant patient Oral Surg Oral Med Oral Pathol 198865292-7
bull 7 Martin C Varner MW Physiologic changes in pregnancysurgical implications Clin Obstet Gynecol 199437241-55
bull 8 Clark SL Cotton DB Lee W Bishop C Hill T Southwick J et al Central hemodynamic assessment of normal term pregnancy Am J Obstet Gynecol 19891611439-42
bull 9 Mabie WC Di Sessa TG Crocker LG Sibai BM Arheart KL A longitudinal study of cardiac output in normal human pregnancy Am J Obstet Gynecol 1994170849-56
bull 10 Clapp JF 3rd Capeless E Cardiovascular function before during and after the first and subsequent pregnancies Am J Cardiol 1997801469-73
bull 11 Duvekot JJ Peeters LL Maternal cardiovascular hemodynamic adaptation to pregnancy Obstet Gynecol Surv 199449(Suppl) S1-14
bull 12 Bhagwat AR Engel PJ Heart disease and pregnancy Cardiol Clin 199513163-78
bull 13 Lanni SM Tillinghast J Silver H Hemodynamic changes and baroreflex gain in the supine hypotensive syndrome Am J Obstet Gynecol 20021871636-41
bull 14 Little JW Falace DA Miller CS Rhodus NL Dental management of the medically compromised patient 6th ed St Louis Mosby 2002 p 303
bull 15 Garcia-Rio F Pino JM Gomez L Alvarez-Sala R Villasante C Villamor J Regulation of breathing and perception of dyspnea in healthy pregnant women Chest 1996110446-53
bull 16 McAuliffe F Kametas N Costello J Rafferty GF Greenough A Nicolaides K Respiratory function in singleton and twin pregnancy BJOG 2002109765-9
bull 17 Clapp JF 3rd Seaward BL Sleamaker RH Hiser J Maternal physiologic adaptations to early human pregnancy Am J Obstet Gynecol 19881591456-60
bull 18 OrsquoDay MP Cardio-respiratory physiological adaptation of pregnancy Semin Perinatol 199721268-75
bull 19 Contreras G Gutierrez M Beroiza T Fantin A Oddo H Villarroel L et al Ventilatory drive and respiratory muscle function in pregnancy Am Rev Respir Dis 1991144837-41
bull 20 Turner M Aziz SR Management of the pregnant oral and maxillofac
bull 21 Sifakis S Pharmakides G Anemia in pregnancy Ann N Y Acad Sci 2000900125-36
bull 22 Branch DW Physiologic adaptations of pregnancy Am J Reprod Immunol 199228120-2
bull 23 Burrows RF Kelton JG Incidentally detected thrombocytopenia in healthy mothers and their infants N Engl J Med 1988319 142-5
bull 24 Hanly JG Antiphospholipid syndrome an overview CMAJ 200324(168)1675-82
bull 25 Heilmann L von Tempelhoff GF Pollow K Antiphospholipid syndrome in obstetrics Clin Appl Thromb Hemost 20039 143-50
bull 26 Sherman P Flaxman SM Nausea and vomiting of pregnancy in an evolutionary perspective Am J Obstet Gynecol 2002 185(Suppl)s190-7
bull 27 Koch KL Gastrointestinal factors in nausea and vomiting of pregnancy Am J Obstet Gynecol 2002185(Suppl)s198-203
bull 28 Koch KL Frissora CL Nausea and vomiting during pregnancy Gastroenterol Clin N Am 200332201-34
bull 29 Baron TH Ramirez B Richter JE Gastrointestinal motility disorders during pregnancy Ann Intern Med 1993118 366-75
bull 30 Richter JE Gastroesophageal reflux disease during pregnancy Gastroenterol Clin N Am 200332235-61
bull 31 Marrero JM Goggin PM de Caestecker JS Pearce JM Maxwell JD Determinants of pregnancy heartburn Br J Obstet Gynaecol 199299731-4
bull 32 Hamaoui E Hamaoui M Nutritional assessment and support during pregnancy Gastroenterol Clin N Am 20033259-121
bull 33 King JC Physiology of pregnancy and nutrient metabolism Am J Clin Nutr 200071(suppl)1218s-25s
bull 34 Casanueva E Pfeffer F Fernandez-Gaxiola AC Gutierrez- Valenzuela V Rothenberg SJ Iron and folate status before pregnancy and anemia during pregnancy Ann Nutr Metab 2003 4760-3
bull 35 Chrsquong CL Morgan M Hainsworth I Kingham JG Prospective study of liver dysfunction in Southwest Wales Gut 200251 876-80
bull 36 Rahman TM Wendon J Severe hepatic dysfunction in pregnancy QJM 200295343-57
bull 37 Knox TA Olans LB Liver disease in pregnancy N Engl J Med 1996335569-76
bull 38 Saftlas AF Olson DR Franks AL Atrash H Pokras R Epidemiology of preeclampsia and eclampsia in the United States 1979e1986 Am J Obstet Gynecol 1990163460-5
bull 39 Walker JJ Pre-eclampsia Lancet 20003561260-5
bull 40 Davidson JM Renal disorders in pregnancy Curr Opin Obstet Gynecol 200113109-14
bull 41 Dafnis E Sabatini S The effect of pregnancy on renal function physiology and pathophysiologyAmJMedSci 1992303184-205
bull 42 Davison JM Shiells EA Philips PR Lindheimer MD Serial evaluation of vasopressin release and thirst in human pregnancy Role of human chorionic gonadotrophin in the osmoregulatory changes of gestation J Clin Invest 198881798-806
bull 43 Glinoer D de Nayer P Bourdoux P Lemone M Robyn C van Steirteghem A et al Regulation of maternal thyroid during pregnancy J Clin Endocrinol Metab 199071276-87
bull 44 Wilson SG Retallack RW Kent JC Worth GK Gutteridge DH Serum free 125-dihydroxyvitamin D and the free 125- dihydroxyvitamin D index during a longitudinal study of human pregnancy and lactation Clin Endocrinol 199032613-22
bull 45 Rasmussen N Frolich A Hornnes PJ Hegedus L Serum ionized calcium and intact parathyroid hormone levels during pregnancy and postpartum Br J Obstet Gynaecol 199097857-9
bull 46 Guyton AC Textbook of medical physiology 8th ed Philadelphia W B Saunders 1991 p 915e28
bull 47 Trainer PJ Corticosteroids and pregnancy Semin Reprod Med 200220375-80
bull 48 Soory M Hormonal factors in periodontal disease Dent Update 200027380-3
bull 49 Hugoson A Gingivitis in pregnant women A longitudinal clinical study Odontol Revy 19712265-84
bull 50 Neville BW Damm DD Allen CM Bouquot JE Oral amp Maxillofacial Pathology 3rd ed Philadelphia W B Saunders 2002 p 329-30 447-9
bull 51 Tilakaratne A Soory M Ranasinghe AW Corea SM Ekanayake SL de Silva M Periodontal disease status during pregnancy and 3 months post-partum in rural population of Sri-Lankan women J Clin Periodontol 200027787-92
bull 52 Laine M Tenovuo J Lehtonen OP Ojanatko-Harri A Vilja P Tuohimaa P Pregnancy e related changes in human whole saliva Arch Oral Biol 198833913-7
bull 53 Yuan K Wing LY Lin MT Pathogenetic roles of angiogenic factors in pyogenic granulomas in pregnancy are modulated by female sex hormones J Periodontol 200273701-8
bull 54 Evans RD Briggs PF Tooth-surface loss related to pregnancyinduced vomiting Prim Dent Care 1994124-6
bull 55 Salvolini E Di Giorgio R Curatola A Mazzanti L Fratto G Biochemical modifications of human whole saliva induced by pregnancy Br J Obstet Gynaec 1998105656-60
bull 56 Mauldin JG Newman RB Preterm birth risk assessment Semin Perinatol 200125215-22
bull 57 Heine RP McGregor JA Goodwin TM Artal R Hayashi RH Robertson PA et al Serial salivary estriol to detect an increased risk of preterm birth Obstet Gynecol 200096490-7
bull 58 Kauh YC Zachian TF Melasma Adv Exp Med Biol 1999455 491-9
bull 59 Wong RC Ellis CN Physiologic skin changes in pregnancy J Am Acad Dermatol 198410929-40
bull 60 Errickson CV Matus NR Skin disorders of pregnancy Am Fam Physician 199449605-10
bull 61 Lopez NJ Smith PC Gutierrez J Periodontal therapy may reduce the risk of preterm low birth weight in women with periodontal disease a randomized controlled trial J Periodontol 200273911-24
bull 62 McGaw T Periodontal disease and preterm delivery of lowbirth- weight infants J Can Dent Assoc 200268165-9
bull 63 Richards AG Dental x-ray protection Dent Clin North Am 1968631-41
bull 64 1990 Recommendations of the International Commission on Radiological Protection Ann ICRP 1991211-201
bull 65 Hall EJ Radiation the two-edged sword cancer risks at high and low doses Cancer J 20006343-50
bull 66 Diethelm L Xu H Diagnostic imaging of the lung during pregnancy Clin Obstet Gynecol 19963936-55
bull 67 Brent RL The effects of embryonic and fetal exposure to x-rays microwaves and ultrasound ClinObstetGynecol 198326484-510
bull 68 National Council on Radiation Protection NCRP report no128 1998 Bethesda Md Author
bull 69 Wasylko L Matsui D Dykxhoorn SM Reider MJ Weinberg S A review of common dental treatments during pregnancy implications for patients and dental personnel J Can Dent Assoc 199864434-9
bull 70 Freeman JP Brand JW Radiation doses of commonly used dental radiographic surveys Oral Surg Oral Med Oral Pathol 199477285-9
bull 71 Kircos LTAngin LL Lorton LOrder ofmagnitude dose reduction in intraoral radiography J Am Dent Assoc 1987114344-7
bull 72 Updegrave WJ Simplified and standardized intraoral radiography with reduced tissue irradiation J Am Dent Assoc 197285861-9
bull 73 Wood RE Harris AM van der Merwe EJ Nortje CJ The leaded apron revisited does it reduce gonadal radiation dose in dental radiology Oral Surg Oral Med Oral Pathol 199171642-6
bull 74 An update on radiographic practices information and recommendations ADA Council on Scientific Affairs J Am Dent Assoc 2001132234-8
bull 75 Rayburn WF Recommending medications during pregnancy an evidence based approach Clin Obstet Gynecol 2002451-5
bull 76 Rathmell JP Viscomi C Ashburn MA Management of nonobstetric pain during pregnancy and lactation Anesth Analg 1997851074-87
bull 77 Teratology society public affairs committee FDA classification of drugs for teratogenic risk Teratology 199449446-7
bull 78 Moore PA Selecting drugs for the pregnant dental patient J Am Dent Assoc 19981291281-6
bull 79 Haas DA An update on analgesics for the management of acute postoperative dental pain J Can Dent Assoc 200268476-82
bull 80 Haas DA Pynn BR Sands TD Drug use for the pregnant or lactating patient Gen Dent 20004854-60
bull 81 Committee on Drugs American Academy of Pediatrics The transfer of drugs and other chemicals into human milk Pediatrics 199493137-50
bull 82 Nielsen GL Sorensen HT Larsen H Pedersen L Risk of adverse birth outcome and miscarriage in pregnant users of nonsteroidal anti-inflammatory drugs population based observational study and case-control study BMJ 2001322266-70
bull 83 Janssen N Genta M The effects of immunosuppressive and anti-inflammatory medications on fertility pregnancy and lactation Arch Intern Med 200016610-9
bull 84 Ostensen M Nonsteroidal anti-inflammatory drugs during pregnancy Scand J Rheumatol Suppl 1998107128-32
bull 85 USPDI -Drug information for the health care professional 22nd ed Greenwood Village CO Micromedex 2002 p 152-79
bull 86 Denson DD Coyle DE Thompson GA Santos D Turner PA Myers JA et al Bupivacaine protein binding in the term parturient effects of lactic acidosis Clin Pharmacol Ther 198435702-9
bull 87 Dillon DE Wagner CL Wiest D Newman RB Drug therapy in the nursing mother Obstet Gynecol Clin North Am 199724 675-96
bull 88 Dashe JS Gilstrap LC Antibiotic use in pregnancy Obstet Gynecol Clin North Am 199724617-29
bull 89 American College of Rheumatology Ad hoc Committee on Clinical Guidelines Guidelines for monitoring drug therapy in rheumatoid arthritis Arthritis Rheum 199639723-31
bull 90 Ng PC The fetal and neonatal hypothalamic-pituitary-adrenal axis Arch Dis Child Fetal Neonatal Ed 200082F250-4
bull 91 Crowley P Antenatal corticosteroidsmdashcurrent thinking BJOG 2003110(Suppl 20)77-8
bull 92 ACOG committee opinion antenatal corticosteroid therapy for fetal maturation Obstet Gynecol 200299871-3
bull 93 Ost L Wettrell G Bjorkhem I Rane A Prednisolone excretion in human milk J Pediatr 19851061008-11
bull 94 Rowland AS Baird DD Shore DL Weinberg CR Savitz DA Wilcox AJ Nitrous oxide and spontaneous abortion in female dental assistants Am J Epidemiol 1995141531-8
bull 95 McGlothlin JD Jensen PA Fischbach TJ Hughes RT Jones JH Control of anesthetic gases in dental operatories Scand J Work Environ Health 199218(Suppl 2)103-5
bull ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY Volume 97 Number 6 Suresh and Radfar 681
bull 96 Rosen MA Nitrous oxide for relief of labor pain a systematic review Am J Obstet Gynecol 2002186(Suppl Nature)S110-6
bull 97 Sands TD Pynn BR Management considerations for the pregnant or nursing emergency patient Ont Dent 199875 17-9
bull 98 Daya S Recurrent spontaneous early pregnancy loss and low dose aspirin Minerva Ginecol 200355441-9
bull 99 Sinclair C Handbook of obstetrical emergencies 1st ed Philadelphia WB Saunders 1996 p 29-39 69
bull 100 Tarsitano BF Rollings RE The pregnant dental patient evaluation and management Gen Dent 199341226-34
bull 101 Livingston MH Dlllinger TM Holder R Consideration in the management of the pregnant patient SCD Special Care in Dentistry 199818183-8
Thank you
- A Review on the principle of Dental Management of the Pregnant patient
- Slide 2
- Questions that a dentist may ask
- Stages of Pregnancy
- Slide 5
- Slide 6
- Physiologic Changes in Pregnancy
- Systemic changes in pregnancy
- FLAT SUPINE POSITIONING
- SUPINE HYPOTENSION SYNDROME (Vena Cava Compression)
- Supine Hypotension Syndrome
- Slide 12
- Supine Hypotension Syndrome
- Prevention of Supine Hypotensive Syndrome
- Treatment of Supine Hypotensive Syndrome
- How should the pregnant woman be positioned
- Slide 17
- Slide 18
- Slide 19
- Slide 20
- Slide 21
- Slide 22
- Slide 23
- Pregnancy Related Oral Health Problems
- Oral Problems in Pregnancy
- Pregnancy Gingivitis Pathophysiology
- Pregnancy Gingivitis
- Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Gum Problems - Pregnancy Granuloma
- Slide 31
- Gum Changes - Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Candidiasis
- Pregnancy Myths
- Other Oral Conditions in Pregnancy
- Changes During Pregnancy that Affect Oral Health
- Saliva changes
- Increased Bacteria
- Slide 40
- Enamel erosion caused by frequent vomiting
- Treatment for Acid Exposure
- Oral Diseases Can Effect Pregnancy
- Periodontal Disease and Preterm Labor
- Periodontal Disease and Low Birth Weight
- Periodontal Disease and Preeclampsia
- Periodontitis and Pre-eclampsia
- Dental Considerations
- Treatment Timing
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Slide 52
- Use of Radiation on Pregnant Patient
- Radiographs during Pregnancy
- Risks of Dental X-Rays
- FDA drug classification for pregnancy
- Slide 57
- FDA drug classification for pregnancy
- Slide 59
- Slide 60
- Slide 61
- Common Analgesics
- Analgesics
- Analgesics - continued
- Analgesics to Use During 1st and 2nd Trimester
- Analgesics to Avoid During the Third Trimester
- Sedation in Pregnancy
- Common Antibiotics
- Antibiotics
- Antibiotics To Use During Pregnancy
- Antibiotics to Avoid during Pregnancy
- The Problem With Tetracycline
- Other Antimicrobial Agents
- Local Anesthetic Use in Pregnancy
- Use of Local Anesthetics
- Ulcer healing drugs
- Slide 77
- Slide 78
- Slide 79
- Use of Nitrous Oxide Gas
- Common Preventives
- Are topical agents safe
- Pre-natal Fluoride
- Is it safe to use mercury restorations
- References
- REFERENCES
- Slide 87
- Slide 88
- Slide 89
- Slide 90
- Slide 91
- Slide 92
- Slide 93
- Slide 94
- Slide 95
- Slide 96
- Slide 97
- Slide 98
- Thank you
-
Antibiotics To Use During Pregnancy
bull Penicillin Vbull Amoxicillinbull Erythromycin (base form)bull Cephalexin cephalosporinbull Clindamycinbull Metronidazole
Antibiotics to Avoid duringPregnancy
bull Doxycyclinebull Tetracyclinebull Erythromycin (estolate form)bull Vancomycin
The Problem With Tetracycline
bull Accumulates in bones and chelates calcium
bull Inhibits bone growthbull Discolors teeth
Other Antimicrobial Agentsbull OK to usebull Nystatin (B)bull Chlorhexidine rinse (B)bull Use with cautionbull Clotrimazole (C)bull Ketoconazole (C)bull Fluconazole (C)bull Do not usebull Doxycycline (D)
Local Anesthetic Use inPregnancy
bull Class Bbull Lidocaine (Xylocaine)bull Etidocainebull Prilocaine bull Class Cbull Procainebull Bupivicainebull Mepivicaine
Use of Local Anestheticsbull Lidocaine + vasoconstrictor most common
local anesthetic used in dentistrybull extensively used in pregnancy with no proven ill
effectsbull accidental intravascular injections of lidocaine
pass through the placenta but the concentrations are too low to harm fetus
bull prilocaine might cause methemoglobinemia
Ulcer healing drugsCimetidine bull FDA category B Famotidinebull FDA category BRanitidinebull FDA category Bbull not known to be harmful
Ulcer healing drugsOmeprazolebull FDA category BNot known to be
harmful Esomeprazolebull FDA category BLansoprazolebull FDA category BPantoprazolebull Avoid unless potential benefit
outweighs riskmdashfetotoxic in animals
Ulcer healing drugs
Misoprostolbull First second third trimesters Avoidmdash
potent uterine stimulant (has been used to induce abortion) and may be teratogenic
Ulcer healing drugs
Antacidsbull Almunium hydroxideMagnesium
hydroxidemdashFDA category B Calcium carbonatemdashFDA category C
SimetheconemdashFDA category C
Use of Nitrous Oxide Gas
bull used over 150 years bull safety is being debatedbull SHORT TERM exposure do not cause
birth defects or spontaneous abortionbull CHRONIC exposure may result in fetal
loss and infertilitybull literature suggests that nitrous oxide
should be avoided until more conclusive research is available
bull FDA Drug class not yet assigned
Common Preventives
bull Fluoridendash No increased risk during pregnancy
bull Xylitolndash No studies no harm reported
bull Chlorhexidinendash No increased risk during pregnancy
Are topical agents safe
bull Fluoridebull Toothpaste amp mouthrinse
bull Xylitol chewing gum bull Chlorhexidine (11 alcohol)bull No over the counter mouthrinses with
alcohol (Listerine 20 alcohol)
Pre-natal Fluoride
bull Daily 22 mg tablet of sodium fluoride during 3rd through 9th months
bull decreases caries rate in offspringbull Safe and effective
Glenn FB 1982
Is it safe to use mercury restorations
bull No evidence of harmful effect
bull Benefits outweigh risks
bull Canada Germany and New Zealand have some restrictions
bull Determine the best option
Referencesbull Wasylko L Matsui D Dykxhoorn SM Rieder MJ Weinberg
S A Review of Common Dental Treatments During Pregnancy J Canadian Dental Association 64434-439 1998
bull Little JW Donald AF Craig SM Rhodus NL Dental Management of the Medically Compromised Patient - 5th edition Mosby Toronto Pp434-442 1997
bull Livingston HM Dellinger TM Holder R Considerations in the management of the pregnant patient Special Care in Dentistry 185 pp183-188 1998
bull Larimore WL Petrie KA Drug use during pregnacy and lactation Primary Care Clinics in Office Practice 271 35-53 2000
bull Health Canada The Safety of DentalAmalgam Minister Of Supply and Services Canada 1996
REFERENCESbull 1 Weiss G Endocrinology of parturition J Clin
Endocrinol Metab 2000854421-5bull 2 Theunissen IM Parer JT Fluid and electrolytes in
pregnancy Clin Obstet Gynecol 1994373-15bull 3 Duvekot JJ Peeters LLH Renal hemodynamics and
volume homeostasis in pregnancy Obstet Gynecol Surv 199449830-9
bull 4 Barron WM Lindheimer MD Medical disorders during pregnancy 2nd ed St Louis Mosby 1995 p 129
bull 5 Thornburg KL Jacobson SL Giraud GD Morton MJ Hemodynamic changes in pregnancy Semin Perinatol 20002411-4
bull 6 Fiese R Herzog S Issues in dental and surgical management of the pregnant patient Oral Surg Oral Med Oral Pathol 198865292-7
bull 7 Martin C Varner MW Physiologic changes in pregnancysurgical implications Clin Obstet Gynecol 199437241-55
bull 8 Clark SL Cotton DB Lee W Bishop C Hill T Southwick J et al Central hemodynamic assessment of normal term pregnancy Am J Obstet Gynecol 19891611439-42
bull 9 Mabie WC Di Sessa TG Crocker LG Sibai BM Arheart KL A longitudinal study of cardiac output in normal human pregnancy Am J Obstet Gynecol 1994170849-56
bull 10 Clapp JF 3rd Capeless E Cardiovascular function before during and after the first and subsequent pregnancies Am J Cardiol 1997801469-73
bull 11 Duvekot JJ Peeters LL Maternal cardiovascular hemodynamic adaptation to pregnancy Obstet Gynecol Surv 199449(Suppl) S1-14
bull 12 Bhagwat AR Engel PJ Heart disease and pregnancy Cardiol Clin 199513163-78
bull 13 Lanni SM Tillinghast J Silver H Hemodynamic changes and baroreflex gain in the supine hypotensive syndrome Am J Obstet Gynecol 20021871636-41
bull 14 Little JW Falace DA Miller CS Rhodus NL Dental management of the medically compromised patient 6th ed St Louis Mosby 2002 p 303
bull 15 Garcia-Rio F Pino JM Gomez L Alvarez-Sala R Villasante C Villamor J Regulation of breathing and perception of dyspnea in healthy pregnant women Chest 1996110446-53
bull 16 McAuliffe F Kametas N Costello J Rafferty GF Greenough A Nicolaides K Respiratory function in singleton and twin pregnancy BJOG 2002109765-9
bull 17 Clapp JF 3rd Seaward BL Sleamaker RH Hiser J Maternal physiologic adaptations to early human pregnancy Am J Obstet Gynecol 19881591456-60
bull 18 OrsquoDay MP Cardio-respiratory physiological adaptation of pregnancy Semin Perinatol 199721268-75
bull 19 Contreras G Gutierrez M Beroiza T Fantin A Oddo H Villarroel L et al Ventilatory drive and respiratory muscle function in pregnancy Am Rev Respir Dis 1991144837-41
bull 20 Turner M Aziz SR Management of the pregnant oral and maxillofac
bull 21 Sifakis S Pharmakides G Anemia in pregnancy Ann N Y Acad Sci 2000900125-36
bull 22 Branch DW Physiologic adaptations of pregnancy Am J Reprod Immunol 199228120-2
bull 23 Burrows RF Kelton JG Incidentally detected thrombocytopenia in healthy mothers and their infants N Engl J Med 1988319 142-5
bull 24 Hanly JG Antiphospholipid syndrome an overview CMAJ 200324(168)1675-82
bull 25 Heilmann L von Tempelhoff GF Pollow K Antiphospholipid syndrome in obstetrics Clin Appl Thromb Hemost 20039 143-50
bull 26 Sherman P Flaxman SM Nausea and vomiting of pregnancy in an evolutionary perspective Am J Obstet Gynecol 2002 185(Suppl)s190-7
bull 27 Koch KL Gastrointestinal factors in nausea and vomiting of pregnancy Am J Obstet Gynecol 2002185(Suppl)s198-203
bull 28 Koch KL Frissora CL Nausea and vomiting during pregnancy Gastroenterol Clin N Am 200332201-34
bull 29 Baron TH Ramirez B Richter JE Gastrointestinal motility disorders during pregnancy Ann Intern Med 1993118 366-75
bull 30 Richter JE Gastroesophageal reflux disease during pregnancy Gastroenterol Clin N Am 200332235-61
bull 31 Marrero JM Goggin PM de Caestecker JS Pearce JM Maxwell JD Determinants of pregnancy heartburn Br J Obstet Gynaecol 199299731-4
bull 32 Hamaoui E Hamaoui M Nutritional assessment and support during pregnancy Gastroenterol Clin N Am 20033259-121
bull 33 King JC Physiology of pregnancy and nutrient metabolism Am J Clin Nutr 200071(suppl)1218s-25s
bull 34 Casanueva E Pfeffer F Fernandez-Gaxiola AC Gutierrez- Valenzuela V Rothenberg SJ Iron and folate status before pregnancy and anemia during pregnancy Ann Nutr Metab 2003 4760-3
bull 35 Chrsquong CL Morgan M Hainsworth I Kingham JG Prospective study of liver dysfunction in Southwest Wales Gut 200251 876-80
bull 36 Rahman TM Wendon J Severe hepatic dysfunction in pregnancy QJM 200295343-57
bull 37 Knox TA Olans LB Liver disease in pregnancy N Engl J Med 1996335569-76
bull 38 Saftlas AF Olson DR Franks AL Atrash H Pokras R Epidemiology of preeclampsia and eclampsia in the United States 1979e1986 Am J Obstet Gynecol 1990163460-5
bull 39 Walker JJ Pre-eclampsia Lancet 20003561260-5
bull 40 Davidson JM Renal disorders in pregnancy Curr Opin Obstet Gynecol 200113109-14
bull 41 Dafnis E Sabatini S The effect of pregnancy on renal function physiology and pathophysiologyAmJMedSci 1992303184-205
bull 42 Davison JM Shiells EA Philips PR Lindheimer MD Serial evaluation of vasopressin release and thirst in human pregnancy Role of human chorionic gonadotrophin in the osmoregulatory changes of gestation J Clin Invest 198881798-806
bull 43 Glinoer D de Nayer P Bourdoux P Lemone M Robyn C van Steirteghem A et al Regulation of maternal thyroid during pregnancy J Clin Endocrinol Metab 199071276-87
bull 44 Wilson SG Retallack RW Kent JC Worth GK Gutteridge DH Serum free 125-dihydroxyvitamin D and the free 125- dihydroxyvitamin D index during a longitudinal study of human pregnancy and lactation Clin Endocrinol 199032613-22
bull 45 Rasmussen N Frolich A Hornnes PJ Hegedus L Serum ionized calcium and intact parathyroid hormone levels during pregnancy and postpartum Br J Obstet Gynaecol 199097857-9
bull 46 Guyton AC Textbook of medical physiology 8th ed Philadelphia W B Saunders 1991 p 915e28
bull 47 Trainer PJ Corticosteroids and pregnancy Semin Reprod Med 200220375-80
bull 48 Soory M Hormonal factors in periodontal disease Dent Update 200027380-3
bull 49 Hugoson A Gingivitis in pregnant women A longitudinal clinical study Odontol Revy 19712265-84
bull 50 Neville BW Damm DD Allen CM Bouquot JE Oral amp Maxillofacial Pathology 3rd ed Philadelphia W B Saunders 2002 p 329-30 447-9
bull 51 Tilakaratne A Soory M Ranasinghe AW Corea SM Ekanayake SL de Silva M Periodontal disease status during pregnancy and 3 months post-partum in rural population of Sri-Lankan women J Clin Periodontol 200027787-92
bull 52 Laine M Tenovuo J Lehtonen OP Ojanatko-Harri A Vilja P Tuohimaa P Pregnancy e related changes in human whole saliva Arch Oral Biol 198833913-7
bull 53 Yuan K Wing LY Lin MT Pathogenetic roles of angiogenic factors in pyogenic granulomas in pregnancy are modulated by female sex hormones J Periodontol 200273701-8
bull 54 Evans RD Briggs PF Tooth-surface loss related to pregnancyinduced vomiting Prim Dent Care 1994124-6
bull 55 Salvolini E Di Giorgio R Curatola A Mazzanti L Fratto G Biochemical modifications of human whole saliva induced by pregnancy Br J Obstet Gynaec 1998105656-60
bull 56 Mauldin JG Newman RB Preterm birth risk assessment Semin Perinatol 200125215-22
bull 57 Heine RP McGregor JA Goodwin TM Artal R Hayashi RH Robertson PA et al Serial salivary estriol to detect an increased risk of preterm birth Obstet Gynecol 200096490-7
bull 58 Kauh YC Zachian TF Melasma Adv Exp Med Biol 1999455 491-9
bull 59 Wong RC Ellis CN Physiologic skin changes in pregnancy J Am Acad Dermatol 198410929-40
bull 60 Errickson CV Matus NR Skin disorders of pregnancy Am Fam Physician 199449605-10
bull 61 Lopez NJ Smith PC Gutierrez J Periodontal therapy may reduce the risk of preterm low birth weight in women with periodontal disease a randomized controlled trial J Periodontol 200273911-24
bull 62 McGaw T Periodontal disease and preterm delivery of lowbirth- weight infants J Can Dent Assoc 200268165-9
bull 63 Richards AG Dental x-ray protection Dent Clin North Am 1968631-41
bull 64 1990 Recommendations of the International Commission on Radiological Protection Ann ICRP 1991211-201
bull 65 Hall EJ Radiation the two-edged sword cancer risks at high and low doses Cancer J 20006343-50
bull 66 Diethelm L Xu H Diagnostic imaging of the lung during pregnancy Clin Obstet Gynecol 19963936-55
bull 67 Brent RL The effects of embryonic and fetal exposure to x-rays microwaves and ultrasound ClinObstetGynecol 198326484-510
bull 68 National Council on Radiation Protection NCRP report no128 1998 Bethesda Md Author
bull 69 Wasylko L Matsui D Dykxhoorn SM Reider MJ Weinberg S A review of common dental treatments during pregnancy implications for patients and dental personnel J Can Dent Assoc 199864434-9
bull 70 Freeman JP Brand JW Radiation doses of commonly used dental radiographic surveys Oral Surg Oral Med Oral Pathol 199477285-9
bull 71 Kircos LTAngin LL Lorton LOrder ofmagnitude dose reduction in intraoral radiography J Am Dent Assoc 1987114344-7
bull 72 Updegrave WJ Simplified and standardized intraoral radiography with reduced tissue irradiation J Am Dent Assoc 197285861-9
bull 73 Wood RE Harris AM van der Merwe EJ Nortje CJ The leaded apron revisited does it reduce gonadal radiation dose in dental radiology Oral Surg Oral Med Oral Pathol 199171642-6
bull 74 An update on radiographic practices information and recommendations ADA Council on Scientific Affairs J Am Dent Assoc 2001132234-8
bull 75 Rayburn WF Recommending medications during pregnancy an evidence based approach Clin Obstet Gynecol 2002451-5
bull 76 Rathmell JP Viscomi C Ashburn MA Management of nonobstetric pain during pregnancy and lactation Anesth Analg 1997851074-87
bull 77 Teratology society public affairs committee FDA classification of drugs for teratogenic risk Teratology 199449446-7
bull 78 Moore PA Selecting drugs for the pregnant dental patient J Am Dent Assoc 19981291281-6
bull 79 Haas DA An update on analgesics for the management of acute postoperative dental pain J Can Dent Assoc 200268476-82
bull 80 Haas DA Pynn BR Sands TD Drug use for the pregnant or lactating patient Gen Dent 20004854-60
bull 81 Committee on Drugs American Academy of Pediatrics The transfer of drugs and other chemicals into human milk Pediatrics 199493137-50
bull 82 Nielsen GL Sorensen HT Larsen H Pedersen L Risk of adverse birth outcome and miscarriage in pregnant users of nonsteroidal anti-inflammatory drugs population based observational study and case-control study BMJ 2001322266-70
bull 83 Janssen N Genta M The effects of immunosuppressive and anti-inflammatory medications on fertility pregnancy and lactation Arch Intern Med 200016610-9
bull 84 Ostensen M Nonsteroidal anti-inflammatory drugs during pregnancy Scand J Rheumatol Suppl 1998107128-32
bull 85 USPDI -Drug information for the health care professional 22nd ed Greenwood Village CO Micromedex 2002 p 152-79
bull 86 Denson DD Coyle DE Thompson GA Santos D Turner PA Myers JA et al Bupivacaine protein binding in the term parturient effects of lactic acidosis Clin Pharmacol Ther 198435702-9
bull 87 Dillon DE Wagner CL Wiest D Newman RB Drug therapy in the nursing mother Obstet Gynecol Clin North Am 199724 675-96
bull 88 Dashe JS Gilstrap LC Antibiotic use in pregnancy Obstet Gynecol Clin North Am 199724617-29
bull 89 American College of Rheumatology Ad hoc Committee on Clinical Guidelines Guidelines for monitoring drug therapy in rheumatoid arthritis Arthritis Rheum 199639723-31
bull 90 Ng PC The fetal and neonatal hypothalamic-pituitary-adrenal axis Arch Dis Child Fetal Neonatal Ed 200082F250-4
bull 91 Crowley P Antenatal corticosteroidsmdashcurrent thinking BJOG 2003110(Suppl 20)77-8
bull 92 ACOG committee opinion antenatal corticosteroid therapy for fetal maturation Obstet Gynecol 200299871-3
bull 93 Ost L Wettrell G Bjorkhem I Rane A Prednisolone excretion in human milk J Pediatr 19851061008-11
bull 94 Rowland AS Baird DD Shore DL Weinberg CR Savitz DA Wilcox AJ Nitrous oxide and spontaneous abortion in female dental assistants Am J Epidemiol 1995141531-8
bull 95 McGlothlin JD Jensen PA Fischbach TJ Hughes RT Jones JH Control of anesthetic gases in dental operatories Scand J Work Environ Health 199218(Suppl 2)103-5
bull ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY Volume 97 Number 6 Suresh and Radfar 681
bull 96 Rosen MA Nitrous oxide for relief of labor pain a systematic review Am J Obstet Gynecol 2002186(Suppl Nature)S110-6
bull 97 Sands TD Pynn BR Management considerations for the pregnant or nursing emergency patient Ont Dent 199875 17-9
bull 98 Daya S Recurrent spontaneous early pregnancy loss and low dose aspirin Minerva Ginecol 200355441-9
bull 99 Sinclair C Handbook of obstetrical emergencies 1st ed Philadelphia WB Saunders 1996 p 29-39 69
bull 100 Tarsitano BF Rollings RE The pregnant dental patient evaluation and management Gen Dent 199341226-34
bull 101 Livingston MH Dlllinger TM Holder R Consideration in the management of the pregnant patient SCD Special Care in Dentistry 199818183-8
Thank you
- A Review on the principle of Dental Management of the Pregnant patient
- Slide 2
- Questions that a dentist may ask
- Stages of Pregnancy
- Slide 5
- Slide 6
- Physiologic Changes in Pregnancy
- Systemic changes in pregnancy
- FLAT SUPINE POSITIONING
- SUPINE HYPOTENSION SYNDROME (Vena Cava Compression)
- Supine Hypotension Syndrome
- Slide 12
- Supine Hypotension Syndrome
- Prevention of Supine Hypotensive Syndrome
- Treatment of Supine Hypotensive Syndrome
- How should the pregnant woman be positioned
- Slide 17
- Slide 18
- Slide 19
- Slide 20
- Slide 21
- Slide 22
- Slide 23
- Pregnancy Related Oral Health Problems
- Oral Problems in Pregnancy
- Pregnancy Gingivitis Pathophysiology
- Pregnancy Gingivitis
- Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Gum Problems - Pregnancy Granuloma
- Slide 31
- Gum Changes - Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Candidiasis
- Pregnancy Myths
- Other Oral Conditions in Pregnancy
- Changes During Pregnancy that Affect Oral Health
- Saliva changes
- Increased Bacteria
- Slide 40
- Enamel erosion caused by frequent vomiting
- Treatment for Acid Exposure
- Oral Diseases Can Effect Pregnancy
- Periodontal Disease and Preterm Labor
- Periodontal Disease and Low Birth Weight
- Periodontal Disease and Preeclampsia
- Periodontitis and Pre-eclampsia
- Dental Considerations
- Treatment Timing
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Slide 52
- Use of Radiation on Pregnant Patient
- Radiographs during Pregnancy
- Risks of Dental X-Rays
- FDA drug classification for pregnancy
- Slide 57
- FDA drug classification for pregnancy
- Slide 59
- Slide 60
- Slide 61
- Common Analgesics
- Analgesics
- Analgesics - continued
- Analgesics to Use During 1st and 2nd Trimester
- Analgesics to Avoid During the Third Trimester
- Sedation in Pregnancy
- Common Antibiotics
- Antibiotics
- Antibiotics To Use During Pregnancy
- Antibiotics to Avoid during Pregnancy
- The Problem With Tetracycline
- Other Antimicrobial Agents
- Local Anesthetic Use in Pregnancy
- Use of Local Anesthetics
- Ulcer healing drugs
- Slide 77
- Slide 78
- Slide 79
- Use of Nitrous Oxide Gas
- Common Preventives
- Are topical agents safe
- Pre-natal Fluoride
- Is it safe to use mercury restorations
- References
- REFERENCES
- Slide 87
- Slide 88
- Slide 89
- Slide 90
- Slide 91
- Slide 92
- Slide 93
- Slide 94
- Slide 95
- Slide 96
- Slide 97
- Slide 98
- Thank you
-
Antibiotics to Avoid duringPregnancy
bull Doxycyclinebull Tetracyclinebull Erythromycin (estolate form)bull Vancomycin
The Problem With Tetracycline
bull Accumulates in bones and chelates calcium
bull Inhibits bone growthbull Discolors teeth
Other Antimicrobial Agentsbull OK to usebull Nystatin (B)bull Chlorhexidine rinse (B)bull Use with cautionbull Clotrimazole (C)bull Ketoconazole (C)bull Fluconazole (C)bull Do not usebull Doxycycline (D)
Local Anesthetic Use inPregnancy
bull Class Bbull Lidocaine (Xylocaine)bull Etidocainebull Prilocaine bull Class Cbull Procainebull Bupivicainebull Mepivicaine
Use of Local Anestheticsbull Lidocaine + vasoconstrictor most common
local anesthetic used in dentistrybull extensively used in pregnancy with no proven ill
effectsbull accidental intravascular injections of lidocaine
pass through the placenta but the concentrations are too low to harm fetus
bull prilocaine might cause methemoglobinemia
Ulcer healing drugsCimetidine bull FDA category B Famotidinebull FDA category BRanitidinebull FDA category Bbull not known to be harmful
Ulcer healing drugsOmeprazolebull FDA category BNot known to be
harmful Esomeprazolebull FDA category BLansoprazolebull FDA category BPantoprazolebull Avoid unless potential benefit
outweighs riskmdashfetotoxic in animals
Ulcer healing drugs
Misoprostolbull First second third trimesters Avoidmdash
potent uterine stimulant (has been used to induce abortion) and may be teratogenic
Ulcer healing drugs
Antacidsbull Almunium hydroxideMagnesium
hydroxidemdashFDA category B Calcium carbonatemdashFDA category C
SimetheconemdashFDA category C
Use of Nitrous Oxide Gas
bull used over 150 years bull safety is being debatedbull SHORT TERM exposure do not cause
birth defects or spontaneous abortionbull CHRONIC exposure may result in fetal
loss and infertilitybull literature suggests that nitrous oxide
should be avoided until more conclusive research is available
bull FDA Drug class not yet assigned
Common Preventives
bull Fluoridendash No increased risk during pregnancy
bull Xylitolndash No studies no harm reported
bull Chlorhexidinendash No increased risk during pregnancy
Are topical agents safe
bull Fluoridebull Toothpaste amp mouthrinse
bull Xylitol chewing gum bull Chlorhexidine (11 alcohol)bull No over the counter mouthrinses with
alcohol (Listerine 20 alcohol)
Pre-natal Fluoride
bull Daily 22 mg tablet of sodium fluoride during 3rd through 9th months
bull decreases caries rate in offspringbull Safe and effective
Glenn FB 1982
Is it safe to use mercury restorations
bull No evidence of harmful effect
bull Benefits outweigh risks
bull Canada Germany and New Zealand have some restrictions
bull Determine the best option
Referencesbull Wasylko L Matsui D Dykxhoorn SM Rieder MJ Weinberg
S A Review of Common Dental Treatments During Pregnancy J Canadian Dental Association 64434-439 1998
bull Little JW Donald AF Craig SM Rhodus NL Dental Management of the Medically Compromised Patient - 5th edition Mosby Toronto Pp434-442 1997
bull Livingston HM Dellinger TM Holder R Considerations in the management of the pregnant patient Special Care in Dentistry 185 pp183-188 1998
bull Larimore WL Petrie KA Drug use during pregnacy and lactation Primary Care Clinics in Office Practice 271 35-53 2000
bull Health Canada The Safety of DentalAmalgam Minister Of Supply and Services Canada 1996
REFERENCESbull 1 Weiss G Endocrinology of parturition J Clin
Endocrinol Metab 2000854421-5bull 2 Theunissen IM Parer JT Fluid and electrolytes in
pregnancy Clin Obstet Gynecol 1994373-15bull 3 Duvekot JJ Peeters LLH Renal hemodynamics and
volume homeostasis in pregnancy Obstet Gynecol Surv 199449830-9
bull 4 Barron WM Lindheimer MD Medical disorders during pregnancy 2nd ed St Louis Mosby 1995 p 129
bull 5 Thornburg KL Jacobson SL Giraud GD Morton MJ Hemodynamic changes in pregnancy Semin Perinatol 20002411-4
bull 6 Fiese R Herzog S Issues in dental and surgical management of the pregnant patient Oral Surg Oral Med Oral Pathol 198865292-7
bull 7 Martin C Varner MW Physiologic changes in pregnancysurgical implications Clin Obstet Gynecol 199437241-55
bull 8 Clark SL Cotton DB Lee W Bishop C Hill T Southwick J et al Central hemodynamic assessment of normal term pregnancy Am J Obstet Gynecol 19891611439-42
bull 9 Mabie WC Di Sessa TG Crocker LG Sibai BM Arheart KL A longitudinal study of cardiac output in normal human pregnancy Am J Obstet Gynecol 1994170849-56
bull 10 Clapp JF 3rd Capeless E Cardiovascular function before during and after the first and subsequent pregnancies Am J Cardiol 1997801469-73
bull 11 Duvekot JJ Peeters LL Maternal cardiovascular hemodynamic adaptation to pregnancy Obstet Gynecol Surv 199449(Suppl) S1-14
bull 12 Bhagwat AR Engel PJ Heart disease and pregnancy Cardiol Clin 199513163-78
bull 13 Lanni SM Tillinghast J Silver H Hemodynamic changes and baroreflex gain in the supine hypotensive syndrome Am J Obstet Gynecol 20021871636-41
bull 14 Little JW Falace DA Miller CS Rhodus NL Dental management of the medically compromised patient 6th ed St Louis Mosby 2002 p 303
bull 15 Garcia-Rio F Pino JM Gomez L Alvarez-Sala R Villasante C Villamor J Regulation of breathing and perception of dyspnea in healthy pregnant women Chest 1996110446-53
bull 16 McAuliffe F Kametas N Costello J Rafferty GF Greenough A Nicolaides K Respiratory function in singleton and twin pregnancy BJOG 2002109765-9
bull 17 Clapp JF 3rd Seaward BL Sleamaker RH Hiser J Maternal physiologic adaptations to early human pregnancy Am J Obstet Gynecol 19881591456-60
bull 18 OrsquoDay MP Cardio-respiratory physiological adaptation of pregnancy Semin Perinatol 199721268-75
bull 19 Contreras G Gutierrez M Beroiza T Fantin A Oddo H Villarroel L et al Ventilatory drive and respiratory muscle function in pregnancy Am Rev Respir Dis 1991144837-41
bull 20 Turner M Aziz SR Management of the pregnant oral and maxillofac
bull 21 Sifakis S Pharmakides G Anemia in pregnancy Ann N Y Acad Sci 2000900125-36
bull 22 Branch DW Physiologic adaptations of pregnancy Am J Reprod Immunol 199228120-2
bull 23 Burrows RF Kelton JG Incidentally detected thrombocytopenia in healthy mothers and their infants N Engl J Med 1988319 142-5
bull 24 Hanly JG Antiphospholipid syndrome an overview CMAJ 200324(168)1675-82
bull 25 Heilmann L von Tempelhoff GF Pollow K Antiphospholipid syndrome in obstetrics Clin Appl Thromb Hemost 20039 143-50
bull 26 Sherman P Flaxman SM Nausea and vomiting of pregnancy in an evolutionary perspective Am J Obstet Gynecol 2002 185(Suppl)s190-7
bull 27 Koch KL Gastrointestinal factors in nausea and vomiting of pregnancy Am J Obstet Gynecol 2002185(Suppl)s198-203
bull 28 Koch KL Frissora CL Nausea and vomiting during pregnancy Gastroenterol Clin N Am 200332201-34
bull 29 Baron TH Ramirez B Richter JE Gastrointestinal motility disorders during pregnancy Ann Intern Med 1993118 366-75
bull 30 Richter JE Gastroesophageal reflux disease during pregnancy Gastroenterol Clin N Am 200332235-61
bull 31 Marrero JM Goggin PM de Caestecker JS Pearce JM Maxwell JD Determinants of pregnancy heartburn Br J Obstet Gynaecol 199299731-4
bull 32 Hamaoui E Hamaoui M Nutritional assessment and support during pregnancy Gastroenterol Clin N Am 20033259-121
bull 33 King JC Physiology of pregnancy and nutrient metabolism Am J Clin Nutr 200071(suppl)1218s-25s
bull 34 Casanueva E Pfeffer F Fernandez-Gaxiola AC Gutierrez- Valenzuela V Rothenberg SJ Iron and folate status before pregnancy and anemia during pregnancy Ann Nutr Metab 2003 4760-3
bull 35 Chrsquong CL Morgan M Hainsworth I Kingham JG Prospective study of liver dysfunction in Southwest Wales Gut 200251 876-80
bull 36 Rahman TM Wendon J Severe hepatic dysfunction in pregnancy QJM 200295343-57
bull 37 Knox TA Olans LB Liver disease in pregnancy N Engl J Med 1996335569-76
bull 38 Saftlas AF Olson DR Franks AL Atrash H Pokras R Epidemiology of preeclampsia and eclampsia in the United States 1979e1986 Am J Obstet Gynecol 1990163460-5
bull 39 Walker JJ Pre-eclampsia Lancet 20003561260-5
bull 40 Davidson JM Renal disorders in pregnancy Curr Opin Obstet Gynecol 200113109-14
bull 41 Dafnis E Sabatini S The effect of pregnancy on renal function physiology and pathophysiologyAmJMedSci 1992303184-205
bull 42 Davison JM Shiells EA Philips PR Lindheimer MD Serial evaluation of vasopressin release and thirst in human pregnancy Role of human chorionic gonadotrophin in the osmoregulatory changes of gestation J Clin Invest 198881798-806
bull 43 Glinoer D de Nayer P Bourdoux P Lemone M Robyn C van Steirteghem A et al Regulation of maternal thyroid during pregnancy J Clin Endocrinol Metab 199071276-87
bull 44 Wilson SG Retallack RW Kent JC Worth GK Gutteridge DH Serum free 125-dihydroxyvitamin D and the free 125- dihydroxyvitamin D index during a longitudinal study of human pregnancy and lactation Clin Endocrinol 199032613-22
bull 45 Rasmussen N Frolich A Hornnes PJ Hegedus L Serum ionized calcium and intact parathyroid hormone levels during pregnancy and postpartum Br J Obstet Gynaecol 199097857-9
bull 46 Guyton AC Textbook of medical physiology 8th ed Philadelphia W B Saunders 1991 p 915e28
bull 47 Trainer PJ Corticosteroids and pregnancy Semin Reprod Med 200220375-80
bull 48 Soory M Hormonal factors in periodontal disease Dent Update 200027380-3
bull 49 Hugoson A Gingivitis in pregnant women A longitudinal clinical study Odontol Revy 19712265-84
bull 50 Neville BW Damm DD Allen CM Bouquot JE Oral amp Maxillofacial Pathology 3rd ed Philadelphia W B Saunders 2002 p 329-30 447-9
bull 51 Tilakaratne A Soory M Ranasinghe AW Corea SM Ekanayake SL de Silva M Periodontal disease status during pregnancy and 3 months post-partum in rural population of Sri-Lankan women J Clin Periodontol 200027787-92
bull 52 Laine M Tenovuo J Lehtonen OP Ojanatko-Harri A Vilja P Tuohimaa P Pregnancy e related changes in human whole saliva Arch Oral Biol 198833913-7
bull 53 Yuan K Wing LY Lin MT Pathogenetic roles of angiogenic factors in pyogenic granulomas in pregnancy are modulated by female sex hormones J Periodontol 200273701-8
bull 54 Evans RD Briggs PF Tooth-surface loss related to pregnancyinduced vomiting Prim Dent Care 1994124-6
bull 55 Salvolini E Di Giorgio R Curatola A Mazzanti L Fratto G Biochemical modifications of human whole saliva induced by pregnancy Br J Obstet Gynaec 1998105656-60
bull 56 Mauldin JG Newman RB Preterm birth risk assessment Semin Perinatol 200125215-22
bull 57 Heine RP McGregor JA Goodwin TM Artal R Hayashi RH Robertson PA et al Serial salivary estriol to detect an increased risk of preterm birth Obstet Gynecol 200096490-7
bull 58 Kauh YC Zachian TF Melasma Adv Exp Med Biol 1999455 491-9
bull 59 Wong RC Ellis CN Physiologic skin changes in pregnancy J Am Acad Dermatol 198410929-40
bull 60 Errickson CV Matus NR Skin disorders of pregnancy Am Fam Physician 199449605-10
bull 61 Lopez NJ Smith PC Gutierrez J Periodontal therapy may reduce the risk of preterm low birth weight in women with periodontal disease a randomized controlled trial J Periodontol 200273911-24
bull 62 McGaw T Periodontal disease and preterm delivery of lowbirth- weight infants J Can Dent Assoc 200268165-9
bull 63 Richards AG Dental x-ray protection Dent Clin North Am 1968631-41
bull 64 1990 Recommendations of the International Commission on Radiological Protection Ann ICRP 1991211-201
bull 65 Hall EJ Radiation the two-edged sword cancer risks at high and low doses Cancer J 20006343-50
bull 66 Diethelm L Xu H Diagnostic imaging of the lung during pregnancy Clin Obstet Gynecol 19963936-55
bull 67 Brent RL The effects of embryonic and fetal exposure to x-rays microwaves and ultrasound ClinObstetGynecol 198326484-510
bull 68 National Council on Radiation Protection NCRP report no128 1998 Bethesda Md Author
bull 69 Wasylko L Matsui D Dykxhoorn SM Reider MJ Weinberg S A review of common dental treatments during pregnancy implications for patients and dental personnel J Can Dent Assoc 199864434-9
bull 70 Freeman JP Brand JW Radiation doses of commonly used dental radiographic surveys Oral Surg Oral Med Oral Pathol 199477285-9
bull 71 Kircos LTAngin LL Lorton LOrder ofmagnitude dose reduction in intraoral radiography J Am Dent Assoc 1987114344-7
bull 72 Updegrave WJ Simplified and standardized intraoral radiography with reduced tissue irradiation J Am Dent Assoc 197285861-9
bull 73 Wood RE Harris AM van der Merwe EJ Nortje CJ The leaded apron revisited does it reduce gonadal radiation dose in dental radiology Oral Surg Oral Med Oral Pathol 199171642-6
bull 74 An update on radiographic practices information and recommendations ADA Council on Scientific Affairs J Am Dent Assoc 2001132234-8
bull 75 Rayburn WF Recommending medications during pregnancy an evidence based approach Clin Obstet Gynecol 2002451-5
bull 76 Rathmell JP Viscomi C Ashburn MA Management of nonobstetric pain during pregnancy and lactation Anesth Analg 1997851074-87
bull 77 Teratology society public affairs committee FDA classification of drugs for teratogenic risk Teratology 199449446-7
bull 78 Moore PA Selecting drugs for the pregnant dental patient J Am Dent Assoc 19981291281-6
bull 79 Haas DA An update on analgesics for the management of acute postoperative dental pain J Can Dent Assoc 200268476-82
bull 80 Haas DA Pynn BR Sands TD Drug use for the pregnant or lactating patient Gen Dent 20004854-60
bull 81 Committee on Drugs American Academy of Pediatrics The transfer of drugs and other chemicals into human milk Pediatrics 199493137-50
bull 82 Nielsen GL Sorensen HT Larsen H Pedersen L Risk of adverse birth outcome and miscarriage in pregnant users of nonsteroidal anti-inflammatory drugs population based observational study and case-control study BMJ 2001322266-70
bull 83 Janssen N Genta M The effects of immunosuppressive and anti-inflammatory medications on fertility pregnancy and lactation Arch Intern Med 200016610-9
bull 84 Ostensen M Nonsteroidal anti-inflammatory drugs during pregnancy Scand J Rheumatol Suppl 1998107128-32
bull 85 USPDI -Drug information for the health care professional 22nd ed Greenwood Village CO Micromedex 2002 p 152-79
bull 86 Denson DD Coyle DE Thompson GA Santos D Turner PA Myers JA et al Bupivacaine protein binding in the term parturient effects of lactic acidosis Clin Pharmacol Ther 198435702-9
bull 87 Dillon DE Wagner CL Wiest D Newman RB Drug therapy in the nursing mother Obstet Gynecol Clin North Am 199724 675-96
bull 88 Dashe JS Gilstrap LC Antibiotic use in pregnancy Obstet Gynecol Clin North Am 199724617-29
bull 89 American College of Rheumatology Ad hoc Committee on Clinical Guidelines Guidelines for monitoring drug therapy in rheumatoid arthritis Arthritis Rheum 199639723-31
bull 90 Ng PC The fetal and neonatal hypothalamic-pituitary-adrenal axis Arch Dis Child Fetal Neonatal Ed 200082F250-4
bull 91 Crowley P Antenatal corticosteroidsmdashcurrent thinking BJOG 2003110(Suppl 20)77-8
bull 92 ACOG committee opinion antenatal corticosteroid therapy for fetal maturation Obstet Gynecol 200299871-3
bull 93 Ost L Wettrell G Bjorkhem I Rane A Prednisolone excretion in human milk J Pediatr 19851061008-11
bull 94 Rowland AS Baird DD Shore DL Weinberg CR Savitz DA Wilcox AJ Nitrous oxide and spontaneous abortion in female dental assistants Am J Epidemiol 1995141531-8
bull 95 McGlothlin JD Jensen PA Fischbach TJ Hughes RT Jones JH Control of anesthetic gases in dental operatories Scand J Work Environ Health 199218(Suppl 2)103-5
bull ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY Volume 97 Number 6 Suresh and Radfar 681
bull 96 Rosen MA Nitrous oxide for relief of labor pain a systematic review Am J Obstet Gynecol 2002186(Suppl Nature)S110-6
bull 97 Sands TD Pynn BR Management considerations for the pregnant or nursing emergency patient Ont Dent 199875 17-9
bull 98 Daya S Recurrent spontaneous early pregnancy loss and low dose aspirin Minerva Ginecol 200355441-9
bull 99 Sinclair C Handbook of obstetrical emergencies 1st ed Philadelphia WB Saunders 1996 p 29-39 69
bull 100 Tarsitano BF Rollings RE The pregnant dental patient evaluation and management Gen Dent 199341226-34
bull 101 Livingston MH Dlllinger TM Holder R Consideration in the management of the pregnant patient SCD Special Care in Dentistry 199818183-8
Thank you
- A Review on the principle of Dental Management of the Pregnant patient
- Slide 2
- Questions that a dentist may ask
- Stages of Pregnancy
- Slide 5
- Slide 6
- Physiologic Changes in Pregnancy
- Systemic changes in pregnancy
- FLAT SUPINE POSITIONING
- SUPINE HYPOTENSION SYNDROME (Vena Cava Compression)
- Supine Hypotension Syndrome
- Slide 12
- Supine Hypotension Syndrome
- Prevention of Supine Hypotensive Syndrome
- Treatment of Supine Hypotensive Syndrome
- How should the pregnant woman be positioned
- Slide 17
- Slide 18
- Slide 19
- Slide 20
- Slide 21
- Slide 22
- Slide 23
- Pregnancy Related Oral Health Problems
- Oral Problems in Pregnancy
- Pregnancy Gingivitis Pathophysiology
- Pregnancy Gingivitis
- Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Gum Problems - Pregnancy Granuloma
- Slide 31
- Gum Changes - Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Candidiasis
- Pregnancy Myths
- Other Oral Conditions in Pregnancy
- Changes During Pregnancy that Affect Oral Health
- Saliva changes
- Increased Bacteria
- Slide 40
- Enamel erosion caused by frequent vomiting
- Treatment for Acid Exposure
- Oral Diseases Can Effect Pregnancy
- Periodontal Disease and Preterm Labor
- Periodontal Disease and Low Birth Weight
- Periodontal Disease and Preeclampsia
- Periodontitis and Pre-eclampsia
- Dental Considerations
- Treatment Timing
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Slide 52
- Use of Radiation on Pregnant Patient
- Radiographs during Pregnancy
- Risks of Dental X-Rays
- FDA drug classification for pregnancy
- Slide 57
- FDA drug classification for pregnancy
- Slide 59
- Slide 60
- Slide 61
- Common Analgesics
- Analgesics
- Analgesics - continued
- Analgesics to Use During 1st and 2nd Trimester
- Analgesics to Avoid During the Third Trimester
- Sedation in Pregnancy
- Common Antibiotics
- Antibiotics
- Antibiotics To Use During Pregnancy
- Antibiotics to Avoid during Pregnancy
- The Problem With Tetracycline
- Other Antimicrobial Agents
- Local Anesthetic Use in Pregnancy
- Use of Local Anesthetics
- Ulcer healing drugs
- Slide 77
- Slide 78
- Slide 79
- Use of Nitrous Oxide Gas
- Common Preventives
- Are topical agents safe
- Pre-natal Fluoride
- Is it safe to use mercury restorations
- References
- REFERENCES
- Slide 87
- Slide 88
- Slide 89
- Slide 90
- Slide 91
- Slide 92
- Slide 93
- Slide 94
- Slide 95
- Slide 96
- Slide 97
- Slide 98
- Thank you
-
The Problem With Tetracycline
bull Accumulates in bones and chelates calcium
bull Inhibits bone growthbull Discolors teeth
Other Antimicrobial Agentsbull OK to usebull Nystatin (B)bull Chlorhexidine rinse (B)bull Use with cautionbull Clotrimazole (C)bull Ketoconazole (C)bull Fluconazole (C)bull Do not usebull Doxycycline (D)
Local Anesthetic Use inPregnancy
bull Class Bbull Lidocaine (Xylocaine)bull Etidocainebull Prilocaine bull Class Cbull Procainebull Bupivicainebull Mepivicaine
Use of Local Anestheticsbull Lidocaine + vasoconstrictor most common
local anesthetic used in dentistrybull extensively used in pregnancy with no proven ill
effectsbull accidental intravascular injections of lidocaine
pass through the placenta but the concentrations are too low to harm fetus
bull prilocaine might cause methemoglobinemia
Ulcer healing drugsCimetidine bull FDA category B Famotidinebull FDA category BRanitidinebull FDA category Bbull not known to be harmful
Ulcer healing drugsOmeprazolebull FDA category BNot known to be
harmful Esomeprazolebull FDA category BLansoprazolebull FDA category BPantoprazolebull Avoid unless potential benefit
outweighs riskmdashfetotoxic in animals
Ulcer healing drugs
Misoprostolbull First second third trimesters Avoidmdash
potent uterine stimulant (has been used to induce abortion) and may be teratogenic
Ulcer healing drugs
Antacidsbull Almunium hydroxideMagnesium
hydroxidemdashFDA category B Calcium carbonatemdashFDA category C
SimetheconemdashFDA category C
Use of Nitrous Oxide Gas
bull used over 150 years bull safety is being debatedbull SHORT TERM exposure do not cause
birth defects or spontaneous abortionbull CHRONIC exposure may result in fetal
loss and infertilitybull literature suggests that nitrous oxide
should be avoided until more conclusive research is available
bull FDA Drug class not yet assigned
Common Preventives
bull Fluoridendash No increased risk during pregnancy
bull Xylitolndash No studies no harm reported
bull Chlorhexidinendash No increased risk during pregnancy
Are topical agents safe
bull Fluoridebull Toothpaste amp mouthrinse
bull Xylitol chewing gum bull Chlorhexidine (11 alcohol)bull No over the counter mouthrinses with
alcohol (Listerine 20 alcohol)
Pre-natal Fluoride
bull Daily 22 mg tablet of sodium fluoride during 3rd through 9th months
bull decreases caries rate in offspringbull Safe and effective
Glenn FB 1982
Is it safe to use mercury restorations
bull No evidence of harmful effect
bull Benefits outweigh risks
bull Canada Germany and New Zealand have some restrictions
bull Determine the best option
Referencesbull Wasylko L Matsui D Dykxhoorn SM Rieder MJ Weinberg
S A Review of Common Dental Treatments During Pregnancy J Canadian Dental Association 64434-439 1998
bull Little JW Donald AF Craig SM Rhodus NL Dental Management of the Medically Compromised Patient - 5th edition Mosby Toronto Pp434-442 1997
bull Livingston HM Dellinger TM Holder R Considerations in the management of the pregnant patient Special Care in Dentistry 185 pp183-188 1998
bull Larimore WL Petrie KA Drug use during pregnacy and lactation Primary Care Clinics in Office Practice 271 35-53 2000
bull Health Canada The Safety of DentalAmalgam Minister Of Supply and Services Canada 1996
REFERENCESbull 1 Weiss G Endocrinology of parturition J Clin
Endocrinol Metab 2000854421-5bull 2 Theunissen IM Parer JT Fluid and electrolytes in
pregnancy Clin Obstet Gynecol 1994373-15bull 3 Duvekot JJ Peeters LLH Renal hemodynamics and
volume homeostasis in pregnancy Obstet Gynecol Surv 199449830-9
bull 4 Barron WM Lindheimer MD Medical disorders during pregnancy 2nd ed St Louis Mosby 1995 p 129
bull 5 Thornburg KL Jacobson SL Giraud GD Morton MJ Hemodynamic changes in pregnancy Semin Perinatol 20002411-4
bull 6 Fiese R Herzog S Issues in dental and surgical management of the pregnant patient Oral Surg Oral Med Oral Pathol 198865292-7
bull 7 Martin C Varner MW Physiologic changes in pregnancysurgical implications Clin Obstet Gynecol 199437241-55
bull 8 Clark SL Cotton DB Lee W Bishop C Hill T Southwick J et al Central hemodynamic assessment of normal term pregnancy Am J Obstet Gynecol 19891611439-42
bull 9 Mabie WC Di Sessa TG Crocker LG Sibai BM Arheart KL A longitudinal study of cardiac output in normal human pregnancy Am J Obstet Gynecol 1994170849-56
bull 10 Clapp JF 3rd Capeless E Cardiovascular function before during and after the first and subsequent pregnancies Am J Cardiol 1997801469-73
bull 11 Duvekot JJ Peeters LL Maternal cardiovascular hemodynamic adaptation to pregnancy Obstet Gynecol Surv 199449(Suppl) S1-14
bull 12 Bhagwat AR Engel PJ Heart disease and pregnancy Cardiol Clin 199513163-78
bull 13 Lanni SM Tillinghast J Silver H Hemodynamic changes and baroreflex gain in the supine hypotensive syndrome Am J Obstet Gynecol 20021871636-41
bull 14 Little JW Falace DA Miller CS Rhodus NL Dental management of the medically compromised patient 6th ed St Louis Mosby 2002 p 303
bull 15 Garcia-Rio F Pino JM Gomez L Alvarez-Sala R Villasante C Villamor J Regulation of breathing and perception of dyspnea in healthy pregnant women Chest 1996110446-53
bull 16 McAuliffe F Kametas N Costello J Rafferty GF Greenough A Nicolaides K Respiratory function in singleton and twin pregnancy BJOG 2002109765-9
bull 17 Clapp JF 3rd Seaward BL Sleamaker RH Hiser J Maternal physiologic adaptations to early human pregnancy Am J Obstet Gynecol 19881591456-60
bull 18 OrsquoDay MP Cardio-respiratory physiological adaptation of pregnancy Semin Perinatol 199721268-75
bull 19 Contreras G Gutierrez M Beroiza T Fantin A Oddo H Villarroel L et al Ventilatory drive and respiratory muscle function in pregnancy Am Rev Respir Dis 1991144837-41
bull 20 Turner M Aziz SR Management of the pregnant oral and maxillofac
bull 21 Sifakis S Pharmakides G Anemia in pregnancy Ann N Y Acad Sci 2000900125-36
bull 22 Branch DW Physiologic adaptations of pregnancy Am J Reprod Immunol 199228120-2
bull 23 Burrows RF Kelton JG Incidentally detected thrombocytopenia in healthy mothers and their infants N Engl J Med 1988319 142-5
bull 24 Hanly JG Antiphospholipid syndrome an overview CMAJ 200324(168)1675-82
bull 25 Heilmann L von Tempelhoff GF Pollow K Antiphospholipid syndrome in obstetrics Clin Appl Thromb Hemost 20039 143-50
bull 26 Sherman P Flaxman SM Nausea and vomiting of pregnancy in an evolutionary perspective Am J Obstet Gynecol 2002 185(Suppl)s190-7
bull 27 Koch KL Gastrointestinal factors in nausea and vomiting of pregnancy Am J Obstet Gynecol 2002185(Suppl)s198-203
bull 28 Koch KL Frissora CL Nausea and vomiting during pregnancy Gastroenterol Clin N Am 200332201-34
bull 29 Baron TH Ramirez B Richter JE Gastrointestinal motility disorders during pregnancy Ann Intern Med 1993118 366-75
bull 30 Richter JE Gastroesophageal reflux disease during pregnancy Gastroenterol Clin N Am 200332235-61
bull 31 Marrero JM Goggin PM de Caestecker JS Pearce JM Maxwell JD Determinants of pregnancy heartburn Br J Obstet Gynaecol 199299731-4
bull 32 Hamaoui E Hamaoui M Nutritional assessment and support during pregnancy Gastroenterol Clin N Am 20033259-121
bull 33 King JC Physiology of pregnancy and nutrient metabolism Am J Clin Nutr 200071(suppl)1218s-25s
bull 34 Casanueva E Pfeffer F Fernandez-Gaxiola AC Gutierrez- Valenzuela V Rothenberg SJ Iron and folate status before pregnancy and anemia during pregnancy Ann Nutr Metab 2003 4760-3
bull 35 Chrsquong CL Morgan M Hainsworth I Kingham JG Prospective study of liver dysfunction in Southwest Wales Gut 200251 876-80
bull 36 Rahman TM Wendon J Severe hepatic dysfunction in pregnancy QJM 200295343-57
bull 37 Knox TA Olans LB Liver disease in pregnancy N Engl J Med 1996335569-76
bull 38 Saftlas AF Olson DR Franks AL Atrash H Pokras R Epidemiology of preeclampsia and eclampsia in the United States 1979e1986 Am J Obstet Gynecol 1990163460-5
bull 39 Walker JJ Pre-eclampsia Lancet 20003561260-5
bull 40 Davidson JM Renal disorders in pregnancy Curr Opin Obstet Gynecol 200113109-14
bull 41 Dafnis E Sabatini S The effect of pregnancy on renal function physiology and pathophysiologyAmJMedSci 1992303184-205
bull 42 Davison JM Shiells EA Philips PR Lindheimer MD Serial evaluation of vasopressin release and thirst in human pregnancy Role of human chorionic gonadotrophin in the osmoregulatory changes of gestation J Clin Invest 198881798-806
bull 43 Glinoer D de Nayer P Bourdoux P Lemone M Robyn C van Steirteghem A et al Regulation of maternal thyroid during pregnancy J Clin Endocrinol Metab 199071276-87
bull 44 Wilson SG Retallack RW Kent JC Worth GK Gutteridge DH Serum free 125-dihydroxyvitamin D and the free 125- dihydroxyvitamin D index during a longitudinal study of human pregnancy and lactation Clin Endocrinol 199032613-22
bull 45 Rasmussen N Frolich A Hornnes PJ Hegedus L Serum ionized calcium and intact parathyroid hormone levels during pregnancy and postpartum Br J Obstet Gynaecol 199097857-9
bull 46 Guyton AC Textbook of medical physiology 8th ed Philadelphia W B Saunders 1991 p 915e28
bull 47 Trainer PJ Corticosteroids and pregnancy Semin Reprod Med 200220375-80
bull 48 Soory M Hormonal factors in periodontal disease Dent Update 200027380-3
bull 49 Hugoson A Gingivitis in pregnant women A longitudinal clinical study Odontol Revy 19712265-84
bull 50 Neville BW Damm DD Allen CM Bouquot JE Oral amp Maxillofacial Pathology 3rd ed Philadelphia W B Saunders 2002 p 329-30 447-9
bull 51 Tilakaratne A Soory M Ranasinghe AW Corea SM Ekanayake SL de Silva M Periodontal disease status during pregnancy and 3 months post-partum in rural population of Sri-Lankan women J Clin Periodontol 200027787-92
bull 52 Laine M Tenovuo J Lehtonen OP Ojanatko-Harri A Vilja P Tuohimaa P Pregnancy e related changes in human whole saliva Arch Oral Biol 198833913-7
bull 53 Yuan K Wing LY Lin MT Pathogenetic roles of angiogenic factors in pyogenic granulomas in pregnancy are modulated by female sex hormones J Periodontol 200273701-8
bull 54 Evans RD Briggs PF Tooth-surface loss related to pregnancyinduced vomiting Prim Dent Care 1994124-6
bull 55 Salvolini E Di Giorgio R Curatola A Mazzanti L Fratto G Biochemical modifications of human whole saliva induced by pregnancy Br J Obstet Gynaec 1998105656-60
bull 56 Mauldin JG Newman RB Preterm birth risk assessment Semin Perinatol 200125215-22
bull 57 Heine RP McGregor JA Goodwin TM Artal R Hayashi RH Robertson PA et al Serial salivary estriol to detect an increased risk of preterm birth Obstet Gynecol 200096490-7
bull 58 Kauh YC Zachian TF Melasma Adv Exp Med Biol 1999455 491-9
bull 59 Wong RC Ellis CN Physiologic skin changes in pregnancy J Am Acad Dermatol 198410929-40
bull 60 Errickson CV Matus NR Skin disorders of pregnancy Am Fam Physician 199449605-10
bull 61 Lopez NJ Smith PC Gutierrez J Periodontal therapy may reduce the risk of preterm low birth weight in women with periodontal disease a randomized controlled trial J Periodontol 200273911-24
bull 62 McGaw T Periodontal disease and preterm delivery of lowbirth- weight infants J Can Dent Assoc 200268165-9
bull 63 Richards AG Dental x-ray protection Dent Clin North Am 1968631-41
bull 64 1990 Recommendations of the International Commission on Radiological Protection Ann ICRP 1991211-201
bull 65 Hall EJ Radiation the two-edged sword cancer risks at high and low doses Cancer J 20006343-50
bull 66 Diethelm L Xu H Diagnostic imaging of the lung during pregnancy Clin Obstet Gynecol 19963936-55
bull 67 Brent RL The effects of embryonic and fetal exposure to x-rays microwaves and ultrasound ClinObstetGynecol 198326484-510
bull 68 National Council on Radiation Protection NCRP report no128 1998 Bethesda Md Author
bull 69 Wasylko L Matsui D Dykxhoorn SM Reider MJ Weinberg S A review of common dental treatments during pregnancy implications for patients and dental personnel J Can Dent Assoc 199864434-9
bull 70 Freeman JP Brand JW Radiation doses of commonly used dental radiographic surveys Oral Surg Oral Med Oral Pathol 199477285-9
bull 71 Kircos LTAngin LL Lorton LOrder ofmagnitude dose reduction in intraoral radiography J Am Dent Assoc 1987114344-7
bull 72 Updegrave WJ Simplified and standardized intraoral radiography with reduced tissue irradiation J Am Dent Assoc 197285861-9
bull 73 Wood RE Harris AM van der Merwe EJ Nortje CJ The leaded apron revisited does it reduce gonadal radiation dose in dental radiology Oral Surg Oral Med Oral Pathol 199171642-6
bull 74 An update on radiographic practices information and recommendations ADA Council on Scientific Affairs J Am Dent Assoc 2001132234-8
bull 75 Rayburn WF Recommending medications during pregnancy an evidence based approach Clin Obstet Gynecol 2002451-5
bull 76 Rathmell JP Viscomi C Ashburn MA Management of nonobstetric pain during pregnancy and lactation Anesth Analg 1997851074-87
bull 77 Teratology society public affairs committee FDA classification of drugs for teratogenic risk Teratology 199449446-7
bull 78 Moore PA Selecting drugs for the pregnant dental patient J Am Dent Assoc 19981291281-6
bull 79 Haas DA An update on analgesics for the management of acute postoperative dental pain J Can Dent Assoc 200268476-82
bull 80 Haas DA Pynn BR Sands TD Drug use for the pregnant or lactating patient Gen Dent 20004854-60
bull 81 Committee on Drugs American Academy of Pediatrics The transfer of drugs and other chemicals into human milk Pediatrics 199493137-50
bull 82 Nielsen GL Sorensen HT Larsen H Pedersen L Risk of adverse birth outcome and miscarriage in pregnant users of nonsteroidal anti-inflammatory drugs population based observational study and case-control study BMJ 2001322266-70
bull 83 Janssen N Genta M The effects of immunosuppressive and anti-inflammatory medications on fertility pregnancy and lactation Arch Intern Med 200016610-9
bull 84 Ostensen M Nonsteroidal anti-inflammatory drugs during pregnancy Scand J Rheumatol Suppl 1998107128-32
bull 85 USPDI -Drug information for the health care professional 22nd ed Greenwood Village CO Micromedex 2002 p 152-79
bull 86 Denson DD Coyle DE Thompson GA Santos D Turner PA Myers JA et al Bupivacaine protein binding in the term parturient effects of lactic acidosis Clin Pharmacol Ther 198435702-9
bull 87 Dillon DE Wagner CL Wiest D Newman RB Drug therapy in the nursing mother Obstet Gynecol Clin North Am 199724 675-96
bull 88 Dashe JS Gilstrap LC Antibiotic use in pregnancy Obstet Gynecol Clin North Am 199724617-29
bull 89 American College of Rheumatology Ad hoc Committee on Clinical Guidelines Guidelines for monitoring drug therapy in rheumatoid arthritis Arthritis Rheum 199639723-31
bull 90 Ng PC The fetal and neonatal hypothalamic-pituitary-adrenal axis Arch Dis Child Fetal Neonatal Ed 200082F250-4
bull 91 Crowley P Antenatal corticosteroidsmdashcurrent thinking BJOG 2003110(Suppl 20)77-8
bull 92 ACOG committee opinion antenatal corticosteroid therapy for fetal maturation Obstet Gynecol 200299871-3
bull 93 Ost L Wettrell G Bjorkhem I Rane A Prednisolone excretion in human milk J Pediatr 19851061008-11
bull 94 Rowland AS Baird DD Shore DL Weinberg CR Savitz DA Wilcox AJ Nitrous oxide and spontaneous abortion in female dental assistants Am J Epidemiol 1995141531-8
bull 95 McGlothlin JD Jensen PA Fischbach TJ Hughes RT Jones JH Control of anesthetic gases in dental operatories Scand J Work Environ Health 199218(Suppl 2)103-5
bull ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY Volume 97 Number 6 Suresh and Radfar 681
bull 96 Rosen MA Nitrous oxide for relief of labor pain a systematic review Am J Obstet Gynecol 2002186(Suppl Nature)S110-6
bull 97 Sands TD Pynn BR Management considerations for the pregnant or nursing emergency patient Ont Dent 199875 17-9
bull 98 Daya S Recurrent spontaneous early pregnancy loss and low dose aspirin Minerva Ginecol 200355441-9
bull 99 Sinclair C Handbook of obstetrical emergencies 1st ed Philadelphia WB Saunders 1996 p 29-39 69
bull 100 Tarsitano BF Rollings RE The pregnant dental patient evaluation and management Gen Dent 199341226-34
bull 101 Livingston MH Dlllinger TM Holder R Consideration in the management of the pregnant patient SCD Special Care in Dentistry 199818183-8
Thank you
- A Review on the principle of Dental Management of the Pregnant patient
- Slide 2
- Questions that a dentist may ask
- Stages of Pregnancy
- Slide 5
- Slide 6
- Physiologic Changes in Pregnancy
- Systemic changes in pregnancy
- FLAT SUPINE POSITIONING
- SUPINE HYPOTENSION SYNDROME (Vena Cava Compression)
- Supine Hypotension Syndrome
- Slide 12
- Supine Hypotension Syndrome
- Prevention of Supine Hypotensive Syndrome
- Treatment of Supine Hypotensive Syndrome
- How should the pregnant woman be positioned
- Slide 17
- Slide 18
- Slide 19
- Slide 20
- Slide 21
- Slide 22
- Slide 23
- Pregnancy Related Oral Health Problems
- Oral Problems in Pregnancy
- Pregnancy Gingivitis Pathophysiology
- Pregnancy Gingivitis
- Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Gum Problems - Pregnancy Granuloma
- Slide 31
- Gum Changes - Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Candidiasis
- Pregnancy Myths
- Other Oral Conditions in Pregnancy
- Changes During Pregnancy that Affect Oral Health
- Saliva changes
- Increased Bacteria
- Slide 40
- Enamel erosion caused by frequent vomiting
- Treatment for Acid Exposure
- Oral Diseases Can Effect Pregnancy
- Periodontal Disease and Preterm Labor
- Periodontal Disease and Low Birth Weight
- Periodontal Disease and Preeclampsia
- Periodontitis and Pre-eclampsia
- Dental Considerations
- Treatment Timing
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Slide 52
- Use of Radiation on Pregnant Patient
- Radiographs during Pregnancy
- Risks of Dental X-Rays
- FDA drug classification for pregnancy
- Slide 57
- FDA drug classification for pregnancy
- Slide 59
- Slide 60
- Slide 61
- Common Analgesics
- Analgesics
- Analgesics - continued
- Analgesics to Use During 1st and 2nd Trimester
- Analgesics to Avoid During the Third Trimester
- Sedation in Pregnancy
- Common Antibiotics
- Antibiotics
- Antibiotics To Use During Pregnancy
- Antibiotics to Avoid during Pregnancy
- The Problem With Tetracycline
- Other Antimicrobial Agents
- Local Anesthetic Use in Pregnancy
- Use of Local Anesthetics
- Ulcer healing drugs
- Slide 77
- Slide 78
- Slide 79
- Use of Nitrous Oxide Gas
- Common Preventives
- Are topical agents safe
- Pre-natal Fluoride
- Is it safe to use mercury restorations
- References
- REFERENCES
- Slide 87
- Slide 88
- Slide 89
- Slide 90
- Slide 91
- Slide 92
- Slide 93
- Slide 94
- Slide 95
- Slide 96
- Slide 97
- Slide 98
- Thank you
-
Other Antimicrobial Agentsbull OK to usebull Nystatin (B)bull Chlorhexidine rinse (B)bull Use with cautionbull Clotrimazole (C)bull Ketoconazole (C)bull Fluconazole (C)bull Do not usebull Doxycycline (D)
Local Anesthetic Use inPregnancy
bull Class Bbull Lidocaine (Xylocaine)bull Etidocainebull Prilocaine bull Class Cbull Procainebull Bupivicainebull Mepivicaine
Use of Local Anestheticsbull Lidocaine + vasoconstrictor most common
local anesthetic used in dentistrybull extensively used in pregnancy with no proven ill
effectsbull accidental intravascular injections of lidocaine
pass through the placenta but the concentrations are too low to harm fetus
bull prilocaine might cause methemoglobinemia
Ulcer healing drugsCimetidine bull FDA category B Famotidinebull FDA category BRanitidinebull FDA category Bbull not known to be harmful
Ulcer healing drugsOmeprazolebull FDA category BNot known to be
harmful Esomeprazolebull FDA category BLansoprazolebull FDA category BPantoprazolebull Avoid unless potential benefit
outweighs riskmdashfetotoxic in animals
Ulcer healing drugs
Misoprostolbull First second third trimesters Avoidmdash
potent uterine stimulant (has been used to induce abortion) and may be teratogenic
Ulcer healing drugs
Antacidsbull Almunium hydroxideMagnesium
hydroxidemdashFDA category B Calcium carbonatemdashFDA category C
SimetheconemdashFDA category C
Use of Nitrous Oxide Gas
bull used over 150 years bull safety is being debatedbull SHORT TERM exposure do not cause
birth defects or spontaneous abortionbull CHRONIC exposure may result in fetal
loss and infertilitybull literature suggests that nitrous oxide
should be avoided until more conclusive research is available
bull FDA Drug class not yet assigned
Common Preventives
bull Fluoridendash No increased risk during pregnancy
bull Xylitolndash No studies no harm reported
bull Chlorhexidinendash No increased risk during pregnancy
Are topical agents safe
bull Fluoridebull Toothpaste amp mouthrinse
bull Xylitol chewing gum bull Chlorhexidine (11 alcohol)bull No over the counter mouthrinses with
alcohol (Listerine 20 alcohol)
Pre-natal Fluoride
bull Daily 22 mg tablet of sodium fluoride during 3rd through 9th months
bull decreases caries rate in offspringbull Safe and effective
Glenn FB 1982
Is it safe to use mercury restorations
bull No evidence of harmful effect
bull Benefits outweigh risks
bull Canada Germany and New Zealand have some restrictions
bull Determine the best option
Referencesbull Wasylko L Matsui D Dykxhoorn SM Rieder MJ Weinberg
S A Review of Common Dental Treatments During Pregnancy J Canadian Dental Association 64434-439 1998
bull Little JW Donald AF Craig SM Rhodus NL Dental Management of the Medically Compromised Patient - 5th edition Mosby Toronto Pp434-442 1997
bull Livingston HM Dellinger TM Holder R Considerations in the management of the pregnant patient Special Care in Dentistry 185 pp183-188 1998
bull Larimore WL Petrie KA Drug use during pregnacy and lactation Primary Care Clinics in Office Practice 271 35-53 2000
bull Health Canada The Safety of DentalAmalgam Minister Of Supply and Services Canada 1996
REFERENCESbull 1 Weiss G Endocrinology of parturition J Clin
Endocrinol Metab 2000854421-5bull 2 Theunissen IM Parer JT Fluid and electrolytes in
pregnancy Clin Obstet Gynecol 1994373-15bull 3 Duvekot JJ Peeters LLH Renal hemodynamics and
volume homeostasis in pregnancy Obstet Gynecol Surv 199449830-9
bull 4 Barron WM Lindheimer MD Medical disorders during pregnancy 2nd ed St Louis Mosby 1995 p 129
bull 5 Thornburg KL Jacobson SL Giraud GD Morton MJ Hemodynamic changes in pregnancy Semin Perinatol 20002411-4
bull 6 Fiese R Herzog S Issues in dental and surgical management of the pregnant patient Oral Surg Oral Med Oral Pathol 198865292-7
bull 7 Martin C Varner MW Physiologic changes in pregnancysurgical implications Clin Obstet Gynecol 199437241-55
bull 8 Clark SL Cotton DB Lee W Bishop C Hill T Southwick J et al Central hemodynamic assessment of normal term pregnancy Am J Obstet Gynecol 19891611439-42
bull 9 Mabie WC Di Sessa TG Crocker LG Sibai BM Arheart KL A longitudinal study of cardiac output in normal human pregnancy Am J Obstet Gynecol 1994170849-56
bull 10 Clapp JF 3rd Capeless E Cardiovascular function before during and after the first and subsequent pregnancies Am J Cardiol 1997801469-73
bull 11 Duvekot JJ Peeters LL Maternal cardiovascular hemodynamic adaptation to pregnancy Obstet Gynecol Surv 199449(Suppl) S1-14
bull 12 Bhagwat AR Engel PJ Heart disease and pregnancy Cardiol Clin 199513163-78
bull 13 Lanni SM Tillinghast J Silver H Hemodynamic changes and baroreflex gain in the supine hypotensive syndrome Am J Obstet Gynecol 20021871636-41
bull 14 Little JW Falace DA Miller CS Rhodus NL Dental management of the medically compromised patient 6th ed St Louis Mosby 2002 p 303
bull 15 Garcia-Rio F Pino JM Gomez L Alvarez-Sala R Villasante C Villamor J Regulation of breathing and perception of dyspnea in healthy pregnant women Chest 1996110446-53
bull 16 McAuliffe F Kametas N Costello J Rafferty GF Greenough A Nicolaides K Respiratory function in singleton and twin pregnancy BJOG 2002109765-9
bull 17 Clapp JF 3rd Seaward BL Sleamaker RH Hiser J Maternal physiologic adaptations to early human pregnancy Am J Obstet Gynecol 19881591456-60
bull 18 OrsquoDay MP Cardio-respiratory physiological adaptation of pregnancy Semin Perinatol 199721268-75
bull 19 Contreras G Gutierrez M Beroiza T Fantin A Oddo H Villarroel L et al Ventilatory drive and respiratory muscle function in pregnancy Am Rev Respir Dis 1991144837-41
bull 20 Turner M Aziz SR Management of the pregnant oral and maxillofac
bull 21 Sifakis S Pharmakides G Anemia in pregnancy Ann N Y Acad Sci 2000900125-36
bull 22 Branch DW Physiologic adaptations of pregnancy Am J Reprod Immunol 199228120-2
bull 23 Burrows RF Kelton JG Incidentally detected thrombocytopenia in healthy mothers and their infants N Engl J Med 1988319 142-5
bull 24 Hanly JG Antiphospholipid syndrome an overview CMAJ 200324(168)1675-82
bull 25 Heilmann L von Tempelhoff GF Pollow K Antiphospholipid syndrome in obstetrics Clin Appl Thromb Hemost 20039 143-50
bull 26 Sherman P Flaxman SM Nausea and vomiting of pregnancy in an evolutionary perspective Am J Obstet Gynecol 2002 185(Suppl)s190-7
bull 27 Koch KL Gastrointestinal factors in nausea and vomiting of pregnancy Am J Obstet Gynecol 2002185(Suppl)s198-203
bull 28 Koch KL Frissora CL Nausea and vomiting during pregnancy Gastroenterol Clin N Am 200332201-34
bull 29 Baron TH Ramirez B Richter JE Gastrointestinal motility disorders during pregnancy Ann Intern Med 1993118 366-75
bull 30 Richter JE Gastroesophageal reflux disease during pregnancy Gastroenterol Clin N Am 200332235-61
bull 31 Marrero JM Goggin PM de Caestecker JS Pearce JM Maxwell JD Determinants of pregnancy heartburn Br J Obstet Gynaecol 199299731-4
bull 32 Hamaoui E Hamaoui M Nutritional assessment and support during pregnancy Gastroenterol Clin N Am 20033259-121
bull 33 King JC Physiology of pregnancy and nutrient metabolism Am J Clin Nutr 200071(suppl)1218s-25s
bull 34 Casanueva E Pfeffer F Fernandez-Gaxiola AC Gutierrez- Valenzuela V Rothenberg SJ Iron and folate status before pregnancy and anemia during pregnancy Ann Nutr Metab 2003 4760-3
bull 35 Chrsquong CL Morgan M Hainsworth I Kingham JG Prospective study of liver dysfunction in Southwest Wales Gut 200251 876-80
bull 36 Rahman TM Wendon J Severe hepatic dysfunction in pregnancy QJM 200295343-57
bull 37 Knox TA Olans LB Liver disease in pregnancy N Engl J Med 1996335569-76
bull 38 Saftlas AF Olson DR Franks AL Atrash H Pokras R Epidemiology of preeclampsia and eclampsia in the United States 1979e1986 Am J Obstet Gynecol 1990163460-5
bull 39 Walker JJ Pre-eclampsia Lancet 20003561260-5
bull 40 Davidson JM Renal disorders in pregnancy Curr Opin Obstet Gynecol 200113109-14
bull 41 Dafnis E Sabatini S The effect of pregnancy on renal function physiology and pathophysiologyAmJMedSci 1992303184-205
bull 42 Davison JM Shiells EA Philips PR Lindheimer MD Serial evaluation of vasopressin release and thirst in human pregnancy Role of human chorionic gonadotrophin in the osmoregulatory changes of gestation J Clin Invest 198881798-806
bull 43 Glinoer D de Nayer P Bourdoux P Lemone M Robyn C van Steirteghem A et al Regulation of maternal thyroid during pregnancy J Clin Endocrinol Metab 199071276-87
bull 44 Wilson SG Retallack RW Kent JC Worth GK Gutteridge DH Serum free 125-dihydroxyvitamin D and the free 125- dihydroxyvitamin D index during a longitudinal study of human pregnancy and lactation Clin Endocrinol 199032613-22
bull 45 Rasmussen N Frolich A Hornnes PJ Hegedus L Serum ionized calcium and intact parathyroid hormone levels during pregnancy and postpartum Br J Obstet Gynaecol 199097857-9
bull 46 Guyton AC Textbook of medical physiology 8th ed Philadelphia W B Saunders 1991 p 915e28
bull 47 Trainer PJ Corticosteroids and pregnancy Semin Reprod Med 200220375-80
bull 48 Soory M Hormonal factors in periodontal disease Dent Update 200027380-3
bull 49 Hugoson A Gingivitis in pregnant women A longitudinal clinical study Odontol Revy 19712265-84
bull 50 Neville BW Damm DD Allen CM Bouquot JE Oral amp Maxillofacial Pathology 3rd ed Philadelphia W B Saunders 2002 p 329-30 447-9
bull 51 Tilakaratne A Soory M Ranasinghe AW Corea SM Ekanayake SL de Silva M Periodontal disease status during pregnancy and 3 months post-partum in rural population of Sri-Lankan women J Clin Periodontol 200027787-92
bull 52 Laine M Tenovuo J Lehtonen OP Ojanatko-Harri A Vilja P Tuohimaa P Pregnancy e related changes in human whole saliva Arch Oral Biol 198833913-7
bull 53 Yuan K Wing LY Lin MT Pathogenetic roles of angiogenic factors in pyogenic granulomas in pregnancy are modulated by female sex hormones J Periodontol 200273701-8
bull 54 Evans RD Briggs PF Tooth-surface loss related to pregnancyinduced vomiting Prim Dent Care 1994124-6
bull 55 Salvolini E Di Giorgio R Curatola A Mazzanti L Fratto G Biochemical modifications of human whole saliva induced by pregnancy Br J Obstet Gynaec 1998105656-60
bull 56 Mauldin JG Newman RB Preterm birth risk assessment Semin Perinatol 200125215-22
bull 57 Heine RP McGregor JA Goodwin TM Artal R Hayashi RH Robertson PA et al Serial salivary estriol to detect an increased risk of preterm birth Obstet Gynecol 200096490-7
bull 58 Kauh YC Zachian TF Melasma Adv Exp Med Biol 1999455 491-9
bull 59 Wong RC Ellis CN Physiologic skin changes in pregnancy J Am Acad Dermatol 198410929-40
bull 60 Errickson CV Matus NR Skin disorders of pregnancy Am Fam Physician 199449605-10
bull 61 Lopez NJ Smith PC Gutierrez J Periodontal therapy may reduce the risk of preterm low birth weight in women with periodontal disease a randomized controlled trial J Periodontol 200273911-24
bull 62 McGaw T Periodontal disease and preterm delivery of lowbirth- weight infants J Can Dent Assoc 200268165-9
bull 63 Richards AG Dental x-ray protection Dent Clin North Am 1968631-41
bull 64 1990 Recommendations of the International Commission on Radiological Protection Ann ICRP 1991211-201
bull 65 Hall EJ Radiation the two-edged sword cancer risks at high and low doses Cancer J 20006343-50
bull 66 Diethelm L Xu H Diagnostic imaging of the lung during pregnancy Clin Obstet Gynecol 19963936-55
bull 67 Brent RL The effects of embryonic and fetal exposure to x-rays microwaves and ultrasound ClinObstetGynecol 198326484-510
bull 68 National Council on Radiation Protection NCRP report no128 1998 Bethesda Md Author
bull 69 Wasylko L Matsui D Dykxhoorn SM Reider MJ Weinberg S A review of common dental treatments during pregnancy implications for patients and dental personnel J Can Dent Assoc 199864434-9
bull 70 Freeman JP Brand JW Radiation doses of commonly used dental radiographic surveys Oral Surg Oral Med Oral Pathol 199477285-9
bull 71 Kircos LTAngin LL Lorton LOrder ofmagnitude dose reduction in intraoral radiography J Am Dent Assoc 1987114344-7
bull 72 Updegrave WJ Simplified and standardized intraoral radiography with reduced tissue irradiation J Am Dent Assoc 197285861-9
bull 73 Wood RE Harris AM van der Merwe EJ Nortje CJ The leaded apron revisited does it reduce gonadal radiation dose in dental radiology Oral Surg Oral Med Oral Pathol 199171642-6
bull 74 An update on radiographic practices information and recommendations ADA Council on Scientific Affairs J Am Dent Assoc 2001132234-8
bull 75 Rayburn WF Recommending medications during pregnancy an evidence based approach Clin Obstet Gynecol 2002451-5
bull 76 Rathmell JP Viscomi C Ashburn MA Management of nonobstetric pain during pregnancy and lactation Anesth Analg 1997851074-87
bull 77 Teratology society public affairs committee FDA classification of drugs for teratogenic risk Teratology 199449446-7
bull 78 Moore PA Selecting drugs for the pregnant dental patient J Am Dent Assoc 19981291281-6
bull 79 Haas DA An update on analgesics for the management of acute postoperative dental pain J Can Dent Assoc 200268476-82
bull 80 Haas DA Pynn BR Sands TD Drug use for the pregnant or lactating patient Gen Dent 20004854-60
bull 81 Committee on Drugs American Academy of Pediatrics The transfer of drugs and other chemicals into human milk Pediatrics 199493137-50
bull 82 Nielsen GL Sorensen HT Larsen H Pedersen L Risk of adverse birth outcome and miscarriage in pregnant users of nonsteroidal anti-inflammatory drugs population based observational study and case-control study BMJ 2001322266-70
bull 83 Janssen N Genta M The effects of immunosuppressive and anti-inflammatory medications on fertility pregnancy and lactation Arch Intern Med 200016610-9
bull 84 Ostensen M Nonsteroidal anti-inflammatory drugs during pregnancy Scand J Rheumatol Suppl 1998107128-32
bull 85 USPDI -Drug information for the health care professional 22nd ed Greenwood Village CO Micromedex 2002 p 152-79
bull 86 Denson DD Coyle DE Thompson GA Santos D Turner PA Myers JA et al Bupivacaine protein binding in the term parturient effects of lactic acidosis Clin Pharmacol Ther 198435702-9
bull 87 Dillon DE Wagner CL Wiest D Newman RB Drug therapy in the nursing mother Obstet Gynecol Clin North Am 199724 675-96
bull 88 Dashe JS Gilstrap LC Antibiotic use in pregnancy Obstet Gynecol Clin North Am 199724617-29
bull 89 American College of Rheumatology Ad hoc Committee on Clinical Guidelines Guidelines for monitoring drug therapy in rheumatoid arthritis Arthritis Rheum 199639723-31
bull 90 Ng PC The fetal and neonatal hypothalamic-pituitary-adrenal axis Arch Dis Child Fetal Neonatal Ed 200082F250-4
bull 91 Crowley P Antenatal corticosteroidsmdashcurrent thinking BJOG 2003110(Suppl 20)77-8
bull 92 ACOG committee opinion antenatal corticosteroid therapy for fetal maturation Obstet Gynecol 200299871-3
bull 93 Ost L Wettrell G Bjorkhem I Rane A Prednisolone excretion in human milk J Pediatr 19851061008-11
bull 94 Rowland AS Baird DD Shore DL Weinberg CR Savitz DA Wilcox AJ Nitrous oxide and spontaneous abortion in female dental assistants Am J Epidemiol 1995141531-8
bull 95 McGlothlin JD Jensen PA Fischbach TJ Hughes RT Jones JH Control of anesthetic gases in dental operatories Scand J Work Environ Health 199218(Suppl 2)103-5
bull ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY Volume 97 Number 6 Suresh and Radfar 681
bull 96 Rosen MA Nitrous oxide for relief of labor pain a systematic review Am J Obstet Gynecol 2002186(Suppl Nature)S110-6
bull 97 Sands TD Pynn BR Management considerations for the pregnant or nursing emergency patient Ont Dent 199875 17-9
bull 98 Daya S Recurrent spontaneous early pregnancy loss and low dose aspirin Minerva Ginecol 200355441-9
bull 99 Sinclair C Handbook of obstetrical emergencies 1st ed Philadelphia WB Saunders 1996 p 29-39 69
bull 100 Tarsitano BF Rollings RE The pregnant dental patient evaluation and management Gen Dent 199341226-34
bull 101 Livingston MH Dlllinger TM Holder R Consideration in the management of the pregnant patient SCD Special Care in Dentistry 199818183-8
Thank you
- A Review on the principle of Dental Management of the Pregnant patient
- Slide 2
- Questions that a dentist may ask
- Stages of Pregnancy
- Slide 5
- Slide 6
- Physiologic Changes in Pregnancy
- Systemic changes in pregnancy
- FLAT SUPINE POSITIONING
- SUPINE HYPOTENSION SYNDROME (Vena Cava Compression)
- Supine Hypotension Syndrome
- Slide 12
- Supine Hypotension Syndrome
- Prevention of Supine Hypotensive Syndrome
- Treatment of Supine Hypotensive Syndrome
- How should the pregnant woman be positioned
- Slide 17
- Slide 18
- Slide 19
- Slide 20
- Slide 21
- Slide 22
- Slide 23
- Pregnancy Related Oral Health Problems
- Oral Problems in Pregnancy
- Pregnancy Gingivitis Pathophysiology
- Pregnancy Gingivitis
- Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Gum Problems - Pregnancy Granuloma
- Slide 31
- Gum Changes - Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Candidiasis
- Pregnancy Myths
- Other Oral Conditions in Pregnancy
- Changes During Pregnancy that Affect Oral Health
- Saliva changes
- Increased Bacteria
- Slide 40
- Enamel erosion caused by frequent vomiting
- Treatment for Acid Exposure
- Oral Diseases Can Effect Pregnancy
- Periodontal Disease and Preterm Labor
- Periodontal Disease and Low Birth Weight
- Periodontal Disease and Preeclampsia
- Periodontitis and Pre-eclampsia
- Dental Considerations
- Treatment Timing
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Slide 52
- Use of Radiation on Pregnant Patient
- Radiographs during Pregnancy
- Risks of Dental X-Rays
- FDA drug classification for pregnancy
- Slide 57
- FDA drug classification for pregnancy
- Slide 59
- Slide 60
- Slide 61
- Common Analgesics
- Analgesics
- Analgesics - continued
- Analgesics to Use During 1st and 2nd Trimester
- Analgesics to Avoid During the Third Trimester
- Sedation in Pregnancy
- Common Antibiotics
- Antibiotics
- Antibiotics To Use During Pregnancy
- Antibiotics to Avoid during Pregnancy
- The Problem With Tetracycline
- Other Antimicrobial Agents
- Local Anesthetic Use in Pregnancy
- Use of Local Anesthetics
- Ulcer healing drugs
- Slide 77
- Slide 78
- Slide 79
- Use of Nitrous Oxide Gas
- Common Preventives
- Are topical agents safe
- Pre-natal Fluoride
- Is it safe to use mercury restorations
- References
- REFERENCES
- Slide 87
- Slide 88
- Slide 89
- Slide 90
- Slide 91
- Slide 92
- Slide 93
- Slide 94
- Slide 95
- Slide 96
- Slide 97
- Slide 98
- Thank you
-
Local Anesthetic Use inPregnancy
bull Class Bbull Lidocaine (Xylocaine)bull Etidocainebull Prilocaine bull Class Cbull Procainebull Bupivicainebull Mepivicaine
Use of Local Anestheticsbull Lidocaine + vasoconstrictor most common
local anesthetic used in dentistrybull extensively used in pregnancy with no proven ill
effectsbull accidental intravascular injections of lidocaine
pass through the placenta but the concentrations are too low to harm fetus
bull prilocaine might cause methemoglobinemia
Ulcer healing drugsCimetidine bull FDA category B Famotidinebull FDA category BRanitidinebull FDA category Bbull not known to be harmful
Ulcer healing drugsOmeprazolebull FDA category BNot known to be
harmful Esomeprazolebull FDA category BLansoprazolebull FDA category BPantoprazolebull Avoid unless potential benefit
outweighs riskmdashfetotoxic in animals
Ulcer healing drugs
Misoprostolbull First second third trimesters Avoidmdash
potent uterine stimulant (has been used to induce abortion) and may be teratogenic
Ulcer healing drugs
Antacidsbull Almunium hydroxideMagnesium
hydroxidemdashFDA category B Calcium carbonatemdashFDA category C
SimetheconemdashFDA category C
Use of Nitrous Oxide Gas
bull used over 150 years bull safety is being debatedbull SHORT TERM exposure do not cause
birth defects or spontaneous abortionbull CHRONIC exposure may result in fetal
loss and infertilitybull literature suggests that nitrous oxide
should be avoided until more conclusive research is available
bull FDA Drug class not yet assigned
Common Preventives
bull Fluoridendash No increased risk during pregnancy
bull Xylitolndash No studies no harm reported
bull Chlorhexidinendash No increased risk during pregnancy
Are topical agents safe
bull Fluoridebull Toothpaste amp mouthrinse
bull Xylitol chewing gum bull Chlorhexidine (11 alcohol)bull No over the counter mouthrinses with
alcohol (Listerine 20 alcohol)
Pre-natal Fluoride
bull Daily 22 mg tablet of sodium fluoride during 3rd through 9th months
bull decreases caries rate in offspringbull Safe and effective
Glenn FB 1982
Is it safe to use mercury restorations
bull No evidence of harmful effect
bull Benefits outweigh risks
bull Canada Germany and New Zealand have some restrictions
bull Determine the best option
Referencesbull Wasylko L Matsui D Dykxhoorn SM Rieder MJ Weinberg
S A Review of Common Dental Treatments During Pregnancy J Canadian Dental Association 64434-439 1998
bull Little JW Donald AF Craig SM Rhodus NL Dental Management of the Medically Compromised Patient - 5th edition Mosby Toronto Pp434-442 1997
bull Livingston HM Dellinger TM Holder R Considerations in the management of the pregnant patient Special Care in Dentistry 185 pp183-188 1998
bull Larimore WL Petrie KA Drug use during pregnacy and lactation Primary Care Clinics in Office Practice 271 35-53 2000
bull Health Canada The Safety of DentalAmalgam Minister Of Supply and Services Canada 1996
REFERENCESbull 1 Weiss G Endocrinology of parturition J Clin
Endocrinol Metab 2000854421-5bull 2 Theunissen IM Parer JT Fluid and electrolytes in
pregnancy Clin Obstet Gynecol 1994373-15bull 3 Duvekot JJ Peeters LLH Renal hemodynamics and
volume homeostasis in pregnancy Obstet Gynecol Surv 199449830-9
bull 4 Barron WM Lindheimer MD Medical disorders during pregnancy 2nd ed St Louis Mosby 1995 p 129
bull 5 Thornburg KL Jacobson SL Giraud GD Morton MJ Hemodynamic changes in pregnancy Semin Perinatol 20002411-4
bull 6 Fiese R Herzog S Issues in dental and surgical management of the pregnant patient Oral Surg Oral Med Oral Pathol 198865292-7
bull 7 Martin C Varner MW Physiologic changes in pregnancysurgical implications Clin Obstet Gynecol 199437241-55
bull 8 Clark SL Cotton DB Lee W Bishop C Hill T Southwick J et al Central hemodynamic assessment of normal term pregnancy Am J Obstet Gynecol 19891611439-42
bull 9 Mabie WC Di Sessa TG Crocker LG Sibai BM Arheart KL A longitudinal study of cardiac output in normal human pregnancy Am J Obstet Gynecol 1994170849-56
bull 10 Clapp JF 3rd Capeless E Cardiovascular function before during and after the first and subsequent pregnancies Am J Cardiol 1997801469-73
bull 11 Duvekot JJ Peeters LL Maternal cardiovascular hemodynamic adaptation to pregnancy Obstet Gynecol Surv 199449(Suppl) S1-14
bull 12 Bhagwat AR Engel PJ Heart disease and pregnancy Cardiol Clin 199513163-78
bull 13 Lanni SM Tillinghast J Silver H Hemodynamic changes and baroreflex gain in the supine hypotensive syndrome Am J Obstet Gynecol 20021871636-41
bull 14 Little JW Falace DA Miller CS Rhodus NL Dental management of the medically compromised patient 6th ed St Louis Mosby 2002 p 303
bull 15 Garcia-Rio F Pino JM Gomez L Alvarez-Sala R Villasante C Villamor J Regulation of breathing and perception of dyspnea in healthy pregnant women Chest 1996110446-53
bull 16 McAuliffe F Kametas N Costello J Rafferty GF Greenough A Nicolaides K Respiratory function in singleton and twin pregnancy BJOG 2002109765-9
bull 17 Clapp JF 3rd Seaward BL Sleamaker RH Hiser J Maternal physiologic adaptations to early human pregnancy Am J Obstet Gynecol 19881591456-60
bull 18 OrsquoDay MP Cardio-respiratory physiological adaptation of pregnancy Semin Perinatol 199721268-75
bull 19 Contreras G Gutierrez M Beroiza T Fantin A Oddo H Villarroel L et al Ventilatory drive and respiratory muscle function in pregnancy Am Rev Respir Dis 1991144837-41
bull 20 Turner M Aziz SR Management of the pregnant oral and maxillofac
bull 21 Sifakis S Pharmakides G Anemia in pregnancy Ann N Y Acad Sci 2000900125-36
bull 22 Branch DW Physiologic adaptations of pregnancy Am J Reprod Immunol 199228120-2
bull 23 Burrows RF Kelton JG Incidentally detected thrombocytopenia in healthy mothers and their infants N Engl J Med 1988319 142-5
bull 24 Hanly JG Antiphospholipid syndrome an overview CMAJ 200324(168)1675-82
bull 25 Heilmann L von Tempelhoff GF Pollow K Antiphospholipid syndrome in obstetrics Clin Appl Thromb Hemost 20039 143-50
bull 26 Sherman P Flaxman SM Nausea and vomiting of pregnancy in an evolutionary perspective Am J Obstet Gynecol 2002 185(Suppl)s190-7
bull 27 Koch KL Gastrointestinal factors in nausea and vomiting of pregnancy Am J Obstet Gynecol 2002185(Suppl)s198-203
bull 28 Koch KL Frissora CL Nausea and vomiting during pregnancy Gastroenterol Clin N Am 200332201-34
bull 29 Baron TH Ramirez B Richter JE Gastrointestinal motility disorders during pregnancy Ann Intern Med 1993118 366-75
bull 30 Richter JE Gastroesophageal reflux disease during pregnancy Gastroenterol Clin N Am 200332235-61
bull 31 Marrero JM Goggin PM de Caestecker JS Pearce JM Maxwell JD Determinants of pregnancy heartburn Br J Obstet Gynaecol 199299731-4
bull 32 Hamaoui E Hamaoui M Nutritional assessment and support during pregnancy Gastroenterol Clin N Am 20033259-121
bull 33 King JC Physiology of pregnancy and nutrient metabolism Am J Clin Nutr 200071(suppl)1218s-25s
bull 34 Casanueva E Pfeffer F Fernandez-Gaxiola AC Gutierrez- Valenzuela V Rothenberg SJ Iron and folate status before pregnancy and anemia during pregnancy Ann Nutr Metab 2003 4760-3
bull 35 Chrsquong CL Morgan M Hainsworth I Kingham JG Prospective study of liver dysfunction in Southwest Wales Gut 200251 876-80
bull 36 Rahman TM Wendon J Severe hepatic dysfunction in pregnancy QJM 200295343-57
bull 37 Knox TA Olans LB Liver disease in pregnancy N Engl J Med 1996335569-76
bull 38 Saftlas AF Olson DR Franks AL Atrash H Pokras R Epidemiology of preeclampsia and eclampsia in the United States 1979e1986 Am J Obstet Gynecol 1990163460-5
bull 39 Walker JJ Pre-eclampsia Lancet 20003561260-5
bull 40 Davidson JM Renal disorders in pregnancy Curr Opin Obstet Gynecol 200113109-14
bull 41 Dafnis E Sabatini S The effect of pregnancy on renal function physiology and pathophysiologyAmJMedSci 1992303184-205
bull 42 Davison JM Shiells EA Philips PR Lindheimer MD Serial evaluation of vasopressin release and thirst in human pregnancy Role of human chorionic gonadotrophin in the osmoregulatory changes of gestation J Clin Invest 198881798-806
bull 43 Glinoer D de Nayer P Bourdoux P Lemone M Robyn C van Steirteghem A et al Regulation of maternal thyroid during pregnancy J Clin Endocrinol Metab 199071276-87
bull 44 Wilson SG Retallack RW Kent JC Worth GK Gutteridge DH Serum free 125-dihydroxyvitamin D and the free 125- dihydroxyvitamin D index during a longitudinal study of human pregnancy and lactation Clin Endocrinol 199032613-22
bull 45 Rasmussen N Frolich A Hornnes PJ Hegedus L Serum ionized calcium and intact parathyroid hormone levels during pregnancy and postpartum Br J Obstet Gynaecol 199097857-9
bull 46 Guyton AC Textbook of medical physiology 8th ed Philadelphia W B Saunders 1991 p 915e28
bull 47 Trainer PJ Corticosteroids and pregnancy Semin Reprod Med 200220375-80
bull 48 Soory M Hormonal factors in periodontal disease Dent Update 200027380-3
bull 49 Hugoson A Gingivitis in pregnant women A longitudinal clinical study Odontol Revy 19712265-84
bull 50 Neville BW Damm DD Allen CM Bouquot JE Oral amp Maxillofacial Pathology 3rd ed Philadelphia W B Saunders 2002 p 329-30 447-9
bull 51 Tilakaratne A Soory M Ranasinghe AW Corea SM Ekanayake SL de Silva M Periodontal disease status during pregnancy and 3 months post-partum in rural population of Sri-Lankan women J Clin Periodontol 200027787-92
bull 52 Laine M Tenovuo J Lehtonen OP Ojanatko-Harri A Vilja P Tuohimaa P Pregnancy e related changes in human whole saliva Arch Oral Biol 198833913-7
bull 53 Yuan K Wing LY Lin MT Pathogenetic roles of angiogenic factors in pyogenic granulomas in pregnancy are modulated by female sex hormones J Periodontol 200273701-8
bull 54 Evans RD Briggs PF Tooth-surface loss related to pregnancyinduced vomiting Prim Dent Care 1994124-6
bull 55 Salvolini E Di Giorgio R Curatola A Mazzanti L Fratto G Biochemical modifications of human whole saliva induced by pregnancy Br J Obstet Gynaec 1998105656-60
bull 56 Mauldin JG Newman RB Preterm birth risk assessment Semin Perinatol 200125215-22
bull 57 Heine RP McGregor JA Goodwin TM Artal R Hayashi RH Robertson PA et al Serial salivary estriol to detect an increased risk of preterm birth Obstet Gynecol 200096490-7
bull 58 Kauh YC Zachian TF Melasma Adv Exp Med Biol 1999455 491-9
bull 59 Wong RC Ellis CN Physiologic skin changes in pregnancy J Am Acad Dermatol 198410929-40
bull 60 Errickson CV Matus NR Skin disorders of pregnancy Am Fam Physician 199449605-10
bull 61 Lopez NJ Smith PC Gutierrez J Periodontal therapy may reduce the risk of preterm low birth weight in women with periodontal disease a randomized controlled trial J Periodontol 200273911-24
bull 62 McGaw T Periodontal disease and preterm delivery of lowbirth- weight infants J Can Dent Assoc 200268165-9
bull 63 Richards AG Dental x-ray protection Dent Clin North Am 1968631-41
bull 64 1990 Recommendations of the International Commission on Radiological Protection Ann ICRP 1991211-201
bull 65 Hall EJ Radiation the two-edged sword cancer risks at high and low doses Cancer J 20006343-50
bull 66 Diethelm L Xu H Diagnostic imaging of the lung during pregnancy Clin Obstet Gynecol 19963936-55
bull 67 Brent RL The effects of embryonic and fetal exposure to x-rays microwaves and ultrasound ClinObstetGynecol 198326484-510
bull 68 National Council on Radiation Protection NCRP report no128 1998 Bethesda Md Author
bull 69 Wasylko L Matsui D Dykxhoorn SM Reider MJ Weinberg S A review of common dental treatments during pregnancy implications for patients and dental personnel J Can Dent Assoc 199864434-9
bull 70 Freeman JP Brand JW Radiation doses of commonly used dental radiographic surveys Oral Surg Oral Med Oral Pathol 199477285-9
bull 71 Kircos LTAngin LL Lorton LOrder ofmagnitude dose reduction in intraoral radiography J Am Dent Assoc 1987114344-7
bull 72 Updegrave WJ Simplified and standardized intraoral radiography with reduced tissue irradiation J Am Dent Assoc 197285861-9
bull 73 Wood RE Harris AM van der Merwe EJ Nortje CJ The leaded apron revisited does it reduce gonadal radiation dose in dental radiology Oral Surg Oral Med Oral Pathol 199171642-6
bull 74 An update on radiographic practices information and recommendations ADA Council on Scientific Affairs J Am Dent Assoc 2001132234-8
bull 75 Rayburn WF Recommending medications during pregnancy an evidence based approach Clin Obstet Gynecol 2002451-5
bull 76 Rathmell JP Viscomi C Ashburn MA Management of nonobstetric pain during pregnancy and lactation Anesth Analg 1997851074-87
bull 77 Teratology society public affairs committee FDA classification of drugs for teratogenic risk Teratology 199449446-7
bull 78 Moore PA Selecting drugs for the pregnant dental patient J Am Dent Assoc 19981291281-6
bull 79 Haas DA An update on analgesics for the management of acute postoperative dental pain J Can Dent Assoc 200268476-82
bull 80 Haas DA Pynn BR Sands TD Drug use for the pregnant or lactating patient Gen Dent 20004854-60
bull 81 Committee on Drugs American Academy of Pediatrics The transfer of drugs and other chemicals into human milk Pediatrics 199493137-50
bull 82 Nielsen GL Sorensen HT Larsen H Pedersen L Risk of adverse birth outcome and miscarriage in pregnant users of nonsteroidal anti-inflammatory drugs population based observational study and case-control study BMJ 2001322266-70
bull 83 Janssen N Genta M The effects of immunosuppressive and anti-inflammatory medications on fertility pregnancy and lactation Arch Intern Med 200016610-9
bull 84 Ostensen M Nonsteroidal anti-inflammatory drugs during pregnancy Scand J Rheumatol Suppl 1998107128-32
bull 85 USPDI -Drug information for the health care professional 22nd ed Greenwood Village CO Micromedex 2002 p 152-79
bull 86 Denson DD Coyle DE Thompson GA Santos D Turner PA Myers JA et al Bupivacaine protein binding in the term parturient effects of lactic acidosis Clin Pharmacol Ther 198435702-9
bull 87 Dillon DE Wagner CL Wiest D Newman RB Drug therapy in the nursing mother Obstet Gynecol Clin North Am 199724 675-96
bull 88 Dashe JS Gilstrap LC Antibiotic use in pregnancy Obstet Gynecol Clin North Am 199724617-29
bull 89 American College of Rheumatology Ad hoc Committee on Clinical Guidelines Guidelines for monitoring drug therapy in rheumatoid arthritis Arthritis Rheum 199639723-31
bull 90 Ng PC The fetal and neonatal hypothalamic-pituitary-adrenal axis Arch Dis Child Fetal Neonatal Ed 200082F250-4
bull 91 Crowley P Antenatal corticosteroidsmdashcurrent thinking BJOG 2003110(Suppl 20)77-8
bull 92 ACOG committee opinion antenatal corticosteroid therapy for fetal maturation Obstet Gynecol 200299871-3
bull 93 Ost L Wettrell G Bjorkhem I Rane A Prednisolone excretion in human milk J Pediatr 19851061008-11
bull 94 Rowland AS Baird DD Shore DL Weinberg CR Savitz DA Wilcox AJ Nitrous oxide and spontaneous abortion in female dental assistants Am J Epidemiol 1995141531-8
bull 95 McGlothlin JD Jensen PA Fischbach TJ Hughes RT Jones JH Control of anesthetic gases in dental operatories Scand J Work Environ Health 199218(Suppl 2)103-5
bull ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY Volume 97 Number 6 Suresh and Radfar 681
bull 96 Rosen MA Nitrous oxide for relief of labor pain a systematic review Am J Obstet Gynecol 2002186(Suppl Nature)S110-6
bull 97 Sands TD Pynn BR Management considerations for the pregnant or nursing emergency patient Ont Dent 199875 17-9
bull 98 Daya S Recurrent spontaneous early pregnancy loss and low dose aspirin Minerva Ginecol 200355441-9
bull 99 Sinclair C Handbook of obstetrical emergencies 1st ed Philadelphia WB Saunders 1996 p 29-39 69
bull 100 Tarsitano BF Rollings RE The pregnant dental patient evaluation and management Gen Dent 199341226-34
bull 101 Livingston MH Dlllinger TM Holder R Consideration in the management of the pregnant patient SCD Special Care in Dentistry 199818183-8
Thank you
- A Review on the principle of Dental Management of the Pregnant patient
- Slide 2
- Questions that a dentist may ask
- Stages of Pregnancy
- Slide 5
- Slide 6
- Physiologic Changes in Pregnancy
- Systemic changes in pregnancy
- FLAT SUPINE POSITIONING
- SUPINE HYPOTENSION SYNDROME (Vena Cava Compression)
- Supine Hypotension Syndrome
- Slide 12
- Supine Hypotension Syndrome
- Prevention of Supine Hypotensive Syndrome
- Treatment of Supine Hypotensive Syndrome
- How should the pregnant woman be positioned
- Slide 17
- Slide 18
- Slide 19
- Slide 20
- Slide 21
- Slide 22
- Slide 23
- Pregnancy Related Oral Health Problems
- Oral Problems in Pregnancy
- Pregnancy Gingivitis Pathophysiology
- Pregnancy Gingivitis
- Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Gum Problems - Pregnancy Granuloma
- Slide 31
- Gum Changes - Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Candidiasis
- Pregnancy Myths
- Other Oral Conditions in Pregnancy
- Changes During Pregnancy that Affect Oral Health
- Saliva changes
- Increased Bacteria
- Slide 40
- Enamel erosion caused by frequent vomiting
- Treatment for Acid Exposure
- Oral Diseases Can Effect Pregnancy
- Periodontal Disease and Preterm Labor
- Periodontal Disease and Low Birth Weight
- Periodontal Disease and Preeclampsia
- Periodontitis and Pre-eclampsia
- Dental Considerations
- Treatment Timing
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Slide 52
- Use of Radiation on Pregnant Patient
- Radiographs during Pregnancy
- Risks of Dental X-Rays
- FDA drug classification for pregnancy
- Slide 57
- FDA drug classification for pregnancy
- Slide 59
- Slide 60
- Slide 61
- Common Analgesics
- Analgesics
- Analgesics - continued
- Analgesics to Use During 1st and 2nd Trimester
- Analgesics to Avoid During the Third Trimester
- Sedation in Pregnancy
- Common Antibiotics
- Antibiotics
- Antibiotics To Use During Pregnancy
- Antibiotics to Avoid during Pregnancy
- The Problem With Tetracycline
- Other Antimicrobial Agents
- Local Anesthetic Use in Pregnancy
- Use of Local Anesthetics
- Ulcer healing drugs
- Slide 77
- Slide 78
- Slide 79
- Use of Nitrous Oxide Gas
- Common Preventives
- Are topical agents safe
- Pre-natal Fluoride
- Is it safe to use mercury restorations
- References
- REFERENCES
- Slide 87
- Slide 88
- Slide 89
- Slide 90
- Slide 91
- Slide 92
- Slide 93
- Slide 94
- Slide 95
- Slide 96
- Slide 97
- Slide 98
- Thank you
-
Use of Local Anestheticsbull Lidocaine + vasoconstrictor most common
local anesthetic used in dentistrybull extensively used in pregnancy with no proven ill
effectsbull accidental intravascular injections of lidocaine
pass through the placenta but the concentrations are too low to harm fetus
bull prilocaine might cause methemoglobinemia
Ulcer healing drugsCimetidine bull FDA category B Famotidinebull FDA category BRanitidinebull FDA category Bbull not known to be harmful
Ulcer healing drugsOmeprazolebull FDA category BNot known to be
harmful Esomeprazolebull FDA category BLansoprazolebull FDA category BPantoprazolebull Avoid unless potential benefit
outweighs riskmdashfetotoxic in animals
Ulcer healing drugs
Misoprostolbull First second third trimesters Avoidmdash
potent uterine stimulant (has been used to induce abortion) and may be teratogenic
Ulcer healing drugs
Antacidsbull Almunium hydroxideMagnesium
hydroxidemdashFDA category B Calcium carbonatemdashFDA category C
SimetheconemdashFDA category C
Use of Nitrous Oxide Gas
bull used over 150 years bull safety is being debatedbull SHORT TERM exposure do not cause
birth defects or spontaneous abortionbull CHRONIC exposure may result in fetal
loss and infertilitybull literature suggests that nitrous oxide
should be avoided until more conclusive research is available
bull FDA Drug class not yet assigned
Common Preventives
bull Fluoridendash No increased risk during pregnancy
bull Xylitolndash No studies no harm reported
bull Chlorhexidinendash No increased risk during pregnancy
Are topical agents safe
bull Fluoridebull Toothpaste amp mouthrinse
bull Xylitol chewing gum bull Chlorhexidine (11 alcohol)bull No over the counter mouthrinses with
alcohol (Listerine 20 alcohol)
Pre-natal Fluoride
bull Daily 22 mg tablet of sodium fluoride during 3rd through 9th months
bull decreases caries rate in offspringbull Safe and effective
Glenn FB 1982
Is it safe to use mercury restorations
bull No evidence of harmful effect
bull Benefits outweigh risks
bull Canada Germany and New Zealand have some restrictions
bull Determine the best option
Referencesbull Wasylko L Matsui D Dykxhoorn SM Rieder MJ Weinberg
S A Review of Common Dental Treatments During Pregnancy J Canadian Dental Association 64434-439 1998
bull Little JW Donald AF Craig SM Rhodus NL Dental Management of the Medically Compromised Patient - 5th edition Mosby Toronto Pp434-442 1997
bull Livingston HM Dellinger TM Holder R Considerations in the management of the pregnant patient Special Care in Dentistry 185 pp183-188 1998
bull Larimore WL Petrie KA Drug use during pregnacy and lactation Primary Care Clinics in Office Practice 271 35-53 2000
bull Health Canada The Safety of DentalAmalgam Minister Of Supply and Services Canada 1996
REFERENCESbull 1 Weiss G Endocrinology of parturition J Clin
Endocrinol Metab 2000854421-5bull 2 Theunissen IM Parer JT Fluid and electrolytes in
pregnancy Clin Obstet Gynecol 1994373-15bull 3 Duvekot JJ Peeters LLH Renal hemodynamics and
volume homeostasis in pregnancy Obstet Gynecol Surv 199449830-9
bull 4 Barron WM Lindheimer MD Medical disorders during pregnancy 2nd ed St Louis Mosby 1995 p 129
bull 5 Thornburg KL Jacobson SL Giraud GD Morton MJ Hemodynamic changes in pregnancy Semin Perinatol 20002411-4
bull 6 Fiese R Herzog S Issues in dental and surgical management of the pregnant patient Oral Surg Oral Med Oral Pathol 198865292-7
bull 7 Martin C Varner MW Physiologic changes in pregnancysurgical implications Clin Obstet Gynecol 199437241-55
bull 8 Clark SL Cotton DB Lee W Bishop C Hill T Southwick J et al Central hemodynamic assessment of normal term pregnancy Am J Obstet Gynecol 19891611439-42
bull 9 Mabie WC Di Sessa TG Crocker LG Sibai BM Arheart KL A longitudinal study of cardiac output in normal human pregnancy Am J Obstet Gynecol 1994170849-56
bull 10 Clapp JF 3rd Capeless E Cardiovascular function before during and after the first and subsequent pregnancies Am J Cardiol 1997801469-73
bull 11 Duvekot JJ Peeters LL Maternal cardiovascular hemodynamic adaptation to pregnancy Obstet Gynecol Surv 199449(Suppl) S1-14
bull 12 Bhagwat AR Engel PJ Heart disease and pregnancy Cardiol Clin 199513163-78
bull 13 Lanni SM Tillinghast J Silver H Hemodynamic changes and baroreflex gain in the supine hypotensive syndrome Am J Obstet Gynecol 20021871636-41
bull 14 Little JW Falace DA Miller CS Rhodus NL Dental management of the medically compromised patient 6th ed St Louis Mosby 2002 p 303
bull 15 Garcia-Rio F Pino JM Gomez L Alvarez-Sala R Villasante C Villamor J Regulation of breathing and perception of dyspnea in healthy pregnant women Chest 1996110446-53
bull 16 McAuliffe F Kametas N Costello J Rafferty GF Greenough A Nicolaides K Respiratory function in singleton and twin pregnancy BJOG 2002109765-9
bull 17 Clapp JF 3rd Seaward BL Sleamaker RH Hiser J Maternal physiologic adaptations to early human pregnancy Am J Obstet Gynecol 19881591456-60
bull 18 OrsquoDay MP Cardio-respiratory physiological adaptation of pregnancy Semin Perinatol 199721268-75
bull 19 Contreras G Gutierrez M Beroiza T Fantin A Oddo H Villarroel L et al Ventilatory drive and respiratory muscle function in pregnancy Am Rev Respir Dis 1991144837-41
bull 20 Turner M Aziz SR Management of the pregnant oral and maxillofac
bull 21 Sifakis S Pharmakides G Anemia in pregnancy Ann N Y Acad Sci 2000900125-36
bull 22 Branch DW Physiologic adaptations of pregnancy Am J Reprod Immunol 199228120-2
bull 23 Burrows RF Kelton JG Incidentally detected thrombocytopenia in healthy mothers and their infants N Engl J Med 1988319 142-5
bull 24 Hanly JG Antiphospholipid syndrome an overview CMAJ 200324(168)1675-82
bull 25 Heilmann L von Tempelhoff GF Pollow K Antiphospholipid syndrome in obstetrics Clin Appl Thromb Hemost 20039 143-50
bull 26 Sherman P Flaxman SM Nausea and vomiting of pregnancy in an evolutionary perspective Am J Obstet Gynecol 2002 185(Suppl)s190-7
bull 27 Koch KL Gastrointestinal factors in nausea and vomiting of pregnancy Am J Obstet Gynecol 2002185(Suppl)s198-203
bull 28 Koch KL Frissora CL Nausea and vomiting during pregnancy Gastroenterol Clin N Am 200332201-34
bull 29 Baron TH Ramirez B Richter JE Gastrointestinal motility disorders during pregnancy Ann Intern Med 1993118 366-75
bull 30 Richter JE Gastroesophageal reflux disease during pregnancy Gastroenterol Clin N Am 200332235-61
bull 31 Marrero JM Goggin PM de Caestecker JS Pearce JM Maxwell JD Determinants of pregnancy heartburn Br J Obstet Gynaecol 199299731-4
bull 32 Hamaoui E Hamaoui M Nutritional assessment and support during pregnancy Gastroenterol Clin N Am 20033259-121
bull 33 King JC Physiology of pregnancy and nutrient metabolism Am J Clin Nutr 200071(suppl)1218s-25s
bull 34 Casanueva E Pfeffer F Fernandez-Gaxiola AC Gutierrez- Valenzuela V Rothenberg SJ Iron and folate status before pregnancy and anemia during pregnancy Ann Nutr Metab 2003 4760-3
bull 35 Chrsquong CL Morgan M Hainsworth I Kingham JG Prospective study of liver dysfunction in Southwest Wales Gut 200251 876-80
bull 36 Rahman TM Wendon J Severe hepatic dysfunction in pregnancy QJM 200295343-57
bull 37 Knox TA Olans LB Liver disease in pregnancy N Engl J Med 1996335569-76
bull 38 Saftlas AF Olson DR Franks AL Atrash H Pokras R Epidemiology of preeclampsia and eclampsia in the United States 1979e1986 Am J Obstet Gynecol 1990163460-5
bull 39 Walker JJ Pre-eclampsia Lancet 20003561260-5
bull 40 Davidson JM Renal disorders in pregnancy Curr Opin Obstet Gynecol 200113109-14
bull 41 Dafnis E Sabatini S The effect of pregnancy on renal function physiology and pathophysiologyAmJMedSci 1992303184-205
bull 42 Davison JM Shiells EA Philips PR Lindheimer MD Serial evaluation of vasopressin release and thirst in human pregnancy Role of human chorionic gonadotrophin in the osmoregulatory changes of gestation J Clin Invest 198881798-806
bull 43 Glinoer D de Nayer P Bourdoux P Lemone M Robyn C van Steirteghem A et al Regulation of maternal thyroid during pregnancy J Clin Endocrinol Metab 199071276-87
bull 44 Wilson SG Retallack RW Kent JC Worth GK Gutteridge DH Serum free 125-dihydroxyvitamin D and the free 125- dihydroxyvitamin D index during a longitudinal study of human pregnancy and lactation Clin Endocrinol 199032613-22
bull 45 Rasmussen N Frolich A Hornnes PJ Hegedus L Serum ionized calcium and intact parathyroid hormone levels during pregnancy and postpartum Br J Obstet Gynaecol 199097857-9
bull 46 Guyton AC Textbook of medical physiology 8th ed Philadelphia W B Saunders 1991 p 915e28
bull 47 Trainer PJ Corticosteroids and pregnancy Semin Reprod Med 200220375-80
bull 48 Soory M Hormonal factors in periodontal disease Dent Update 200027380-3
bull 49 Hugoson A Gingivitis in pregnant women A longitudinal clinical study Odontol Revy 19712265-84
bull 50 Neville BW Damm DD Allen CM Bouquot JE Oral amp Maxillofacial Pathology 3rd ed Philadelphia W B Saunders 2002 p 329-30 447-9
bull 51 Tilakaratne A Soory M Ranasinghe AW Corea SM Ekanayake SL de Silva M Periodontal disease status during pregnancy and 3 months post-partum in rural population of Sri-Lankan women J Clin Periodontol 200027787-92
bull 52 Laine M Tenovuo J Lehtonen OP Ojanatko-Harri A Vilja P Tuohimaa P Pregnancy e related changes in human whole saliva Arch Oral Biol 198833913-7
bull 53 Yuan K Wing LY Lin MT Pathogenetic roles of angiogenic factors in pyogenic granulomas in pregnancy are modulated by female sex hormones J Periodontol 200273701-8
bull 54 Evans RD Briggs PF Tooth-surface loss related to pregnancyinduced vomiting Prim Dent Care 1994124-6
bull 55 Salvolini E Di Giorgio R Curatola A Mazzanti L Fratto G Biochemical modifications of human whole saliva induced by pregnancy Br J Obstet Gynaec 1998105656-60
bull 56 Mauldin JG Newman RB Preterm birth risk assessment Semin Perinatol 200125215-22
bull 57 Heine RP McGregor JA Goodwin TM Artal R Hayashi RH Robertson PA et al Serial salivary estriol to detect an increased risk of preterm birth Obstet Gynecol 200096490-7
bull 58 Kauh YC Zachian TF Melasma Adv Exp Med Biol 1999455 491-9
bull 59 Wong RC Ellis CN Physiologic skin changes in pregnancy J Am Acad Dermatol 198410929-40
bull 60 Errickson CV Matus NR Skin disorders of pregnancy Am Fam Physician 199449605-10
bull 61 Lopez NJ Smith PC Gutierrez J Periodontal therapy may reduce the risk of preterm low birth weight in women with periodontal disease a randomized controlled trial J Periodontol 200273911-24
bull 62 McGaw T Periodontal disease and preterm delivery of lowbirth- weight infants J Can Dent Assoc 200268165-9
bull 63 Richards AG Dental x-ray protection Dent Clin North Am 1968631-41
bull 64 1990 Recommendations of the International Commission on Radiological Protection Ann ICRP 1991211-201
bull 65 Hall EJ Radiation the two-edged sword cancer risks at high and low doses Cancer J 20006343-50
bull 66 Diethelm L Xu H Diagnostic imaging of the lung during pregnancy Clin Obstet Gynecol 19963936-55
bull 67 Brent RL The effects of embryonic and fetal exposure to x-rays microwaves and ultrasound ClinObstetGynecol 198326484-510
bull 68 National Council on Radiation Protection NCRP report no128 1998 Bethesda Md Author
bull 69 Wasylko L Matsui D Dykxhoorn SM Reider MJ Weinberg S A review of common dental treatments during pregnancy implications for patients and dental personnel J Can Dent Assoc 199864434-9
bull 70 Freeman JP Brand JW Radiation doses of commonly used dental radiographic surveys Oral Surg Oral Med Oral Pathol 199477285-9
bull 71 Kircos LTAngin LL Lorton LOrder ofmagnitude dose reduction in intraoral radiography J Am Dent Assoc 1987114344-7
bull 72 Updegrave WJ Simplified and standardized intraoral radiography with reduced tissue irradiation J Am Dent Assoc 197285861-9
bull 73 Wood RE Harris AM van der Merwe EJ Nortje CJ The leaded apron revisited does it reduce gonadal radiation dose in dental radiology Oral Surg Oral Med Oral Pathol 199171642-6
bull 74 An update on radiographic practices information and recommendations ADA Council on Scientific Affairs J Am Dent Assoc 2001132234-8
bull 75 Rayburn WF Recommending medications during pregnancy an evidence based approach Clin Obstet Gynecol 2002451-5
bull 76 Rathmell JP Viscomi C Ashburn MA Management of nonobstetric pain during pregnancy and lactation Anesth Analg 1997851074-87
bull 77 Teratology society public affairs committee FDA classification of drugs for teratogenic risk Teratology 199449446-7
bull 78 Moore PA Selecting drugs for the pregnant dental patient J Am Dent Assoc 19981291281-6
bull 79 Haas DA An update on analgesics for the management of acute postoperative dental pain J Can Dent Assoc 200268476-82
bull 80 Haas DA Pynn BR Sands TD Drug use for the pregnant or lactating patient Gen Dent 20004854-60
bull 81 Committee on Drugs American Academy of Pediatrics The transfer of drugs and other chemicals into human milk Pediatrics 199493137-50
bull 82 Nielsen GL Sorensen HT Larsen H Pedersen L Risk of adverse birth outcome and miscarriage in pregnant users of nonsteroidal anti-inflammatory drugs population based observational study and case-control study BMJ 2001322266-70
bull 83 Janssen N Genta M The effects of immunosuppressive and anti-inflammatory medications on fertility pregnancy and lactation Arch Intern Med 200016610-9
bull 84 Ostensen M Nonsteroidal anti-inflammatory drugs during pregnancy Scand J Rheumatol Suppl 1998107128-32
bull 85 USPDI -Drug information for the health care professional 22nd ed Greenwood Village CO Micromedex 2002 p 152-79
bull 86 Denson DD Coyle DE Thompson GA Santos D Turner PA Myers JA et al Bupivacaine protein binding in the term parturient effects of lactic acidosis Clin Pharmacol Ther 198435702-9
bull 87 Dillon DE Wagner CL Wiest D Newman RB Drug therapy in the nursing mother Obstet Gynecol Clin North Am 199724 675-96
bull 88 Dashe JS Gilstrap LC Antibiotic use in pregnancy Obstet Gynecol Clin North Am 199724617-29
bull 89 American College of Rheumatology Ad hoc Committee on Clinical Guidelines Guidelines for monitoring drug therapy in rheumatoid arthritis Arthritis Rheum 199639723-31
bull 90 Ng PC The fetal and neonatal hypothalamic-pituitary-adrenal axis Arch Dis Child Fetal Neonatal Ed 200082F250-4
bull 91 Crowley P Antenatal corticosteroidsmdashcurrent thinking BJOG 2003110(Suppl 20)77-8
bull 92 ACOG committee opinion antenatal corticosteroid therapy for fetal maturation Obstet Gynecol 200299871-3
bull 93 Ost L Wettrell G Bjorkhem I Rane A Prednisolone excretion in human milk J Pediatr 19851061008-11
bull 94 Rowland AS Baird DD Shore DL Weinberg CR Savitz DA Wilcox AJ Nitrous oxide and spontaneous abortion in female dental assistants Am J Epidemiol 1995141531-8
bull 95 McGlothlin JD Jensen PA Fischbach TJ Hughes RT Jones JH Control of anesthetic gases in dental operatories Scand J Work Environ Health 199218(Suppl 2)103-5
bull ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY Volume 97 Number 6 Suresh and Radfar 681
bull 96 Rosen MA Nitrous oxide for relief of labor pain a systematic review Am J Obstet Gynecol 2002186(Suppl Nature)S110-6
bull 97 Sands TD Pynn BR Management considerations for the pregnant or nursing emergency patient Ont Dent 199875 17-9
bull 98 Daya S Recurrent spontaneous early pregnancy loss and low dose aspirin Minerva Ginecol 200355441-9
bull 99 Sinclair C Handbook of obstetrical emergencies 1st ed Philadelphia WB Saunders 1996 p 29-39 69
bull 100 Tarsitano BF Rollings RE The pregnant dental patient evaluation and management Gen Dent 199341226-34
bull 101 Livingston MH Dlllinger TM Holder R Consideration in the management of the pregnant patient SCD Special Care in Dentistry 199818183-8
Thank you
- A Review on the principle of Dental Management of the Pregnant patient
- Slide 2
- Questions that a dentist may ask
- Stages of Pregnancy
- Slide 5
- Slide 6
- Physiologic Changes in Pregnancy
- Systemic changes in pregnancy
- FLAT SUPINE POSITIONING
- SUPINE HYPOTENSION SYNDROME (Vena Cava Compression)
- Supine Hypotension Syndrome
- Slide 12
- Supine Hypotension Syndrome
- Prevention of Supine Hypotensive Syndrome
- Treatment of Supine Hypotensive Syndrome
- How should the pregnant woman be positioned
- Slide 17
- Slide 18
- Slide 19
- Slide 20
- Slide 21
- Slide 22
- Slide 23
- Pregnancy Related Oral Health Problems
- Oral Problems in Pregnancy
- Pregnancy Gingivitis Pathophysiology
- Pregnancy Gingivitis
- Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Gum Problems - Pregnancy Granuloma
- Slide 31
- Gum Changes - Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Candidiasis
- Pregnancy Myths
- Other Oral Conditions in Pregnancy
- Changes During Pregnancy that Affect Oral Health
- Saliva changes
- Increased Bacteria
- Slide 40
- Enamel erosion caused by frequent vomiting
- Treatment for Acid Exposure
- Oral Diseases Can Effect Pregnancy
- Periodontal Disease and Preterm Labor
- Periodontal Disease and Low Birth Weight
- Periodontal Disease and Preeclampsia
- Periodontitis and Pre-eclampsia
- Dental Considerations
- Treatment Timing
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Slide 52
- Use of Radiation on Pregnant Patient
- Radiographs during Pregnancy
- Risks of Dental X-Rays
- FDA drug classification for pregnancy
- Slide 57
- FDA drug classification for pregnancy
- Slide 59
- Slide 60
- Slide 61
- Common Analgesics
- Analgesics
- Analgesics - continued
- Analgesics to Use During 1st and 2nd Trimester
- Analgesics to Avoid During the Third Trimester
- Sedation in Pregnancy
- Common Antibiotics
- Antibiotics
- Antibiotics To Use During Pregnancy
- Antibiotics to Avoid during Pregnancy
- The Problem With Tetracycline
- Other Antimicrobial Agents
- Local Anesthetic Use in Pregnancy
- Use of Local Anesthetics
- Ulcer healing drugs
- Slide 77
- Slide 78
- Slide 79
- Use of Nitrous Oxide Gas
- Common Preventives
- Are topical agents safe
- Pre-natal Fluoride
- Is it safe to use mercury restorations
- References
- REFERENCES
- Slide 87
- Slide 88
- Slide 89
- Slide 90
- Slide 91
- Slide 92
- Slide 93
- Slide 94
- Slide 95
- Slide 96
- Slide 97
- Slide 98
- Thank you
-
Ulcer healing drugsCimetidine bull FDA category B Famotidinebull FDA category BRanitidinebull FDA category Bbull not known to be harmful
Ulcer healing drugsOmeprazolebull FDA category BNot known to be
harmful Esomeprazolebull FDA category BLansoprazolebull FDA category BPantoprazolebull Avoid unless potential benefit
outweighs riskmdashfetotoxic in animals
Ulcer healing drugs
Misoprostolbull First second third trimesters Avoidmdash
potent uterine stimulant (has been used to induce abortion) and may be teratogenic
Ulcer healing drugs
Antacidsbull Almunium hydroxideMagnesium
hydroxidemdashFDA category B Calcium carbonatemdashFDA category C
SimetheconemdashFDA category C
Use of Nitrous Oxide Gas
bull used over 150 years bull safety is being debatedbull SHORT TERM exposure do not cause
birth defects or spontaneous abortionbull CHRONIC exposure may result in fetal
loss and infertilitybull literature suggests that nitrous oxide
should be avoided until more conclusive research is available
bull FDA Drug class not yet assigned
Common Preventives
bull Fluoridendash No increased risk during pregnancy
bull Xylitolndash No studies no harm reported
bull Chlorhexidinendash No increased risk during pregnancy
Are topical agents safe
bull Fluoridebull Toothpaste amp mouthrinse
bull Xylitol chewing gum bull Chlorhexidine (11 alcohol)bull No over the counter mouthrinses with
alcohol (Listerine 20 alcohol)
Pre-natal Fluoride
bull Daily 22 mg tablet of sodium fluoride during 3rd through 9th months
bull decreases caries rate in offspringbull Safe and effective
Glenn FB 1982
Is it safe to use mercury restorations
bull No evidence of harmful effect
bull Benefits outweigh risks
bull Canada Germany and New Zealand have some restrictions
bull Determine the best option
Referencesbull Wasylko L Matsui D Dykxhoorn SM Rieder MJ Weinberg
S A Review of Common Dental Treatments During Pregnancy J Canadian Dental Association 64434-439 1998
bull Little JW Donald AF Craig SM Rhodus NL Dental Management of the Medically Compromised Patient - 5th edition Mosby Toronto Pp434-442 1997
bull Livingston HM Dellinger TM Holder R Considerations in the management of the pregnant patient Special Care in Dentistry 185 pp183-188 1998
bull Larimore WL Petrie KA Drug use during pregnacy and lactation Primary Care Clinics in Office Practice 271 35-53 2000
bull Health Canada The Safety of DentalAmalgam Minister Of Supply and Services Canada 1996
REFERENCESbull 1 Weiss G Endocrinology of parturition J Clin
Endocrinol Metab 2000854421-5bull 2 Theunissen IM Parer JT Fluid and electrolytes in
pregnancy Clin Obstet Gynecol 1994373-15bull 3 Duvekot JJ Peeters LLH Renal hemodynamics and
volume homeostasis in pregnancy Obstet Gynecol Surv 199449830-9
bull 4 Barron WM Lindheimer MD Medical disorders during pregnancy 2nd ed St Louis Mosby 1995 p 129
bull 5 Thornburg KL Jacobson SL Giraud GD Morton MJ Hemodynamic changes in pregnancy Semin Perinatol 20002411-4
bull 6 Fiese R Herzog S Issues in dental and surgical management of the pregnant patient Oral Surg Oral Med Oral Pathol 198865292-7
bull 7 Martin C Varner MW Physiologic changes in pregnancysurgical implications Clin Obstet Gynecol 199437241-55
bull 8 Clark SL Cotton DB Lee W Bishop C Hill T Southwick J et al Central hemodynamic assessment of normal term pregnancy Am J Obstet Gynecol 19891611439-42
bull 9 Mabie WC Di Sessa TG Crocker LG Sibai BM Arheart KL A longitudinal study of cardiac output in normal human pregnancy Am J Obstet Gynecol 1994170849-56
bull 10 Clapp JF 3rd Capeless E Cardiovascular function before during and after the first and subsequent pregnancies Am J Cardiol 1997801469-73
bull 11 Duvekot JJ Peeters LL Maternal cardiovascular hemodynamic adaptation to pregnancy Obstet Gynecol Surv 199449(Suppl) S1-14
bull 12 Bhagwat AR Engel PJ Heart disease and pregnancy Cardiol Clin 199513163-78
bull 13 Lanni SM Tillinghast J Silver H Hemodynamic changes and baroreflex gain in the supine hypotensive syndrome Am J Obstet Gynecol 20021871636-41
bull 14 Little JW Falace DA Miller CS Rhodus NL Dental management of the medically compromised patient 6th ed St Louis Mosby 2002 p 303
bull 15 Garcia-Rio F Pino JM Gomez L Alvarez-Sala R Villasante C Villamor J Regulation of breathing and perception of dyspnea in healthy pregnant women Chest 1996110446-53
bull 16 McAuliffe F Kametas N Costello J Rafferty GF Greenough A Nicolaides K Respiratory function in singleton and twin pregnancy BJOG 2002109765-9
bull 17 Clapp JF 3rd Seaward BL Sleamaker RH Hiser J Maternal physiologic adaptations to early human pregnancy Am J Obstet Gynecol 19881591456-60
bull 18 OrsquoDay MP Cardio-respiratory physiological adaptation of pregnancy Semin Perinatol 199721268-75
bull 19 Contreras G Gutierrez M Beroiza T Fantin A Oddo H Villarroel L et al Ventilatory drive and respiratory muscle function in pregnancy Am Rev Respir Dis 1991144837-41
bull 20 Turner M Aziz SR Management of the pregnant oral and maxillofac
bull 21 Sifakis S Pharmakides G Anemia in pregnancy Ann N Y Acad Sci 2000900125-36
bull 22 Branch DW Physiologic adaptations of pregnancy Am J Reprod Immunol 199228120-2
bull 23 Burrows RF Kelton JG Incidentally detected thrombocytopenia in healthy mothers and their infants N Engl J Med 1988319 142-5
bull 24 Hanly JG Antiphospholipid syndrome an overview CMAJ 200324(168)1675-82
bull 25 Heilmann L von Tempelhoff GF Pollow K Antiphospholipid syndrome in obstetrics Clin Appl Thromb Hemost 20039 143-50
bull 26 Sherman P Flaxman SM Nausea and vomiting of pregnancy in an evolutionary perspective Am J Obstet Gynecol 2002 185(Suppl)s190-7
bull 27 Koch KL Gastrointestinal factors in nausea and vomiting of pregnancy Am J Obstet Gynecol 2002185(Suppl)s198-203
bull 28 Koch KL Frissora CL Nausea and vomiting during pregnancy Gastroenterol Clin N Am 200332201-34
bull 29 Baron TH Ramirez B Richter JE Gastrointestinal motility disorders during pregnancy Ann Intern Med 1993118 366-75
bull 30 Richter JE Gastroesophageal reflux disease during pregnancy Gastroenterol Clin N Am 200332235-61
bull 31 Marrero JM Goggin PM de Caestecker JS Pearce JM Maxwell JD Determinants of pregnancy heartburn Br J Obstet Gynaecol 199299731-4
bull 32 Hamaoui E Hamaoui M Nutritional assessment and support during pregnancy Gastroenterol Clin N Am 20033259-121
bull 33 King JC Physiology of pregnancy and nutrient metabolism Am J Clin Nutr 200071(suppl)1218s-25s
bull 34 Casanueva E Pfeffer F Fernandez-Gaxiola AC Gutierrez- Valenzuela V Rothenberg SJ Iron and folate status before pregnancy and anemia during pregnancy Ann Nutr Metab 2003 4760-3
bull 35 Chrsquong CL Morgan M Hainsworth I Kingham JG Prospective study of liver dysfunction in Southwest Wales Gut 200251 876-80
bull 36 Rahman TM Wendon J Severe hepatic dysfunction in pregnancy QJM 200295343-57
bull 37 Knox TA Olans LB Liver disease in pregnancy N Engl J Med 1996335569-76
bull 38 Saftlas AF Olson DR Franks AL Atrash H Pokras R Epidemiology of preeclampsia and eclampsia in the United States 1979e1986 Am J Obstet Gynecol 1990163460-5
bull 39 Walker JJ Pre-eclampsia Lancet 20003561260-5
bull 40 Davidson JM Renal disorders in pregnancy Curr Opin Obstet Gynecol 200113109-14
bull 41 Dafnis E Sabatini S The effect of pregnancy on renal function physiology and pathophysiologyAmJMedSci 1992303184-205
bull 42 Davison JM Shiells EA Philips PR Lindheimer MD Serial evaluation of vasopressin release and thirst in human pregnancy Role of human chorionic gonadotrophin in the osmoregulatory changes of gestation J Clin Invest 198881798-806
bull 43 Glinoer D de Nayer P Bourdoux P Lemone M Robyn C van Steirteghem A et al Regulation of maternal thyroid during pregnancy J Clin Endocrinol Metab 199071276-87
bull 44 Wilson SG Retallack RW Kent JC Worth GK Gutteridge DH Serum free 125-dihydroxyvitamin D and the free 125- dihydroxyvitamin D index during a longitudinal study of human pregnancy and lactation Clin Endocrinol 199032613-22
bull 45 Rasmussen N Frolich A Hornnes PJ Hegedus L Serum ionized calcium and intact parathyroid hormone levels during pregnancy and postpartum Br J Obstet Gynaecol 199097857-9
bull 46 Guyton AC Textbook of medical physiology 8th ed Philadelphia W B Saunders 1991 p 915e28
bull 47 Trainer PJ Corticosteroids and pregnancy Semin Reprod Med 200220375-80
bull 48 Soory M Hormonal factors in periodontal disease Dent Update 200027380-3
bull 49 Hugoson A Gingivitis in pregnant women A longitudinal clinical study Odontol Revy 19712265-84
bull 50 Neville BW Damm DD Allen CM Bouquot JE Oral amp Maxillofacial Pathology 3rd ed Philadelphia W B Saunders 2002 p 329-30 447-9
bull 51 Tilakaratne A Soory M Ranasinghe AW Corea SM Ekanayake SL de Silva M Periodontal disease status during pregnancy and 3 months post-partum in rural population of Sri-Lankan women J Clin Periodontol 200027787-92
bull 52 Laine M Tenovuo J Lehtonen OP Ojanatko-Harri A Vilja P Tuohimaa P Pregnancy e related changes in human whole saliva Arch Oral Biol 198833913-7
bull 53 Yuan K Wing LY Lin MT Pathogenetic roles of angiogenic factors in pyogenic granulomas in pregnancy are modulated by female sex hormones J Periodontol 200273701-8
bull 54 Evans RD Briggs PF Tooth-surface loss related to pregnancyinduced vomiting Prim Dent Care 1994124-6
bull 55 Salvolini E Di Giorgio R Curatola A Mazzanti L Fratto G Biochemical modifications of human whole saliva induced by pregnancy Br J Obstet Gynaec 1998105656-60
bull 56 Mauldin JG Newman RB Preterm birth risk assessment Semin Perinatol 200125215-22
bull 57 Heine RP McGregor JA Goodwin TM Artal R Hayashi RH Robertson PA et al Serial salivary estriol to detect an increased risk of preterm birth Obstet Gynecol 200096490-7
bull 58 Kauh YC Zachian TF Melasma Adv Exp Med Biol 1999455 491-9
bull 59 Wong RC Ellis CN Physiologic skin changes in pregnancy J Am Acad Dermatol 198410929-40
bull 60 Errickson CV Matus NR Skin disorders of pregnancy Am Fam Physician 199449605-10
bull 61 Lopez NJ Smith PC Gutierrez J Periodontal therapy may reduce the risk of preterm low birth weight in women with periodontal disease a randomized controlled trial J Periodontol 200273911-24
bull 62 McGaw T Periodontal disease and preterm delivery of lowbirth- weight infants J Can Dent Assoc 200268165-9
bull 63 Richards AG Dental x-ray protection Dent Clin North Am 1968631-41
bull 64 1990 Recommendations of the International Commission on Radiological Protection Ann ICRP 1991211-201
bull 65 Hall EJ Radiation the two-edged sword cancer risks at high and low doses Cancer J 20006343-50
bull 66 Diethelm L Xu H Diagnostic imaging of the lung during pregnancy Clin Obstet Gynecol 19963936-55
bull 67 Brent RL The effects of embryonic and fetal exposure to x-rays microwaves and ultrasound ClinObstetGynecol 198326484-510
bull 68 National Council on Radiation Protection NCRP report no128 1998 Bethesda Md Author
bull 69 Wasylko L Matsui D Dykxhoorn SM Reider MJ Weinberg S A review of common dental treatments during pregnancy implications for patients and dental personnel J Can Dent Assoc 199864434-9
bull 70 Freeman JP Brand JW Radiation doses of commonly used dental radiographic surveys Oral Surg Oral Med Oral Pathol 199477285-9
bull 71 Kircos LTAngin LL Lorton LOrder ofmagnitude dose reduction in intraoral radiography J Am Dent Assoc 1987114344-7
bull 72 Updegrave WJ Simplified and standardized intraoral radiography with reduced tissue irradiation J Am Dent Assoc 197285861-9
bull 73 Wood RE Harris AM van der Merwe EJ Nortje CJ The leaded apron revisited does it reduce gonadal radiation dose in dental radiology Oral Surg Oral Med Oral Pathol 199171642-6
bull 74 An update on radiographic practices information and recommendations ADA Council on Scientific Affairs J Am Dent Assoc 2001132234-8
bull 75 Rayburn WF Recommending medications during pregnancy an evidence based approach Clin Obstet Gynecol 2002451-5
bull 76 Rathmell JP Viscomi C Ashburn MA Management of nonobstetric pain during pregnancy and lactation Anesth Analg 1997851074-87
bull 77 Teratology society public affairs committee FDA classification of drugs for teratogenic risk Teratology 199449446-7
bull 78 Moore PA Selecting drugs for the pregnant dental patient J Am Dent Assoc 19981291281-6
bull 79 Haas DA An update on analgesics for the management of acute postoperative dental pain J Can Dent Assoc 200268476-82
bull 80 Haas DA Pynn BR Sands TD Drug use for the pregnant or lactating patient Gen Dent 20004854-60
bull 81 Committee on Drugs American Academy of Pediatrics The transfer of drugs and other chemicals into human milk Pediatrics 199493137-50
bull 82 Nielsen GL Sorensen HT Larsen H Pedersen L Risk of adverse birth outcome and miscarriage in pregnant users of nonsteroidal anti-inflammatory drugs population based observational study and case-control study BMJ 2001322266-70
bull 83 Janssen N Genta M The effects of immunosuppressive and anti-inflammatory medications on fertility pregnancy and lactation Arch Intern Med 200016610-9
bull 84 Ostensen M Nonsteroidal anti-inflammatory drugs during pregnancy Scand J Rheumatol Suppl 1998107128-32
bull 85 USPDI -Drug information for the health care professional 22nd ed Greenwood Village CO Micromedex 2002 p 152-79
bull 86 Denson DD Coyle DE Thompson GA Santos D Turner PA Myers JA et al Bupivacaine protein binding in the term parturient effects of lactic acidosis Clin Pharmacol Ther 198435702-9
bull 87 Dillon DE Wagner CL Wiest D Newman RB Drug therapy in the nursing mother Obstet Gynecol Clin North Am 199724 675-96
bull 88 Dashe JS Gilstrap LC Antibiotic use in pregnancy Obstet Gynecol Clin North Am 199724617-29
bull 89 American College of Rheumatology Ad hoc Committee on Clinical Guidelines Guidelines for monitoring drug therapy in rheumatoid arthritis Arthritis Rheum 199639723-31
bull 90 Ng PC The fetal and neonatal hypothalamic-pituitary-adrenal axis Arch Dis Child Fetal Neonatal Ed 200082F250-4
bull 91 Crowley P Antenatal corticosteroidsmdashcurrent thinking BJOG 2003110(Suppl 20)77-8
bull 92 ACOG committee opinion antenatal corticosteroid therapy for fetal maturation Obstet Gynecol 200299871-3
bull 93 Ost L Wettrell G Bjorkhem I Rane A Prednisolone excretion in human milk J Pediatr 19851061008-11
bull 94 Rowland AS Baird DD Shore DL Weinberg CR Savitz DA Wilcox AJ Nitrous oxide and spontaneous abortion in female dental assistants Am J Epidemiol 1995141531-8
bull 95 McGlothlin JD Jensen PA Fischbach TJ Hughes RT Jones JH Control of anesthetic gases in dental operatories Scand J Work Environ Health 199218(Suppl 2)103-5
bull ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY Volume 97 Number 6 Suresh and Radfar 681
bull 96 Rosen MA Nitrous oxide for relief of labor pain a systematic review Am J Obstet Gynecol 2002186(Suppl Nature)S110-6
bull 97 Sands TD Pynn BR Management considerations for the pregnant or nursing emergency patient Ont Dent 199875 17-9
bull 98 Daya S Recurrent spontaneous early pregnancy loss and low dose aspirin Minerva Ginecol 200355441-9
bull 99 Sinclair C Handbook of obstetrical emergencies 1st ed Philadelphia WB Saunders 1996 p 29-39 69
bull 100 Tarsitano BF Rollings RE The pregnant dental patient evaluation and management Gen Dent 199341226-34
bull 101 Livingston MH Dlllinger TM Holder R Consideration in the management of the pregnant patient SCD Special Care in Dentistry 199818183-8
Thank you
- A Review on the principle of Dental Management of the Pregnant patient
- Slide 2
- Questions that a dentist may ask
- Stages of Pregnancy
- Slide 5
- Slide 6
- Physiologic Changes in Pregnancy
- Systemic changes in pregnancy
- FLAT SUPINE POSITIONING
- SUPINE HYPOTENSION SYNDROME (Vena Cava Compression)
- Supine Hypotension Syndrome
- Slide 12
- Supine Hypotension Syndrome
- Prevention of Supine Hypotensive Syndrome
- Treatment of Supine Hypotensive Syndrome
- How should the pregnant woman be positioned
- Slide 17
- Slide 18
- Slide 19
- Slide 20
- Slide 21
- Slide 22
- Slide 23
- Pregnancy Related Oral Health Problems
- Oral Problems in Pregnancy
- Pregnancy Gingivitis Pathophysiology
- Pregnancy Gingivitis
- Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Gum Problems - Pregnancy Granuloma
- Slide 31
- Gum Changes - Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Candidiasis
- Pregnancy Myths
- Other Oral Conditions in Pregnancy
- Changes During Pregnancy that Affect Oral Health
- Saliva changes
- Increased Bacteria
- Slide 40
- Enamel erosion caused by frequent vomiting
- Treatment for Acid Exposure
- Oral Diseases Can Effect Pregnancy
- Periodontal Disease and Preterm Labor
- Periodontal Disease and Low Birth Weight
- Periodontal Disease and Preeclampsia
- Periodontitis and Pre-eclampsia
- Dental Considerations
- Treatment Timing
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Slide 52
- Use of Radiation on Pregnant Patient
- Radiographs during Pregnancy
- Risks of Dental X-Rays
- FDA drug classification for pregnancy
- Slide 57
- FDA drug classification for pregnancy
- Slide 59
- Slide 60
- Slide 61
- Common Analgesics
- Analgesics
- Analgesics - continued
- Analgesics to Use During 1st and 2nd Trimester
- Analgesics to Avoid During the Third Trimester
- Sedation in Pregnancy
- Common Antibiotics
- Antibiotics
- Antibiotics To Use During Pregnancy
- Antibiotics to Avoid during Pregnancy
- The Problem With Tetracycline
- Other Antimicrobial Agents
- Local Anesthetic Use in Pregnancy
- Use of Local Anesthetics
- Ulcer healing drugs
- Slide 77
- Slide 78
- Slide 79
- Use of Nitrous Oxide Gas
- Common Preventives
- Are topical agents safe
- Pre-natal Fluoride
- Is it safe to use mercury restorations
- References
- REFERENCES
- Slide 87
- Slide 88
- Slide 89
- Slide 90
- Slide 91
- Slide 92
- Slide 93
- Slide 94
- Slide 95
- Slide 96
- Slide 97
- Slide 98
- Thank you
-
Ulcer healing drugsOmeprazolebull FDA category BNot known to be
harmful Esomeprazolebull FDA category BLansoprazolebull FDA category BPantoprazolebull Avoid unless potential benefit
outweighs riskmdashfetotoxic in animals
Ulcer healing drugs
Misoprostolbull First second third trimesters Avoidmdash
potent uterine stimulant (has been used to induce abortion) and may be teratogenic
Ulcer healing drugs
Antacidsbull Almunium hydroxideMagnesium
hydroxidemdashFDA category B Calcium carbonatemdashFDA category C
SimetheconemdashFDA category C
Use of Nitrous Oxide Gas
bull used over 150 years bull safety is being debatedbull SHORT TERM exposure do not cause
birth defects or spontaneous abortionbull CHRONIC exposure may result in fetal
loss and infertilitybull literature suggests that nitrous oxide
should be avoided until more conclusive research is available
bull FDA Drug class not yet assigned
Common Preventives
bull Fluoridendash No increased risk during pregnancy
bull Xylitolndash No studies no harm reported
bull Chlorhexidinendash No increased risk during pregnancy
Are topical agents safe
bull Fluoridebull Toothpaste amp mouthrinse
bull Xylitol chewing gum bull Chlorhexidine (11 alcohol)bull No over the counter mouthrinses with
alcohol (Listerine 20 alcohol)
Pre-natal Fluoride
bull Daily 22 mg tablet of sodium fluoride during 3rd through 9th months
bull decreases caries rate in offspringbull Safe and effective
Glenn FB 1982
Is it safe to use mercury restorations
bull No evidence of harmful effect
bull Benefits outweigh risks
bull Canada Germany and New Zealand have some restrictions
bull Determine the best option
Referencesbull Wasylko L Matsui D Dykxhoorn SM Rieder MJ Weinberg
S A Review of Common Dental Treatments During Pregnancy J Canadian Dental Association 64434-439 1998
bull Little JW Donald AF Craig SM Rhodus NL Dental Management of the Medically Compromised Patient - 5th edition Mosby Toronto Pp434-442 1997
bull Livingston HM Dellinger TM Holder R Considerations in the management of the pregnant patient Special Care in Dentistry 185 pp183-188 1998
bull Larimore WL Petrie KA Drug use during pregnacy and lactation Primary Care Clinics in Office Practice 271 35-53 2000
bull Health Canada The Safety of DentalAmalgam Minister Of Supply and Services Canada 1996
REFERENCESbull 1 Weiss G Endocrinology of parturition J Clin
Endocrinol Metab 2000854421-5bull 2 Theunissen IM Parer JT Fluid and electrolytes in
pregnancy Clin Obstet Gynecol 1994373-15bull 3 Duvekot JJ Peeters LLH Renal hemodynamics and
volume homeostasis in pregnancy Obstet Gynecol Surv 199449830-9
bull 4 Barron WM Lindheimer MD Medical disorders during pregnancy 2nd ed St Louis Mosby 1995 p 129
bull 5 Thornburg KL Jacobson SL Giraud GD Morton MJ Hemodynamic changes in pregnancy Semin Perinatol 20002411-4
bull 6 Fiese R Herzog S Issues in dental and surgical management of the pregnant patient Oral Surg Oral Med Oral Pathol 198865292-7
bull 7 Martin C Varner MW Physiologic changes in pregnancysurgical implications Clin Obstet Gynecol 199437241-55
bull 8 Clark SL Cotton DB Lee W Bishop C Hill T Southwick J et al Central hemodynamic assessment of normal term pregnancy Am J Obstet Gynecol 19891611439-42
bull 9 Mabie WC Di Sessa TG Crocker LG Sibai BM Arheart KL A longitudinal study of cardiac output in normal human pregnancy Am J Obstet Gynecol 1994170849-56
bull 10 Clapp JF 3rd Capeless E Cardiovascular function before during and after the first and subsequent pregnancies Am J Cardiol 1997801469-73
bull 11 Duvekot JJ Peeters LL Maternal cardiovascular hemodynamic adaptation to pregnancy Obstet Gynecol Surv 199449(Suppl) S1-14
bull 12 Bhagwat AR Engel PJ Heart disease and pregnancy Cardiol Clin 199513163-78
bull 13 Lanni SM Tillinghast J Silver H Hemodynamic changes and baroreflex gain in the supine hypotensive syndrome Am J Obstet Gynecol 20021871636-41
bull 14 Little JW Falace DA Miller CS Rhodus NL Dental management of the medically compromised patient 6th ed St Louis Mosby 2002 p 303
bull 15 Garcia-Rio F Pino JM Gomez L Alvarez-Sala R Villasante C Villamor J Regulation of breathing and perception of dyspnea in healthy pregnant women Chest 1996110446-53
bull 16 McAuliffe F Kametas N Costello J Rafferty GF Greenough A Nicolaides K Respiratory function in singleton and twin pregnancy BJOG 2002109765-9
bull 17 Clapp JF 3rd Seaward BL Sleamaker RH Hiser J Maternal physiologic adaptations to early human pregnancy Am J Obstet Gynecol 19881591456-60
bull 18 OrsquoDay MP Cardio-respiratory physiological adaptation of pregnancy Semin Perinatol 199721268-75
bull 19 Contreras G Gutierrez M Beroiza T Fantin A Oddo H Villarroel L et al Ventilatory drive and respiratory muscle function in pregnancy Am Rev Respir Dis 1991144837-41
bull 20 Turner M Aziz SR Management of the pregnant oral and maxillofac
bull 21 Sifakis S Pharmakides G Anemia in pregnancy Ann N Y Acad Sci 2000900125-36
bull 22 Branch DW Physiologic adaptations of pregnancy Am J Reprod Immunol 199228120-2
bull 23 Burrows RF Kelton JG Incidentally detected thrombocytopenia in healthy mothers and their infants N Engl J Med 1988319 142-5
bull 24 Hanly JG Antiphospholipid syndrome an overview CMAJ 200324(168)1675-82
bull 25 Heilmann L von Tempelhoff GF Pollow K Antiphospholipid syndrome in obstetrics Clin Appl Thromb Hemost 20039 143-50
bull 26 Sherman P Flaxman SM Nausea and vomiting of pregnancy in an evolutionary perspective Am J Obstet Gynecol 2002 185(Suppl)s190-7
bull 27 Koch KL Gastrointestinal factors in nausea and vomiting of pregnancy Am J Obstet Gynecol 2002185(Suppl)s198-203
bull 28 Koch KL Frissora CL Nausea and vomiting during pregnancy Gastroenterol Clin N Am 200332201-34
bull 29 Baron TH Ramirez B Richter JE Gastrointestinal motility disorders during pregnancy Ann Intern Med 1993118 366-75
bull 30 Richter JE Gastroesophageal reflux disease during pregnancy Gastroenterol Clin N Am 200332235-61
bull 31 Marrero JM Goggin PM de Caestecker JS Pearce JM Maxwell JD Determinants of pregnancy heartburn Br J Obstet Gynaecol 199299731-4
bull 32 Hamaoui E Hamaoui M Nutritional assessment and support during pregnancy Gastroenterol Clin N Am 20033259-121
bull 33 King JC Physiology of pregnancy and nutrient metabolism Am J Clin Nutr 200071(suppl)1218s-25s
bull 34 Casanueva E Pfeffer F Fernandez-Gaxiola AC Gutierrez- Valenzuela V Rothenberg SJ Iron and folate status before pregnancy and anemia during pregnancy Ann Nutr Metab 2003 4760-3
bull 35 Chrsquong CL Morgan M Hainsworth I Kingham JG Prospective study of liver dysfunction in Southwest Wales Gut 200251 876-80
bull 36 Rahman TM Wendon J Severe hepatic dysfunction in pregnancy QJM 200295343-57
bull 37 Knox TA Olans LB Liver disease in pregnancy N Engl J Med 1996335569-76
bull 38 Saftlas AF Olson DR Franks AL Atrash H Pokras R Epidemiology of preeclampsia and eclampsia in the United States 1979e1986 Am J Obstet Gynecol 1990163460-5
bull 39 Walker JJ Pre-eclampsia Lancet 20003561260-5
bull 40 Davidson JM Renal disorders in pregnancy Curr Opin Obstet Gynecol 200113109-14
bull 41 Dafnis E Sabatini S The effect of pregnancy on renal function physiology and pathophysiologyAmJMedSci 1992303184-205
bull 42 Davison JM Shiells EA Philips PR Lindheimer MD Serial evaluation of vasopressin release and thirst in human pregnancy Role of human chorionic gonadotrophin in the osmoregulatory changes of gestation J Clin Invest 198881798-806
bull 43 Glinoer D de Nayer P Bourdoux P Lemone M Robyn C van Steirteghem A et al Regulation of maternal thyroid during pregnancy J Clin Endocrinol Metab 199071276-87
bull 44 Wilson SG Retallack RW Kent JC Worth GK Gutteridge DH Serum free 125-dihydroxyvitamin D and the free 125- dihydroxyvitamin D index during a longitudinal study of human pregnancy and lactation Clin Endocrinol 199032613-22
bull 45 Rasmussen N Frolich A Hornnes PJ Hegedus L Serum ionized calcium and intact parathyroid hormone levels during pregnancy and postpartum Br J Obstet Gynaecol 199097857-9
bull 46 Guyton AC Textbook of medical physiology 8th ed Philadelphia W B Saunders 1991 p 915e28
bull 47 Trainer PJ Corticosteroids and pregnancy Semin Reprod Med 200220375-80
bull 48 Soory M Hormonal factors in periodontal disease Dent Update 200027380-3
bull 49 Hugoson A Gingivitis in pregnant women A longitudinal clinical study Odontol Revy 19712265-84
bull 50 Neville BW Damm DD Allen CM Bouquot JE Oral amp Maxillofacial Pathology 3rd ed Philadelphia W B Saunders 2002 p 329-30 447-9
bull 51 Tilakaratne A Soory M Ranasinghe AW Corea SM Ekanayake SL de Silva M Periodontal disease status during pregnancy and 3 months post-partum in rural population of Sri-Lankan women J Clin Periodontol 200027787-92
bull 52 Laine M Tenovuo J Lehtonen OP Ojanatko-Harri A Vilja P Tuohimaa P Pregnancy e related changes in human whole saliva Arch Oral Biol 198833913-7
bull 53 Yuan K Wing LY Lin MT Pathogenetic roles of angiogenic factors in pyogenic granulomas in pregnancy are modulated by female sex hormones J Periodontol 200273701-8
bull 54 Evans RD Briggs PF Tooth-surface loss related to pregnancyinduced vomiting Prim Dent Care 1994124-6
bull 55 Salvolini E Di Giorgio R Curatola A Mazzanti L Fratto G Biochemical modifications of human whole saliva induced by pregnancy Br J Obstet Gynaec 1998105656-60
bull 56 Mauldin JG Newman RB Preterm birth risk assessment Semin Perinatol 200125215-22
bull 57 Heine RP McGregor JA Goodwin TM Artal R Hayashi RH Robertson PA et al Serial salivary estriol to detect an increased risk of preterm birth Obstet Gynecol 200096490-7
bull 58 Kauh YC Zachian TF Melasma Adv Exp Med Biol 1999455 491-9
bull 59 Wong RC Ellis CN Physiologic skin changes in pregnancy J Am Acad Dermatol 198410929-40
bull 60 Errickson CV Matus NR Skin disorders of pregnancy Am Fam Physician 199449605-10
bull 61 Lopez NJ Smith PC Gutierrez J Periodontal therapy may reduce the risk of preterm low birth weight in women with periodontal disease a randomized controlled trial J Periodontol 200273911-24
bull 62 McGaw T Periodontal disease and preterm delivery of lowbirth- weight infants J Can Dent Assoc 200268165-9
bull 63 Richards AG Dental x-ray protection Dent Clin North Am 1968631-41
bull 64 1990 Recommendations of the International Commission on Radiological Protection Ann ICRP 1991211-201
bull 65 Hall EJ Radiation the two-edged sword cancer risks at high and low doses Cancer J 20006343-50
bull 66 Diethelm L Xu H Diagnostic imaging of the lung during pregnancy Clin Obstet Gynecol 19963936-55
bull 67 Brent RL The effects of embryonic and fetal exposure to x-rays microwaves and ultrasound ClinObstetGynecol 198326484-510
bull 68 National Council on Radiation Protection NCRP report no128 1998 Bethesda Md Author
bull 69 Wasylko L Matsui D Dykxhoorn SM Reider MJ Weinberg S A review of common dental treatments during pregnancy implications for patients and dental personnel J Can Dent Assoc 199864434-9
bull 70 Freeman JP Brand JW Radiation doses of commonly used dental radiographic surveys Oral Surg Oral Med Oral Pathol 199477285-9
bull 71 Kircos LTAngin LL Lorton LOrder ofmagnitude dose reduction in intraoral radiography J Am Dent Assoc 1987114344-7
bull 72 Updegrave WJ Simplified and standardized intraoral radiography with reduced tissue irradiation J Am Dent Assoc 197285861-9
bull 73 Wood RE Harris AM van der Merwe EJ Nortje CJ The leaded apron revisited does it reduce gonadal radiation dose in dental radiology Oral Surg Oral Med Oral Pathol 199171642-6
bull 74 An update on radiographic practices information and recommendations ADA Council on Scientific Affairs J Am Dent Assoc 2001132234-8
bull 75 Rayburn WF Recommending medications during pregnancy an evidence based approach Clin Obstet Gynecol 2002451-5
bull 76 Rathmell JP Viscomi C Ashburn MA Management of nonobstetric pain during pregnancy and lactation Anesth Analg 1997851074-87
bull 77 Teratology society public affairs committee FDA classification of drugs for teratogenic risk Teratology 199449446-7
bull 78 Moore PA Selecting drugs for the pregnant dental patient J Am Dent Assoc 19981291281-6
bull 79 Haas DA An update on analgesics for the management of acute postoperative dental pain J Can Dent Assoc 200268476-82
bull 80 Haas DA Pynn BR Sands TD Drug use for the pregnant or lactating patient Gen Dent 20004854-60
bull 81 Committee on Drugs American Academy of Pediatrics The transfer of drugs and other chemicals into human milk Pediatrics 199493137-50
bull 82 Nielsen GL Sorensen HT Larsen H Pedersen L Risk of adverse birth outcome and miscarriage in pregnant users of nonsteroidal anti-inflammatory drugs population based observational study and case-control study BMJ 2001322266-70
bull 83 Janssen N Genta M The effects of immunosuppressive and anti-inflammatory medications on fertility pregnancy and lactation Arch Intern Med 200016610-9
bull 84 Ostensen M Nonsteroidal anti-inflammatory drugs during pregnancy Scand J Rheumatol Suppl 1998107128-32
bull 85 USPDI -Drug information for the health care professional 22nd ed Greenwood Village CO Micromedex 2002 p 152-79
bull 86 Denson DD Coyle DE Thompson GA Santos D Turner PA Myers JA et al Bupivacaine protein binding in the term parturient effects of lactic acidosis Clin Pharmacol Ther 198435702-9
bull 87 Dillon DE Wagner CL Wiest D Newman RB Drug therapy in the nursing mother Obstet Gynecol Clin North Am 199724 675-96
bull 88 Dashe JS Gilstrap LC Antibiotic use in pregnancy Obstet Gynecol Clin North Am 199724617-29
bull 89 American College of Rheumatology Ad hoc Committee on Clinical Guidelines Guidelines for monitoring drug therapy in rheumatoid arthritis Arthritis Rheum 199639723-31
bull 90 Ng PC The fetal and neonatal hypothalamic-pituitary-adrenal axis Arch Dis Child Fetal Neonatal Ed 200082F250-4
bull 91 Crowley P Antenatal corticosteroidsmdashcurrent thinking BJOG 2003110(Suppl 20)77-8
bull 92 ACOG committee opinion antenatal corticosteroid therapy for fetal maturation Obstet Gynecol 200299871-3
bull 93 Ost L Wettrell G Bjorkhem I Rane A Prednisolone excretion in human milk J Pediatr 19851061008-11
bull 94 Rowland AS Baird DD Shore DL Weinberg CR Savitz DA Wilcox AJ Nitrous oxide and spontaneous abortion in female dental assistants Am J Epidemiol 1995141531-8
bull 95 McGlothlin JD Jensen PA Fischbach TJ Hughes RT Jones JH Control of anesthetic gases in dental operatories Scand J Work Environ Health 199218(Suppl 2)103-5
bull ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY Volume 97 Number 6 Suresh and Radfar 681
bull 96 Rosen MA Nitrous oxide for relief of labor pain a systematic review Am J Obstet Gynecol 2002186(Suppl Nature)S110-6
bull 97 Sands TD Pynn BR Management considerations for the pregnant or nursing emergency patient Ont Dent 199875 17-9
bull 98 Daya S Recurrent spontaneous early pregnancy loss and low dose aspirin Minerva Ginecol 200355441-9
bull 99 Sinclair C Handbook of obstetrical emergencies 1st ed Philadelphia WB Saunders 1996 p 29-39 69
bull 100 Tarsitano BF Rollings RE The pregnant dental patient evaluation and management Gen Dent 199341226-34
bull 101 Livingston MH Dlllinger TM Holder R Consideration in the management of the pregnant patient SCD Special Care in Dentistry 199818183-8
Thank you
- A Review on the principle of Dental Management of the Pregnant patient
- Slide 2
- Questions that a dentist may ask
- Stages of Pregnancy
- Slide 5
- Slide 6
- Physiologic Changes in Pregnancy
- Systemic changes in pregnancy
- FLAT SUPINE POSITIONING
- SUPINE HYPOTENSION SYNDROME (Vena Cava Compression)
- Supine Hypotension Syndrome
- Slide 12
- Supine Hypotension Syndrome
- Prevention of Supine Hypotensive Syndrome
- Treatment of Supine Hypotensive Syndrome
- How should the pregnant woman be positioned
- Slide 17
- Slide 18
- Slide 19
- Slide 20
- Slide 21
- Slide 22
- Slide 23
- Pregnancy Related Oral Health Problems
- Oral Problems in Pregnancy
- Pregnancy Gingivitis Pathophysiology
- Pregnancy Gingivitis
- Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Gum Problems - Pregnancy Granuloma
- Slide 31
- Gum Changes - Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Candidiasis
- Pregnancy Myths
- Other Oral Conditions in Pregnancy
- Changes During Pregnancy that Affect Oral Health
- Saliva changes
- Increased Bacteria
- Slide 40
- Enamel erosion caused by frequent vomiting
- Treatment for Acid Exposure
- Oral Diseases Can Effect Pregnancy
- Periodontal Disease and Preterm Labor
- Periodontal Disease and Low Birth Weight
- Periodontal Disease and Preeclampsia
- Periodontitis and Pre-eclampsia
- Dental Considerations
- Treatment Timing
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Slide 52
- Use of Radiation on Pregnant Patient
- Radiographs during Pregnancy
- Risks of Dental X-Rays
- FDA drug classification for pregnancy
- Slide 57
- FDA drug classification for pregnancy
- Slide 59
- Slide 60
- Slide 61
- Common Analgesics
- Analgesics
- Analgesics - continued
- Analgesics to Use During 1st and 2nd Trimester
- Analgesics to Avoid During the Third Trimester
- Sedation in Pregnancy
- Common Antibiotics
- Antibiotics
- Antibiotics To Use During Pregnancy
- Antibiotics to Avoid during Pregnancy
- The Problem With Tetracycline
- Other Antimicrobial Agents
- Local Anesthetic Use in Pregnancy
- Use of Local Anesthetics
- Ulcer healing drugs
- Slide 77
- Slide 78
- Slide 79
- Use of Nitrous Oxide Gas
- Common Preventives
- Are topical agents safe
- Pre-natal Fluoride
- Is it safe to use mercury restorations
- References
- REFERENCES
- Slide 87
- Slide 88
- Slide 89
- Slide 90
- Slide 91
- Slide 92
- Slide 93
- Slide 94
- Slide 95
- Slide 96
- Slide 97
- Slide 98
- Thank you
-
Ulcer healing drugs
Misoprostolbull First second third trimesters Avoidmdash
potent uterine stimulant (has been used to induce abortion) and may be teratogenic
Ulcer healing drugs
Antacidsbull Almunium hydroxideMagnesium
hydroxidemdashFDA category B Calcium carbonatemdashFDA category C
SimetheconemdashFDA category C
Use of Nitrous Oxide Gas
bull used over 150 years bull safety is being debatedbull SHORT TERM exposure do not cause
birth defects or spontaneous abortionbull CHRONIC exposure may result in fetal
loss and infertilitybull literature suggests that nitrous oxide
should be avoided until more conclusive research is available
bull FDA Drug class not yet assigned
Common Preventives
bull Fluoridendash No increased risk during pregnancy
bull Xylitolndash No studies no harm reported
bull Chlorhexidinendash No increased risk during pregnancy
Are topical agents safe
bull Fluoridebull Toothpaste amp mouthrinse
bull Xylitol chewing gum bull Chlorhexidine (11 alcohol)bull No over the counter mouthrinses with
alcohol (Listerine 20 alcohol)
Pre-natal Fluoride
bull Daily 22 mg tablet of sodium fluoride during 3rd through 9th months
bull decreases caries rate in offspringbull Safe and effective
Glenn FB 1982
Is it safe to use mercury restorations
bull No evidence of harmful effect
bull Benefits outweigh risks
bull Canada Germany and New Zealand have some restrictions
bull Determine the best option
Referencesbull Wasylko L Matsui D Dykxhoorn SM Rieder MJ Weinberg
S A Review of Common Dental Treatments During Pregnancy J Canadian Dental Association 64434-439 1998
bull Little JW Donald AF Craig SM Rhodus NL Dental Management of the Medically Compromised Patient - 5th edition Mosby Toronto Pp434-442 1997
bull Livingston HM Dellinger TM Holder R Considerations in the management of the pregnant patient Special Care in Dentistry 185 pp183-188 1998
bull Larimore WL Petrie KA Drug use during pregnacy and lactation Primary Care Clinics in Office Practice 271 35-53 2000
bull Health Canada The Safety of DentalAmalgam Minister Of Supply and Services Canada 1996
REFERENCESbull 1 Weiss G Endocrinology of parturition J Clin
Endocrinol Metab 2000854421-5bull 2 Theunissen IM Parer JT Fluid and electrolytes in
pregnancy Clin Obstet Gynecol 1994373-15bull 3 Duvekot JJ Peeters LLH Renal hemodynamics and
volume homeostasis in pregnancy Obstet Gynecol Surv 199449830-9
bull 4 Barron WM Lindheimer MD Medical disorders during pregnancy 2nd ed St Louis Mosby 1995 p 129
bull 5 Thornburg KL Jacobson SL Giraud GD Morton MJ Hemodynamic changes in pregnancy Semin Perinatol 20002411-4
bull 6 Fiese R Herzog S Issues in dental and surgical management of the pregnant patient Oral Surg Oral Med Oral Pathol 198865292-7
bull 7 Martin C Varner MW Physiologic changes in pregnancysurgical implications Clin Obstet Gynecol 199437241-55
bull 8 Clark SL Cotton DB Lee W Bishop C Hill T Southwick J et al Central hemodynamic assessment of normal term pregnancy Am J Obstet Gynecol 19891611439-42
bull 9 Mabie WC Di Sessa TG Crocker LG Sibai BM Arheart KL A longitudinal study of cardiac output in normal human pregnancy Am J Obstet Gynecol 1994170849-56
bull 10 Clapp JF 3rd Capeless E Cardiovascular function before during and after the first and subsequent pregnancies Am J Cardiol 1997801469-73
bull 11 Duvekot JJ Peeters LL Maternal cardiovascular hemodynamic adaptation to pregnancy Obstet Gynecol Surv 199449(Suppl) S1-14
bull 12 Bhagwat AR Engel PJ Heart disease and pregnancy Cardiol Clin 199513163-78
bull 13 Lanni SM Tillinghast J Silver H Hemodynamic changes and baroreflex gain in the supine hypotensive syndrome Am J Obstet Gynecol 20021871636-41
bull 14 Little JW Falace DA Miller CS Rhodus NL Dental management of the medically compromised patient 6th ed St Louis Mosby 2002 p 303
bull 15 Garcia-Rio F Pino JM Gomez L Alvarez-Sala R Villasante C Villamor J Regulation of breathing and perception of dyspnea in healthy pregnant women Chest 1996110446-53
bull 16 McAuliffe F Kametas N Costello J Rafferty GF Greenough A Nicolaides K Respiratory function in singleton and twin pregnancy BJOG 2002109765-9
bull 17 Clapp JF 3rd Seaward BL Sleamaker RH Hiser J Maternal physiologic adaptations to early human pregnancy Am J Obstet Gynecol 19881591456-60
bull 18 OrsquoDay MP Cardio-respiratory physiological adaptation of pregnancy Semin Perinatol 199721268-75
bull 19 Contreras G Gutierrez M Beroiza T Fantin A Oddo H Villarroel L et al Ventilatory drive and respiratory muscle function in pregnancy Am Rev Respir Dis 1991144837-41
bull 20 Turner M Aziz SR Management of the pregnant oral and maxillofac
bull 21 Sifakis S Pharmakides G Anemia in pregnancy Ann N Y Acad Sci 2000900125-36
bull 22 Branch DW Physiologic adaptations of pregnancy Am J Reprod Immunol 199228120-2
bull 23 Burrows RF Kelton JG Incidentally detected thrombocytopenia in healthy mothers and their infants N Engl J Med 1988319 142-5
bull 24 Hanly JG Antiphospholipid syndrome an overview CMAJ 200324(168)1675-82
bull 25 Heilmann L von Tempelhoff GF Pollow K Antiphospholipid syndrome in obstetrics Clin Appl Thromb Hemost 20039 143-50
bull 26 Sherman P Flaxman SM Nausea and vomiting of pregnancy in an evolutionary perspective Am J Obstet Gynecol 2002 185(Suppl)s190-7
bull 27 Koch KL Gastrointestinal factors in nausea and vomiting of pregnancy Am J Obstet Gynecol 2002185(Suppl)s198-203
bull 28 Koch KL Frissora CL Nausea and vomiting during pregnancy Gastroenterol Clin N Am 200332201-34
bull 29 Baron TH Ramirez B Richter JE Gastrointestinal motility disorders during pregnancy Ann Intern Med 1993118 366-75
bull 30 Richter JE Gastroesophageal reflux disease during pregnancy Gastroenterol Clin N Am 200332235-61
bull 31 Marrero JM Goggin PM de Caestecker JS Pearce JM Maxwell JD Determinants of pregnancy heartburn Br J Obstet Gynaecol 199299731-4
bull 32 Hamaoui E Hamaoui M Nutritional assessment and support during pregnancy Gastroenterol Clin N Am 20033259-121
bull 33 King JC Physiology of pregnancy and nutrient metabolism Am J Clin Nutr 200071(suppl)1218s-25s
bull 34 Casanueva E Pfeffer F Fernandez-Gaxiola AC Gutierrez- Valenzuela V Rothenberg SJ Iron and folate status before pregnancy and anemia during pregnancy Ann Nutr Metab 2003 4760-3
bull 35 Chrsquong CL Morgan M Hainsworth I Kingham JG Prospective study of liver dysfunction in Southwest Wales Gut 200251 876-80
bull 36 Rahman TM Wendon J Severe hepatic dysfunction in pregnancy QJM 200295343-57
bull 37 Knox TA Olans LB Liver disease in pregnancy N Engl J Med 1996335569-76
bull 38 Saftlas AF Olson DR Franks AL Atrash H Pokras R Epidemiology of preeclampsia and eclampsia in the United States 1979e1986 Am J Obstet Gynecol 1990163460-5
bull 39 Walker JJ Pre-eclampsia Lancet 20003561260-5
bull 40 Davidson JM Renal disorders in pregnancy Curr Opin Obstet Gynecol 200113109-14
bull 41 Dafnis E Sabatini S The effect of pregnancy on renal function physiology and pathophysiologyAmJMedSci 1992303184-205
bull 42 Davison JM Shiells EA Philips PR Lindheimer MD Serial evaluation of vasopressin release and thirst in human pregnancy Role of human chorionic gonadotrophin in the osmoregulatory changes of gestation J Clin Invest 198881798-806
bull 43 Glinoer D de Nayer P Bourdoux P Lemone M Robyn C van Steirteghem A et al Regulation of maternal thyroid during pregnancy J Clin Endocrinol Metab 199071276-87
bull 44 Wilson SG Retallack RW Kent JC Worth GK Gutteridge DH Serum free 125-dihydroxyvitamin D and the free 125- dihydroxyvitamin D index during a longitudinal study of human pregnancy and lactation Clin Endocrinol 199032613-22
bull 45 Rasmussen N Frolich A Hornnes PJ Hegedus L Serum ionized calcium and intact parathyroid hormone levels during pregnancy and postpartum Br J Obstet Gynaecol 199097857-9
bull 46 Guyton AC Textbook of medical physiology 8th ed Philadelphia W B Saunders 1991 p 915e28
bull 47 Trainer PJ Corticosteroids and pregnancy Semin Reprod Med 200220375-80
bull 48 Soory M Hormonal factors in periodontal disease Dent Update 200027380-3
bull 49 Hugoson A Gingivitis in pregnant women A longitudinal clinical study Odontol Revy 19712265-84
bull 50 Neville BW Damm DD Allen CM Bouquot JE Oral amp Maxillofacial Pathology 3rd ed Philadelphia W B Saunders 2002 p 329-30 447-9
bull 51 Tilakaratne A Soory M Ranasinghe AW Corea SM Ekanayake SL de Silva M Periodontal disease status during pregnancy and 3 months post-partum in rural population of Sri-Lankan women J Clin Periodontol 200027787-92
bull 52 Laine M Tenovuo J Lehtonen OP Ojanatko-Harri A Vilja P Tuohimaa P Pregnancy e related changes in human whole saliva Arch Oral Biol 198833913-7
bull 53 Yuan K Wing LY Lin MT Pathogenetic roles of angiogenic factors in pyogenic granulomas in pregnancy are modulated by female sex hormones J Periodontol 200273701-8
bull 54 Evans RD Briggs PF Tooth-surface loss related to pregnancyinduced vomiting Prim Dent Care 1994124-6
bull 55 Salvolini E Di Giorgio R Curatola A Mazzanti L Fratto G Biochemical modifications of human whole saliva induced by pregnancy Br J Obstet Gynaec 1998105656-60
bull 56 Mauldin JG Newman RB Preterm birth risk assessment Semin Perinatol 200125215-22
bull 57 Heine RP McGregor JA Goodwin TM Artal R Hayashi RH Robertson PA et al Serial salivary estriol to detect an increased risk of preterm birth Obstet Gynecol 200096490-7
bull 58 Kauh YC Zachian TF Melasma Adv Exp Med Biol 1999455 491-9
bull 59 Wong RC Ellis CN Physiologic skin changes in pregnancy J Am Acad Dermatol 198410929-40
bull 60 Errickson CV Matus NR Skin disorders of pregnancy Am Fam Physician 199449605-10
bull 61 Lopez NJ Smith PC Gutierrez J Periodontal therapy may reduce the risk of preterm low birth weight in women with periodontal disease a randomized controlled trial J Periodontol 200273911-24
bull 62 McGaw T Periodontal disease and preterm delivery of lowbirth- weight infants J Can Dent Assoc 200268165-9
bull 63 Richards AG Dental x-ray protection Dent Clin North Am 1968631-41
bull 64 1990 Recommendations of the International Commission on Radiological Protection Ann ICRP 1991211-201
bull 65 Hall EJ Radiation the two-edged sword cancer risks at high and low doses Cancer J 20006343-50
bull 66 Diethelm L Xu H Diagnostic imaging of the lung during pregnancy Clin Obstet Gynecol 19963936-55
bull 67 Brent RL The effects of embryonic and fetal exposure to x-rays microwaves and ultrasound ClinObstetGynecol 198326484-510
bull 68 National Council on Radiation Protection NCRP report no128 1998 Bethesda Md Author
bull 69 Wasylko L Matsui D Dykxhoorn SM Reider MJ Weinberg S A review of common dental treatments during pregnancy implications for patients and dental personnel J Can Dent Assoc 199864434-9
bull 70 Freeman JP Brand JW Radiation doses of commonly used dental radiographic surveys Oral Surg Oral Med Oral Pathol 199477285-9
bull 71 Kircos LTAngin LL Lorton LOrder ofmagnitude dose reduction in intraoral radiography J Am Dent Assoc 1987114344-7
bull 72 Updegrave WJ Simplified and standardized intraoral radiography with reduced tissue irradiation J Am Dent Assoc 197285861-9
bull 73 Wood RE Harris AM van der Merwe EJ Nortje CJ The leaded apron revisited does it reduce gonadal radiation dose in dental radiology Oral Surg Oral Med Oral Pathol 199171642-6
bull 74 An update on radiographic practices information and recommendations ADA Council on Scientific Affairs J Am Dent Assoc 2001132234-8
bull 75 Rayburn WF Recommending medications during pregnancy an evidence based approach Clin Obstet Gynecol 2002451-5
bull 76 Rathmell JP Viscomi C Ashburn MA Management of nonobstetric pain during pregnancy and lactation Anesth Analg 1997851074-87
bull 77 Teratology society public affairs committee FDA classification of drugs for teratogenic risk Teratology 199449446-7
bull 78 Moore PA Selecting drugs for the pregnant dental patient J Am Dent Assoc 19981291281-6
bull 79 Haas DA An update on analgesics for the management of acute postoperative dental pain J Can Dent Assoc 200268476-82
bull 80 Haas DA Pynn BR Sands TD Drug use for the pregnant or lactating patient Gen Dent 20004854-60
bull 81 Committee on Drugs American Academy of Pediatrics The transfer of drugs and other chemicals into human milk Pediatrics 199493137-50
bull 82 Nielsen GL Sorensen HT Larsen H Pedersen L Risk of adverse birth outcome and miscarriage in pregnant users of nonsteroidal anti-inflammatory drugs population based observational study and case-control study BMJ 2001322266-70
bull 83 Janssen N Genta M The effects of immunosuppressive and anti-inflammatory medications on fertility pregnancy and lactation Arch Intern Med 200016610-9
bull 84 Ostensen M Nonsteroidal anti-inflammatory drugs during pregnancy Scand J Rheumatol Suppl 1998107128-32
bull 85 USPDI -Drug information for the health care professional 22nd ed Greenwood Village CO Micromedex 2002 p 152-79
bull 86 Denson DD Coyle DE Thompson GA Santos D Turner PA Myers JA et al Bupivacaine protein binding in the term parturient effects of lactic acidosis Clin Pharmacol Ther 198435702-9
bull 87 Dillon DE Wagner CL Wiest D Newman RB Drug therapy in the nursing mother Obstet Gynecol Clin North Am 199724 675-96
bull 88 Dashe JS Gilstrap LC Antibiotic use in pregnancy Obstet Gynecol Clin North Am 199724617-29
bull 89 American College of Rheumatology Ad hoc Committee on Clinical Guidelines Guidelines for monitoring drug therapy in rheumatoid arthritis Arthritis Rheum 199639723-31
bull 90 Ng PC The fetal and neonatal hypothalamic-pituitary-adrenal axis Arch Dis Child Fetal Neonatal Ed 200082F250-4
bull 91 Crowley P Antenatal corticosteroidsmdashcurrent thinking BJOG 2003110(Suppl 20)77-8
bull 92 ACOG committee opinion antenatal corticosteroid therapy for fetal maturation Obstet Gynecol 200299871-3
bull 93 Ost L Wettrell G Bjorkhem I Rane A Prednisolone excretion in human milk J Pediatr 19851061008-11
bull 94 Rowland AS Baird DD Shore DL Weinberg CR Savitz DA Wilcox AJ Nitrous oxide and spontaneous abortion in female dental assistants Am J Epidemiol 1995141531-8
bull 95 McGlothlin JD Jensen PA Fischbach TJ Hughes RT Jones JH Control of anesthetic gases in dental operatories Scand J Work Environ Health 199218(Suppl 2)103-5
bull ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY Volume 97 Number 6 Suresh and Radfar 681
bull 96 Rosen MA Nitrous oxide for relief of labor pain a systematic review Am J Obstet Gynecol 2002186(Suppl Nature)S110-6
bull 97 Sands TD Pynn BR Management considerations for the pregnant or nursing emergency patient Ont Dent 199875 17-9
bull 98 Daya S Recurrent spontaneous early pregnancy loss and low dose aspirin Minerva Ginecol 200355441-9
bull 99 Sinclair C Handbook of obstetrical emergencies 1st ed Philadelphia WB Saunders 1996 p 29-39 69
bull 100 Tarsitano BF Rollings RE The pregnant dental patient evaluation and management Gen Dent 199341226-34
bull 101 Livingston MH Dlllinger TM Holder R Consideration in the management of the pregnant patient SCD Special Care in Dentistry 199818183-8
Thank you
- A Review on the principle of Dental Management of the Pregnant patient
- Slide 2
- Questions that a dentist may ask
- Stages of Pregnancy
- Slide 5
- Slide 6
- Physiologic Changes in Pregnancy
- Systemic changes in pregnancy
- FLAT SUPINE POSITIONING
- SUPINE HYPOTENSION SYNDROME (Vena Cava Compression)
- Supine Hypotension Syndrome
- Slide 12
- Supine Hypotension Syndrome
- Prevention of Supine Hypotensive Syndrome
- Treatment of Supine Hypotensive Syndrome
- How should the pregnant woman be positioned
- Slide 17
- Slide 18
- Slide 19
- Slide 20
- Slide 21
- Slide 22
- Slide 23
- Pregnancy Related Oral Health Problems
- Oral Problems in Pregnancy
- Pregnancy Gingivitis Pathophysiology
- Pregnancy Gingivitis
- Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Gum Problems - Pregnancy Granuloma
- Slide 31
- Gum Changes - Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Candidiasis
- Pregnancy Myths
- Other Oral Conditions in Pregnancy
- Changes During Pregnancy that Affect Oral Health
- Saliva changes
- Increased Bacteria
- Slide 40
- Enamel erosion caused by frequent vomiting
- Treatment for Acid Exposure
- Oral Diseases Can Effect Pregnancy
- Periodontal Disease and Preterm Labor
- Periodontal Disease and Low Birth Weight
- Periodontal Disease and Preeclampsia
- Periodontitis and Pre-eclampsia
- Dental Considerations
- Treatment Timing
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Slide 52
- Use of Radiation on Pregnant Patient
- Radiographs during Pregnancy
- Risks of Dental X-Rays
- FDA drug classification for pregnancy
- Slide 57
- FDA drug classification for pregnancy
- Slide 59
- Slide 60
- Slide 61
- Common Analgesics
- Analgesics
- Analgesics - continued
- Analgesics to Use During 1st and 2nd Trimester
- Analgesics to Avoid During the Third Trimester
- Sedation in Pregnancy
- Common Antibiotics
- Antibiotics
- Antibiotics To Use During Pregnancy
- Antibiotics to Avoid during Pregnancy
- The Problem With Tetracycline
- Other Antimicrobial Agents
- Local Anesthetic Use in Pregnancy
- Use of Local Anesthetics
- Ulcer healing drugs
- Slide 77
- Slide 78
- Slide 79
- Use of Nitrous Oxide Gas
- Common Preventives
- Are topical agents safe
- Pre-natal Fluoride
- Is it safe to use mercury restorations
- References
- REFERENCES
- Slide 87
- Slide 88
- Slide 89
- Slide 90
- Slide 91
- Slide 92
- Slide 93
- Slide 94
- Slide 95
- Slide 96
- Slide 97
- Slide 98
- Thank you
-
Ulcer healing drugs
Antacidsbull Almunium hydroxideMagnesium
hydroxidemdashFDA category B Calcium carbonatemdashFDA category C
SimetheconemdashFDA category C
Use of Nitrous Oxide Gas
bull used over 150 years bull safety is being debatedbull SHORT TERM exposure do not cause
birth defects or spontaneous abortionbull CHRONIC exposure may result in fetal
loss and infertilitybull literature suggests that nitrous oxide
should be avoided until more conclusive research is available
bull FDA Drug class not yet assigned
Common Preventives
bull Fluoridendash No increased risk during pregnancy
bull Xylitolndash No studies no harm reported
bull Chlorhexidinendash No increased risk during pregnancy
Are topical agents safe
bull Fluoridebull Toothpaste amp mouthrinse
bull Xylitol chewing gum bull Chlorhexidine (11 alcohol)bull No over the counter mouthrinses with
alcohol (Listerine 20 alcohol)
Pre-natal Fluoride
bull Daily 22 mg tablet of sodium fluoride during 3rd through 9th months
bull decreases caries rate in offspringbull Safe and effective
Glenn FB 1982
Is it safe to use mercury restorations
bull No evidence of harmful effect
bull Benefits outweigh risks
bull Canada Germany and New Zealand have some restrictions
bull Determine the best option
Referencesbull Wasylko L Matsui D Dykxhoorn SM Rieder MJ Weinberg
S A Review of Common Dental Treatments During Pregnancy J Canadian Dental Association 64434-439 1998
bull Little JW Donald AF Craig SM Rhodus NL Dental Management of the Medically Compromised Patient - 5th edition Mosby Toronto Pp434-442 1997
bull Livingston HM Dellinger TM Holder R Considerations in the management of the pregnant patient Special Care in Dentistry 185 pp183-188 1998
bull Larimore WL Petrie KA Drug use during pregnacy and lactation Primary Care Clinics in Office Practice 271 35-53 2000
bull Health Canada The Safety of DentalAmalgam Minister Of Supply and Services Canada 1996
REFERENCESbull 1 Weiss G Endocrinology of parturition J Clin
Endocrinol Metab 2000854421-5bull 2 Theunissen IM Parer JT Fluid and electrolytes in
pregnancy Clin Obstet Gynecol 1994373-15bull 3 Duvekot JJ Peeters LLH Renal hemodynamics and
volume homeostasis in pregnancy Obstet Gynecol Surv 199449830-9
bull 4 Barron WM Lindheimer MD Medical disorders during pregnancy 2nd ed St Louis Mosby 1995 p 129
bull 5 Thornburg KL Jacobson SL Giraud GD Morton MJ Hemodynamic changes in pregnancy Semin Perinatol 20002411-4
bull 6 Fiese R Herzog S Issues in dental and surgical management of the pregnant patient Oral Surg Oral Med Oral Pathol 198865292-7
bull 7 Martin C Varner MW Physiologic changes in pregnancysurgical implications Clin Obstet Gynecol 199437241-55
bull 8 Clark SL Cotton DB Lee W Bishop C Hill T Southwick J et al Central hemodynamic assessment of normal term pregnancy Am J Obstet Gynecol 19891611439-42
bull 9 Mabie WC Di Sessa TG Crocker LG Sibai BM Arheart KL A longitudinal study of cardiac output in normal human pregnancy Am J Obstet Gynecol 1994170849-56
bull 10 Clapp JF 3rd Capeless E Cardiovascular function before during and after the first and subsequent pregnancies Am J Cardiol 1997801469-73
bull 11 Duvekot JJ Peeters LL Maternal cardiovascular hemodynamic adaptation to pregnancy Obstet Gynecol Surv 199449(Suppl) S1-14
bull 12 Bhagwat AR Engel PJ Heart disease and pregnancy Cardiol Clin 199513163-78
bull 13 Lanni SM Tillinghast J Silver H Hemodynamic changes and baroreflex gain in the supine hypotensive syndrome Am J Obstet Gynecol 20021871636-41
bull 14 Little JW Falace DA Miller CS Rhodus NL Dental management of the medically compromised patient 6th ed St Louis Mosby 2002 p 303
bull 15 Garcia-Rio F Pino JM Gomez L Alvarez-Sala R Villasante C Villamor J Regulation of breathing and perception of dyspnea in healthy pregnant women Chest 1996110446-53
bull 16 McAuliffe F Kametas N Costello J Rafferty GF Greenough A Nicolaides K Respiratory function in singleton and twin pregnancy BJOG 2002109765-9
bull 17 Clapp JF 3rd Seaward BL Sleamaker RH Hiser J Maternal physiologic adaptations to early human pregnancy Am J Obstet Gynecol 19881591456-60
bull 18 OrsquoDay MP Cardio-respiratory physiological adaptation of pregnancy Semin Perinatol 199721268-75
bull 19 Contreras G Gutierrez M Beroiza T Fantin A Oddo H Villarroel L et al Ventilatory drive and respiratory muscle function in pregnancy Am Rev Respir Dis 1991144837-41
bull 20 Turner M Aziz SR Management of the pregnant oral and maxillofac
bull 21 Sifakis S Pharmakides G Anemia in pregnancy Ann N Y Acad Sci 2000900125-36
bull 22 Branch DW Physiologic adaptations of pregnancy Am J Reprod Immunol 199228120-2
bull 23 Burrows RF Kelton JG Incidentally detected thrombocytopenia in healthy mothers and their infants N Engl J Med 1988319 142-5
bull 24 Hanly JG Antiphospholipid syndrome an overview CMAJ 200324(168)1675-82
bull 25 Heilmann L von Tempelhoff GF Pollow K Antiphospholipid syndrome in obstetrics Clin Appl Thromb Hemost 20039 143-50
bull 26 Sherman P Flaxman SM Nausea and vomiting of pregnancy in an evolutionary perspective Am J Obstet Gynecol 2002 185(Suppl)s190-7
bull 27 Koch KL Gastrointestinal factors in nausea and vomiting of pregnancy Am J Obstet Gynecol 2002185(Suppl)s198-203
bull 28 Koch KL Frissora CL Nausea and vomiting during pregnancy Gastroenterol Clin N Am 200332201-34
bull 29 Baron TH Ramirez B Richter JE Gastrointestinal motility disorders during pregnancy Ann Intern Med 1993118 366-75
bull 30 Richter JE Gastroesophageal reflux disease during pregnancy Gastroenterol Clin N Am 200332235-61
bull 31 Marrero JM Goggin PM de Caestecker JS Pearce JM Maxwell JD Determinants of pregnancy heartburn Br J Obstet Gynaecol 199299731-4
bull 32 Hamaoui E Hamaoui M Nutritional assessment and support during pregnancy Gastroenterol Clin N Am 20033259-121
bull 33 King JC Physiology of pregnancy and nutrient metabolism Am J Clin Nutr 200071(suppl)1218s-25s
bull 34 Casanueva E Pfeffer F Fernandez-Gaxiola AC Gutierrez- Valenzuela V Rothenberg SJ Iron and folate status before pregnancy and anemia during pregnancy Ann Nutr Metab 2003 4760-3
bull 35 Chrsquong CL Morgan M Hainsworth I Kingham JG Prospective study of liver dysfunction in Southwest Wales Gut 200251 876-80
bull 36 Rahman TM Wendon J Severe hepatic dysfunction in pregnancy QJM 200295343-57
bull 37 Knox TA Olans LB Liver disease in pregnancy N Engl J Med 1996335569-76
bull 38 Saftlas AF Olson DR Franks AL Atrash H Pokras R Epidemiology of preeclampsia and eclampsia in the United States 1979e1986 Am J Obstet Gynecol 1990163460-5
bull 39 Walker JJ Pre-eclampsia Lancet 20003561260-5
bull 40 Davidson JM Renal disorders in pregnancy Curr Opin Obstet Gynecol 200113109-14
bull 41 Dafnis E Sabatini S The effect of pregnancy on renal function physiology and pathophysiologyAmJMedSci 1992303184-205
bull 42 Davison JM Shiells EA Philips PR Lindheimer MD Serial evaluation of vasopressin release and thirst in human pregnancy Role of human chorionic gonadotrophin in the osmoregulatory changes of gestation J Clin Invest 198881798-806
bull 43 Glinoer D de Nayer P Bourdoux P Lemone M Robyn C van Steirteghem A et al Regulation of maternal thyroid during pregnancy J Clin Endocrinol Metab 199071276-87
bull 44 Wilson SG Retallack RW Kent JC Worth GK Gutteridge DH Serum free 125-dihydroxyvitamin D and the free 125- dihydroxyvitamin D index during a longitudinal study of human pregnancy and lactation Clin Endocrinol 199032613-22
bull 45 Rasmussen N Frolich A Hornnes PJ Hegedus L Serum ionized calcium and intact parathyroid hormone levels during pregnancy and postpartum Br J Obstet Gynaecol 199097857-9
bull 46 Guyton AC Textbook of medical physiology 8th ed Philadelphia W B Saunders 1991 p 915e28
bull 47 Trainer PJ Corticosteroids and pregnancy Semin Reprod Med 200220375-80
bull 48 Soory M Hormonal factors in periodontal disease Dent Update 200027380-3
bull 49 Hugoson A Gingivitis in pregnant women A longitudinal clinical study Odontol Revy 19712265-84
bull 50 Neville BW Damm DD Allen CM Bouquot JE Oral amp Maxillofacial Pathology 3rd ed Philadelphia W B Saunders 2002 p 329-30 447-9
bull 51 Tilakaratne A Soory M Ranasinghe AW Corea SM Ekanayake SL de Silva M Periodontal disease status during pregnancy and 3 months post-partum in rural population of Sri-Lankan women J Clin Periodontol 200027787-92
bull 52 Laine M Tenovuo J Lehtonen OP Ojanatko-Harri A Vilja P Tuohimaa P Pregnancy e related changes in human whole saliva Arch Oral Biol 198833913-7
bull 53 Yuan K Wing LY Lin MT Pathogenetic roles of angiogenic factors in pyogenic granulomas in pregnancy are modulated by female sex hormones J Periodontol 200273701-8
bull 54 Evans RD Briggs PF Tooth-surface loss related to pregnancyinduced vomiting Prim Dent Care 1994124-6
bull 55 Salvolini E Di Giorgio R Curatola A Mazzanti L Fratto G Biochemical modifications of human whole saliva induced by pregnancy Br J Obstet Gynaec 1998105656-60
bull 56 Mauldin JG Newman RB Preterm birth risk assessment Semin Perinatol 200125215-22
bull 57 Heine RP McGregor JA Goodwin TM Artal R Hayashi RH Robertson PA et al Serial salivary estriol to detect an increased risk of preterm birth Obstet Gynecol 200096490-7
bull 58 Kauh YC Zachian TF Melasma Adv Exp Med Biol 1999455 491-9
bull 59 Wong RC Ellis CN Physiologic skin changes in pregnancy J Am Acad Dermatol 198410929-40
bull 60 Errickson CV Matus NR Skin disorders of pregnancy Am Fam Physician 199449605-10
bull 61 Lopez NJ Smith PC Gutierrez J Periodontal therapy may reduce the risk of preterm low birth weight in women with periodontal disease a randomized controlled trial J Periodontol 200273911-24
bull 62 McGaw T Periodontal disease and preterm delivery of lowbirth- weight infants J Can Dent Assoc 200268165-9
bull 63 Richards AG Dental x-ray protection Dent Clin North Am 1968631-41
bull 64 1990 Recommendations of the International Commission on Radiological Protection Ann ICRP 1991211-201
bull 65 Hall EJ Radiation the two-edged sword cancer risks at high and low doses Cancer J 20006343-50
bull 66 Diethelm L Xu H Diagnostic imaging of the lung during pregnancy Clin Obstet Gynecol 19963936-55
bull 67 Brent RL The effects of embryonic and fetal exposure to x-rays microwaves and ultrasound ClinObstetGynecol 198326484-510
bull 68 National Council on Radiation Protection NCRP report no128 1998 Bethesda Md Author
bull 69 Wasylko L Matsui D Dykxhoorn SM Reider MJ Weinberg S A review of common dental treatments during pregnancy implications for patients and dental personnel J Can Dent Assoc 199864434-9
bull 70 Freeman JP Brand JW Radiation doses of commonly used dental radiographic surveys Oral Surg Oral Med Oral Pathol 199477285-9
bull 71 Kircos LTAngin LL Lorton LOrder ofmagnitude dose reduction in intraoral radiography J Am Dent Assoc 1987114344-7
bull 72 Updegrave WJ Simplified and standardized intraoral radiography with reduced tissue irradiation J Am Dent Assoc 197285861-9
bull 73 Wood RE Harris AM van der Merwe EJ Nortje CJ The leaded apron revisited does it reduce gonadal radiation dose in dental radiology Oral Surg Oral Med Oral Pathol 199171642-6
bull 74 An update on radiographic practices information and recommendations ADA Council on Scientific Affairs J Am Dent Assoc 2001132234-8
bull 75 Rayburn WF Recommending medications during pregnancy an evidence based approach Clin Obstet Gynecol 2002451-5
bull 76 Rathmell JP Viscomi C Ashburn MA Management of nonobstetric pain during pregnancy and lactation Anesth Analg 1997851074-87
bull 77 Teratology society public affairs committee FDA classification of drugs for teratogenic risk Teratology 199449446-7
bull 78 Moore PA Selecting drugs for the pregnant dental patient J Am Dent Assoc 19981291281-6
bull 79 Haas DA An update on analgesics for the management of acute postoperative dental pain J Can Dent Assoc 200268476-82
bull 80 Haas DA Pynn BR Sands TD Drug use for the pregnant or lactating patient Gen Dent 20004854-60
bull 81 Committee on Drugs American Academy of Pediatrics The transfer of drugs and other chemicals into human milk Pediatrics 199493137-50
bull 82 Nielsen GL Sorensen HT Larsen H Pedersen L Risk of adverse birth outcome and miscarriage in pregnant users of nonsteroidal anti-inflammatory drugs population based observational study and case-control study BMJ 2001322266-70
bull 83 Janssen N Genta M The effects of immunosuppressive and anti-inflammatory medications on fertility pregnancy and lactation Arch Intern Med 200016610-9
bull 84 Ostensen M Nonsteroidal anti-inflammatory drugs during pregnancy Scand J Rheumatol Suppl 1998107128-32
bull 85 USPDI -Drug information for the health care professional 22nd ed Greenwood Village CO Micromedex 2002 p 152-79
bull 86 Denson DD Coyle DE Thompson GA Santos D Turner PA Myers JA et al Bupivacaine protein binding in the term parturient effects of lactic acidosis Clin Pharmacol Ther 198435702-9
bull 87 Dillon DE Wagner CL Wiest D Newman RB Drug therapy in the nursing mother Obstet Gynecol Clin North Am 199724 675-96
bull 88 Dashe JS Gilstrap LC Antibiotic use in pregnancy Obstet Gynecol Clin North Am 199724617-29
bull 89 American College of Rheumatology Ad hoc Committee on Clinical Guidelines Guidelines for monitoring drug therapy in rheumatoid arthritis Arthritis Rheum 199639723-31
bull 90 Ng PC The fetal and neonatal hypothalamic-pituitary-adrenal axis Arch Dis Child Fetal Neonatal Ed 200082F250-4
bull 91 Crowley P Antenatal corticosteroidsmdashcurrent thinking BJOG 2003110(Suppl 20)77-8
bull 92 ACOG committee opinion antenatal corticosteroid therapy for fetal maturation Obstet Gynecol 200299871-3
bull 93 Ost L Wettrell G Bjorkhem I Rane A Prednisolone excretion in human milk J Pediatr 19851061008-11
bull 94 Rowland AS Baird DD Shore DL Weinberg CR Savitz DA Wilcox AJ Nitrous oxide and spontaneous abortion in female dental assistants Am J Epidemiol 1995141531-8
bull 95 McGlothlin JD Jensen PA Fischbach TJ Hughes RT Jones JH Control of anesthetic gases in dental operatories Scand J Work Environ Health 199218(Suppl 2)103-5
bull ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY Volume 97 Number 6 Suresh and Radfar 681
bull 96 Rosen MA Nitrous oxide for relief of labor pain a systematic review Am J Obstet Gynecol 2002186(Suppl Nature)S110-6
bull 97 Sands TD Pynn BR Management considerations for the pregnant or nursing emergency patient Ont Dent 199875 17-9
bull 98 Daya S Recurrent spontaneous early pregnancy loss and low dose aspirin Minerva Ginecol 200355441-9
bull 99 Sinclair C Handbook of obstetrical emergencies 1st ed Philadelphia WB Saunders 1996 p 29-39 69
bull 100 Tarsitano BF Rollings RE The pregnant dental patient evaluation and management Gen Dent 199341226-34
bull 101 Livingston MH Dlllinger TM Holder R Consideration in the management of the pregnant patient SCD Special Care in Dentistry 199818183-8
Thank you
- A Review on the principle of Dental Management of the Pregnant patient
- Slide 2
- Questions that a dentist may ask
- Stages of Pregnancy
- Slide 5
- Slide 6
- Physiologic Changes in Pregnancy
- Systemic changes in pregnancy
- FLAT SUPINE POSITIONING
- SUPINE HYPOTENSION SYNDROME (Vena Cava Compression)
- Supine Hypotension Syndrome
- Slide 12
- Supine Hypotension Syndrome
- Prevention of Supine Hypotensive Syndrome
- Treatment of Supine Hypotensive Syndrome
- How should the pregnant woman be positioned
- Slide 17
- Slide 18
- Slide 19
- Slide 20
- Slide 21
- Slide 22
- Slide 23
- Pregnancy Related Oral Health Problems
- Oral Problems in Pregnancy
- Pregnancy Gingivitis Pathophysiology
- Pregnancy Gingivitis
- Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Gum Problems - Pregnancy Granuloma
- Slide 31
- Gum Changes - Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Candidiasis
- Pregnancy Myths
- Other Oral Conditions in Pregnancy
- Changes During Pregnancy that Affect Oral Health
- Saliva changes
- Increased Bacteria
- Slide 40
- Enamel erosion caused by frequent vomiting
- Treatment for Acid Exposure
- Oral Diseases Can Effect Pregnancy
- Periodontal Disease and Preterm Labor
- Periodontal Disease and Low Birth Weight
- Periodontal Disease and Preeclampsia
- Periodontitis and Pre-eclampsia
- Dental Considerations
- Treatment Timing
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Slide 52
- Use of Radiation on Pregnant Patient
- Radiographs during Pregnancy
- Risks of Dental X-Rays
- FDA drug classification for pregnancy
- Slide 57
- FDA drug classification for pregnancy
- Slide 59
- Slide 60
- Slide 61
- Common Analgesics
- Analgesics
- Analgesics - continued
- Analgesics to Use During 1st and 2nd Trimester
- Analgesics to Avoid During the Third Trimester
- Sedation in Pregnancy
- Common Antibiotics
- Antibiotics
- Antibiotics To Use During Pregnancy
- Antibiotics to Avoid during Pregnancy
- The Problem With Tetracycline
- Other Antimicrobial Agents
- Local Anesthetic Use in Pregnancy
- Use of Local Anesthetics
- Ulcer healing drugs
- Slide 77
- Slide 78
- Slide 79
- Use of Nitrous Oxide Gas
- Common Preventives
- Are topical agents safe
- Pre-natal Fluoride
- Is it safe to use mercury restorations
- References
- REFERENCES
- Slide 87
- Slide 88
- Slide 89
- Slide 90
- Slide 91
- Slide 92
- Slide 93
- Slide 94
- Slide 95
- Slide 96
- Slide 97
- Slide 98
- Thank you
-
Use of Nitrous Oxide Gas
bull used over 150 years bull safety is being debatedbull SHORT TERM exposure do not cause
birth defects or spontaneous abortionbull CHRONIC exposure may result in fetal
loss and infertilitybull literature suggests that nitrous oxide
should be avoided until more conclusive research is available
bull FDA Drug class not yet assigned
Common Preventives
bull Fluoridendash No increased risk during pregnancy
bull Xylitolndash No studies no harm reported
bull Chlorhexidinendash No increased risk during pregnancy
Are topical agents safe
bull Fluoridebull Toothpaste amp mouthrinse
bull Xylitol chewing gum bull Chlorhexidine (11 alcohol)bull No over the counter mouthrinses with
alcohol (Listerine 20 alcohol)
Pre-natal Fluoride
bull Daily 22 mg tablet of sodium fluoride during 3rd through 9th months
bull decreases caries rate in offspringbull Safe and effective
Glenn FB 1982
Is it safe to use mercury restorations
bull No evidence of harmful effect
bull Benefits outweigh risks
bull Canada Germany and New Zealand have some restrictions
bull Determine the best option
Referencesbull Wasylko L Matsui D Dykxhoorn SM Rieder MJ Weinberg
S A Review of Common Dental Treatments During Pregnancy J Canadian Dental Association 64434-439 1998
bull Little JW Donald AF Craig SM Rhodus NL Dental Management of the Medically Compromised Patient - 5th edition Mosby Toronto Pp434-442 1997
bull Livingston HM Dellinger TM Holder R Considerations in the management of the pregnant patient Special Care in Dentistry 185 pp183-188 1998
bull Larimore WL Petrie KA Drug use during pregnacy and lactation Primary Care Clinics in Office Practice 271 35-53 2000
bull Health Canada The Safety of DentalAmalgam Minister Of Supply and Services Canada 1996
REFERENCESbull 1 Weiss G Endocrinology of parturition J Clin
Endocrinol Metab 2000854421-5bull 2 Theunissen IM Parer JT Fluid and electrolytes in
pregnancy Clin Obstet Gynecol 1994373-15bull 3 Duvekot JJ Peeters LLH Renal hemodynamics and
volume homeostasis in pregnancy Obstet Gynecol Surv 199449830-9
bull 4 Barron WM Lindheimer MD Medical disorders during pregnancy 2nd ed St Louis Mosby 1995 p 129
bull 5 Thornburg KL Jacobson SL Giraud GD Morton MJ Hemodynamic changes in pregnancy Semin Perinatol 20002411-4
bull 6 Fiese R Herzog S Issues in dental and surgical management of the pregnant patient Oral Surg Oral Med Oral Pathol 198865292-7
bull 7 Martin C Varner MW Physiologic changes in pregnancysurgical implications Clin Obstet Gynecol 199437241-55
bull 8 Clark SL Cotton DB Lee W Bishop C Hill T Southwick J et al Central hemodynamic assessment of normal term pregnancy Am J Obstet Gynecol 19891611439-42
bull 9 Mabie WC Di Sessa TG Crocker LG Sibai BM Arheart KL A longitudinal study of cardiac output in normal human pregnancy Am J Obstet Gynecol 1994170849-56
bull 10 Clapp JF 3rd Capeless E Cardiovascular function before during and after the first and subsequent pregnancies Am J Cardiol 1997801469-73
bull 11 Duvekot JJ Peeters LL Maternal cardiovascular hemodynamic adaptation to pregnancy Obstet Gynecol Surv 199449(Suppl) S1-14
bull 12 Bhagwat AR Engel PJ Heart disease and pregnancy Cardiol Clin 199513163-78
bull 13 Lanni SM Tillinghast J Silver H Hemodynamic changes and baroreflex gain in the supine hypotensive syndrome Am J Obstet Gynecol 20021871636-41
bull 14 Little JW Falace DA Miller CS Rhodus NL Dental management of the medically compromised patient 6th ed St Louis Mosby 2002 p 303
bull 15 Garcia-Rio F Pino JM Gomez L Alvarez-Sala R Villasante C Villamor J Regulation of breathing and perception of dyspnea in healthy pregnant women Chest 1996110446-53
bull 16 McAuliffe F Kametas N Costello J Rafferty GF Greenough A Nicolaides K Respiratory function in singleton and twin pregnancy BJOG 2002109765-9
bull 17 Clapp JF 3rd Seaward BL Sleamaker RH Hiser J Maternal physiologic adaptations to early human pregnancy Am J Obstet Gynecol 19881591456-60
bull 18 OrsquoDay MP Cardio-respiratory physiological adaptation of pregnancy Semin Perinatol 199721268-75
bull 19 Contreras G Gutierrez M Beroiza T Fantin A Oddo H Villarroel L et al Ventilatory drive and respiratory muscle function in pregnancy Am Rev Respir Dis 1991144837-41
bull 20 Turner M Aziz SR Management of the pregnant oral and maxillofac
bull 21 Sifakis S Pharmakides G Anemia in pregnancy Ann N Y Acad Sci 2000900125-36
bull 22 Branch DW Physiologic adaptations of pregnancy Am J Reprod Immunol 199228120-2
bull 23 Burrows RF Kelton JG Incidentally detected thrombocytopenia in healthy mothers and their infants N Engl J Med 1988319 142-5
bull 24 Hanly JG Antiphospholipid syndrome an overview CMAJ 200324(168)1675-82
bull 25 Heilmann L von Tempelhoff GF Pollow K Antiphospholipid syndrome in obstetrics Clin Appl Thromb Hemost 20039 143-50
bull 26 Sherman P Flaxman SM Nausea and vomiting of pregnancy in an evolutionary perspective Am J Obstet Gynecol 2002 185(Suppl)s190-7
bull 27 Koch KL Gastrointestinal factors in nausea and vomiting of pregnancy Am J Obstet Gynecol 2002185(Suppl)s198-203
bull 28 Koch KL Frissora CL Nausea and vomiting during pregnancy Gastroenterol Clin N Am 200332201-34
bull 29 Baron TH Ramirez B Richter JE Gastrointestinal motility disorders during pregnancy Ann Intern Med 1993118 366-75
bull 30 Richter JE Gastroesophageal reflux disease during pregnancy Gastroenterol Clin N Am 200332235-61
bull 31 Marrero JM Goggin PM de Caestecker JS Pearce JM Maxwell JD Determinants of pregnancy heartburn Br J Obstet Gynaecol 199299731-4
bull 32 Hamaoui E Hamaoui M Nutritional assessment and support during pregnancy Gastroenterol Clin N Am 20033259-121
bull 33 King JC Physiology of pregnancy and nutrient metabolism Am J Clin Nutr 200071(suppl)1218s-25s
bull 34 Casanueva E Pfeffer F Fernandez-Gaxiola AC Gutierrez- Valenzuela V Rothenberg SJ Iron and folate status before pregnancy and anemia during pregnancy Ann Nutr Metab 2003 4760-3
bull 35 Chrsquong CL Morgan M Hainsworth I Kingham JG Prospective study of liver dysfunction in Southwest Wales Gut 200251 876-80
bull 36 Rahman TM Wendon J Severe hepatic dysfunction in pregnancy QJM 200295343-57
bull 37 Knox TA Olans LB Liver disease in pregnancy N Engl J Med 1996335569-76
bull 38 Saftlas AF Olson DR Franks AL Atrash H Pokras R Epidemiology of preeclampsia and eclampsia in the United States 1979e1986 Am J Obstet Gynecol 1990163460-5
bull 39 Walker JJ Pre-eclampsia Lancet 20003561260-5
bull 40 Davidson JM Renal disorders in pregnancy Curr Opin Obstet Gynecol 200113109-14
bull 41 Dafnis E Sabatini S The effect of pregnancy on renal function physiology and pathophysiologyAmJMedSci 1992303184-205
bull 42 Davison JM Shiells EA Philips PR Lindheimer MD Serial evaluation of vasopressin release and thirst in human pregnancy Role of human chorionic gonadotrophin in the osmoregulatory changes of gestation J Clin Invest 198881798-806
bull 43 Glinoer D de Nayer P Bourdoux P Lemone M Robyn C van Steirteghem A et al Regulation of maternal thyroid during pregnancy J Clin Endocrinol Metab 199071276-87
bull 44 Wilson SG Retallack RW Kent JC Worth GK Gutteridge DH Serum free 125-dihydroxyvitamin D and the free 125- dihydroxyvitamin D index during a longitudinal study of human pregnancy and lactation Clin Endocrinol 199032613-22
bull 45 Rasmussen N Frolich A Hornnes PJ Hegedus L Serum ionized calcium and intact parathyroid hormone levels during pregnancy and postpartum Br J Obstet Gynaecol 199097857-9
bull 46 Guyton AC Textbook of medical physiology 8th ed Philadelphia W B Saunders 1991 p 915e28
bull 47 Trainer PJ Corticosteroids and pregnancy Semin Reprod Med 200220375-80
bull 48 Soory M Hormonal factors in periodontal disease Dent Update 200027380-3
bull 49 Hugoson A Gingivitis in pregnant women A longitudinal clinical study Odontol Revy 19712265-84
bull 50 Neville BW Damm DD Allen CM Bouquot JE Oral amp Maxillofacial Pathology 3rd ed Philadelphia W B Saunders 2002 p 329-30 447-9
bull 51 Tilakaratne A Soory M Ranasinghe AW Corea SM Ekanayake SL de Silva M Periodontal disease status during pregnancy and 3 months post-partum in rural population of Sri-Lankan women J Clin Periodontol 200027787-92
bull 52 Laine M Tenovuo J Lehtonen OP Ojanatko-Harri A Vilja P Tuohimaa P Pregnancy e related changes in human whole saliva Arch Oral Biol 198833913-7
bull 53 Yuan K Wing LY Lin MT Pathogenetic roles of angiogenic factors in pyogenic granulomas in pregnancy are modulated by female sex hormones J Periodontol 200273701-8
bull 54 Evans RD Briggs PF Tooth-surface loss related to pregnancyinduced vomiting Prim Dent Care 1994124-6
bull 55 Salvolini E Di Giorgio R Curatola A Mazzanti L Fratto G Biochemical modifications of human whole saliva induced by pregnancy Br J Obstet Gynaec 1998105656-60
bull 56 Mauldin JG Newman RB Preterm birth risk assessment Semin Perinatol 200125215-22
bull 57 Heine RP McGregor JA Goodwin TM Artal R Hayashi RH Robertson PA et al Serial salivary estriol to detect an increased risk of preterm birth Obstet Gynecol 200096490-7
bull 58 Kauh YC Zachian TF Melasma Adv Exp Med Biol 1999455 491-9
bull 59 Wong RC Ellis CN Physiologic skin changes in pregnancy J Am Acad Dermatol 198410929-40
bull 60 Errickson CV Matus NR Skin disorders of pregnancy Am Fam Physician 199449605-10
bull 61 Lopez NJ Smith PC Gutierrez J Periodontal therapy may reduce the risk of preterm low birth weight in women with periodontal disease a randomized controlled trial J Periodontol 200273911-24
bull 62 McGaw T Periodontal disease and preterm delivery of lowbirth- weight infants J Can Dent Assoc 200268165-9
bull 63 Richards AG Dental x-ray protection Dent Clin North Am 1968631-41
bull 64 1990 Recommendations of the International Commission on Radiological Protection Ann ICRP 1991211-201
bull 65 Hall EJ Radiation the two-edged sword cancer risks at high and low doses Cancer J 20006343-50
bull 66 Diethelm L Xu H Diagnostic imaging of the lung during pregnancy Clin Obstet Gynecol 19963936-55
bull 67 Brent RL The effects of embryonic and fetal exposure to x-rays microwaves and ultrasound ClinObstetGynecol 198326484-510
bull 68 National Council on Radiation Protection NCRP report no128 1998 Bethesda Md Author
bull 69 Wasylko L Matsui D Dykxhoorn SM Reider MJ Weinberg S A review of common dental treatments during pregnancy implications for patients and dental personnel J Can Dent Assoc 199864434-9
bull 70 Freeman JP Brand JW Radiation doses of commonly used dental radiographic surveys Oral Surg Oral Med Oral Pathol 199477285-9
bull 71 Kircos LTAngin LL Lorton LOrder ofmagnitude dose reduction in intraoral radiography J Am Dent Assoc 1987114344-7
bull 72 Updegrave WJ Simplified and standardized intraoral radiography with reduced tissue irradiation J Am Dent Assoc 197285861-9
bull 73 Wood RE Harris AM van der Merwe EJ Nortje CJ The leaded apron revisited does it reduce gonadal radiation dose in dental radiology Oral Surg Oral Med Oral Pathol 199171642-6
bull 74 An update on radiographic practices information and recommendations ADA Council on Scientific Affairs J Am Dent Assoc 2001132234-8
bull 75 Rayburn WF Recommending medications during pregnancy an evidence based approach Clin Obstet Gynecol 2002451-5
bull 76 Rathmell JP Viscomi C Ashburn MA Management of nonobstetric pain during pregnancy and lactation Anesth Analg 1997851074-87
bull 77 Teratology society public affairs committee FDA classification of drugs for teratogenic risk Teratology 199449446-7
bull 78 Moore PA Selecting drugs for the pregnant dental patient J Am Dent Assoc 19981291281-6
bull 79 Haas DA An update on analgesics for the management of acute postoperative dental pain J Can Dent Assoc 200268476-82
bull 80 Haas DA Pynn BR Sands TD Drug use for the pregnant or lactating patient Gen Dent 20004854-60
bull 81 Committee on Drugs American Academy of Pediatrics The transfer of drugs and other chemicals into human milk Pediatrics 199493137-50
bull 82 Nielsen GL Sorensen HT Larsen H Pedersen L Risk of adverse birth outcome and miscarriage in pregnant users of nonsteroidal anti-inflammatory drugs population based observational study and case-control study BMJ 2001322266-70
bull 83 Janssen N Genta M The effects of immunosuppressive and anti-inflammatory medications on fertility pregnancy and lactation Arch Intern Med 200016610-9
bull 84 Ostensen M Nonsteroidal anti-inflammatory drugs during pregnancy Scand J Rheumatol Suppl 1998107128-32
bull 85 USPDI -Drug information for the health care professional 22nd ed Greenwood Village CO Micromedex 2002 p 152-79
bull 86 Denson DD Coyle DE Thompson GA Santos D Turner PA Myers JA et al Bupivacaine protein binding in the term parturient effects of lactic acidosis Clin Pharmacol Ther 198435702-9
bull 87 Dillon DE Wagner CL Wiest D Newman RB Drug therapy in the nursing mother Obstet Gynecol Clin North Am 199724 675-96
bull 88 Dashe JS Gilstrap LC Antibiotic use in pregnancy Obstet Gynecol Clin North Am 199724617-29
bull 89 American College of Rheumatology Ad hoc Committee on Clinical Guidelines Guidelines for monitoring drug therapy in rheumatoid arthritis Arthritis Rheum 199639723-31
bull 90 Ng PC The fetal and neonatal hypothalamic-pituitary-adrenal axis Arch Dis Child Fetal Neonatal Ed 200082F250-4
bull 91 Crowley P Antenatal corticosteroidsmdashcurrent thinking BJOG 2003110(Suppl 20)77-8
bull 92 ACOG committee opinion antenatal corticosteroid therapy for fetal maturation Obstet Gynecol 200299871-3
bull 93 Ost L Wettrell G Bjorkhem I Rane A Prednisolone excretion in human milk J Pediatr 19851061008-11
bull 94 Rowland AS Baird DD Shore DL Weinberg CR Savitz DA Wilcox AJ Nitrous oxide and spontaneous abortion in female dental assistants Am J Epidemiol 1995141531-8
bull 95 McGlothlin JD Jensen PA Fischbach TJ Hughes RT Jones JH Control of anesthetic gases in dental operatories Scand J Work Environ Health 199218(Suppl 2)103-5
bull ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY Volume 97 Number 6 Suresh and Radfar 681
bull 96 Rosen MA Nitrous oxide for relief of labor pain a systematic review Am J Obstet Gynecol 2002186(Suppl Nature)S110-6
bull 97 Sands TD Pynn BR Management considerations for the pregnant or nursing emergency patient Ont Dent 199875 17-9
bull 98 Daya S Recurrent spontaneous early pregnancy loss and low dose aspirin Minerva Ginecol 200355441-9
bull 99 Sinclair C Handbook of obstetrical emergencies 1st ed Philadelphia WB Saunders 1996 p 29-39 69
bull 100 Tarsitano BF Rollings RE The pregnant dental patient evaluation and management Gen Dent 199341226-34
bull 101 Livingston MH Dlllinger TM Holder R Consideration in the management of the pregnant patient SCD Special Care in Dentistry 199818183-8
Thank you
- A Review on the principle of Dental Management of the Pregnant patient
- Slide 2
- Questions that a dentist may ask
- Stages of Pregnancy
- Slide 5
- Slide 6
- Physiologic Changes in Pregnancy
- Systemic changes in pregnancy
- FLAT SUPINE POSITIONING
- SUPINE HYPOTENSION SYNDROME (Vena Cava Compression)
- Supine Hypotension Syndrome
- Slide 12
- Supine Hypotension Syndrome
- Prevention of Supine Hypotensive Syndrome
- Treatment of Supine Hypotensive Syndrome
- How should the pregnant woman be positioned
- Slide 17
- Slide 18
- Slide 19
- Slide 20
- Slide 21
- Slide 22
- Slide 23
- Pregnancy Related Oral Health Problems
- Oral Problems in Pregnancy
- Pregnancy Gingivitis Pathophysiology
- Pregnancy Gingivitis
- Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Gum Problems - Pregnancy Granuloma
- Slide 31
- Gum Changes - Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Candidiasis
- Pregnancy Myths
- Other Oral Conditions in Pregnancy
- Changes During Pregnancy that Affect Oral Health
- Saliva changes
- Increased Bacteria
- Slide 40
- Enamel erosion caused by frequent vomiting
- Treatment for Acid Exposure
- Oral Diseases Can Effect Pregnancy
- Periodontal Disease and Preterm Labor
- Periodontal Disease and Low Birth Weight
- Periodontal Disease and Preeclampsia
- Periodontitis and Pre-eclampsia
- Dental Considerations
- Treatment Timing
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Slide 52
- Use of Radiation on Pregnant Patient
- Radiographs during Pregnancy
- Risks of Dental X-Rays
- FDA drug classification for pregnancy
- Slide 57
- FDA drug classification for pregnancy
- Slide 59
- Slide 60
- Slide 61
- Common Analgesics
- Analgesics
- Analgesics - continued
- Analgesics to Use During 1st and 2nd Trimester
- Analgesics to Avoid During the Third Trimester
- Sedation in Pregnancy
- Common Antibiotics
- Antibiotics
- Antibiotics To Use During Pregnancy
- Antibiotics to Avoid during Pregnancy
- The Problem With Tetracycline
- Other Antimicrobial Agents
- Local Anesthetic Use in Pregnancy
- Use of Local Anesthetics
- Ulcer healing drugs
- Slide 77
- Slide 78
- Slide 79
- Use of Nitrous Oxide Gas
- Common Preventives
- Are topical agents safe
- Pre-natal Fluoride
- Is it safe to use mercury restorations
- References
- REFERENCES
- Slide 87
- Slide 88
- Slide 89
- Slide 90
- Slide 91
- Slide 92
- Slide 93
- Slide 94
- Slide 95
- Slide 96
- Slide 97
- Slide 98
- Thank you
-
Common Preventives
bull Fluoridendash No increased risk during pregnancy
bull Xylitolndash No studies no harm reported
bull Chlorhexidinendash No increased risk during pregnancy
Are topical agents safe
bull Fluoridebull Toothpaste amp mouthrinse
bull Xylitol chewing gum bull Chlorhexidine (11 alcohol)bull No over the counter mouthrinses with
alcohol (Listerine 20 alcohol)
Pre-natal Fluoride
bull Daily 22 mg tablet of sodium fluoride during 3rd through 9th months
bull decreases caries rate in offspringbull Safe and effective
Glenn FB 1982
Is it safe to use mercury restorations
bull No evidence of harmful effect
bull Benefits outweigh risks
bull Canada Germany and New Zealand have some restrictions
bull Determine the best option
Referencesbull Wasylko L Matsui D Dykxhoorn SM Rieder MJ Weinberg
S A Review of Common Dental Treatments During Pregnancy J Canadian Dental Association 64434-439 1998
bull Little JW Donald AF Craig SM Rhodus NL Dental Management of the Medically Compromised Patient - 5th edition Mosby Toronto Pp434-442 1997
bull Livingston HM Dellinger TM Holder R Considerations in the management of the pregnant patient Special Care in Dentistry 185 pp183-188 1998
bull Larimore WL Petrie KA Drug use during pregnacy and lactation Primary Care Clinics in Office Practice 271 35-53 2000
bull Health Canada The Safety of DentalAmalgam Minister Of Supply and Services Canada 1996
REFERENCESbull 1 Weiss G Endocrinology of parturition J Clin
Endocrinol Metab 2000854421-5bull 2 Theunissen IM Parer JT Fluid and electrolytes in
pregnancy Clin Obstet Gynecol 1994373-15bull 3 Duvekot JJ Peeters LLH Renal hemodynamics and
volume homeostasis in pregnancy Obstet Gynecol Surv 199449830-9
bull 4 Barron WM Lindheimer MD Medical disorders during pregnancy 2nd ed St Louis Mosby 1995 p 129
bull 5 Thornburg KL Jacobson SL Giraud GD Morton MJ Hemodynamic changes in pregnancy Semin Perinatol 20002411-4
bull 6 Fiese R Herzog S Issues in dental and surgical management of the pregnant patient Oral Surg Oral Med Oral Pathol 198865292-7
bull 7 Martin C Varner MW Physiologic changes in pregnancysurgical implications Clin Obstet Gynecol 199437241-55
bull 8 Clark SL Cotton DB Lee W Bishop C Hill T Southwick J et al Central hemodynamic assessment of normal term pregnancy Am J Obstet Gynecol 19891611439-42
bull 9 Mabie WC Di Sessa TG Crocker LG Sibai BM Arheart KL A longitudinal study of cardiac output in normal human pregnancy Am J Obstet Gynecol 1994170849-56
bull 10 Clapp JF 3rd Capeless E Cardiovascular function before during and after the first and subsequent pregnancies Am J Cardiol 1997801469-73
bull 11 Duvekot JJ Peeters LL Maternal cardiovascular hemodynamic adaptation to pregnancy Obstet Gynecol Surv 199449(Suppl) S1-14
bull 12 Bhagwat AR Engel PJ Heart disease and pregnancy Cardiol Clin 199513163-78
bull 13 Lanni SM Tillinghast J Silver H Hemodynamic changes and baroreflex gain in the supine hypotensive syndrome Am J Obstet Gynecol 20021871636-41
bull 14 Little JW Falace DA Miller CS Rhodus NL Dental management of the medically compromised patient 6th ed St Louis Mosby 2002 p 303
bull 15 Garcia-Rio F Pino JM Gomez L Alvarez-Sala R Villasante C Villamor J Regulation of breathing and perception of dyspnea in healthy pregnant women Chest 1996110446-53
bull 16 McAuliffe F Kametas N Costello J Rafferty GF Greenough A Nicolaides K Respiratory function in singleton and twin pregnancy BJOG 2002109765-9
bull 17 Clapp JF 3rd Seaward BL Sleamaker RH Hiser J Maternal physiologic adaptations to early human pregnancy Am J Obstet Gynecol 19881591456-60
bull 18 OrsquoDay MP Cardio-respiratory physiological adaptation of pregnancy Semin Perinatol 199721268-75
bull 19 Contreras G Gutierrez M Beroiza T Fantin A Oddo H Villarroel L et al Ventilatory drive and respiratory muscle function in pregnancy Am Rev Respir Dis 1991144837-41
bull 20 Turner M Aziz SR Management of the pregnant oral and maxillofac
bull 21 Sifakis S Pharmakides G Anemia in pregnancy Ann N Y Acad Sci 2000900125-36
bull 22 Branch DW Physiologic adaptations of pregnancy Am J Reprod Immunol 199228120-2
bull 23 Burrows RF Kelton JG Incidentally detected thrombocytopenia in healthy mothers and their infants N Engl J Med 1988319 142-5
bull 24 Hanly JG Antiphospholipid syndrome an overview CMAJ 200324(168)1675-82
bull 25 Heilmann L von Tempelhoff GF Pollow K Antiphospholipid syndrome in obstetrics Clin Appl Thromb Hemost 20039 143-50
bull 26 Sherman P Flaxman SM Nausea and vomiting of pregnancy in an evolutionary perspective Am J Obstet Gynecol 2002 185(Suppl)s190-7
bull 27 Koch KL Gastrointestinal factors in nausea and vomiting of pregnancy Am J Obstet Gynecol 2002185(Suppl)s198-203
bull 28 Koch KL Frissora CL Nausea and vomiting during pregnancy Gastroenterol Clin N Am 200332201-34
bull 29 Baron TH Ramirez B Richter JE Gastrointestinal motility disorders during pregnancy Ann Intern Med 1993118 366-75
bull 30 Richter JE Gastroesophageal reflux disease during pregnancy Gastroenterol Clin N Am 200332235-61
bull 31 Marrero JM Goggin PM de Caestecker JS Pearce JM Maxwell JD Determinants of pregnancy heartburn Br J Obstet Gynaecol 199299731-4
bull 32 Hamaoui E Hamaoui M Nutritional assessment and support during pregnancy Gastroenterol Clin N Am 20033259-121
bull 33 King JC Physiology of pregnancy and nutrient metabolism Am J Clin Nutr 200071(suppl)1218s-25s
bull 34 Casanueva E Pfeffer F Fernandez-Gaxiola AC Gutierrez- Valenzuela V Rothenberg SJ Iron and folate status before pregnancy and anemia during pregnancy Ann Nutr Metab 2003 4760-3
bull 35 Chrsquong CL Morgan M Hainsworth I Kingham JG Prospective study of liver dysfunction in Southwest Wales Gut 200251 876-80
bull 36 Rahman TM Wendon J Severe hepatic dysfunction in pregnancy QJM 200295343-57
bull 37 Knox TA Olans LB Liver disease in pregnancy N Engl J Med 1996335569-76
bull 38 Saftlas AF Olson DR Franks AL Atrash H Pokras R Epidemiology of preeclampsia and eclampsia in the United States 1979e1986 Am J Obstet Gynecol 1990163460-5
bull 39 Walker JJ Pre-eclampsia Lancet 20003561260-5
bull 40 Davidson JM Renal disorders in pregnancy Curr Opin Obstet Gynecol 200113109-14
bull 41 Dafnis E Sabatini S The effect of pregnancy on renal function physiology and pathophysiologyAmJMedSci 1992303184-205
bull 42 Davison JM Shiells EA Philips PR Lindheimer MD Serial evaluation of vasopressin release and thirst in human pregnancy Role of human chorionic gonadotrophin in the osmoregulatory changes of gestation J Clin Invest 198881798-806
bull 43 Glinoer D de Nayer P Bourdoux P Lemone M Robyn C van Steirteghem A et al Regulation of maternal thyroid during pregnancy J Clin Endocrinol Metab 199071276-87
bull 44 Wilson SG Retallack RW Kent JC Worth GK Gutteridge DH Serum free 125-dihydroxyvitamin D and the free 125- dihydroxyvitamin D index during a longitudinal study of human pregnancy and lactation Clin Endocrinol 199032613-22
bull 45 Rasmussen N Frolich A Hornnes PJ Hegedus L Serum ionized calcium and intact parathyroid hormone levels during pregnancy and postpartum Br J Obstet Gynaecol 199097857-9
bull 46 Guyton AC Textbook of medical physiology 8th ed Philadelphia W B Saunders 1991 p 915e28
bull 47 Trainer PJ Corticosteroids and pregnancy Semin Reprod Med 200220375-80
bull 48 Soory M Hormonal factors in periodontal disease Dent Update 200027380-3
bull 49 Hugoson A Gingivitis in pregnant women A longitudinal clinical study Odontol Revy 19712265-84
bull 50 Neville BW Damm DD Allen CM Bouquot JE Oral amp Maxillofacial Pathology 3rd ed Philadelphia W B Saunders 2002 p 329-30 447-9
bull 51 Tilakaratne A Soory M Ranasinghe AW Corea SM Ekanayake SL de Silva M Periodontal disease status during pregnancy and 3 months post-partum in rural population of Sri-Lankan women J Clin Periodontol 200027787-92
bull 52 Laine M Tenovuo J Lehtonen OP Ojanatko-Harri A Vilja P Tuohimaa P Pregnancy e related changes in human whole saliva Arch Oral Biol 198833913-7
bull 53 Yuan K Wing LY Lin MT Pathogenetic roles of angiogenic factors in pyogenic granulomas in pregnancy are modulated by female sex hormones J Periodontol 200273701-8
bull 54 Evans RD Briggs PF Tooth-surface loss related to pregnancyinduced vomiting Prim Dent Care 1994124-6
bull 55 Salvolini E Di Giorgio R Curatola A Mazzanti L Fratto G Biochemical modifications of human whole saliva induced by pregnancy Br J Obstet Gynaec 1998105656-60
bull 56 Mauldin JG Newman RB Preterm birth risk assessment Semin Perinatol 200125215-22
bull 57 Heine RP McGregor JA Goodwin TM Artal R Hayashi RH Robertson PA et al Serial salivary estriol to detect an increased risk of preterm birth Obstet Gynecol 200096490-7
bull 58 Kauh YC Zachian TF Melasma Adv Exp Med Biol 1999455 491-9
bull 59 Wong RC Ellis CN Physiologic skin changes in pregnancy J Am Acad Dermatol 198410929-40
bull 60 Errickson CV Matus NR Skin disorders of pregnancy Am Fam Physician 199449605-10
bull 61 Lopez NJ Smith PC Gutierrez J Periodontal therapy may reduce the risk of preterm low birth weight in women with periodontal disease a randomized controlled trial J Periodontol 200273911-24
bull 62 McGaw T Periodontal disease and preterm delivery of lowbirth- weight infants J Can Dent Assoc 200268165-9
bull 63 Richards AG Dental x-ray protection Dent Clin North Am 1968631-41
bull 64 1990 Recommendations of the International Commission on Radiological Protection Ann ICRP 1991211-201
bull 65 Hall EJ Radiation the two-edged sword cancer risks at high and low doses Cancer J 20006343-50
bull 66 Diethelm L Xu H Diagnostic imaging of the lung during pregnancy Clin Obstet Gynecol 19963936-55
bull 67 Brent RL The effects of embryonic and fetal exposure to x-rays microwaves and ultrasound ClinObstetGynecol 198326484-510
bull 68 National Council on Radiation Protection NCRP report no128 1998 Bethesda Md Author
bull 69 Wasylko L Matsui D Dykxhoorn SM Reider MJ Weinberg S A review of common dental treatments during pregnancy implications for patients and dental personnel J Can Dent Assoc 199864434-9
bull 70 Freeman JP Brand JW Radiation doses of commonly used dental radiographic surveys Oral Surg Oral Med Oral Pathol 199477285-9
bull 71 Kircos LTAngin LL Lorton LOrder ofmagnitude dose reduction in intraoral radiography J Am Dent Assoc 1987114344-7
bull 72 Updegrave WJ Simplified and standardized intraoral radiography with reduced tissue irradiation J Am Dent Assoc 197285861-9
bull 73 Wood RE Harris AM van der Merwe EJ Nortje CJ The leaded apron revisited does it reduce gonadal radiation dose in dental radiology Oral Surg Oral Med Oral Pathol 199171642-6
bull 74 An update on radiographic practices information and recommendations ADA Council on Scientific Affairs J Am Dent Assoc 2001132234-8
bull 75 Rayburn WF Recommending medications during pregnancy an evidence based approach Clin Obstet Gynecol 2002451-5
bull 76 Rathmell JP Viscomi C Ashburn MA Management of nonobstetric pain during pregnancy and lactation Anesth Analg 1997851074-87
bull 77 Teratology society public affairs committee FDA classification of drugs for teratogenic risk Teratology 199449446-7
bull 78 Moore PA Selecting drugs for the pregnant dental patient J Am Dent Assoc 19981291281-6
bull 79 Haas DA An update on analgesics for the management of acute postoperative dental pain J Can Dent Assoc 200268476-82
bull 80 Haas DA Pynn BR Sands TD Drug use for the pregnant or lactating patient Gen Dent 20004854-60
bull 81 Committee on Drugs American Academy of Pediatrics The transfer of drugs and other chemicals into human milk Pediatrics 199493137-50
bull 82 Nielsen GL Sorensen HT Larsen H Pedersen L Risk of adverse birth outcome and miscarriage in pregnant users of nonsteroidal anti-inflammatory drugs population based observational study and case-control study BMJ 2001322266-70
bull 83 Janssen N Genta M The effects of immunosuppressive and anti-inflammatory medications on fertility pregnancy and lactation Arch Intern Med 200016610-9
bull 84 Ostensen M Nonsteroidal anti-inflammatory drugs during pregnancy Scand J Rheumatol Suppl 1998107128-32
bull 85 USPDI -Drug information for the health care professional 22nd ed Greenwood Village CO Micromedex 2002 p 152-79
bull 86 Denson DD Coyle DE Thompson GA Santos D Turner PA Myers JA et al Bupivacaine protein binding in the term parturient effects of lactic acidosis Clin Pharmacol Ther 198435702-9
bull 87 Dillon DE Wagner CL Wiest D Newman RB Drug therapy in the nursing mother Obstet Gynecol Clin North Am 199724 675-96
bull 88 Dashe JS Gilstrap LC Antibiotic use in pregnancy Obstet Gynecol Clin North Am 199724617-29
bull 89 American College of Rheumatology Ad hoc Committee on Clinical Guidelines Guidelines for monitoring drug therapy in rheumatoid arthritis Arthritis Rheum 199639723-31
bull 90 Ng PC The fetal and neonatal hypothalamic-pituitary-adrenal axis Arch Dis Child Fetal Neonatal Ed 200082F250-4
bull 91 Crowley P Antenatal corticosteroidsmdashcurrent thinking BJOG 2003110(Suppl 20)77-8
bull 92 ACOG committee opinion antenatal corticosteroid therapy for fetal maturation Obstet Gynecol 200299871-3
bull 93 Ost L Wettrell G Bjorkhem I Rane A Prednisolone excretion in human milk J Pediatr 19851061008-11
bull 94 Rowland AS Baird DD Shore DL Weinberg CR Savitz DA Wilcox AJ Nitrous oxide and spontaneous abortion in female dental assistants Am J Epidemiol 1995141531-8
bull 95 McGlothlin JD Jensen PA Fischbach TJ Hughes RT Jones JH Control of anesthetic gases in dental operatories Scand J Work Environ Health 199218(Suppl 2)103-5
bull ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY Volume 97 Number 6 Suresh and Radfar 681
bull 96 Rosen MA Nitrous oxide for relief of labor pain a systematic review Am J Obstet Gynecol 2002186(Suppl Nature)S110-6
bull 97 Sands TD Pynn BR Management considerations for the pregnant or nursing emergency patient Ont Dent 199875 17-9
bull 98 Daya S Recurrent spontaneous early pregnancy loss and low dose aspirin Minerva Ginecol 200355441-9
bull 99 Sinclair C Handbook of obstetrical emergencies 1st ed Philadelphia WB Saunders 1996 p 29-39 69
bull 100 Tarsitano BF Rollings RE The pregnant dental patient evaluation and management Gen Dent 199341226-34
bull 101 Livingston MH Dlllinger TM Holder R Consideration in the management of the pregnant patient SCD Special Care in Dentistry 199818183-8
Thank you
- A Review on the principle of Dental Management of the Pregnant patient
- Slide 2
- Questions that a dentist may ask
- Stages of Pregnancy
- Slide 5
- Slide 6
- Physiologic Changes in Pregnancy
- Systemic changes in pregnancy
- FLAT SUPINE POSITIONING
- SUPINE HYPOTENSION SYNDROME (Vena Cava Compression)
- Supine Hypotension Syndrome
- Slide 12
- Supine Hypotension Syndrome
- Prevention of Supine Hypotensive Syndrome
- Treatment of Supine Hypotensive Syndrome
- How should the pregnant woman be positioned
- Slide 17
- Slide 18
- Slide 19
- Slide 20
- Slide 21
- Slide 22
- Slide 23
- Pregnancy Related Oral Health Problems
- Oral Problems in Pregnancy
- Pregnancy Gingivitis Pathophysiology
- Pregnancy Gingivitis
- Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Gum Problems - Pregnancy Granuloma
- Slide 31
- Gum Changes - Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Candidiasis
- Pregnancy Myths
- Other Oral Conditions in Pregnancy
- Changes During Pregnancy that Affect Oral Health
- Saliva changes
- Increased Bacteria
- Slide 40
- Enamel erosion caused by frequent vomiting
- Treatment for Acid Exposure
- Oral Diseases Can Effect Pregnancy
- Periodontal Disease and Preterm Labor
- Periodontal Disease and Low Birth Weight
- Periodontal Disease and Preeclampsia
- Periodontitis and Pre-eclampsia
- Dental Considerations
- Treatment Timing
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Slide 52
- Use of Radiation on Pregnant Patient
- Radiographs during Pregnancy
- Risks of Dental X-Rays
- FDA drug classification for pregnancy
- Slide 57
- FDA drug classification for pregnancy
- Slide 59
- Slide 60
- Slide 61
- Common Analgesics
- Analgesics
- Analgesics - continued
- Analgesics to Use During 1st and 2nd Trimester
- Analgesics to Avoid During the Third Trimester
- Sedation in Pregnancy
- Common Antibiotics
- Antibiotics
- Antibiotics To Use During Pregnancy
- Antibiotics to Avoid during Pregnancy
- The Problem With Tetracycline
- Other Antimicrobial Agents
- Local Anesthetic Use in Pregnancy
- Use of Local Anesthetics
- Ulcer healing drugs
- Slide 77
- Slide 78
- Slide 79
- Use of Nitrous Oxide Gas
- Common Preventives
- Are topical agents safe
- Pre-natal Fluoride
- Is it safe to use mercury restorations
- References
- REFERENCES
- Slide 87
- Slide 88
- Slide 89
- Slide 90
- Slide 91
- Slide 92
- Slide 93
- Slide 94
- Slide 95
- Slide 96
- Slide 97
- Slide 98
- Thank you
-
Are topical agents safe
bull Fluoridebull Toothpaste amp mouthrinse
bull Xylitol chewing gum bull Chlorhexidine (11 alcohol)bull No over the counter mouthrinses with
alcohol (Listerine 20 alcohol)
Pre-natal Fluoride
bull Daily 22 mg tablet of sodium fluoride during 3rd through 9th months
bull decreases caries rate in offspringbull Safe and effective
Glenn FB 1982
Is it safe to use mercury restorations
bull No evidence of harmful effect
bull Benefits outweigh risks
bull Canada Germany and New Zealand have some restrictions
bull Determine the best option
Referencesbull Wasylko L Matsui D Dykxhoorn SM Rieder MJ Weinberg
S A Review of Common Dental Treatments During Pregnancy J Canadian Dental Association 64434-439 1998
bull Little JW Donald AF Craig SM Rhodus NL Dental Management of the Medically Compromised Patient - 5th edition Mosby Toronto Pp434-442 1997
bull Livingston HM Dellinger TM Holder R Considerations in the management of the pregnant patient Special Care in Dentistry 185 pp183-188 1998
bull Larimore WL Petrie KA Drug use during pregnacy and lactation Primary Care Clinics in Office Practice 271 35-53 2000
bull Health Canada The Safety of DentalAmalgam Minister Of Supply and Services Canada 1996
REFERENCESbull 1 Weiss G Endocrinology of parturition J Clin
Endocrinol Metab 2000854421-5bull 2 Theunissen IM Parer JT Fluid and electrolytes in
pregnancy Clin Obstet Gynecol 1994373-15bull 3 Duvekot JJ Peeters LLH Renal hemodynamics and
volume homeostasis in pregnancy Obstet Gynecol Surv 199449830-9
bull 4 Barron WM Lindheimer MD Medical disorders during pregnancy 2nd ed St Louis Mosby 1995 p 129
bull 5 Thornburg KL Jacobson SL Giraud GD Morton MJ Hemodynamic changes in pregnancy Semin Perinatol 20002411-4
bull 6 Fiese R Herzog S Issues in dental and surgical management of the pregnant patient Oral Surg Oral Med Oral Pathol 198865292-7
bull 7 Martin C Varner MW Physiologic changes in pregnancysurgical implications Clin Obstet Gynecol 199437241-55
bull 8 Clark SL Cotton DB Lee W Bishop C Hill T Southwick J et al Central hemodynamic assessment of normal term pregnancy Am J Obstet Gynecol 19891611439-42
bull 9 Mabie WC Di Sessa TG Crocker LG Sibai BM Arheart KL A longitudinal study of cardiac output in normal human pregnancy Am J Obstet Gynecol 1994170849-56
bull 10 Clapp JF 3rd Capeless E Cardiovascular function before during and after the first and subsequent pregnancies Am J Cardiol 1997801469-73
bull 11 Duvekot JJ Peeters LL Maternal cardiovascular hemodynamic adaptation to pregnancy Obstet Gynecol Surv 199449(Suppl) S1-14
bull 12 Bhagwat AR Engel PJ Heart disease and pregnancy Cardiol Clin 199513163-78
bull 13 Lanni SM Tillinghast J Silver H Hemodynamic changes and baroreflex gain in the supine hypotensive syndrome Am J Obstet Gynecol 20021871636-41
bull 14 Little JW Falace DA Miller CS Rhodus NL Dental management of the medically compromised patient 6th ed St Louis Mosby 2002 p 303
bull 15 Garcia-Rio F Pino JM Gomez L Alvarez-Sala R Villasante C Villamor J Regulation of breathing and perception of dyspnea in healthy pregnant women Chest 1996110446-53
bull 16 McAuliffe F Kametas N Costello J Rafferty GF Greenough A Nicolaides K Respiratory function in singleton and twin pregnancy BJOG 2002109765-9
bull 17 Clapp JF 3rd Seaward BL Sleamaker RH Hiser J Maternal physiologic adaptations to early human pregnancy Am J Obstet Gynecol 19881591456-60
bull 18 OrsquoDay MP Cardio-respiratory physiological adaptation of pregnancy Semin Perinatol 199721268-75
bull 19 Contreras G Gutierrez M Beroiza T Fantin A Oddo H Villarroel L et al Ventilatory drive and respiratory muscle function in pregnancy Am Rev Respir Dis 1991144837-41
bull 20 Turner M Aziz SR Management of the pregnant oral and maxillofac
bull 21 Sifakis S Pharmakides G Anemia in pregnancy Ann N Y Acad Sci 2000900125-36
bull 22 Branch DW Physiologic adaptations of pregnancy Am J Reprod Immunol 199228120-2
bull 23 Burrows RF Kelton JG Incidentally detected thrombocytopenia in healthy mothers and their infants N Engl J Med 1988319 142-5
bull 24 Hanly JG Antiphospholipid syndrome an overview CMAJ 200324(168)1675-82
bull 25 Heilmann L von Tempelhoff GF Pollow K Antiphospholipid syndrome in obstetrics Clin Appl Thromb Hemost 20039 143-50
bull 26 Sherman P Flaxman SM Nausea and vomiting of pregnancy in an evolutionary perspective Am J Obstet Gynecol 2002 185(Suppl)s190-7
bull 27 Koch KL Gastrointestinal factors in nausea and vomiting of pregnancy Am J Obstet Gynecol 2002185(Suppl)s198-203
bull 28 Koch KL Frissora CL Nausea and vomiting during pregnancy Gastroenterol Clin N Am 200332201-34
bull 29 Baron TH Ramirez B Richter JE Gastrointestinal motility disorders during pregnancy Ann Intern Med 1993118 366-75
bull 30 Richter JE Gastroesophageal reflux disease during pregnancy Gastroenterol Clin N Am 200332235-61
bull 31 Marrero JM Goggin PM de Caestecker JS Pearce JM Maxwell JD Determinants of pregnancy heartburn Br J Obstet Gynaecol 199299731-4
bull 32 Hamaoui E Hamaoui M Nutritional assessment and support during pregnancy Gastroenterol Clin N Am 20033259-121
bull 33 King JC Physiology of pregnancy and nutrient metabolism Am J Clin Nutr 200071(suppl)1218s-25s
bull 34 Casanueva E Pfeffer F Fernandez-Gaxiola AC Gutierrez- Valenzuela V Rothenberg SJ Iron and folate status before pregnancy and anemia during pregnancy Ann Nutr Metab 2003 4760-3
bull 35 Chrsquong CL Morgan M Hainsworth I Kingham JG Prospective study of liver dysfunction in Southwest Wales Gut 200251 876-80
bull 36 Rahman TM Wendon J Severe hepatic dysfunction in pregnancy QJM 200295343-57
bull 37 Knox TA Olans LB Liver disease in pregnancy N Engl J Med 1996335569-76
bull 38 Saftlas AF Olson DR Franks AL Atrash H Pokras R Epidemiology of preeclampsia and eclampsia in the United States 1979e1986 Am J Obstet Gynecol 1990163460-5
bull 39 Walker JJ Pre-eclampsia Lancet 20003561260-5
bull 40 Davidson JM Renal disorders in pregnancy Curr Opin Obstet Gynecol 200113109-14
bull 41 Dafnis E Sabatini S The effect of pregnancy on renal function physiology and pathophysiologyAmJMedSci 1992303184-205
bull 42 Davison JM Shiells EA Philips PR Lindheimer MD Serial evaluation of vasopressin release and thirst in human pregnancy Role of human chorionic gonadotrophin in the osmoregulatory changes of gestation J Clin Invest 198881798-806
bull 43 Glinoer D de Nayer P Bourdoux P Lemone M Robyn C van Steirteghem A et al Regulation of maternal thyroid during pregnancy J Clin Endocrinol Metab 199071276-87
bull 44 Wilson SG Retallack RW Kent JC Worth GK Gutteridge DH Serum free 125-dihydroxyvitamin D and the free 125- dihydroxyvitamin D index during a longitudinal study of human pregnancy and lactation Clin Endocrinol 199032613-22
bull 45 Rasmussen N Frolich A Hornnes PJ Hegedus L Serum ionized calcium and intact parathyroid hormone levels during pregnancy and postpartum Br J Obstet Gynaecol 199097857-9
bull 46 Guyton AC Textbook of medical physiology 8th ed Philadelphia W B Saunders 1991 p 915e28
bull 47 Trainer PJ Corticosteroids and pregnancy Semin Reprod Med 200220375-80
bull 48 Soory M Hormonal factors in periodontal disease Dent Update 200027380-3
bull 49 Hugoson A Gingivitis in pregnant women A longitudinal clinical study Odontol Revy 19712265-84
bull 50 Neville BW Damm DD Allen CM Bouquot JE Oral amp Maxillofacial Pathology 3rd ed Philadelphia W B Saunders 2002 p 329-30 447-9
bull 51 Tilakaratne A Soory M Ranasinghe AW Corea SM Ekanayake SL de Silva M Periodontal disease status during pregnancy and 3 months post-partum in rural population of Sri-Lankan women J Clin Periodontol 200027787-92
bull 52 Laine M Tenovuo J Lehtonen OP Ojanatko-Harri A Vilja P Tuohimaa P Pregnancy e related changes in human whole saliva Arch Oral Biol 198833913-7
bull 53 Yuan K Wing LY Lin MT Pathogenetic roles of angiogenic factors in pyogenic granulomas in pregnancy are modulated by female sex hormones J Periodontol 200273701-8
bull 54 Evans RD Briggs PF Tooth-surface loss related to pregnancyinduced vomiting Prim Dent Care 1994124-6
bull 55 Salvolini E Di Giorgio R Curatola A Mazzanti L Fratto G Biochemical modifications of human whole saliva induced by pregnancy Br J Obstet Gynaec 1998105656-60
bull 56 Mauldin JG Newman RB Preterm birth risk assessment Semin Perinatol 200125215-22
bull 57 Heine RP McGregor JA Goodwin TM Artal R Hayashi RH Robertson PA et al Serial salivary estriol to detect an increased risk of preterm birth Obstet Gynecol 200096490-7
bull 58 Kauh YC Zachian TF Melasma Adv Exp Med Biol 1999455 491-9
bull 59 Wong RC Ellis CN Physiologic skin changes in pregnancy J Am Acad Dermatol 198410929-40
bull 60 Errickson CV Matus NR Skin disorders of pregnancy Am Fam Physician 199449605-10
bull 61 Lopez NJ Smith PC Gutierrez J Periodontal therapy may reduce the risk of preterm low birth weight in women with periodontal disease a randomized controlled trial J Periodontol 200273911-24
bull 62 McGaw T Periodontal disease and preterm delivery of lowbirth- weight infants J Can Dent Assoc 200268165-9
bull 63 Richards AG Dental x-ray protection Dent Clin North Am 1968631-41
bull 64 1990 Recommendations of the International Commission on Radiological Protection Ann ICRP 1991211-201
bull 65 Hall EJ Radiation the two-edged sword cancer risks at high and low doses Cancer J 20006343-50
bull 66 Diethelm L Xu H Diagnostic imaging of the lung during pregnancy Clin Obstet Gynecol 19963936-55
bull 67 Brent RL The effects of embryonic and fetal exposure to x-rays microwaves and ultrasound ClinObstetGynecol 198326484-510
bull 68 National Council on Radiation Protection NCRP report no128 1998 Bethesda Md Author
bull 69 Wasylko L Matsui D Dykxhoorn SM Reider MJ Weinberg S A review of common dental treatments during pregnancy implications for patients and dental personnel J Can Dent Assoc 199864434-9
bull 70 Freeman JP Brand JW Radiation doses of commonly used dental radiographic surveys Oral Surg Oral Med Oral Pathol 199477285-9
bull 71 Kircos LTAngin LL Lorton LOrder ofmagnitude dose reduction in intraoral radiography J Am Dent Assoc 1987114344-7
bull 72 Updegrave WJ Simplified and standardized intraoral radiography with reduced tissue irradiation J Am Dent Assoc 197285861-9
bull 73 Wood RE Harris AM van der Merwe EJ Nortje CJ The leaded apron revisited does it reduce gonadal radiation dose in dental radiology Oral Surg Oral Med Oral Pathol 199171642-6
bull 74 An update on radiographic practices information and recommendations ADA Council on Scientific Affairs J Am Dent Assoc 2001132234-8
bull 75 Rayburn WF Recommending medications during pregnancy an evidence based approach Clin Obstet Gynecol 2002451-5
bull 76 Rathmell JP Viscomi C Ashburn MA Management of nonobstetric pain during pregnancy and lactation Anesth Analg 1997851074-87
bull 77 Teratology society public affairs committee FDA classification of drugs for teratogenic risk Teratology 199449446-7
bull 78 Moore PA Selecting drugs for the pregnant dental patient J Am Dent Assoc 19981291281-6
bull 79 Haas DA An update on analgesics for the management of acute postoperative dental pain J Can Dent Assoc 200268476-82
bull 80 Haas DA Pynn BR Sands TD Drug use for the pregnant or lactating patient Gen Dent 20004854-60
bull 81 Committee on Drugs American Academy of Pediatrics The transfer of drugs and other chemicals into human milk Pediatrics 199493137-50
bull 82 Nielsen GL Sorensen HT Larsen H Pedersen L Risk of adverse birth outcome and miscarriage in pregnant users of nonsteroidal anti-inflammatory drugs population based observational study and case-control study BMJ 2001322266-70
bull 83 Janssen N Genta M The effects of immunosuppressive and anti-inflammatory medications on fertility pregnancy and lactation Arch Intern Med 200016610-9
bull 84 Ostensen M Nonsteroidal anti-inflammatory drugs during pregnancy Scand J Rheumatol Suppl 1998107128-32
bull 85 USPDI -Drug information for the health care professional 22nd ed Greenwood Village CO Micromedex 2002 p 152-79
bull 86 Denson DD Coyle DE Thompson GA Santos D Turner PA Myers JA et al Bupivacaine protein binding in the term parturient effects of lactic acidosis Clin Pharmacol Ther 198435702-9
bull 87 Dillon DE Wagner CL Wiest D Newman RB Drug therapy in the nursing mother Obstet Gynecol Clin North Am 199724 675-96
bull 88 Dashe JS Gilstrap LC Antibiotic use in pregnancy Obstet Gynecol Clin North Am 199724617-29
bull 89 American College of Rheumatology Ad hoc Committee on Clinical Guidelines Guidelines for monitoring drug therapy in rheumatoid arthritis Arthritis Rheum 199639723-31
bull 90 Ng PC The fetal and neonatal hypothalamic-pituitary-adrenal axis Arch Dis Child Fetal Neonatal Ed 200082F250-4
bull 91 Crowley P Antenatal corticosteroidsmdashcurrent thinking BJOG 2003110(Suppl 20)77-8
bull 92 ACOG committee opinion antenatal corticosteroid therapy for fetal maturation Obstet Gynecol 200299871-3
bull 93 Ost L Wettrell G Bjorkhem I Rane A Prednisolone excretion in human milk J Pediatr 19851061008-11
bull 94 Rowland AS Baird DD Shore DL Weinberg CR Savitz DA Wilcox AJ Nitrous oxide and spontaneous abortion in female dental assistants Am J Epidemiol 1995141531-8
bull 95 McGlothlin JD Jensen PA Fischbach TJ Hughes RT Jones JH Control of anesthetic gases in dental operatories Scand J Work Environ Health 199218(Suppl 2)103-5
bull ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY Volume 97 Number 6 Suresh and Radfar 681
bull 96 Rosen MA Nitrous oxide for relief of labor pain a systematic review Am J Obstet Gynecol 2002186(Suppl Nature)S110-6
bull 97 Sands TD Pynn BR Management considerations for the pregnant or nursing emergency patient Ont Dent 199875 17-9
bull 98 Daya S Recurrent spontaneous early pregnancy loss and low dose aspirin Minerva Ginecol 200355441-9
bull 99 Sinclair C Handbook of obstetrical emergencies 1st ed Philadelphia WB Saunders 1996 p 29-39 69
bull 100 Tarsitano BF Rollings RE The pregnant dental patient evaluation and management Gen Dent 199341226-34
bull 101 Livingston MH Dlllinger TM Holder R Consideration in the management of the pregnant patient SCD Special Care in Dentistry 199818183-8
Thank you
- A Review on the principle of Dental Management of the Pregnant patient
- Slide 2
- Questions that a dentist may ask
- Stages of Pregnancy
- Slide 5
- Slide 6
- Physiologic Changes in Pregnancy
- Systemic changes in pregnancy
- FLAT SUPINE POSITIONING
- SUPINE HYPOTENSION SYNDROME (Vena Cava Compression)
- Supine Hypotension Syndrome
- Slide 12
- Supine Hypotension Syndrome
- Prevention of Supine Hypotensive Syndrome
- Treatment of Supine Hypotensive Syndrome
- How should the pregnant woman be positioned
- Slide 17
- Slide 18
- Slide 19
- Slide 20
- Slide 21
- Slide 22
- Slide 23
- Pregnancy Related Oral Health Problems
- Oral Problems in Pregnancy
- Pregnancy Gingivitis Pathophysiology
- Pregnancy Gingivitis
- Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Gum Problems - Pregnancy Granuloma
- Slide 31
- Gum Changes - Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Candidiasis
- Pregnancy Myths
- Other Oral Conditions in Pregnancy
- Changes During Pregnancy that Affect Oral Health
- Saliva changes
- Increased Bacteria
- Slide 40
- Enamel erosion caused by frequent vomiting
- Treatment for Acid Exposure
- Oral Diseases Can Effect Pregnancy
- Periodontal Disease and Preterm Labor
- Periodontal Disease and Low Birth Weight
- Periodontal Disease and Preeclampsia
- Periodontitis and Pre-eclampsia
- Dental Considerations
- Treatment Timing
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Slide 52
- Use of Radiation on Pregnant Patient
- Radiographs during Pregnancy
- Risks of Dental X-Rays
- FDA drug classification for pregnancy
- Slide 57
- FDA drug classification for pregnancy
- Slide 59
- Slide 60
- Slide 61
- Common Analgesics
- Analgesics
- Analgesics - continued
- Analgesics to Use During 1st and 2nd Trimester
- Analgesics to Avoid During the Third Trimester
- Sedation in Pregnancy
- Common Antibiotics
- Antibiotics
- Antibiotics To Use During Pregnancy
- Antibiotics to Avoid during Pregnancy
- The Problem With Tetracycline
- Other Antimicrobial Agents
- Local Anesthetic Use in Pregnancy
- Use of Local Anesthetics
- Ulcer healing drugs
- Slide 77
- Slide 78
- Slide 79
- Use of Nitrous Oxide Gas
- Common Preventives
- Are topical agents safe
- Pre-natal Fluoride
- Is it safe to use mercury restorations
- References
- REFERENCES
- Slide 87
- Slide 88
- Slide 89
- Slide 90
- Slide 91
- Slide 92
- Slide 93
- Slide 94
- Slide 95
- Slide 96
- Slide 97
- Slide 98
- Thank you
-
Pre-natal Fluoride
bull Daily 22 mg tablet of sodium fluoride during 3rd through 9th months
bull decreases caries rate in offspringbull Safe and effective
Glenn FB 1982
Is it safe to use mercury restorations
bull No evidence of harmful effect
bull Benefits outweigh risks
bull Canada Germany and New Zealand have some restrictions
bull Determine the best option
Referencesbull Wasylko L Matsui D Dykxhoorn SM Rieder MJ Weinberg
S A Review of Common Dental Treatments During Pregnancy J Canadian Dental Association 64434-439 1998
bull Little JW Donald AF Craig SM Rhodus NL Dental Management of the Medically Compromised Patient - 5th edition Mosby Toronto Pp434-442 1997
bull Livingston HM Dellinger TM Holder R Considerations in the management of the pregnant patient Special Care in Dentistry 185 pp183-188 1998
bull Larimore WL Petrie KA Drug use during pregnacy and lactation Primary Care Clinics in Office Practice 271 35-53 2000
bull Health Canada The Safety of DentalAmalgam Minister Of Supply and Services Canada 1996
REFERENCESbull 1 Weiss G Endocrinology of parturition J Clin
Endocrinol Metab 2000854421-5bull 2 Theunissen IM Parer JT Fluid and electrolytes in
pregnancy Clin Obstet Gynecol 1994373-15bull 3 Duvekot JJ Peeters LLH Renal hemodynamics and
volume homeostasis in pregnancy Obstet Gynecol Surv 199449830-9
bull 4 Barron WM Lindheimer MD Medical disorders during pregnancy 2nd ed St Louis Mosby 1995 p 129
bull 5 Thornburg KL Jacobson SL Giraud GD Morton MJ Hemodynamic changes in pregnancy Semin Perinatol 20002411-4
bull 6 Fiese R Herzog S Issues in dental and surgical management of the pregnant patient Oral Surg Oral Med Oral Pathol 198865292-7
bull 7 Martin C Varner MW Physiologic changes in pregnancysurgical implications Clin Obstet Gynecol 199437241-55
bull 8 Clark SL Cotton DB Lee W Bishop C Hill T Southwick J et al Central hemodynamic assessment of normal term pregnancy Am J Obstet Gynecol 19891611439-42
bull 9 Mabie WC Di Sessa TG Crocker LG Sibai BM Arheart KL A longitudinal study of cardiac output in normal human pregnancy Am J Obstet Gynecol 1994170849-56
bull 10 Clapp JF 3rd Capeless E Cardiovascular function before during and after the first and subsequent pregnancies Am J Cardiol 1997801469-73
bull 11 Duvekot JJ Peeters LL Maternal cardiovascular hemodynamic adaptation to pregnancy Obstet Gynecol Surv 199449(Suppl) S1-14
bull 12 Bhagwat AR Engel PJ Heart disease and pregnancy Cardiol Clin 199513163-78
bull 13 Lanni SM Tillinghast J Silver H Hemodynamic changes and baroreflex gain in the supine hypotensive syndrome Am J Obstet Gynecol 20021871636-41
bull 14 Little JW Falace DA Miller CS Rhodus NL Dental management of the medically compromised patient 6th ed St Louis Mosby 2002 p 303
bull 15 Garcia-Rio F Pino JM Gomez L Alvarez-Sala R Villasante C Villamor J Regulation of breathing and perception of dyspnea in healthy pregnant women Chest 1996110446-53
bull 16 McAuliffe F Kametas N Costello J Rafferty GF Greenough A Nicolaides K Respiratory function in singleton and twin pregnancy BJOG 2002109765-9
bull 17 Clapp JF 3rd Seaward BL Sleamaker RH Hiser J Maternal physiologic adaptations to early human pregnancy Am J Obstet Gynecol 19881591456-60
bull 18 OrsquoDay MP Cardio-respiratory physiological adaptation of pregnancy Semin Perinatol 199721268-75
bull 19 Contreras G Gutierrez M Beroiza T Fantin A Oddo H Villarroel L et al Ventilatory drive and respiratory muscle function in pregnancy Am Rev Respir Dis 1991144837-41
bull 20 Turner M Aziz SR Management of the pregnant oral and maxillofac
bull 21 Sifakis S Pharmakides G Anemia in pregnancy Ann N Y Acad Sci 2000900125-36
bull 22 Branch DW Physiologic adaptations of pregnancy Am J Reprod Immunol 199228120-2
bull 23 Burrows RF Kelton JG Incidentally detected thrombocytopenia in healthy mothers and their infants N Engl J Med 1988319 142-5
bull 24 Hanly JG Antiphospholipid syndrome an overview CMAJ 200324(168)1675-82
bull 25 Heilmann L von Tempelhoff GF Pollow K Antiphospholipid syndrome in obstetrics Clin Appl Thromb Hemost 20039 143-50
bull 26 Sherman P Flaxman SM Nausea and vomiting of pregnancy in an evolutionary perspective Am J Obstet Gynecol 2002 185(Suppl)s190-7
bull 27 Koch KL Gastrointestinal factors in nausea and vomiting of pregnancy Am J Obstet Gynecol 2002185(Suppl)s198-203
bull 28 Koch KL Frissora CL Nausea and vomiting during pregnancy Gastroenterol Clin N Am 200332201-34
bull 29 Baron TH Ramirez B Richter JE Gastrointestinal motility disorders during pregnancy Ann Intern Med 1993118 366-75
bull 30 Richter JE Gastroesophageal reflux disease during pregnancy Gastroenterol Clin N Am 200332235-61
bull 31 Marrero JM Goggin PM de Caestecker JS Pearce JM Maxwell JD Determinants of pregnancy heartburn Br J Obstet Gynaecol 199299731-4
bull 32 Hamaoui E Hamaoui M Nutritional assessment and support during pregnancy Gastroenterol Clin N Am 20033259-121
bull 33 King JC Physiology of pregnancy and nutrient metabolism Am J Clin Nutr 200071(suppl)1218s-25s
bull 34 Casanueva E Pfeffer F Fernandez-Gaxiola AC Gutierrez- Valenzuela V Rothenberg SJ Iron and folate status before pregnancy and anemia during pregnancy Ann Nutr Metab 2003 4760-3
bull 35 Chrsquong CL Morgan M Hainsworth I Kingham JG Prospective study of liver dysfunction in Southwest Wales Gut 200251 876-80
bull 36 Rahman TM Wendon J Severe hepatic dysfunction in pregnancy QJM 200295343-57
bull 37 Knox TA Olans LB Liver disease in pregnancy N Engl J Med 1996335569-76
bull 38 Saftlas AF Olson DR Franks AL Atrash H Pokras R Epidemiology of preeclampsia and eclampsia in the United States 1979e1986 Am J Obstet Gynecol 1990163460-5
bull 39 Walker JJ Pre-eclampsia Lancet 20003561260-5
bull 40 Davidson JM Renal disorders in pregnancy Curr Opin Obstet Gynecol 200113109-14
bull 41 Dafnis E Sabatini S The effect of pregnancy on renal function physiology and pathophysiologyAmJMedSci 1992303184-205
bull 42 Davison JM Shiells EA Philips PR Lindheimer MD Serial evaluation of vasopressin release and thirst in human pregnancy Role of human chorionic gonadotrophin in the osmoregulatory changes of gestation J Clin Invest 198881798-806
bull 43 Glinoer D de Nayer P Bourdoux P Lemone M Robyn C van Steirteghem A et al Regulation of maternal thyroid during pregnancy J Clin Endocrinol Metab 199071276-87
bull 44 Wilson SG Retallack RW Kent JC Worth GK Gutteridge DH Serum free 125-dihydroxyvitamin D and the free 125- dihydroxyvitamin D index during a longitudinal study of human pregnancy and lactation Clin Endocrinol 199032613-22
bull 45 Rasmussen N Frolich A Hornnes PJ Hegedus L Serum ionized calcium and intact parathyroid hormone levels during pregnancy and postpartum Br J Obstet Gynaecol 199097857-9
bull 46 Guyton AC Textbook of medical physiology 8th ed Philadelphia W B Saunders 1991 p 915e28
bull 47 Trainer PJ Corticosteroids and pregnancy Semin Reprod Med 200220375-80
bull 48 Soory M Hormonal factors in periodontal disease Dent Update 200027380-3
bull 49 Hugoson A Gingivitis in pregnant women A longitudinal clinical study Odontol Revy 19712265-84
bull 50 Neville BW Damm DD Allen CM Bouquot JE Oral amp Maxillofacial Pathology 3rd ed Philadelphia W B Saunders 2002 p 329-30 447-9
bull 51 Tilakaratne A Soory M Ranasinghe AW Corea SM Ekanayake SL de Silva M Periodontal disease status during pregnancy and 3 months post-partum in rural population of Sri-Lankan women J Clin Periodontol 200027787-92
bull 52 Laine M Tenovuo J Lehtonen OP Ojanatko-Harri A Vilja P Tuohimaa P Pregnancy e related changes in human whole saliva Arch Oral Biol 198833913-7
bull 53 Yuan K Wing LY Lin MT Pathogenetic roles of angiogenic factors in pyogenic granulomas in pregnancy are modulated by female sex hormones J Periodontol 200273701-8
bull 54 Evans RD Briggs PF Tooth-surface loss related to pregnancyinduced vomiting Prim Dent Care 1994124-6
bull 55 Salvolini E Di Giorgio R Curatola A Mazzanti L Fratto G Biochemical modifications of human whole saliva induced by pregnancy Br J Obstet Gynaec 1998105656-60
bull 56 Mauldin JG Newman RB Preterm birth risk assessment Semin Perinatol 200125215-22
bull 57 Heine RP McGregor JA Goodwin TM Artal R Hayashi RH Robertson PA et al Serial salivary estriol to detect an increased risk of preterm birth Obstet Gynecol 200096490-7
bull 58 Kauh YC Zachian TF Melasma Adv Exp Med Biol 1999455 491-9
bull 59 Wong RC Ellis CN Physiologic skin changes in pregnancy J Am Acad Dermatol 198410929-40
bull 60 Errickson CV Matus NR Skin disorders of pregnancy Am Fam Physician 199449605-10
bull 61 Lopez NJ Smith PC Gutierrez J Periodontal therapy may reduce the risk of preterm low birth weight in women with periodontal disease a randomized controlled trial J Periodontol 200273911-24
bull 62 McGaw T Periodontal disease and preterm delivery of lowbirth- weight infants J Can Dent Assoc 200268165-9
bull 63 Richards AG Dental x-ray protection Dent Clin North Am 1968631-41
bull 64 1990 Recommendations of the International Commission on Radiological Protection Ann ICRP 1991211-201
bull 65 Hall EJ Radiation the two-edged sword cancer risks at high and low doses Cancer J 20006343-50
bull 66 Diethelm L Xu H Diagnostic imaging of the lung during pregnancy Clin Obstet Gynecol 19963936-55
bull 67 Brent RL The effects of embryonic and fetal exposure to x-rays microwaves and ultrasound ClinObstetGynecol 198326484-510
bull 68 National Council on Radiation Protection NCRP report no128 1998 Bethesda Md Author
bull 69 Wasylko L Matsui D Dykxhoorn SM Reider MJ Weinberg S A review of common dental treatments during pregnancy implications for patients and dental personnel J Can Dent Assoc 199864434-9
bull 70 Freeman JP Brand JW Radiation doses of commonly used dental radiographic surveys Oral Surg Oral Med Oral Pathol 199477285-9
bull 71 Kircos LTAngin LL Lorton LOrder ofmagnitude dose reduction in intraoral radiography J Am Dent Assoc 1987114344-7
bull 72 Updegrave WJ Simplified and standardized intraoral radiography with reduced tissue irradiation J Am Dent Assoc 197285861-9
bull 73 Wood RE Harris AM van der Merwe EJ Nortje CJ The leaded apron revisited does it reduce gonadal radiation dose in dental radiology Oral Surg Oral Med Oral Pathol 199171642-6
bull 74 An update on radiographic practices information and recommendations ADA Council on Scientific Affairs J Am Dent Assoc 2001132234-8
bull 75 Rayburn WF Recommending medications during pregnancy an evidence based approach Clin Obstet Gynecol 2002451-5
bull 76 Rathmell JP Viscomi C Ashburn MA Management of nonobstetric pain during pregnancy and lactation Anesth Analg 1997851074-87
bull 77 Teratology society public affairs committee FDA classification of drugs for teratogenic risk Teratology 199449446-7
bull 78 Moore PA Selecting drugs for the pregnant dental patient J Am Dent Assoc 19981291281-6
bull 79 Haas DA An update on analgesics for the management of acute postoperative dental pain J Can Dent Assoc 200268476-82
bull 80 Haas DA Pynn BR Sands TD Drug use for the pregnant or lactating patient Gen Dent 20004854-60
bull 81 Committee on Drugs American Academy of Pediatrics The transfer of drugs and other chemicals into human milk Pediatrics 199493137-50
bull 82 Nielsen GL Sorensen HT Larsen H Pedersen L Risk of adverse birth outcome and miscarriage in pregnant users of nonsteroidal anti-inflammatory drugs population based observational study and case-control study BMJ 2001322266-70
bull 83 Janssen N Genta M The effects of immunosuppressive and anti-inflammatory medications on fertility pregnancy and lactation Arch Intern Med 200016610-9
bull 84 Ostensen M Nonsteroidal anti-inflammatory drugs during pregnancy Scand J Rheumatol Suppl 1998107128-32
bull 85 USPDI -Drug information for the health care professional 22nd ed Greenwood Village CO Micromedex 2002 p 152-79
bull 86 Denson DD Coyle DE Thompson GA Santos D Turner PA Myers JA et al Bupivacaine protein binding in the term parturient effects of lactic acidosis Clin Pharmacol Ther 198435702-9
bull 87 Dillon DE Wagner CL Wiest D Newman RB Drug therapy in the nursing mother Obstet Gynecol Clin North Am 199724 675-96
bull 88 Dashe JS Gilstrap LC Antibiotic use in pregnancy Obstet Gynecol Clin North Am 199724617-29
bull 89 American College of Rheumatology Ad hoc Committee on Clinical Guidelines Guidelines for monitoring drug therapy in rheumatoid arthritis Arthritis Rheum 199639723-31
bull 90 Ng PC The fetal and neonatal hypothalamic-pituitary-adrenal axis Arch Dis Child Fetal Neonatal Ed 200082F250-4
bull 91 Crowley P Antenatal corticosteroidsmdashcurrent thinking BJOG 2003110(Suppl 20)77-8
bull 92 ACOG committee opinion antenatal corticosteroid therapy for fetal maturation Obstet Gynecol 200299871-3
bull 93 Ost L Wettrell G Bjorkhem I Rane A Prednisolone excretion in human milk J Pediatr 19851061008-11
bull 94 Rowland AS Baird DD Shore DL Weinberg CR Savitz DA Wilcox AJ Nitrous oxide and spontaneous abortion in female dental assistants Am J Epidemiol 1995141531-8
bull 95 McGlothlin JD Jensen PA Fischbach TJ Hughes RT Jones JH Control of anesthetic gases in dental operatories Scand J Work Environ Health 199218(Suppl 2)103-5
bull ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY Volume 97 Number 6 Suresh and Radfar 681
bull 96 Rosen MA Nitrous oxide for relief of labor pain a systematic review Am J Obstet Gynecol 2002186(Suppl Nature)S110-6
bull 97 Sands TD Pynn BR Management considerations for the pregnant or nursing emergency patient Ont Dent 199875 17-9
bull 98 Daya S Recurrent spontaneous early pregnancy loss and low dose aspirin Minerva Ginecol 200355441-9
bull 99 Sinclair C Handbook of obstetrical emergencies 1st ed Philadelphia WB Saunders 1996 p 29-39 69
bull 100 Tarsitano BF Rollings RE The pregnant dental patient evaluation and management Gen Dent 199341226-34
bull 101 Livingston MH Dlllinger TM Holder R Consideration in the management of the pregnant patient SCD Special Care in Dentistry 199818183-8
Thank you
- A Review on the principle of Dental Management of the Pregnant patient
- Slide 2
- Questions that a dentist may ask
- Stages of Pregnancy
- Slide 5
- Slide 6
- Physiologic Changes in Pregnancy
- Systemic changes in pregnancy
- FLAT SUPINE POSITIONING
- SUPINE HYPOTENSION SYNDROME (Vena Cava Compression)
- Supine Hypotension Syndrome
- Slide 12
- Supine Hypotension Syndrome
- Prevention of Supine Hypotensive Syndrome
- Treatment of Supine Hypotensive Syndrome
- How should the pregnant woman be positioned
- Slide 17
- Slide 18
- Slide 19
- Slide 20
- Slide 21
- Slide 22
- Slide 23
- Pregnancy Related Oral Health Problems
- Oral Problems in Pregnancy
- Pregnancy Gingivitis Pathophysiology
- Pregnancy Gingivitis
- Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Gum Problems - Pregnancy Granuloma
- Slide 31
- Gum Changes - Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Candidiasis
- Pregnancy Myths
- Other Oral Conditions in Pregnancy
- Changes During Pregnancy that Affect Oral Health
- Saliva changes
- Increased Bacteria
- Slide 40
- Enamel erosion caused by frequent vomiting
- Treatment for Acid Exposure
- Oral Diseases Can Effect Pregnancy
- Periodontal Disease and Preterm Labor
- Periodontal Disease and Low Birth Weight
- Periodontal Disease and Preeclampsia
- Periodontitis and Pre-eclampsia
- Dental Considerations
- Treatment Timing
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Slide 52
- Use of Radiation on Pregnant Patient
- Radiographs during Pregnancy
- Risks of Dental X-Rays
- FDA drug classification for pregnancy
- Slide 57
- FDA drug classification for pregnancy
- Slide 59
- Slide 60
- Slide 61
- Common Analgesics
- Analgesics
- Analgesics - continued
- Analgesics to Use During 1st and 2nd Trimester
- Analgesics to Avoid During the Third Trimester
- Sedation in Pregnancy
- Common Antibiotics
- Antibiotics
- Antibiotics To Use During Pregnancy
- Antibiotics to Avoid during Pregnancy
- The Problem With Tetracycline
- Other Antimicrobial Agents
- Local Anesthetic Use in Pregnancy
- Use of Local Anesthetics
- Ulcer healing drugs
- Slide 77
- Slide 78
- Slide 79
- Use of Nitrous Oxide Gas
- Common Preventives
- Are topical agents safe
- Pre-natal Fluoride
- Is it safe to use mercury restorations
- References
- REFERENCES
- Slide 87
- Slide 88
- Slide 89
- Slide 90
- Slide 91
- Slide 92
- Slide 93
- Slide 94
- Slide 95
- Slide 96
- Slide 97
- Slide 98
- Thank you
-
Is it safe to use mercury restorations
bull No evidence of harmful effect
bull Benefits outweigh risks
bull Canada Germany and New Zealand have some restrictions
bull Determine the best option
Referencesbull Wasylko L Matsui D Dykxhoorn SM Rieder MJ Weinberg
S A Review of Common Dental Treatments During Pregnancy J Canadian Dental Association 64434-439 1998
bull Little JW Donald AF Craig SM Rhodus NL Dental Management of the Medically Compromised Patient - 5th edition Mosby Toronto Pp434-442 1997
bull Livingston HM Dellinger TM Holder R Considerations in the management of the pregnant patient Special Care in Dentistry 185 pp183-188 1998
bull Larimore WL Petrie KA Drug use during pregnacy and lactation Primary Care Clinics in Office Practice 271 35-53 2000
bull Health Canada The Safety of DentalAmalgam Minister Of Supply and Services Canada 1996
REFERENCESbull 1 Weiss G Endocrinology of parturition J Clin
Endocrinol Metab 2000854421-5bull 2 Theunissen IM Parer JT Fluid and electrolytes in
pregnancy Clin Obstet Gynecol 1994373-15bull 3 Duvekot JJ Peeters LLH Renal hemodynamics and
volume homeostasis in pregnancy Obstet Gynecol Surv 199449830-9
bull 4 Barron WM Lindheimer MD Medical disorders during pregnancy 2nd ed St Louis Mosby 1995 p 129
bull 5 Thornburg KL Jacobson SL Giraud GD Morton MJ Hemodynamic changes in pregnancy Semin Perinatol 20002411-4
bull 6 Fiese R Herzog S Issues in dental and surgical management of the pregnant patient Oral Surg Oral Med Oral Pathol 198865292-7
bull 7 Martin C Varner MW Physiologic changes in pregnancysurgical implications Clin Obstet Gynecol 199437241-55
bull 8 Clark SL Cotton DB Lee W Bishop C Hill T Southwick J et al Central hemodynamic assessment of normal term pregnancy Am J Obstet Gynecol 19891611439-42
bull 9 Mabie WC Di Sessa TG Crocker LG Sibai BM Arheart KL A longitudinal study of cardiac output in normal human pregnancy Am J Obstet Gynecol 1994170849-56
bull 10 Clapp JF 3rd Capeless E Cardiovascular function before during and after the first and subsequent pregnancies Am J Cardiol 1997801469-73
bull 11 Duvekot JJ Peeters LL Maternal cardiovascular hemodynamic adaptation to pregnancy Obstet Gynecol Surv 199449(Suppl) S1-14
bull 12 Bhagwat AR Engel PJ Heart disease and pregnancy Cardiol Clin 199513163-78
bull 13 Lanni SM Tillinghast J Silver H Hemodynamic changes and baroreflex gain in the supine hypotensive syndrome Am J Obstet Gynecol 20021871636-41
bull 14 Little JW Falace DA Miller CS Rhodus NL Dental management of the medically compromised patient 6th ed St Louis Mosby 2002 p 303
bull 15 Garcia-Rio F Pino JM Gomez L Alvarez-Sala R Villasante C Villamor J Regulation of breathing and perception of dyspnea in healthy pregnant women Chest 1996110446-53
bull 16 McAuliffe F Kametas N Costello J Rafferty GF Greenough A Nicolaides K Respiratory function in singleton and twin pregnancy BJOG 2002109765-9
bull 17 Clapp JF 3rd Seaward BL Sleamaker RH Hiser J Maternal physiologic adaptations to early human pregnancy Am J Obstet Gynecol 19881591456-60
bull 18 OrsquoDay MP Cardio-respiratory physiological adaptation of pregnancy Semin Perinatol 199721268-75
bull 19 Contreras G Gutierrez M Beroiza T Fantin A Oddo H Villarroel L et al Ventilatory drive and respiratory muscle function in pregnancy Am Rev Respir Dis 1991144837-41
bull 20 Turner M Aziz SR Management of the pregnant oral and maxillofac
bull 21 Sifakis S Pharmakides G Anemia in pregnancy Ann N Y Acad Sci 2000900125-36
bull 22 Branch DW Physiologic adaptations of pregnancy Am J Reprod Immunol 199228120-2
bull 23 Burrows RF Kelton JG Incidentally detected thrombocytopenia in healthy mothers and their infants N Engl J Med 1988319 142-5
bull 24 Hanly JG Antiphospholipid syndrome an overview CMAJ 200324(168)1675-82
bull 25 Heilmann L von Tempelhoff GF Pollow K Antiphospholipid syndrome in obstetrics Clin Appl Thromb Hemost 20039 143-50
bull 26 Sherman P Flaxman SM Nausea and vomiting of pregnancy in an evolutionary perspective Am J Obstet Gynecol 2002 185(Suppl)s190-7
bull 27 Koch KL Gastrointestinal factors in nausea and vomiting of pregnancy Am J Obstet Gynecol 2002185(Suppl)s198-203
bull 28 Koch KL Frissora CL Nausea and vomiting during pregnancy Gastroenterol Clin N Am 200332201-34
bull 29 Baron TH Ramirez B Richter JE Gastrointestinal motility disorders during pregnancy Ann Intern Med 1993118 366-75
bull 30 Richter JE Gastroesophageal reflux disease during pregnancy Gastroenterol Clin N Am 200332235-61
bull 31 Marrero JM Goggin PM de Caestecker JS Pearce JM Maxwell JD Determinants of pregnancy heartburn Br J Obstet Gynaecol 199299731-4
bull 32 Hamaoui E Hamaoui M Nutritional assessment and support during pregnancy Gastroenterol Clin N Am 20033259-121
bull 33 King JC Physiology of pregnancy and nutrient metabolism Am J Clin Nutr 200071(suppl)1218s-25s
bull 34 Casanueva E Pfeffer F Fernandez-Gaxiola AC Gutierrez- Valenzuela V Rothenberg SJ Iron and folate status before pregnancy and anemia during pregnancy Ann Nutr Metab 2003 4760-3
bull 35 Chrsquong CL Morgan M Hainsworth I Kingham JG Prospective study of liver dysfunction in Southwest Wales Gut 200251 876-80
bull 36 Rahman TM Wendon J Severe hepatic dysfunction in pregnancy QJM 200295343-57
bull 37 Knox TA Olans LB Liver disease in pregnancy N Engl J Med 1996335569-76
bull 38 Saftlas AF Olson DR Franks AL Atrash H Pokras R Epidemiology of preeclampsia and eclampsia in the United States 1979e1986 Am J Obstet Gynecol 1990163460-5
bull 39 Walker JJ Pre-eclampsia Lancet 20003561260-5
bull 40 Davidson JM Renal disorders in pregnancy Curr Opin Obstet Gynecol 200113109-14
bull 41 Dafnis E Sabatini S The effect of pregnancy on renal function physiology and pathophysiologyAmJMedSci 1992303184-205
bull 42 Davison JM Shiells EA Philips PR Lindheimer MD Serial evaluation of vasopressin release and thirst in human pregnancy Role of human chorionic gonadotrophin in the osmoregulatory changes of gestation J Clin Invest 198881798-806
bull 43 Glinoer D de Nayer P Bourdoux P Lemone M Robyn C van Steirteghem A et al Regulation of maternal thyroid during pregnancy J Clin Endocrinol Metab 199071276-87
bull 44 Wilson SG Retallack RW Kent JC Worth GK Gutteridge DH Serum free 125-dihydroxyvitamin D and the free 125- dihydroxyvitamin D index during a longitudinal study of human pregnancy and lactation Clin Endocrinol 199032613-22
bull 45 Rasmussen N Frolich A Hornnes PJ Hegedus L Serum ionized calcium and intact parathyroid hormone levels during pregnancy and postpartum Br J Obstet Gynaecol 199097857-9
bull 46 Guyton AC Textbook of medical physiology 8th ed Philadelphia W B Saunders 1991 p 915e28
bull 47 Trainer PJ Corticosteroids and pregnancy Semin Reprod Med 200220375-80
bull 48 Soory M Hormonal factors in periodontal disease Dent Update 200027380-3
bull 49 Hugoson A Gingivitis in pregnant women A longitudinal clinical study Odontol Revy 19712265-84
bull 50 Neville BW Damm DD Allen CM Bouquot JE Oral amp Maxillofacial Pathology 3rd ed Philadelphia W B Saunders 2002 p 329-30 447-9
bull 51 Tilakaratne A Soory M Ranasinghe AW Corea SM Ekanayake SL de Silva M Periodontal disease status during pregnancy and 3 months post-partum in rural population of Sri-Lankan women J Clin Periodontol 200027787-92
bull 52 Laine M Tenovuo J Lehtonen OP Ojanatko-Harri A Vilja P Tuohimaa P Pregnancy e related changes in human whole saliva Arch Oral Biol 198833913-7
bull 53 Yuan K Wing LY Lin MT Pathogenetic roles of angiogenic factors in pyogenic granulomas in pregnancy are modulated by female sex hormones J Periodontol 200273701-8
bull 54 Evans RD Briggs PF Tooth-surface loss related to pregnancyinduced vomiting Prim Dent Care 1994124-6
bull 55 Salvolini E Di Giorgio R Curatola A Mazzanti L Fratto G Biochemical modifications of human whole saliva induced by pregnancy Br J Obstet Gynaec 1998105656-60
bull 56 Mauldin JG Newman RB Preterm birth risk assessment Semin Perinatol 200125215-22
bull 57 Heine RP McGregor JA Goodwin TM Artal R Hayashi RH Robertson PA et al Serial salivary estriol to detect an increased risk of preterm birth Obstet Gynecol 200096490-7
bull 58 Kauh YC Zachian TF Melasma Adv Exp Med Biol 1999455 491-9
bull 59 Wong RC Ellis CN Physiologic skin changes in pregnancy J Am Acad Dermatol 198410929-40
bull 60 Errickson CV Matus NR Skin disorders of pregnancy Am Fam Physician 199449605-10
bull 61 Lopez NJ Smith PC Gutierrez J Periodontal therapy may reduce the risk of preterm low birth weight in women with periodontal disease a randomized controlled trial J Periodontol 200273911-24
bull 62 McGaw T Periodontal disease and preterm delivery of lowbirth- weight infants J Can Dent Assoc 200268165-9
bull 63 Richards AG Dental x-ray protection Dent Clin North Am 1968631-41
bull 64 1990 Recommendations of the International Commission on Radiological Protection Ann ICRP 1991211-201
bull 65 Hall EJ Radiation the two-edged sword cancer risks at high and low doses Cancer J 20006343-50
bull 66 Diethelm L Xu H Diagnostic imaging of the lung during pregnancy Clin Obstet Gynecol 19963936-55
bull 67 Brent RL The effects of embryonic and fetal exposure to x-rays microwaves and ultrasound ClinObstetGynecol 198326484-510
bull 68 National Council on Radiation Protection NCRP report no128 1998 Bethesda Md Author
bull 69 Wasylko L Matsui D Dykxhoorn SM Reider MJ Weinberg S A review of common dental treatments during pregnancy implications for patients and dental personnel J Can Dent Assoc 199864434-9
bull 70 Freeman JP Brand JW Radiation doses of commonly used dental radiographic surveys Oral Surg Oral Med Oral Pathol 199477285-9
bull 71 Kircos LTAngin LL Lorton LOrder ofmagnitude dose reduction in intraoral radiography J Am Dent Assoc 1987114344-7
bull 72 Updegrave WJ Simplified and standardized intraoral radiography with reduced tissue irradiation J Am Dent Assoc 197285861-9
bull 73 Wood RE Harris AM van der Merwe EJ Nortje CJ The leaded apron revisited does it reduce gonadal radiation dose in dental radiology Oral Surg Oral Med Oral Pathol 199171642-6
bull 74 An update on radiographic practices information and recommendations ADA Council on Scientific Affairs J Am Dent Assoc 2001132234-8
bull 75 Rayburn WF Recommending medications during pregnancy an evidence based approach Clin Obstet Gynecol 2002451-5
bull 76 Rathmell JP Viscomi C Ashburn MA Management of nonobstetric pain during pregnancy and lactation Anesth Analg 1997851074-87
bull 77 Teratology society public affairs committee FDA classification of drugs for teratogenic risk Teratology 199449446-7
bull 78 Moore PA Selecting drugs for the pregnant dental patient J Am Dent Assoc 19981291281-6
bull 79 Haas DA An update on analgesics for the management of acute postoperative dental pain J Can Dent Assoc 200268476-82
bull 80 Haas DA Pynn BR Sands TD Drug use for the pregnant or lactating patient Gen Dent 20004854-60
bull 81 Committee on Drugs American Academy of Pediatrics The transfer of drugs and other chemicals into human milk Pediatrics 199493137-50
bull 82 Nielsen GL Sorensen HT Larsen H Pedersen L Risk of adverse birth outcome and miscarriage in pregnant users of nonsteroidal anti-inflammatory drugs population based observational study and case-control study BMJ 2001322266-70
bull 83 Janssen N Genta M The effects of immunosuppressive and anti-inflammatory medications on fertility pregnancy and lactation Arch Intern Med 200016610-9
bull 84 Ostensen M Nonsteroidal anti-inflammatory drugs during pregnancy Scand J Rheumatol Suppl 1998107128-32
bull 85 USPDI -Drug information for the health care professional 22nd ed Greenwood Village CO Micromedex 2002 p 152-79
bull 86 Denson DD Coyle DE Thompson GA Santos D Turner PA Myers JA et al Bupivacaine protein binding in the term parturient effects of lactic acidosis Clin Pharmacol Ther 198435702-9
bull 87 Dillon DE Wagner CL Wiest D Newman RB Drug therapy in the nursing mother Obstet Gynecol Clin North Am 199724 675-96
bull 88 Dashe JS Gilstrap LC Antibiotic use in pregnancy Obstet Gynecol Clin North Am 199724617-29
bull 89 American College of Rheumatology Ad hoc Committee on Clinical Guidelines Guidelines for monitoring drug therapy in rheumatoid arthritis Arthritis Rheum 199639723-31
bull 90 Ng PC The fetal and neonatal hypothalamic-pituitary-adrenal axis Arch Dis Child Fetal Neonatal Ed 200082F250-4
bull 91 Crowley P Antenatal corticosteroidsmdashcurrent thinking BJOG 2003110(Suppl 20)77-8
bull 92 ACOG committee opinion antenatal corticosteroid therapy for fetal maturation Obstet Gynecol 200299871-3
bull 93 Ost L Wettrell G Bjorkhem I Rane A Prednisolone excretion in human milk J Pediatr 19851061008-11
bull 94 Rowland AS Baird DD Shore DL Weinberg CR Savitz DA Wilcox AJ Nitrous oxide and spontaneous abortion in female dental assistants Am J Epidemiol 1995141531-8
bull 95 McGlothlin JD Jensen PA Fischbach TJ Hughes RT Jones JH Control of anesthetic gases in dental operatories Scand J Work Environ Health 199218(Suppl 2)103-5
bull ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY Volume 97 Number 6 Suresh and Radfar 681
bull 96 Rosen MA Nitrous oxide for relief of labor pain a systematic review Am J Obstet Gynecol 2002186(Suppl Nature)S110-6
bull 97 Sands TD Pynn BR Management considerations for the pregnant or nursing emergency patient Ont Dent 199875 17-9
bull 98 Daya S Recurrent spontaneous early pregnancy loss and low dose aspirin Minerva Ginecol 200355441-9
bull 99 Sinclair C Handbook of obstetrical emergencies 1st ed Philadelphia WB Saunders 1996 p 29-39 69
bull 100 Tarsitano BF Rollings RE The pregnant dental patient evaluation and management Gen Dent 199341226-34
bull 101 Livingston MH Dlllinger TM Holder R Consideration in the management of the pregnant patient SCD Special Care in Dentistry 199818183-8
Thank you
- A Review on the principle of Dental Management of the Pregnant patient
- Slide 2
- Questions that a dentist may ask
- Stages of Pregnancy
- Slide 5
- Slide 6
- Physiologic Changes in Pregnancy
- Systemic changes in pregnancy
- FLAT SUPINE POSITIONING
- SUPINE HYPOTENSION SYNDROME (Vena Cava Compression)
- Supine Hypotension Syndrome
- Slide 12
- Supine Hypotension Syndrome
- Prevention of Supine Hypotensive Syndrome
- Treatment of Supine Hypotensive Syndrome
- How should the pregnant woman be positioned
- Slide 17
- Slide 18
- Slide 19
- Slide 20
- Slide 21
- Slide 22
- Slide 23
- Pregnancy Related Oral Health Problems
- Oral Problems in Pregnancy
- Pregnancy Gingivitis Pathophysiology
- Pregnancy Gingivitis
- Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Gum Problems - Pregnancy Granuloma
- Slide 31
- Gum Changes - Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Candidiasis
- Pregnancy Myths
- Other Oral Conditions in Pregnancy
- Changes During Pregnancy that Affect Oral Health
- Saliva changes
- Increased Bacteria
- Slide 40
- Enamel erosion caused by frequent vomiting
- Treatment for Acid Exposure
- Oral Diseases Can Effect Pregnancy
- Periodontal Disease and Preterm Labor
- Periodontal Disease and Low Birth Weight
- Periodontal Disease and Preeclampsia
- Periodontitis and Pre-eclampsia
- Dental Considerations
- Treatment Timing
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Slide 52
- Use of Radiation on Pregnant Patient
- Radiographs during Pregnancy
- Risks of Dental X-Rays
- FDA drug classification for pregnancy
- Slide 57
- FDA drug classification for pregnancy
- Slide 59
- Slide 60
- Slide 61
- Common Analgesics
- Analgesics
- Analgesics - continued
- Analgesics to Use During 1st and 2nd Trimester
- Analgesics to Avoid During the Third Trimester
- Sedation in Pregnancy
- Common Antibiotics
- Antibiotics
- Antibiotics To Use During Pregnancy
- Antibiotics to Avoid during Pregnancy
- The Problem With Tetracycline
- Other Antimicrobial Agents
- Local Anesthetic Use in Pregnancy
- Use of Local Anesthetics
- Ulcer healing drugs
- Slide 77
- Slide 78
- Slide 79
- Use of Nitrous Oxide Gas
- Common Preventives
- Are topical agents safe
- Pre-natal Fluoride
- Is it safe to use mercury restorations
- References
- REFERENCES
- Slide 87
- Slide 88
- Slide 89
- Slide 90
- Slide 91
- Slide 92
- Slide 93
- Slide 94
- Slide 95
- Slide 96
- Slide 97
- Slide 98
- Thank you
-
Referencesbull Wasylko L Matsui D Dykxhoorn SM Rieder MJ Weinberg
S A Review of Common Dental Treatments During Pregnancy J Canadian Dental Association 64434-439 1998
bull Little JW Donald AF Craig SM Rhodus NL Dental Management of the Medically Compromised Patient - 5th edition Mosby Toronto Pp434-442 1997
bull Livingston HM Dellinger TM Holder R Considerations in the management of the pregnant patient Special Care in Dentistry 185 pp183-188 1998
bull Larimore WL Petrie KA Drug use during pregnacy and lactation Primary Care Clinics in Office Practice 271 35-53 2000
bull Health Canada The Safety of DentalAmalgam Minister Of Supply and Services Canada 1996
REFERENCESbull 1 Weiss G Endocrinology of parturition J Clin
Endocrinol Metab 2000854421-5bull 2 Theunissen IM Parer JT Fluid and electrolytes in
pregnancy Clin Obstet Gynecol 1994373-15bull 3 Duvekot JJ Peeters LLH Renal hemodynamics and
volume homeostasis in pregnancy Obstet Gynecol Surv 199449830-9
bull 4 Barron WM Lindheimer MD Medical disorders during pregnancy 2nd ed St Louis Mosby 1995 p 129
bull 5 Thornburg KL Jacobson SL Giraud GD Morton MJ Hemodynamic changes in pregnancy Semin Perinatol 20002411-4
bull 6 Fiese R Herzog S Issues in dental and surgical management of the pregnant patient Oral Surg Oral Med Oral Pathol 198865292-7
bull 7 Martin C Varner MW Physiologic changes in pregnancysurgical implications Clin Obstet Gynecol 199437241-55
bull 8 Clark SL Cotton DB Lee W Bishop C Hill T Southwick J et al Central hemodynamic assessment of normal term pregnancy Am J Obstet Gynecol 19891611439-42
bull 9 Mabie WC Di Sessa TG Crocker LG Sibai BM Arheart KL A longitudinal study of cardiac output in normal human pregnancy Am J Obstet Gynecol 1994170849-56
bull 10 Clapp JF 3rd Capeless E Cardiovascular function before during and after the first and subsequent pregnancies Am J Cardiol 1997801469-73
bull 11 Duvekot JJ Peeters LL Maternal cardiovascular hemodynamic adaptation to pregnancy Obstet Gynecol Surv 199449(Suppl) S1-14
bull 12 Bhagwat AR Engel PJ Heart disease and pregnancy Cardiol Clin 199513163-78
bull 13 Lanni SM Tillinghast J Silver H Hemodynamic changes and baroreflex gain in the supine hypotensive syndrome Am J Obstet Gynecol 20021871636-41
bull 14 Little JW Falace DA Miller CS Rhodus NL Dental management of the medically compromised patient 6th ed St Louis Mosby 2002 p 303
bull 15 Garcia-Rio F Pino JM Gomez L Alvarez-Sala R Villasante C Villamor J Regulation of breathing and perception of dyspnea in healthy pregnant women Chest 1996110446-53
bull 16 McAuliffe F Kametas N Costello J Rafferty GF Greenough A Nicolaides K Respiratory function in singleton and twin pregnancy BJOG 2002109765-9
bull 17 Clapp JF 3rd Seaward BL Sleamaker RH Hiser J Maternal physiologic adaptations to early human pregnancy Am J Obstet Gynecol 19881591456-60
bull 18 OrsquoDay MP Cardio-respiratory physiological adaptation of pregnancy Semin Perinatol 199721268-75
bull 19 Contreras G Gutierrez M Beroiza T Fantin A Oddo H Villarroel L et al Ventilatory drive and respiratory muscle function in pregnancy Am Rev Respir Dis 1991144837-41
bull 20 Turner M Aziz SR Management of the pregnant oral and maxillofac
bull 21 Sifakis S Pharmakides G Anemia in pregnancy Ann N Y Acad Sci 2000900125-36
bull 22 Branch DW Physiologic adaptations of pregnancy Am J Reprod Immunol 199228120-2
bull 23 Burrows RF Kelton JG Incidentally detected thrombocytopenia in healthy mothers and their infants N Engl J Med 1988319 142-5
bull 24 Hanly JG Antiphospholipid syndrome an overview CMAJ 200324(168)1675-82
bull 25 Heilmann L von Tempelhoff GF Pollow K Antiphospholipid syndrome in obstetrics Clin Appl Thromb Hemost 20039 143-50
bull 26 Sherman P Flaxman SM Nausea and vomiting of pregnancy in an evolutionary perspective Am J Obstet Gynecol 2002 185(Suppl)s190-7
bull 27 Koch KL Gastrointestinal factors in nausea and vomiting of pregnancy Am J Obstet Gynecol 2002185(Suppl)s198-203
bull 28 Koch KL Frissora CL Nausea and vomiting during pregnancy Gastroenterol Clin N Am 200332201-34
bull 29 Baron TH Ramirez B Richter JE Gastrointestinal motility disorders during pregnancy Ann Intern Med 1993118 366-75
bull 30 Richter JE Gastroesophageal reflux disease during pregnancy Gastroenterol Clin N Am 200332235-61
bull 31 Marrero JM Goggin PM de Caestecker JS Pearce JM Maxwell JD Determinants of pregnancy heartburn Br J Obstet Gynaecol 199299731-4
bull 32 Hamaoui E Hamaoui M Nutritional assessment and support during pregnancy Gastroenterol Clin N Am 20033259-121
bull 33 King JC Physiology of pregnancy and nutrient metabolism Am J Clin Nutr 200071(suppl)1218s-25s
bull 34 Casanueva E Pfeffer F Fernandez-Gaxiola AC Gutierrez- Valenzuela V Rothenberg SJ Iron and folate status before pregnancy and anemia during pregnancy Ann Nutr Metab 2003 4760-3
bull 35 Chrsquong CL Morgan M Hainsworth I Kingham JG Prospective study of liver dysfunction in Southwest Wales Gut 200251 876-80
bull 36 Rahman TM Wendon J Severe hepatic dysfunction in pregnancy QJM 200295343-57
bull 37 Knox TA Olans LB Liver disease in pregnancy N Engl J Med 1996335569-76
bull 38 Saftlas AF Olson DR Franks AL Atrash H Pokras R Epidemiology of preeclampsia and eclampsia in the United States 1979e1986 Am J Obstet Gynecol 1990163460-5
bull 39 Walker JJ Pre-eclampsia Lancet 20003561260-5
bull 40 Davidson JM Renal disorders in pregnancy Curr Opin Obstet Gynecol 200113109-14
bull 41 Dafnis E Sabatini S The effect of pregnancy on renal function physiology and pathophysiologyAmJMedSci 1992303184-205
bull 42 Davison JM Shiells EA Philips PR Lindheimer MD Serial evaluation of vasopressin release and thirst in human pregnancy Role of human chorionic gonadotrophin in the osmoregulatory changes of gestation J Clin Invest 198881798-806
bull 43 Glinoer D de Nayer P Bourdoux P Lemone M Robyn C van Steirteghem A et al Regulation of maternal thyroid during pregnancy J Clin Endocrinol Metab 199071276-87
bull 44 Wilson SG Retallack RW Kent JC Worth GK Gutteridge DH Serum free 125-dihydroxyvitamin D and the free 125- dihydroxyvitamin D index during a longitudinal study of human pregnancy and lactation Clin Endocrinol 199032613-22
bull 45 Rasmussen N Frolich A Hornnes PJ Hegedus L Serum ionized calcium and intact parathyroid hormone levels during pregnancy and postpartum Br J Obstet Gynaecol 199097857-9
bull 46 Guyton AC Textbook of medical physiology 8th ed Philadelphia W B Saunders 1991 p 915e28
bull 47 Trainer PJ Corticosteroids and pregnancy Semin Reprod Med 200220375-80
bull 48 Soory M Hormonal factors in periodontal disease Dent Update 200027380-3
bull 49 Hugoson A Gingivitis in pregnant women A longitudinal clinical study Odontol Revy 19712265-84
bull 50 Neville BW Damm DD Allen CM Bouquot JE Oral amp Maxillofacial Pathology 3rd ed Philadelphia W B Saunders 2002 p 329-30 447-9
bull 51 Tilakaratne A Soory M Ranasinghe AW Corea SM Ekanayake SL de Silva M Periodontal disease status during pregnancy and 3 months post-partum in rural population of Sri-Lankan women J Clin Periodontol 200027787-92
bull 52 Laine M Tenovuo J Lehtonen OP Ojanatko-Harri A Vilja P Tuohimaa P Pregnancy e related changes in human whole saliva Arch Oral Biol 198833913-7
bull 53 Yuan K Wing LY Lin MT Pathogenetic roles of angiogenic factors in pyogenic granulomas in pregnancy are modulated by female sex hormones J Periodontol 200273701-8
bull 54 Evans RD Briggs PF Tooth-surface loss related to pregnancyinduced vomiting Prim Dent Care 1994124-6
bull 55 Salvolini E Di Giorgio R Curatola A Mazzanti L Fratto G Biochemical modifications of human whole saliva induced by pregnancy Br J Obstet Gynaec 1998105656-60
bull 56 Mauldin JG Newman RB Preterm birth risk assessment Semin Perinatol 200125215-22
bull 57 Heine RP McGregor JA Goodwin TM Artal R Hayashi RH Robertson PA et al Serial salivary estriol to detect an increased risk of preterm birth Obstet Gynecol 200096490-7
bull 58 Kauh YC Zachian TF Melasma Adv Exp Med Biol 1999455 491-9
bull 59 Wong RC Ellis CN Physiologic skin changes in pregnancy J Am Acad Dermatol 198410929-40
bull 60 Errickson CV Matus NR Skin disorders of pregnancy Am Fam Physician 199449605-10
bull 61 Lopez NJ Smith PC Gutierrez J Periodontal therapy may reduce the risk of preterm low birth weight in women with periodontal disease a randomized controlled trial J Periodontol 200273911-24
bull 62 McGaw T Periodontal disease and preterm delivery of lowbirth- weight infants J Can Dent Assoc 200268165-9
bull 63 Richards AG Dental x-ray protection Dent Clin North Am 1968631-41
bull 64 1990 Recommendations of the International Commission on Radiological Protection Ann ICRP 1991211-201
bull 65 Hall EJ Radiation the two-edged sword cancer risks at high and low doses Cancer J 20006343-50
bull 66 Diethelm L Xu H Diagnostic imaging of the lung during pregnancy Clin Obstet Gynecol 19963936-55
bull 67 Brent RL The effects of embryonic and fetal exposure to x-rays microwaves and ultrasound ClinObstetGynecol 198326484-510
bull 68 National Council on Radiation Protection NCRP report no128 1998 Bethesda Md Author
bull 69 Wasylko L Matsui D Dykxhoorn SM Reider MJ Weinberg S A review of common dental treatments during pregnancy implications for patients and dental personnel J Can Dent Assoc 199864434-9
bull 70 Freeman JP Brand JW Radiation doses of commonly used dental radiographic surveys Oral Surg Oral Med Oral Pathol 199477285-9
bull 71 Kircos LTAngin LL Lorton LOrder ofmagnitude dose reduction in intraoral radiography J Am Dent Assoc 1987114344-7
bull 72 Updegrave WJ Simplified and standardized intraoral radiography with reduced tissue irradiation J Am Dent Assoc 197285861-9
bull 73 Wood RE Harris AM van der Merwe EJ Nortje CJ The leaded apron revisited does it reduce gonadal radiation dose in dental radiology Oral Surg Oral Med Oral Pathol 199171642-6
bull 74 An update on radiographic practices information and recommendations ADA Council on Scientific Affairs J Am Dent Assoc 2001132234-8
bull 75 Rayburn WF Recommending medications during pregnancy an evidence based approach Clin Obstet Gynecol 2002451-5
bull 76 Rathmell JP Viscomi C Ashburn MA Management of nonobstetric pain during pregnancy and lactation Anesth Analg 1997851074-87
bull 77 Teratology society public affairs committee FDA classification of drugs for teratogenic risk Teratology 199449446-7
bull 78 Moore PA Selecting drugs for the pregnant dental patient J Am Dent Assoc 19981291281-6
bull 79 Haas DA An update on analgesics for the management of acute postoperative dental pain J Can Dent Assoc 200268476-82
bull 80 Haas DA Pynn BR Sands TD Drug use for the pregnant or lactating patient Gen Dent 20004854-60
bull 81 Committee on Drugs American Academy of Pediatrics The transfer of drugs and other chemicals into human milk Pediatrics 199493137-50
bull 82 Nielsen GL Sorensen HT Larsen H Pedersen L Risk of adverse birth outcome and miscarriage in pregnant users of nonsteroidal anti-inflammatory drugs population based observational study and case-control study BMJ 2001322266-70
bull 83 Janssen N Genta M The effects of immunosuppressive and anti-inflammatory medications on fertility pregnancy and lactation Arch Intern Med 200016610-9
bull 84 Ostensen M Nonsteroidal anti-inflammatory drugs during pregnancy Scand J Rheumatol Suppl 1998107128-32
bull 85 USPDI -Drug information for the health care professional 22nd ed Greenwood Village CO Micromedex 2002 p 152-79
bull 86 Denson DD Coyle DE Thompson GA Santos D Turner PA Myers JA et al Bupivacaine protein binding in the term parturient effects of lactic acidosis Clin Pharmacol Ther 198435702-9
bull 87 Dillon DE Wagner CL Wiest D Newman RB Drug therapy in the nursing mother Obstet Gynecol Clin North Am 199724 675-96
bull 88 Dashe JS Gilstrap LC Antibiotic use in pregnancy Obstet Gynecol Clin North Am 199724617-29
bull 89 American College of Rheumatology Ad hoc Committee on Clinical Guidelines Guidelines for monitoring drug therapy in rheumatoid arthritis Arthritis Rheum 199639723-31
bull 90 Ng PC The fetal and neonatal hypothalamic-pituitary-adrenal axis Arch Dis Child Fetal Neonatal Ed 200082F250-4
bull 91 Crowley P Antenatal corticosteroidsmdashcurrent thinking BJOG 2003110(Suppl 20)77-8
bull 92 ACOG committee opinion antenatal corticosteroid therapy for fetal maturation Obstet Gynecol 200299871-3
bull 93 Ost L Wettrell G Bjorkhem I Rane A Prednisolone excretion in human milk J Pediatr 19851061008-11
bull 94 Rowland AS Baird DD Shore DL Weinberg CR Savitz DA Wilcox AJ Nitrous oxide and spontaneous abortion in female dental assistants Am J Epidemiol 1995141531-8
bull 95 McGlothlin JD Jensen PA Fischbach TJ Hughes RT Jones JH Control of anesthetic gases in dental operatories Scand J Work Environ Health 199218(Suppl 2)103-5
bull ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY Volume 97 Number 6 Suresh and Radfar 681
bull 96 Rosen MA Nitrous oxide for relief of labor pain a systematic review Am J Obstet Gynecol 2002186(Suppl Nature)S110-6
bull 97 Sands TD Pynn BR Management considerations for the pregnant or nursing emergency patient Ont Dent 199875 17-9
bull 98 Daya S Recurrent spontaneous early pregnancy loss and low dose aspirin Minerva Ginecol 200355441-9
bull 99 Sinclair C Handbook of obstetrical emergencies 1st ed Philadelphia WB Saunders 1996 p 29-39 69
bull 100 Tarsitano BF Rollings RE The pregnant dental patient evaluation and management Gen Dent 199341226-34
bull 101 Livingston MH Dlllinger TM Holder R Consideration in the management of the pregnant patient SCD Special Care in Dentistry 199818183-8
Thank you
- A Review on the principle of Dental Management of the Pregnant patient
- Slide 2
- Questions that a dentist may ask
- Stages of Pregnancy
- Slide 5
- Slide 6
- Physiologic Changes in Pregnancy
- Systemic changes in pregnancy
- FLAT SUPINE POSITIONING
- SUPINE HYPOTENSION SYNDROME (Vena Cava Compression)
- Supine Hypotension Syndrome
- Slide 12
- Supine Hypotension Syndrome
- Prevention of Supine Hypotensive Syndrome
- Treatment of Supine Hypotensive Syndrome
- How should the pregnant woman be positioned
- Slide 17
- Slide 18
- Slide 19
- Slide 20
- Slide 21
- Slide 22
- Slide 23
- Pregnancy Related Oral Health Problems
- Oral Problems in Pregnancy
- Pregnancy Gingivitis Pathophysiology
- Pregnancy Gingivitis
- Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Gum Problems - Pregnancy Granuloma
- Slide 31
- Gum Changes - Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Candidiasis
- Pregnancy Myths
- Other Oral Conditions in Pregnancy
- Changes During Pregnancy that Affect Oral Health
- Saliva changes
- Increased Bacteria
- Slide 40
- Enamel erosion caused by frequent vomiting
- Treatment for Acid Exposure
- Oral Diseases Can Effect Pregnancy
- Periodontal Disease and Preterm Labor
- Periodontal Disease and Low Birth Weight
- Periodontal Disease and Preeclampsia
- Periodontitis and Pre-eclampsia
- Dental Considerations
- Treatment Timing
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Slide 52
- Use of Radiation on Pregnant Patient
- Radiographs during Pregnancy
- Risks of Dental X-Rays
- FDA drug classification for pregnancy
- Slide 57
- FDA drug classification for pregnancy
- Slide 59
- Slide 60
- Slide 61
- Common Analgesics
- Analgesics
- Analgesics - continued
- Analgesics to Use During 1st and 2nd Trimester
- Analgesics to Avoid During the Third Trimester
- Sedation in Pregnancy
- Common Antibiotics
- Antibiotics
- Antibiotics To Use During Pregnancy
- Antibiotics to Avoid during Pregnancy
- The Problem With Tetracycline
- Other Antimicrobial Agents
- Local Anesthetic Use in Pregnancy
- Use of Local Anesthetics
- Ulcer healing drugs
- Slide 77
- Slide 78
- Slide 79
- Use of Nitrous Oxide Gas
- Common Preventives
- Are topical agents safe
- Pre-natal Fluoride
- Is it safe to use mercury restorations
- References
- REFERENCES
- Slide 87
- Slide 88
- Slide 89
- Slide 90
- Slide 91
- Slide 92
- Slide 93
- Slide 94
- Slide 95
- Slide 96
- Slide 97
- Slide 98
- Thank you
-
REFERENCESbull 1 Weiss G Endocrinology of parturition J Clin
Endocrinol Metab 2000854421-5bull 2 Theunissen IM Parer JT Fluid and electrolytes in
pregnancy Clin Obstet Gynecol 1994373-15bull 3 Duvekot JJ Peeters LLH Renal hemodynamics and
volume homeostasis in pregnancy Obstet Gynecol Surv 199449830-9
bull 4 Barron WM Lindheimer MD Medical disorders during pregnancy 2nd ed St Louis Mosby 1995 p 129
bull 5 Thornburg KL Jacobson SL Giraud GD Morton MJ Hemodynamic changes in pregnancy Semin Perinatol 20002411-4
bull 6 Fiese R Herzog S Issues in dental and surgical management of the pregnant patient Oral Surg Oral Med Oral Pathol 198865292-7
bull 7 Martin C Varner MW Physiologic changes in pregnancysurgical implications Clin Obstet Gynecol 199437241-55
bull 8 Clark SL Cotton DB Lee W Bishop C Hill T Southwick J et al Central hemodynamic assessment of normal term pregnancy Am J Obstet Gynecol 19891611439-42
bull 9 Mabie WC Di Sessa TG Crocker LG Sibai BM Arheart KL A longitudinal study of cardiac output in normal human pregnancy Am J Obstet Gynecol 1994170849-56
bull 10 Clapp JF 3rd Capeless E Cardiovascular function before during and after the first and subsequent pregnancies Am J Cardiol 1997801469-73
bull 11 Duvekot JJ Peeters LL Maternal cardiovascular hemodynamic adaptation to pregnancy Obstet Gynecol Surv 199449(Suppl) S1-14
bull 12 Bhagwat AR Engel PJ Heart disease and pregnancy Cardiol Clin 199513163-78
bull 13 Lanni SM Tillinghast J Silver H Hemodynamic changes and baroreflex gain in the supine hypotensive syndrome Am J Obstet Gynecol 20021871636-41
bull 14 Little JW Falace DA Miller CS Rhodus NL Dental management of the medically compromised patient 6th ed St Louis Mosby 2002 p 303
bull 15 Garcia-Rio F Pino JM Gomez L Alvarez-Sala R Villasante C Villamor J Regulation of breathing and perception of dyspnea in healthy pregnant women Chest 1996110446-53
bull 16 McAuliffe F Kametas N Costello J Rafferty GF Greenough A Nicolaides K Respiratory function in singleton and twin pregnancy BJOG 2002109765-9
bull 17 Clapp JF 3rd Seaward BL Sleamaker RH Hiser J Maternal physiologic adaptations to early human pregnancy Am J Obstet Gynecol 19881591456-60
bull 18 OrsquoDay MP Cardio-respiratory physiological adaptation of pregnancy Semin Perinatol 199721268-75
bull 19 Contreras G Gutierrez M Beroiza T Fantin A Oddo H Villarroel L et al Ventilatory drive and respiratory muscle function in pregnancy Am Rev Respir Dis 1991144837-41
bull 20 Turner M Aziz SR Management of the pregnant oral and maxillofac
bull 21 Sifakis S Pharmakides G Anemia in pregnancy Ann N Y Acad Sci 2000900125-36
bull 22 Branch DW Physiologic adaptations of pregnancy Am J Reprod Immunol 199228120-2
bull 23 Burrows RF Kelton JG Incidentally detected thrombocytopenia in healthy mothers and their infants N Engl J Med 1988319 142-5
bull 24 Hanly JG Antiphospholipid syndrome an overview CMAJ 200324(168)1675-82
bull 25 Heilmann L von Tempelhoff GF Pollow K Antiphospholipid syndrome in obstetrics Clin Appl Thromb Hemost 20039 143-50
bull 26 Sherman P Flaxman SM Nausea and vomiting of pregnancy in an evolutionary perspective Am J Obstet Gynecol 2002 185(Suppl)s190-7
bull 27 Koch KL Gastrointestinal factors in nausea and vomiting of pregnancy Am J Obstet Gynecol 2002185(Suppl)s198-203
bull 28 Koch KL Frissora CL Nausea and vomiting during pregnancy Gastroenterol Clin N Am 200332201-34
bull 29 Baron TH Ramirez B Richter JE Gastrointestinal motility disorders during pregnancy Ann Intern Med 1993118 366-75
bull 30 Richter JE Gastroesophageal reflux disease during pregnancy Gastroenterol Clin N Am 200332235-61
bull 31 Marrero JM Goggin PM de Caestecker JS Pearce JM Maxwell JD Determinants of pregnancy heartburn Br J Obstet Gynaecol 199299731-4
bull 32 Hamaoui E Hamaoui M Nutritional assessment and support during pregnancy Gastroenterol Clin N Am 20033259-121
bull 33 King JC Physiology of pregnancy and nutrient metabolism Am J Clin Nutr 200071(suppl)1218s-25s
bull 34 Casanueva E Pfeffer F Fernandez-Gaxiola AC Gutierrez- Valenzuela V Rothenberg SJ Iron and folate status before pregnancy and anemia during pregnancy Ann Nutr Metab 2003 4760-3
bull 35 Chrsquong CL Morgan M Hainsworth I Kingham JG Prospective study of liver dysfunction in Southwest Wales Gut 200251 876-80
bull 36 Rahman TM Wendon J Severe hepatic dysfunction in pregnancy QJM 200295343-57
bull 37 Knox TA Olans LB Liver disease in pregnancy N Engl J Med 1996335569-76
bull 38 Saftlas AF Olson DR Franks AL Atrash H Pokras R Epidemiology of preeclampsia and eclampsia in the United States 1979e1986 Am J Obstet Gynecol 1990163460-5
bull 39 Walker JJ Pre-eclampsia Lancet 20003561260-5
bull 40 Davidson JM Renal disorders in pregnancy Curr Opin Obstet Gynecol 200113109-14
bull 41 Dafnis E Sabatini S The effect of pregnancy on renal function physiology and pathophysiologyAmJMedSci 1992303184-205
bull 42 Davison JM Shiells EA Philips PR Lindheimer MD Serial evaluation of vasopressin release and thirst in human pregnancy Role of human chorionic gonadotrophin in the osmoregulatory changes of gestation J Clin Invest 198881798-806
bull 43 Glinoer D de Nayer P Bourdoux P Lemone M Robyn C van Steirteghem A et al Regulation of maternal thyroid during pregnancy J Clin Endocrinol Metab 199071276-87
bull 44 Wilson SG Retallack RW Kent JC Worth GK Gutteridge DH Serum free 125-dihydroxyvitamin D and the free 125- dihydroxyvitamin D index during a longitudinal study of human pregnancy and lactation Clin Endocrinol 199032613-22
bull 45 Rasmussen N Frolich A Hornnes PJ Hegedus L Serum ionized calcium and intact parathyroid hormone levels during pregnancy and postpartum Br J Obstet Gynaecol 199097857-9
bull 46 Guyton AC Textbook of medical physiology 8th ed Philadelphia W B Saunders 1991 p 915e28
bull 47 Trainer PJ Corticosteroids and pregnancy Semin Reprod Med 200220375-80
bull 48 Soory M Hormonal factors in periodontal disease Dent Update 200027380-3
bull 49 Hugoson A Gingivitis in pregnant women A longitudinal clinical study Odontol Revy 19712265-84
bull 50 Neville BW Damm DD Allen CM Bouquot JE Oral amp Maxillofacial Pathology 3rd ed Philadelphia W B Saunders 2002 p 329-30 447-9
bull 51 Tilakaratne A Soory M Ranasinghe AW Corea SM Ekanayake SL de Silva M Periodontal disease status during pregnancy and 3 months post-partum in rural population of Sri-Lankan women J Clin Periodontol 200027787-92
bull 52 Laine M Tenovuo J Lehtonen OP Ojanatko-Harri A Vilja P Tuohimaa P Pregnancy e related changes in human whole saliva Arch Oral Biol 198833913-7
bull 53 Yuan K Wing LY Lin MT Pathogenetic roles of angiogenic factors in pyogenic granulomas in pregnancy are modulated by female sex hormones J Periodontol 200273701-8
bull 54 Evans RD Briggs PF Tooth-surface loss related to pregnancyinduced vomiting Prim Dent Care 1994124-6
bull 55 Salvolini E Di Giorgio R Curatola A Mazzanti L Fratto G Biochemical modifications of human whole saliva induced by pregnancy Br J Obstet Gynaec 1998105656-60
bull 56 Mauldin JG Newman RB Preterm birth risk assessment Semin Perinatol 200125215-22
bull 57 Heine RP McGregor JA Goodwin TM Artal R Hayashi RH Robertson PA et al Serial salivary estriol to detect an increased risk of preterm birth Obstet Gynecol 200096490-7
bull 58 Kauh YC Zachian TF Melasma Adv Exp Med Biol 1999455 491-9
bull 59 Wong RC Ellis CN Physiologic skin changes in pregnancy J Am Acad Dermatol 198410929-40
bull 60 Errickson CV Matus NR Skin disorders of pregnancy Am Fam Physician 199449605-10
bull 61 Lopez NJ Smith PC Gutierrez J Periodontal therapy may reduce the risk of preterm low birth weight in women with periodontal disease a randomized controlled trial J Periodontol 200273911-24
bull 62 McGaw T Periodontal disease and preterm delivery of lowbirth- weight infants J Can Dent Assoc 200268165-9
bull 63 Richards AG Dental x-ray protection Dent Clin North Am 1968631-41
bull 64 1990 Recommendations of the International Commission on Radiological Protection Ann ICRP 1991211-201
bull 65 Hall EJ Radiation the two-edged sword cancer risks at high and low doses Cancer J 20006343-50
bull 66 Diethelm L Xu H Diagnostic imaging of the lung during pregnancy Clin Obstet Gynecol 19963936-55
bull 67 Brent RL The effects of embryonic and fetal exposure to x-rays microwaves and ultrasound ClinObstetGynecol 198326484-510
bull 68 National Council on Radiation Protection NCRP report no128 1998 Bethesda Md Author
bull 69 Wasylko L Matsui D Dykxhoorn SM Reider MJ Weinberg S A review of common dental treatments during pregnancy implications for patients and dental personnel J Can Dent Assoc 199864434-9
bull 70 Freeman JP Brand JW Radiation doses of commonly used dental radiographic surveys Oral Surg Oral Med Oral Pathol 199477285-9
bull 71 Kircos LTAngin LL Lorton LOrder ofmagnitude dose reduction in intraoral radiography J Am Dent Assoc 1987114344-7
bull 72 Updegrave WJ Simplified and standardized intraoral radiography with reduced tissue irradiation J Am Dent Assoc 197285861-9
bull 73 Wood RE Harris AM van der Merwe EJ Nortje CJ The leaded apron revisited does it reduce gonadal radiation dose in dental radiology Oral Surg Oral Med Oral Pathol 199171642-6
bull 74 An update on radiographic practices information and recommendations ADA Council on Scientific Affairs J Am Dent Assoc 2001132234-8
bull 75 Rayburn WF Recommending medications during pregnancy an evidence based approach Clin Obstet Gynecol 2002451-5
bull 76 Rathmell JP Viscomi C Ashburn MA Management of nonobstetric pain during pregnancy and lactation Anesth Analg 1997851074-87
bull 77 Teratology society public affairs committee FDA classification of drugs for teratogenic risk Teratology 199449446-7
bull 78 Moore PA Selecting drugs for the pregnant dental patient J Am Dent Assoc 19981291281-6
bull 79 Haas DA An update on analgesics for the management of acute postoperative dental pain J Can Dent Assoc 200268476-82
bull 80 Haas DA Pynn BR Sands TD Drug use for the pregnant or lactating patient Gen Dent 20004854-60
bull 81 Committee on Drugs American Academy of Pediatrics The transfer of drugs and other chemicals into human milk Pediatrics 199493137-50
bull 82 Nielsen GL Sorensen HT Larsen H Pedersen L Risk of adverse birth outcome and miscarriage in pregnant users of nonsteroidal anti-inflammatory drugs population based observational study and case-control study BMJ 2001322266-70
bull 83 Janssen N Genta M The effects of immunosuppressive and anti-inflammatory medications on fertility pregnancy and lactation Arch Intern Med 200016610-9
bull 84 Ostensen M Nonsteroidal anti-inflammatory drugs during pregnancy Scand J Rheumatol Suppl 1998107128-32
bull 85 USPDI -Drug information for the health care professional 22nd ed Greenwood Village CO Micromedex 2002 p 152-79
bull 86 Denson DD Coyle DE Thompson GA Santos D Turner PA Myers JA et al Bupivacaine protein binding in the term parturient effects of lactic acidosis Clin Pharmacol Ther 198435702-9
bull 87 Dillon DE Wagner CL Wiest D Newman RB Drug therapy in the nursing mother Obstet Gynecol Clin North Am 199724 675-96
bull 88 Dashe JS Gilstrap LC Antibiotic use in pregnancy Obstet Gynecol Clin North Am 199724617-29
bull 89 American College of Rheumatology Ad hoc Committee on Clinical Guidelines Guidelines for monitoring drug therapy in rheumatoid arthritis Arthritis Rheum 199639723-31
bull 90 Ng PC The fetal and neonatal hypothalamic-pituitary-adrenal axis Arch Dis Child Fetal Neonatal Ed 200082F250-4
bull 91 Crowley P Antenatal corticosteroidsmdashcurrent thinking BJOG 2003110(Suppl 20)77-8
bull 92 ACOG committee opinion antenatal corticosteroid therapy for fetal maturation Obstet Gynecol 200299871-3
bull 93 Ost L Wettrell G Bjorkhem I Rane A Prednisolone excretion in human milk J Pediatr 19851061008-11
bull 94 Rowland AS Baird DD Shore DL Weinberg CR Savitz DA Wilcox AJ Nitrous oxide and spontaneous abortion in female dental assistants Am J Epidemiol 1995141531-8
bull 95 McGlothlin JD Jensen PA Fischbach TJ Hughes RT Jones JH Control of anesthetic gases in dental operatories Scand J Work Environ Health 199218(Suppl 2)103-5
bull ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY Volume 97 Number 6 Suresh and Radfar 681
bull 96 Rosen MA Nitrous oxide for relief of labor pain a systematic review Am J Obstet Gynecol 2002186(Suppl Nature)S110-6
bull 97 Sands TD Pynn BR Management considerations for the pregnant or nursing emergency patient Ont Dent 199875 17-9
bull 98 Daya S Recurrent spontaneous early pregnancy loss and low dose aspirin Minerva Ginecol 200355441-9
bull 99 Sinclair C Handbook of obstetrical emergencies 1st ed Philadelphia WB Saunders 1996 p 29-39 69
bull 100 Tarsitano BF Rollings RE The pregnant dental patient evaluation and management Gen Dent 199341226-34
bull 101 Livingston MH Dlllinger TM Holder R Consideration in the management of the pregnant patient SCD Special Care in Dentistry 199818183-8
Thank you
- A Review on the principle of Dental Management of the Pregnant patient
- Slide 2
- Questions that a dentist may ask
- Stages of Pregnancy
- Slide 5
- Slide 6
- Physiologic Changes in Pregnancy
- Systemic changes in pregnancy
- FLAT SUPINE POSITIONING
- SUPINE HYPOTENSION SYNDROME (Vena Cava Compression)
- Supine Hypotension Syndrome
- Slide 12
- Supine Hypotension Syndrome
- Prevention of Supine Hypotensive Syndrome
- Treatment of Supine Hypotensive Syndrome
- How should the pregnant woman be positioned
- Slide 17
- Slide 18
- Slide 19
- Slide 20
- Slide 21
- Slide 22
- Slide 23
- Pregnancy Related Oral Health Problems
- Oral Problems in Pregnancy
- Pregnancy Gingivitis Pathophysiology
- Pregnancy Gingivitis
- Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Gum Problems - Pregnancy Granuloma
- Slide 31
- Gum Changes - Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Candidiasis
- Pregnancy Myths
- Other Oral Conditions in Pregnancy
- Changes During Pregnancy that Affect Oral Health
- Saliva changes
- Increased Bacteria
- Slide 40
- Enamel erosion caused by frequent vomiting
- Treatment for Acid Exposure
- Oral Diseases Can Effect Pregnancy
- Periodontal Disease and Preterm Labor
- Periodontal Disease and Low Birth Weight
- Periodontal Disease and Preeclampsia
- Periodontitis and Pre-eclampsia
- Dental Considerations
- Treatment Timing
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Slide 52
- Use of Radiation on Pregnant Patient
- Radiographs during Pregnancy
- Risks of Dental X-Rays
- FDA drug classification for pregnancy
- Slide 57
- FDA drug classification for pregnancy
- Slide 59
- Slide 60
- Slide 61
- Common Analgesics
- Analgesics
- Analgesics - continued
- Analgesics to Use During 1st and 2nd Trimester
- Analgesics to Avoid During the Third Trimester
- Sedation in Pregnancy
- Common Antibiotics
- Antibiotics
- Antibiotics To Use During Pregnancy
- Antibiotics to Avoid during Pregnancy
- The Problem With Tetracycline
- Other Antimicrobial Agents
- Local Anesthetic Use in Pregnancy
- Use of Local Anesthetics
- Ulcer healing drugs
- Slide 77
- Slide 78
- Slide 79
- Use of Nitrous Oxide Gas
- Common Preventives
- Are topical agents safe
- Pre-natal Fluoride
- Is it safe to use mercury restorations
- References
- REFERENCES
- Slide 87
- Slide 88
- Slide 89
- Slide 90
- Slide 91
- Slide 92
- Slide 93
- Slide 94
- Slide 95
- Slide 96
- Slide 97
- Slide 98
- Thank you
-
bull 8 Clark SL Cotton DB Lee W Bishop C Hill T Southwick J et al Central hemodynamic assessment of normal term pregnancy Am J Obstet Gynecol 19891611439-42
bull 9 Mabie WC Di Sessa TG Crocker LG Sibai BM Arheart KL A longitudinal study of cardiac output in normal human pregnancy Am J Obstet Gynecol 1994170849-56
bull 10 Clapp JF 3rd Capeless E Cardiovascular function before during and after the first and subsequent pregnancies Am J Cardiol 1997801469-73
bull 11 Duvekot JJ Peeters LL Maternal cardiovascular hemodynamic adaptation to pregnancy Obstet Gynecol Surv 199449(Suppl) S1-14
bull 12 Bhagwat AR Engel PJ Heart disease and pregnancy Cardiol Clin 199513163-78
bull 13 Lanni SM Tillinghast J Silver H Hemodynamic changes and baroreflex gain in the supine hypotensive syndrome Am J Obstet Gynecol 20021871636-41
bull 14 Little JW Falace DA Miller CS Rhodus NL Dental management of the medically compromised patient 6th ed St Louis Mosby 2002 p 303
bull 15 Garcia-Rio F Pino JM Gomez L Alvarez-Sala R Villasante C Villamor J Regulation of breathing and perception of dyspnea in healthy pregnant women Chest 1996110446-53
bull 16 McAuliffe F Kametas N Costello J Rafferty GF Greenough A Nicolaides K Respiratory function in singleton and twin pregnancy BJOG 2002109765-9
bull 17 Clapp JF 3rd Seaward BL Sleamaker RH Hiser J Maternal physiologic adaptations to early human pregnancy Am J Obstet Gynecol 19881591456-60
bull 18 OrsquoDay MP Cardio-respiratory physiological adaptation of pregnancy Semin Perinatol 199721268-75
bull 19 Contreras G Gutierrez M Beroiza T Fantin A Oddo H Villarroel L et al Ventilatory drive and respiratory muscle function in pregnancy Am Rev Respir Dis 1991144837-41
bull 20 Turner M Aziz SR Management of the pregnant oral and maxillofac
bull 21 Sifakis S Pharmakides G Anemia in pregnancy Ann N Y Acad Sci 2000900125-36
bull 22 Branch DW Physiologic adaptations of pregnancy Am J Reprod Immunol 199228120-2
bull 23 Burrows RF Kelton JG Incidentally detected thrombocytopenia in healthy mothers and their infants N Engl J Med 1988319 142-5
bull 24 Hanly JG Antiphospholipid syndrome an overview CMAJ 200324(168)1675-82
bull 25 Heilmann L von Tempelhoff GF Pollow K Antiphospholipid syndrome in obstetrics Clin Appl Thromb Hemost 20039 143-50
bull 26 Sherman P Flaxman SM Nausea and vomiting of pregnancy in an evolutionary perspective Am J Obstet Gynecol 2002 185(Suppl)s190-7
bull 27 Koch KL Gastrointestinal factors in nausea and vomiting of pregnancy Am J Obstet Gynecol 2002185(Suppl)s198-203
bull 28 Koch KL Frissora CL Nausea and vomiting during pregnancy Gastroenterol Clin N Am 200332201-34
bull 29 Baron TH Ramirez B Richter JE Gastrointestinal motility disorders during pregnancy Ann Intern Med 1993118 366-75
bull 30 Richter JE Gastroesophageal reflux disease during pregnancy Gastroenterol Clin N Am 200332235-61
bull 31 Marrero JM Goggin PM de Caestecker JS Pearce JM Maxwell JD Determinants of pregnancy heartburn Br J Obstet Gynaecol 199299731-4
bull 32 Hamaoui E Hamaoui M Nutritional assessment and support during pregnancy Gastroenterol Clin N Am 20033259-121
bull 33 King JC Physiology of pregnancy and nutrient metabolism Am J Clin Nutr 200071(suppl)1218s-25s
bull 34 Casanueva E Pfeffer F Fernandez-Gaxiola AC Gutierrez- Valenzuela V Rothenberg SJ Iron and folate status before pregnancy and anemia during pregnancy Ann Nutr Metab 2003 4760-3
bull 35 Chrsquong CL Morgan M Hainsworth I Kingham JG Prospective study of liver dysfunction in Southwest Wales Gut 200251 876-80
bull 36 Rahman TM Wendon J Severe hepatic dysfunction in pregnancy QJM 200295343-57
bull 37 Knox TA Olans LB Liver disease in pregnancy N Engl J Med 1996335569-76
bull 38 Saftlas AF Olson DR Franks AL Atrash H Pokras R Epidemiology of preeclampsia and eclampsia in the United States 1979e1986 Am J Obstet Gynecol 1990163460-5
bull 39 Walker JJ Pre-eclampsia Lancet 20003561260-5
bull 40 Davidson JM Renal disorders in pregnancy Curr Opin Obstet Gynecol 200113109-14
bull 41 Dafnis E Sabatini S The effect of pregnancy on renal function physiology and pathophysiologyAmJMedSci 1992303184-205
bull 42 Davison JM Shiells EA Philips PR Lindheimer MD Serial evaluation of vasopressin release and thirst in human pregnancy Role of human chorionic gonadotrophin in the osmoregulatory changes of gestation J Clin Invest 198881798-806
bull 43 Glinoer D de Nayer P Bourdoux P Lemone M Robyn C van Steirteghem A et al Regulation of maternal thyroid during pregnancy J Clin Endocrinol Metab 199071276-87
bull 44 Wilson SG Retallack RW Kent JC Worth GK Gutteridge DH Serum free 125-dihydroxyvitamin D and the free 125- dihydroxyvitamin D index during a longitudinal study of human pregnancy and lactation Clin Endocrinol 199032613-22
bull 45 Rasmussen N Frolich A Hornnes PJ Hegedus L Serum ionized calcium and intact parathyroid hormone levels during pregnancy and postpartum Br J Obstet Gynaecol 199097857-9
bull 46 Guyton AC Textbook of medical physiology 8th ed Philadelphia W B Saunders 1991 p 915e28
bull 47 Trainer PJ Corticosteroids and pregnancy Semin Reprod Med 200220375-80
bull 48 Soory M Hormonal factors in periodontal disease Dent Update 200027380-3
bull 49 Hugoson A Gingivitis in pregnant women A longitudinal clinical study Odontol Revy 19712265-84
bull 50 Neville BW Damm DD Allen CM Bouquot JE Oral amp Maxillofacial Pathology 3rd ed Philadelphia W B Saunders 2002 p 329-30 447-9
bull 51 Tilakaratne A Soory M Ranasinghe AW Corea SM Ekanayake SL de Silva M Periodontal disease status during pregnancy and 3 months post-partum in rural population of Sri-Lankan women J Clin Periodontol 200027787-92
bull 52 Laine M Tenovuo J Lehtonen OP Ojanatko-Harri A Vilja P Tuohimaa P Pregnancy e related changes in human whole saliva Arch Oral Biol 198833913-7
bull 53 Yuan K Wing LY Lin MT Pathogenetic roles of angiogenic factors in pyogenic granulomas in pregnancy are modulated by female sex hormones J Periodontol 200273701-8
bull 54 Evans RD Briggs PF Tooth-surface loss related to pregnancyinduced vomiting Prim Dent Care 1994124-6
bull 55 Salvolini E Di Giorgio R Curatola A Mazzanti L Fratto G Biochemical modifications of human whole saliva induced by pregnancy Br J Obstet Gynaec 1998105656-60
bull 56 Mauldin JG Newman RB Preterm birth risk assessment Semin Perinatol 200125215-22
bull 57 Heine RP McGregor JA Goodwin TM Artal R Hayashi RH Robertson PA et al Serial salivary estriol to detect an increased risk of preterm birth Obstet Gynecol 200096490-7
bull 58 Kauh YC Zachian TF Melasma Adv Exp Med Biol 1999455 491-9
bull 59 Wong RC Ellis CN Physiologic skin changes in pregnancy J Am Acad Dermatol 198410929-40
bull 60 Errickson CV Matus NR Skin disorders of pregnancy Am Fam Physician 199449605-10
bull 61 Lopez NJ Smith PC Gutierrez J Periodontal therapy may reduce the risk of preterm low birth weight in women with periodontal disease a randomized controlled trial J Periodontol 200273911-24
bull 62 McGaw T Periodontal disease and preterm delivery of lowbirth- weight infants J Can Dent Assoc 200268165-9
bull 63 Richards AG Dental x-ray protection Dent Clin North Am 1968631-41
bull 64 1990 Recommendations of the International Commission on Radiological Protection Ann ICRP 1991211-201
bull 65 Hall EJ Radiation the two-edged sword cancer risks at high and low doses Cancer J 20006343-50
bull 66 Diethelm L Xu H Diagnostic imaging of the lung during pregnancy Clin Obstet Gynecol 19963936-55
bull 67 Brent RL The effects of embryonic and fetal exposure to x-rays microwaves and ultrasound ClinObstetGynecol 198326484-510
bull 68 National Council on Radiation Protection NCRP report no128 1998 Bethesda Md Author
bull 69 Wasylko L Matsui D Dykxhoorn SM Reider MJ Weinberg S A review of common dental treatments during pregnancy implications for patients and dental personnel J Can Dent Assoc 199864434-9
bull 70 Freeman JP Brand JW Radiation doses of commonly used dental radiographic surveys Oral Surg Oral Med Oral Pathol 199477285-9
bull 71 Kircos LTAngin LL Lorton LOrder ofmagnitude dose reduction in intraoral radiography J Am Dent Assoc 1987114344-7
bull 72 Updegrave WJ Simplified and standardized intraoral radiography with reduced tissue irradiation J Am Dent Assoc 197285861-9
bull 73 Wood RE Harris AM van der Merwe EJ Nortje CJ The leaded apron revisited does it reduce gonadal radiation dose in dental radiology Oral Surg Oral Med Oral Pathol 199171642-6
bull 74 An update on radiographic practices information and recommendations ADA Council on Scientific Affairs J Am Dent Assoc 2001132234-8
bull 75 Rayburn WF Recommending medications during pregnancy an evidence based approach Clin Obstet Gynecol 2002451-5
bull 76 Rathmell JP Viscomi C Ashburn MA Management of nonobstetric pain during pregnancy and lactation Anesth Analg 1997851074-87
bull 77 Teratology society public affairs committee FDA classification of drugs for teratogenic risk Teratology 199449446-7
bull 78 Moore PA Selecting drugs for the pregnant dental patient J Am Dent Assoc 19981291281-6
bull 79 Haas DA An update on analgesics for the management of acute postoperative dental pain J Can Dent Assoc 200268476-82
bull 80 Haas DA Pynn BR Sands TD Drug use for the pregnant or lactating patient Gen Dent 20004854-60
bull 81 Committee on Drugs American Academy of Pediatrics The transfer of drugs and other chemicals into human milk Pediatrics 199493137-50
bull 82 Nielsen GL Sorensen HT Larsen H Pedersen L Risk of adverse birth outcome and miscarriage in pregnant users of nonsteroidal anti-inflammatory drugs population based observational study and case-control study BMJ 2001322266-70
bull 83 Janssen N Genta M The effects of immunosuppressive and anti-inflammatory medications on fertility pregnancy and lactation Arch Intern Med 200016610-9
bull 84 Ostensen M Nonsteroidal anti-inflammatory drugs during pregnancy Scand J Rheumatol Suppl 1998107128-32
bull 85 USPDI -Drug information for the health care professional 22nd ed Greenwood Village CO Micromedex 2002 p 152-79
bull 86 Denson DD Coyle DE Thompson GA Santos D Turner PA Myers JA et al Bupivacaine protein binding in the term parturient effects of lactic acidosis Clin Pharmacol Ther 198435702-9
bull 87 Dillon DE Wagner CL Wiest D Newman RB Drug therapy in the nursing mother Obstet Gynecol Clin North Am 199724 675-96
bull 88 Dashe JS Gilstrap LC Antibiotic use in pregnancy Obstet Gynecol Clin North Am 199724617-29
bull 89 American College of Rheumatology Ad hoc Committee on Clinical Guidelines Guidelines for monitoring drug therapy in rheumatoid arthritis Arthritis Rheum 199639723-31
bull 90 Ng PC The fetal and neonatal hypothalamic-pituitary-adrenal axis Arch Dis Child Fetal Neonatal Ed 200082F250-4
bull 91 Crowley P Antenatal corticosteroidsmdashcurrent thinking BJOG 2003110(Suppl 20)77-8
bull 92 ACOG committee opinion antenatal corticosteroid therapy for fetal maturation Obstet Gynecol 200299871-3
bull 93 Ost L Wettrell G Bjorkhem I Rane A Prednisolone excretion in human milk J Pediatr 19851061008-11
bull 94 Rowland AS Baird DD Shore DL Weinberg CR Savitz DA Wilcox AJ Nitrous oxide and spontaneous abortion in female dental assistants Am J Epidemiol 1995141531-8
bull 95 McGlothlin JD Jensen PA Fischbach TJ Hughes RT Jones JH Control of anesthetic gases in dental operatories Scand J Work Environ Health 199218(Suppl 2)103-5
bull ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY Volume 97 Number 6 Suresh and Radfar 681
bull 96 Rosen MA Nitrous oxide for relief of labor pain a systematic review Am J Obstet Gynecol 2002186(Suppl Nature)S110-6
bull 97 Sands TD Pynn BR Management considerations for the pregnant or nursing emergency patient Ont Dent 199875 17-9
bull 98 Daya S Recurrent spontaneous early pregnancy loss and low dose aspirin Minerva Ginecol 200355441-9
bull 99 Sinclair C Handbook of obstetrical emergencies 1st ed Philadelphia WB Saunders 1996 p 29-39 69
bull 100 Tarsitano BF Rollings RE The pregnant dental patient evaluation and management Gen Dent 199341226-34
bull 101 Livingston MH Dlllinger TM Holder R Consideration in the management of the pregnant patient SCD Special Care in Dentistry 199818183-8
Thank you
- A Review on the principle of Dental Management of the Pregnant patient
- Slide 2
- Questions that a dentist may ask
- Stages of Pregnancy
- Slide 5
- Slide 6
- Physiologic Changes in Pregnancy
- Systemic changes in pregnancy
- FLAT SUPINE POSITIONING
- SUPINE HYPOTENSION SYNDROME (Vena Cava Compression)
- Supine Hypotension Syndrome
- Slide 12
- Supine Hypotension Syndrome
- Prevention of Supine Hypotensive Syndrome
- Treatment of Supine Hypotensive Syndrome
- How should the pregnant woman be positioned
- Slide 17
- Slide 18
- Slide 19
- Slide 20
- Slide 21
- Slide 22
- Slide 23
- Pregnancy Related Oral Health Problems
- Oral Problems in Pregnancy
- Pregnancy Gingivitis Pathophysiology
- Pregnancy Gingivitis
- Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Gum Problems - Pregnancy Granuloma
- Slide 31
- Gum Changes - Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Candidiasis
- Pregnancy Myths
- Other Oral Conditions in Pregnancy
- Changes During Pregnancy that Affect Oral Health
- Saliva changes
- Increased Bacteria
- Slide 40
- Enamel erosion caused by frequent vomiting
- Treatment for Acid Exposure
- Oral Diseases Can Effect Pregnancy
- Periodontal Disease and Preterm Labor
- Periodontal Disease and Low Birth Weight
- Periodontal Disease and Preeclampsia
- Periodontitis and Pre-eclampsia
- Dental Considerations
- Treatment Timing
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Slide 52
- Use of Radiation on Pregnant Patient
- Radiographs during Pregnancy
- Risks of Dental X-Rays
- FDA drug classification for pregnancy
- Slide 57
- FDA drug classification for pregnancy
- Slide 59
- Slide 60
- Slide 61
- Common Analgesics
- Analgesics
- Analgesics - continued
- Analgesics to Use During 1st and 2nd Trimester
- Analgesics to Avoid During the Third Trimester
- Sedation in Pregnancy
- Common Antibiotics
- Antibiotics
- Antibiotics To Use During Pregnancy
- Antibiotics to Avoid during Pregnancy
- The Problem With Tetracycline
- Other Antimicrobial Agents
- Local Anesthetic Use in Pregnancy
- Use of Local Anesthetics
- Ulcer healing drugs
- Slide 77
- Slide 78
- Slide 79
- Use of Nitrous Oxide Gas
- Common Preventives
- Are topical agents safe
- Pre-natal Fluoride
- Is it safe to use mercury restorations
- References
- REFERENCES
- Slide 87
- Slide 88
- Slide 89
- Slide 90
- Slide 91
- Slide 92
- Slide 93
- Slide 94
- Slide 95
- Slide 96
- Slide 97
- Slide 98
- Thank you
-
bull 12 Bhagwat AR Engel PJ Heart disease and pregnancy Cardiol Clin 199513163-78
bull 13 Lanni SM Tillinghast J Silver H Hemodynamic changes and baroreflex gain in the supine hypotensive syndrome Am J Obstet Gynecol 20021871636-41
bull 14 Little JW Falace DA Miller CS Rhodus NL Dental management of the medically compromised patient 6th ed St Louis Mosby 2002 p 303
bull 15 Garcia-Rio F Pino JM Gomez L Alvarez-Sala R Villasante C Villamor J Regulation of breathing and perception of dyspnea in healthy pregnant women Chest 1996110446-53
bull 16 McAuliffe F Kametas N Costello J Rafferty GF Greenough A Nicolaides K Respiratory function in singleton and twin pregnancy BJOG 2002109765-9
bull 17 Clapp JF 3rd Seaward BL Sleamaker RH Hiser J Maternal physiologic adaptations to early human pregnancy Am J Obstet Gynecol 19881591456-60
bull 18 OrsquoDay MP Cardio-respiratory physiological adaptation of pregnancy Semin Perinatol 199721268-75
bull 19 Contreras G Gutierrez M Beroiza T Fantin A Oddo H Villarroel L et al Ventilatory drive and respiratory muscle function in pregnancy Am Rev Respir Dis 1991144837-41
bull 20 Turner M Aziz SR Management of the pregnant oral and maxillofac
bull 21 Sifakis S Pharmakides G Anemia in pregnancy Ann N Y Acad Sci 2000900125-36
bull 22 Branch DW Physiologic adaptations of pregnancy Am J Reprod Immunol 199228120-2
bull 23 Burrows RF Kelton JG Incidentally detected thrombocytopenia in healthy mothers and their infants N Engl J Med 1988319 142-5
bull 24 Hanly JG Antiphospholipid syndrome an overview CMAJ 200324(168)1675-82
bull 25 Heilmann L von Tempelhoff GF Pollow K Antiphospholipid syndrome in obstetrics Clin Appl Thromb Hemost 20039 143-50
bull 26 Sherman P Flaxman SM Nausea and vomiting of pregnancy in an evolutionary perspective Am J Obstet Gynecol 2002 185(Suppl)s190-7
bull 27 Koch KL Gastrointestinal factors in nausea and vomiting of pregnancy Am J Obstet Gynecol 2002185(Suppl)s198-203
bull 28 Koch KL Frissora CL Nausea and vomiting during pregnancy Gastroenterol Clin N Am 200332201-34
bull 29 Baron TH Ramirez B Richter JE Gastrointestinal motility disorders during pregnancy Ann Intern Med 1993118 366-75
bull 30 Richter JE Gastroesophageal reflux disease during pregnancy Gastroenterol Clin N Am 200332235-61
bull 31 Marrero JM Goggin PM de Caestecker JS Pearce JM Maxwell JD Determinants of pregnancy heartburn Br J Obstet Gynaecol 199299731-4
bull 32 Hamaoui E Hamaoui M Nutritional assessment and support during pregnancy Gastroenterol Clin N Am 20033259-121
bull 33 King JC Physiology of pregnancy and nutrient metabolism Am J Clin Nutr 200071(suppl)1218s-25s
bull 34 Casanueva E Pfeffer F Fernandez-Gaxiola AC Gutierrez- Valenzuela V Rothenberg SJ Iron and folate status before pregnancy and anemia during pregnancy Ann Nutr Metab 2003 4760-3
bull 35 Chrsquong CL Morgan M Hainsworth I Kingham JG Prospective study of liver dysfunction in Southwest Wales Gut 200251 876-80
bull 36 Rahman TM Wendon J Severe hepatic dysfunction in pregnancy QJM 200295343-57
bull 37 Knox TA Olans LB Liver disease in pregnancy N Engl J Med 1996335569-76
bull 38 Saftlas AF Olson DR Franks AL Atrash H Pokras R Epidemiology of preeclampsia and eclampsia in the United States 1979e1986 Am J Obstet Gynecol 1990163460-5
bull 39 Walker JJ Pre-eclampsia Lancet 20003561260-5
bull 40 Davidson JM Renal disorders in pregnancy Curr Opin Obstet Gynecol 200113109-14
bull 41 Dafnis E Sabatini S The effect of pregnancy on renal function physiology and pathophysiologyAmJMedSci 1992303184-205
bull 42 Davison JM Shiells EA Philips PR Lindheimer MD Serial evaluation of vasopressin release and thirst in human pregnancy Role of human chorionic gonadotrophin in the osmoregulatory changes of gestation J Clin Invest 198881798-806
bull 43 Glinoer D de Nayer P Bourdoux P Lemone M Robyn C van Steirteghem A et al Regulation of maternal thyroid during pregnancy J Clin Endocrinol Metab 199071276-87
bull 44 Wilson SG Retallack RW Kent JC Worth GK Gutteridge DH Serum free 125-dihydroxyvitamin D and the free 125- dihydroxyvitamin D index during a longitudinal study of human pregnancy and lactation Clin Endocrinol 199032613-22
bull 45 Rasmussen N Frolich A Hornnes PJ Hegedus L Serum ionized calcium and intact parathyroid hormone levels during pregnancy and postpartum Br J Obstet Gynaecol 199097857-9
bull 46 Guyton AC Textbook of medical physiology 8th ed Philadelphia W B Saunders 1991 p 915e28
bull 47 Trainer PJ Corticosteroids and pregnancy Semin Reprod Med 200220375-80
bull 48 Soory M Hormonal factors in periodontal disease Dent Update 200027380-3
bull 49 Hugoson A Gingivitis in pregnant women A longitudinal clinical study Odontol Revy 19712265-84
bull 50 Neville BW Damm DD Allen CM Bouquot JE Oral amp Maxillofacial Pathology 3rd ed Philadelphia W B Saunders 2002 p 329-30 447-9
bull 51 Tilakaratne A Soory M Ranasinghe AW Corea SM Ekanayake SL de Silva M Periodontal disease status during pregnancy and 3 months post-partum in rural population of Sri-Lankan women J Clin Periodontol 200027787-92
bull 52 Laine M Tenovuo J Lehtonen OP Ojanatko-Harri A Vilja P Tuohimaa P Pregnancy e related changes in human whole saliva Arch Oral Biol 198833913-7
bull 53 Yuan K Wing LY Lin MT Pathogenetic roles of angiogenic factors in pyogenic granulomas in pregnancy are modulated by female sex hormones J Periodontol 200273701-8
bull 54 Evans RD Briggs PF Tooth-surface loss related to pregnancyinduced vomiting Prim Dent Care 1994124-6
bull 55 Salvolini E Di Giorgio R Curatola A Mazzanti L Fratto G Biochemical modifications of human whole saliva induced by pregnancy Br J Obstet Gynaec 1998105656-60
bull 56 Mauldin JG Newman RB Preterm birth risk assessment Semin Perinatol 200125215-22
bull 57 Heine RP McGregor JA Goodwin TM Artal R Hayashi RH Robertson PA et al Serial salivary estriol to detect an increased risk of preterm birth Obstet Gynecol 200096490-7
bull 58 Kauh YC Zachian TF Melasma Adv Exp Med Biol 1999455 491-9
bull 59 Wong RC Ellis CN Physiologic skin changes in pregnancy J Am Acad Dermatol 198410929-40
bull 60 Errickson CV Matus NR Skin disorders of pregnancy Am Fam Physician 199449605-10
bull 61 Lopez NJ Smith PC Gutierrez J Periodontal therapy may reduce the risk of preterm low birth weight in women with periodontal disease a randomized controlled trial J Periodontol 200273911-24
bull 62 McGaw T Periodontal disease and preterm delivery of lowbirth- weight infants J Can Dent Assoc 200268165-9
bull 63 Richards AG Dental x-ray protection Dent Clin North Am 1968631-41
bull 64 1990 Recommendations of the International Commission on Radiological Protection Ann ICRP 1991211-201
bull 65 Hall EJ Radiation the two-edged sword cancer risks at high and low doses Cancer J 20006343-50
bull 66 Diethelm L Xu H Diagnostic imaging of the lung during pregnancy Clin Obstet Gynecol 19963936-55
bull 67 Brent RL The effects of embryonic and fetal exposure to x-rays microwaves and ultrasound ClinObstetGynecol 198326484-510
bull 68 National Council on Radiation Protection NCRP report no128 1998 Bethesda Md Author
bull 69 Wasylko L Matsui D Dykxhoorn SM Reider MJ Weinberg S A review of common dental treatments during pregnancy implications for patients and dental personnel J Can Dent Assoc 199864434-9
bull 70 Freeman JP Brand JW Radiation doses of commonly used dental radiographic surveys Oral Surg Oral Med Oral Pathol 199477285-9
bull 71 Kircos LTAngin LL Lorton LOrder ofmagnitude dose reduction in intraoral radiography J Am Dent Assoc 1987114344-7
bull 72 Updegrave WJ Simplified and standardized intraoral radiography with reduced tissue irradiation J Am Dent Assoc 197285861-9
bull 73 Wood RE Harris AM van der Merwe EJ Nortje CJ The leaded apron revisited does it reduce gonadal radiation dose in dental radiology Oral Surg Oral Med Oral Pathol 199171642-6
bull 74 An update on radiographic practices information and recommendations ADA Council on Scientific Affairs J Am Dent Assoc 2001132234-8
bull 75 Rayburn WF Recommending medications during pregnancy an evidence based approach Clin Obstet Gynecol 2002451-5
bull 76 Rathmell JP Viscomi C Ashburn MA Management of nonobstetric pain during pregnancy and lactation Anesth Analg 1997851074-87
bull 77 Teratology society public affairs committee FDA classification of drugs for teratogenic risk Teratology 199449446-7
bull 78 Moore PA Selecting drugs for the pregnant dental patient J Am Dent Assoc 19981291281-6
bull 79 Haas DA An update on analgesics for the management of acute postoperative dental pain J Can Dent Assoc 200268476-82
bull 80 Haas DA Pynn BR Sands TD Drug use for the pregnant or lactating patient Gen Dent 20004854-60
bull 81 Committee on Drugs American Academy of Pediatrics The transfer of drugs and other chemicals into human milk Pediatrics 199493137-50
bull 82 Nielsen GL Sorensen HT Larsen H Pedersen L Risk of adverse birth outcome and miscarriage in pregnant users of nonsteroidal anti-inflammatory drugs population based observational study and case-control study BMJ 2001322266-70
bull 83 Janssen N Genta M The effects of immunosuppressive and anti-inflammatory medications on fertility pregnancy and lactation Arch Intern Med 200016610-9
bull 84 Ostensen M Nonsteroidal anti-inflammatory drugs during pregnancy Scand J Rheumatol Suppl 1998107128-32
bull 85 USPDI -Drug information for the health care professional 22nd ed Greenwood Village CO Micromedex 2002 p 152-79
bull 86 Denson DD Coyle DE Thompson GA Santos D Turner PA Myers JA et al Bupivacaine protein binding in the term parturient effects of lactic acidosis Clin Pharmacol Ther 198435702-9
bull 87 Dillon DE Wagner CL Wiest D Newman RB Drug therapy in the nursing mother Obstet Gynecol Clin North Am 199724 675-96
bull 88 Dashe JS Gilstrap LC Antibiotic use in pregnancy Obstet Gynecol Clin North Am 199724617-29
bull 89 American College of Rheumatology Ad hoc Committee on Clinical Guidelines Guidelines for monitoring drug therapy in rheumatoid arthritis Arthritis Rheum 199639723-31
bull 90 Ng PC The fetal and neonatal hypothalamic-pituitary-adrenal axis Arch Dis Child Fetal Neonatal Ed 200082F250-4
bull 91 Crowley P Antenatal corticosteroidsmdashcurrent thinking BJOG 2003110(Suppl 20)77-8
bull 92 ACOG committee opinion antenatal corticosteroid therapy for fetal maturation Obstet Gynecol 200299871-3
bull 93 Ost L Wettrell G Bjorkhem I Rane A Prednisolone excretion in human milk J Pediatr 19851061008-11
bull 94 Rowland AS Baird DD Shore DL Weinberg CR Savitz DA Wilcox AJ Nitrous oxide and spontaneous abortion in female dental assistants Am J Epidemiol 1995141531-8
bull 95 McGlothlin JD Jensen PA Fischbach TJ Hughes RT Jones JH Control of anesthetic gases in dental operatories Scand J Work Environ Health 199218(Suppl 2)103-5
bull ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY Volume 97 Number 6 Suresh and Radfar 681
bull 96 Rosen MA Nitrous oxide for relief of labor pain a systematic review Am J Obstet Gynecol 2002186(Suppl Nature)S110-6
bull 97 Sands TD Pynn BR Management considerations for the pregnant or nursing emergency patient Ont Dent 199875 17-9
bull 98 Daya S Recurrent spontaneous early pregnancy loss and low dose aspirin Minerva Ginecol 200355441-9
bull 99 Sinclair C Handbook of obstetrical emergencies 1st ed Philadelphia WB Saunders 1996 p 29-39 69
bull 100 Tarsitano BF Rollings RE The pregnant dental patient evaluation and management Gen Dent 199341226-34
bull 101 Livingston MH Dlllinger TM Holder R Consideration in the management of the pregnant patient SCD Special Care in Dentistry 199818183-8
Thank you
- A Review on the principle of Dental Management of the Pregnant patient
- Slide 2
- Questions that a dentist may ask
- Stages of Pregnancy
- Slide 5
- Slide 6
- Physiologic Changes in Pregnancy
- Systemic changes in pregnancy
- FLAT SUPINE POSITIONING
- SUPINE HYPOTENSION SYNDROME (Vena Cava Compression)
- Supine Hypotension Syndrome
- Slide 12
- Supine Hypotension Syndrome
- Prevention of Supine Hypotensive Syndrome
- Treatment of Supine Hypotensive Syndrome
- How should the pregnant woman be positioned
- Slide 17
- Slide 18
- Slide 19
- Slide 20
- Slide 21
- Slide 22
- Slide 23
- Pregnancy Related Oral Health Problems
- Oral Problems in Pregnancy
- Pregnancy Gingivitis Pathophysiology
- Pregnancy Gingivitis
- Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Gum Problems - Pregnancy Granuloma
- Slide 31
- Gum Changes - Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Candidiasis
- Pregnancy Myths
- Other Oral Conditions in Pregnancy
- Changes During Pregnancy that Affect Oral Health
- Saliva changes
- Increased Bacteria
- Slide 40
- Enamel erosion caused by frequent vomiting
- Treatment for Acid Exposure
- Oral Diseases Can Effect Pregnancy
- Periodontal Disease and Preterm Labor
- Periodontal Disease and Low Birth Weight
- Periodontal Disease and Preeclampsia
- Periodontitis and Pre-eclampsia
- Dental Considerations
- Treatment Timing
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Slide 52
- Use of Radiation on Pregnant Patient
- Radiographs during Pregnancy
- Risks of Dental X-Rays
- FDA drug classification for pregnancy
- Slide 57
- FDA drug classification for pregnancy
- Slide 59
- Slide 60
- Slide 61
- Common Analgesics
- Analgesics
- Analgesics - continued
- Analgesics to Use During 1st and 2nd Trimester
- Analgesics to Avoid During the Third Trimester
- Sedation in Pregnancy
- Common Antibiotics
- Antibiotics
- Antibiotics To Use During Pregnancy
- Antibiotics to Avoid during Pregnancy
- The Problem With Tetracycline
- Other Antimicrobial Agents
- Local Anesthetic Use in Pregnancy
- Use of Local Anesthetics
- Ulcer healing drugs
- Slide 77
- Slide 78
- Slide 79
- Use of Nitrous Oxide Gas
- Common Preventives
- Are topical agents safe
- Pre-natal Fluoride
- Is it safe to use mercury restorations
- References
- REFERENCES
- Slide 87
- Slide 88
- Slide 89
- Slide 90
- Slide 91
- Slide 92
- Slide 93
- Slide 94
- Slide 95
- Slide 96
- Slide 97
- Slide 98
- Thank you
-
bull 21 Sifakis S Pharmakides G Anemia in pregnancy Ann N Y Acad Sci 2000900125-36
bull 22 Branch DW Physiologic adaptations of pregnancy Am J Reprod Immunol 199228120-2
bull 23 Burrows RF Kelton JG Incidentally detected thrombocytopenia in healthy mothers and their infants N Engl J Med 1988319 142-5
bull 24 Hanly JG Antiphospholipid syndrome an overview CMAJ 200324(168)1675-82
bull 25 Heilmann L von Tempelhoff GF Pollow K Antiphospholipid syndrome in obstetrics Clin Appl Thromb Hemost 20039 143-50
bull 26 Sherman P Flaxman SM Nausea and vomiting of pregnancy in an evolutionary perspective Am J Obstet Gynecol 2002 185(Suppl)s190-7
bull 27 Koch KL Gastrointestinal factors in nausea and vomiting of pregnancy Am J Obstet Gynecol 2002185(Suppl)s198-203
bull 28 Koch KL Frissora CL Nausea and vomiting during pregnancy Gastroenterol Clin N Am 200332201-34
bull 29 Baron TH Ramirez B Richter JE Gastrointestinal motility disorders during pregnancy Ann Intern Med 1993118 366-75
bull 30 Richter JE Gastroesophageal reflux disease during pregnancy Gastroenterol Clin N Am 200332235-61
bull 31 Marrero JM Goggin PM de Caestecker JS Pearce JM Maxwell JD Determinants of pregnancy heartburn Br J Obstet Gynaecol 199299731-4
bull 32 Hamaoui E Hamaoui M Nutritional assessment and support during pregnancy Gastroenterol Clin N Am 20033259-121
bull 33 King JC Physiology of pregnancy and nutrient metabolism Am J Clin Nutr 200071(suppl)1218s-25s
bull 34 Casanueva E Pfeffer F Fernandez-Gaxiola AC Gutierrez- Valenzuela V Rothenberg SJ Iron and folate status before pregnancy and anemia during pregnancy Ann Nutr Metab 2003 4760-3
bull 35 Chrsquong CL Morgan M Hainsworth I Kingham JG Prospective study of liver dysfunction in Southwest Wales Gut 200251 876-80
bull 36 Rahman TM Wendon J Severe hepatic dysfunction in pregnancy QJM 200295343-57
bull 37 Knox TA Olans LB Liver disease in pregnancy N Engl J Med 1996335569-76
bull 38 Saftlas AF Olson DR Franks AL Atrash H Pokras R Epidemiology of preeclampsia and eclampsia in the United States 1979e1986 Am J Obstet Gynecol 1990163460-5
bull 39 Walker JJ Pre-eclampsia Lancet 20003561260-5
bull 40 Davidson JM Renal disorders in pregnancy Curr Opin Obstet Gynecol 200113109-14
bull 41 Dafnis E Sabatini S The effect of pregnancy on renal function physiology and pathophysiologyAmJMedSci 1992303184-205
bull 42 Davison JM Shiells EA Philips PR Lindheimer MD Serial evaluation of vasopressin release and thirst in human pregnancy Role of human chorionic gonadotrophin in the osmoregulatory changes of gestation J Clin Invest 198881798-806
bull 43 Glinoer D de Nayer P Bourdoux P Lemone M Robyn C van Steirteghem A et al Regulation of maternal thyroid during pregnancy J Clin Endocrinol Metab 199071276-87
bull 44 Wilson SG Retallack RW Kent JC Worth GK Gutteridge DH Serum free 125-dihydroxyvitamin D and the free 125- dihydroxyvitamin D index during a longitudinal study of human pregnancy and lactation Clin Endocrinol 199032613-22
bull 45 Rasmussen N Frolich A Hornnes PJ Hegedus L Serum ionized calcium and intact parathyroid hormone levels during pregnancy and postpartum Br J Obstet Gynaecol 199097857-9
bull 46 Guyton AC Textbook of medical physiology 8th ed Philadelphia W B Saunders 1991 p 915e28
bull 47 Trainer PJ Corticosteroids and pregnancy Semin Reprod Med 200220375-80
bull 48 Soory M Hormonal factors in periodontal disease Dent Update 200027380-3
bull 49 Hugoson A Gingivitis in pregnant women A longitudinal clinical study Odontol Revy 19712265-84
bull 50 Neville BW Damm DD Allen CM Bouquot JE Oral amp Maxillofacial Pathology 3rd ed Philadelphia W B Saunders 2002 p 329-30 447-9
bull 51 Tilakaratne A Soory M Ranasinghe AW Corea SM Ekanayake SL de Silva M Periodontal disease status during pregnancy and 3 months post-partum in rural population of Sri-Lankan women J Clin Periodontol 200027787-92
bull 52 Laine M Tenovuo J Lehtonen OP Ojanatko-Harri A Vilja P Tuohimaa P Pregnancy e related changes in human whole saliva Arch Oral Biol 198833913-7
bull 53 Yuan K Wing LY Lin MT Pathogenetic roles of angiogenic factors in pyogenic granulomas in pregnancy are modulated by female sex hormones J Periodontol 200273701-8
bull 54 Evans RD Briggs PF Tooth-surface loss related to pregnancyinduced vomiting Prim Dent Care 1994124-6
bull 55 Salvolini E Di Giorgio R Curatola A Mazzanti L Fratto G Biochemical modifications of human whole saliva induced by pregnancy Br J Obstet Gynaec 1998105656-60
bull 56 Mauldin JG Newman RB Preterm birth risk assessment Semin Perinatol 200125215-22
bull 57 Heine RP McGregor JA Goodwin TM Artal R Hayashi RH Robertson PA et al Serial salivary estriol to detect an increased risk of preterm birth Obstet Gynecol 200096490-7
bull 58 Kauh YC Zachian TF Melasma Adv Exp Med Biol 1999455 491-9
bull 59 Wong RC Ellis CN Physiologic skin changes in pregnancy J Am Acad Dermatol 198410929-40
bull 60 Errickson CV Matus NR Skin disorders of pregnancy Am Fam Physician 199449605-10
bull 61 Lopez NJ Smith PC Gutierrez J Periodontal therapy may reduce the risk of preterm low birth weight in women with periodontal disease a randomized controlled trial J Periodontol 200273911-24
bull 62 McGaw T Periodontal disease and preterm delivery of lowbirth- weight infants J Can Dent Assoc 200268165-9
bull 63 Richards AG Dental x-ray protection Dent Clin North Am 1968631-41
bull 64 1990 Recommendations of the International Commission on Radiological Protection Ann ICRP 1991211-201
bull 65 Hall EJ Radiation the two-edged sword cancer risks at high and low doses Cancer J 20006343-50
bull 66 Diethelm L Xu H Diagnostic imaging of the lung during pregnancy Clin Obstet Gynecol 19963936-55
bull 67 Brent RL The effects of embryonic and fetal exposure to x-rays microwaves and ultrasound ClinObstetGynecol 198326484-510
bull 68 National Council on Radiation Protection NCRP report no128 1998 Bethesda Md Author
bull 69 Wasylko L Matsui D Dykxhoorn SM Reider MJ Weinberg S A review of common dental treatments during pregnancy implications for patients and dental personnel J Can Dent Assoc 199864434-9
bull 70 Freeman JP Brand JW Radiation doses of commonly used dental radiographic surveys Oral Surg Oral Med Oral Pathol 199477285-9
bull 71 Kircos LTAngin LL Lorton LOrder ofmagnitude dose reduction in intraoral radiography J Am Dent Assoc 1987114344-7
bull 72 Updegrave WJ Simplified and standardized intraoral radiography with reduced tissue irradiation J Am Dent Assoc 197285861-9
bull 73 Wood RE Harris AM van der Merwe EJ Nortje CJ The leaded apron revisited does it reduce gonadal radiation dose in dental radiology Oral Surg Oral Med Oral Pathol 199171642-6
bull 74 An update on radiographic practices information and recommendations ADA Council on Scientific Affairs J Am Dent Assoc 2001132234-8
bull 75 Rayburn WF Recommending medications during pregnancy an evidence based approach Clin Obstet Gynecol 2002451-5
bull 76 Rathmell JP Viscomi C Ashburn MA Management of nonobstetric pain during pregnancy and lactation Anesth Analg 1997851074-87
bull 77 Teratology society public affairs committee FDA classification of drugs for teratogenic risk Teratology 199449446-7
bull 78 Moore PA Selecting drugs for the pregnant dental patient J Am Dent Assoc 19981291281-6
bull 79 Haas DA An update on analgesics for the management of acute postoperative dental pain J Can Dent Assoc 200268476-82
bull 80 Haas DA Pynn BR Sands TD Drug use for the pregnant or lactating patient Gen Dent 20004854-60
bull 81 Committee on Drugs American Academy of Pediatrics The transfer of drugs and other chemicals into human milk Pediatrics 199493137-50
bull 82 Nielsen GL Sorensen HT Larsen H Pedersen L Risk of adverse birth outcome and miscarriage in pregnant users of nonsteroidal anti-inflammatory drugs population based observational study and case-control study BMJ 2001322266-70
bull 83 Janssen N Genta M The effects of immunosuppressive and anti-inflammatory medications on fertility pregnancy and lactation Arch Intern Med 200016610-9
bull 84 Ostensen M Nonsteroidal anti-inflammatory drugs during pregnancy Scand J Rheumatol Suppl 1998107128-32
bull 85 USPDI -Drug information for the health care professional 22nd ed Greenwood Village CO Micromedex 2002 p 152-79
bull 86 Denson DD Coyle DE Thompson GA Santos D Turner PA Myers JA et al Bupivacaine protein binding in the term parturient effects of lactic acidosis Clin Pharmacol Ther 198435702-9
bull 87 Dillon DE Wagner CL Wiest D Newman RB Drug therapy in the nursing mother Obstet Gynecol Clin North Am 199724 675-96
bull 88 Dashe JS Gilstrap LC Antibiotic use in pregnancy Obstet Gynecol Clin North Am 199724617-29
bull 89 American College of Rheumatology Ad hoc Committee on Clinical Guidelines Guidelines for monitoring drug therapy in rheumatoid arthritis Arthritis Rheum 199639723-31
bull 90 Ng PC The fetal and neonatal hypothalamic-pituitary-adrenal axis Arch Dis Child Fetal Neonatal Ed 200082F250-4
bull 91 Crowley P Antenatal corticosteroidsmdashcurrent thinking BJOG 2003110(Suppl 20)77-8
bull 92 ACOG committee opinion antenatal corticosteroid therapy for fetal maturation Obstet Gynecol 200299871-3
bull 93 Ost L Wettrell G Bjorkhem I Rane A Prednisolone excretion in human milk J Pediatr 19851061008-11
bull 94 Rowland AS Baird DD Shore DL Weinberg CR Savitz DA Wilcox AJ Nitrous oxide and spontaneous abortion in female dental assistants Am J Epidemiol 1995141531-8
bull 95 McGlothlin JD Jensen PA Fischbach TJ Hughes RT Jones JH Control of anesthetic gases in dental operatories Scand J Work Environ Health 199218(Suppl 2)103-5
bull ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY Volume 97 Number 6 Suresh and Radfar 681
bull 96 Rosen MA Nitrous oxide for relief of labor pain a systematic review Am J Obstet Gynecol 2002186(Suppl Nature)S110-6
bull 97 Sands TD Pynn BR Management considerations for the pregnant or nursing emergency patient Ont Dent 199875 17-9
bull 98 Daya S Recurrent spontaneous early pregnancy loss and low dose aspirin Minerva Ginecol 200355441-9
bull 99 Sinclair C Handbook of obstetrical emergencies 1st ed Philadelphia WB Saunders 1996 p 29-39 69
bull 100 Tarsitano BF Rollings RE The pregnant dental patient evaluation and management Gen Dent 199341226-34
bull 101 Livingston MH Dlllinger TM Holder R Consideration in the management of the pregnant patient SCD Special Care in Dentistry 199818183-8
Thank you
- A Review on the principle of Dental Management of the Pregnant patient
- Slide 2
- Questions that a dentist may ask
- Stages of Pregnancy
- Slide 5
- Slide 6
- Physiologic Changes in Pregnancy
- Systemic changes in pregnancy
- FLAT SUPINE POSITIONING
- SUPINE HYPOTENSION SYNDROME (Vena Cava Compression)
- Supine Hypotension Syndrome
- Slide 12
- Supine Hypotension Syndrome
- Prevention of Supine Hypotensive Syndrome
- Treatment of Supine Hypotensive Syndrome
- How should the pregnant woman be positioned
- Slide 17
- Slide 18
- Slide 19
- Slide 20
- Slide 21
- Slide 22
- Slide 23
- Pregnancy Related Oral Health Problems
- Oral Problems in Pregnancy
- Pregnancy Gingivitis Pathophysiology
- Pregnancy Gingivitis
- Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Gum Problems - Pregnancy Granuloma
- Slide 31
- Gum Changes - Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Candidiasis
- Pregnancy Myths
- Other Oral Conditions in Pregnancy
- Changes During Pregnancy that Affect Oral Health
- Saliva changes
- Increased Bacteria
- Slide 40
- Enamel erosion caused by frequent vomiting
- Treatment for Acid Exposure
- Oral Diseases Can Effect Pregnancy
- Periodontal Disease and Preterm Labor
- Periodontal Disease and Low Birth Weight
- Periodontal Disease and Preeclampsia
- Periodontitis and Pre-eclampsia
- Dental Considerations
- Treatment Timing
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Slide 52
- Use of Radiation on Pregnant Patient
- Radiographs during Pregnancy
- Risks of Dental X-Rays
- FDA drug classification for pregnancy
- Slide 57
- FDA drug classification for pregnancy
- Slide 59
- Slide 60
- Slide 61
- Common Analgesics
- Analgesics
- Analgesics - continued
- Analgesics to Use During 1st and 2nd Trimester
- Analgesics to Avoid During the Third Trimester
- Sedation in Pregnancy
- Common Antibiotics
- Antibiotics
- Antibiotics To Use During Pregnancy
- Antibiotics to Avoid during Pregnancy
- The Problem With Tetracycline
- Other Antimicrobial Agents
- Local Anesthetic Use in Pregnancy
- Use of Local Anesthetics
- Ulcer healing drugs
- Slide 77
- Slide 78
- Slide 79
- Use of Nitrous Oxide Gas
- Common Preventives
- Are topical agents safe
- Pre-natal Fluoride
- Is it safe to use mercury restorations
- References
- REFERENCES
- Slide 87
- Slide 88
- Slide 89
- Slide 90
- Slide 91
- Slide 92
- Slide 93
- Slide 94
- Slide 95
- Slide 96
- Slide 97
- Slide 98
- Thank you
-
bull 31 Marrero JM Goggin PM de Caestecker JS Pearce JM Maxwell JD Determinants of pregnancy heartburn Br J Obstet Gynaecol 199299731-4
bull 32 Hamaoui E Hamaoui M Nutritional assessment and support during pregnancy Gastroenterol Clin N Am 20033259-121
bull 33 King JC Physiology of pregnancy and nutrient metabolism Am J Clin Nutr 200071(suppl)1218s-25s
bull 34 Casanueva E Pfeffer F Fernandez-Gaxiola AC Gutierrez- Valenzuela V Rothenberg SJ Iron and folate status before pregnancy and anemia during pregnancy Ann Nutr Metab 2003 4760-3
bull 35 Chrsquong CL Morgan M Hainsworth I Kingham JG Prospective study of liver dysfunction in Southwest Wales Gut 200251 876-80
bull 36 Rahman TM Wendon J Severe hepatic dysfunction in pregnancy QJM 200295343-57
bull 37 Knox TA Olans LB Liver disease in pregnancy N Engl J Med 1996335569-76
bull 38 Saftlas AF Olson DR Franks AL Atrash H Pokras R Epidemiology of preeclampsia and eclampsia in the United States 1979e1986 Am J Obstet Gynecol 1990163460-5
bull 39 Walker JJ Pre-eclampsia Lancet 20003561260-5
bull 40 Davidson JM Renal disorders in pregnancy Curr Opin Obstet Gynecol 200113109-14
bull 41 Dafnis E Sabatini S The effect of pregnancy on renal function physiology and pathophysiologyAmJMedSci 1992303184-205
bull 42 Davison JM Shiells EA Philips PR Lindheimer MD Serial evaluation of vasopressin release and thirst in human pregnancy Role of human chorionic gonadotrophin in the osmoregulatory changes of gestation J Clin Invest 198881798-806
bull 43 Glinoer D de Nayer P Bourdoux P Lemone M Robyn C van Steirteghem A et al Regulation of maternal thyroid during pregnancy J Clin Endocrinol Metab 199071276-87
bull 44 Wilson SG Retallack RW Kent JC Worth GK Gutteridge DH Serum free 125-dihydroxyvitamin D and the free 125- dihydroxyvitamin D index during a longitudinal study of human pregnancy and lactation Clin Endocrinol 199032613-22
bull 45 Rasmussen N Frolich A Hornnes PJ Hegedus L Serum ionized calcium and intact parathyroid hormone levels during pregnancy and postpartum Br J Obstet Gynaecol 199097857-9
bull 46 Guyton AC Textbook of medical physiology 8th ed Philadelphia W B Saunders 1991 p 915e28
bull 47 Trainer PJ Corticosteroids and pregnancy Semin Reprod Med 200220375-80
bull 48 Soory M Hormonal factors in periodontal disease Dent Update 200027380-3
bull 49 Hugoson A Gingivitis in pregnant women A longitudinal clinical study Odontol Revy 19712265-84
bull 50 Neville BW Damm DD Allen CM Bouquot JE Oral amp Maxillofacial Pathology 3rd ed Philadelphia W B Saunders 2002 p 329-30 447-9
bull 51 Tilakaratne A Soory M Ranasinghe AW Corea SM Ekanayake SL de Silva M Periodontal disease status during pregnancy and 3 months post-partum in rural population of Sri-Lankan women J Clin Periodontol 200027787-92
bull 52 Laine M Tenovuo J Lehtonen OP Ojanatko-Harri A Vilja P Tuohimaa P Pregnancy e related changes in human whole saliva Arch Oral Biol 198833913-7
bull 53 Yuan K Wing LY Lin MT Pathogenetic roles of angiogenic factors in pyogenic granulomas in pregnancy are modulated by female sex hormones J Periodontol 200273701-8
bull 54 Evans RD Briggs PF Tooth-surface loss related to pregnancyinduced vomiting Prim Dent Care 1994124-6
bull 55 Salvolini E Di Giorgio R Curatola A Mazzanti L Fratto G Biochemical modifications of human whole saliva induced by pregnancy Br J Obstet Gynaec 1998105656-60
bull 56 Mauldin JG Newman RB Preterm birth risk assessment Semin Perinatol 200125215-22
bull 57 Heine RP McGregor JA Goodwin TM Artal R Hayashi RH Robertson PA et al Serial salivary estriol to detect an increased risk of preterm birth Obstet Gynecol 200096490-7
bull 58 Kauh YC Zachian TF Melasma Adv Exp Med Biol 1999455 491-9
bull 59 Wong RC Ellis CN Physiologic skin changes in pregnancy J Am Acad Dermatol 198410929-40
bull 60 Errickson CV Matus NR Skin disorders of pregnancy Am Fam Physician 199449605-10
bull 61 Lopez NJ Smith PC Gutierrez J Periodontal therapy may reduce the risk of preterm low birth weight in women with periodontal disease a randomized controlled trial J Periodontol 200273911-24
bull 62 McGaw T Periodontal disease and preterm delivery of lowbirth- weight infants J Can Dent Assoc 200268165-9
bull 63 Richards AG Dental x-ray protection Dent Clin North Am 1968631-41
bull 64 1990 Recommendations of the International Commission on Radiological Protection Ann ICRP 1991211-201
bull 65 Hall EJ Radiation the two-edged sword cancer risks at high and low doses Cancer J 20006343-50
bull 66 Diethelm L Xu H Diagnostic imaging of the lung during pregnancy Clin Obstet Gynecol 19963936-55
bull 67 Brent RL The effects of embryonic and fetal exposure to x-rays microwaves and ultrasound ClinObstetGynecol 198326484-510
bull 68 National Council on Radiation Protection NCRP report no128 1998 Bethesda Md Author
bull 69 Wasylko L Matsui D Dykxhoorn SM Reider MJ Weinberg S A review of common dental treatments during pregnancy implications for patients and dental personnel J Can Dent Assoc 199864434-9
bull 70 Freeman JP Brand JW Radiation doses of commonly used dental radiographic surveys Oral Surg Oral Med Oral Pathol 199477285-9
bull 71 Kircos LTAngin LL Lorton LOrder ofmagnitude dose reduction in intraoral radiography J Am Dent Assoc 1987114344-7
bull 72 Updegrave WJ Simplified and standardized intraoral radiography with reduced tissue irradiation J Am Dent Assoc 197285861-9
bull 73 Wood RE Harris AM van der Merwe EJ Nortje CJ The leaded apron revisited does it reduce gonadal radiation dose in dental radiology Oral Surg Oral Med Oral Pathol 199171642-6
bull 74 An update on radiographic practices information and recommendations ADA Council on Scientific Affairs J Am Dent Assoc 2001132234-8
bull 75 Rayburn WF Recommending medications during pregnancy an evidence based approach Clin Obstet Gynecol 2002451-5
bull 76 Rathmell JP Viscomi C Ashburn MA Management of nonobstetric pain during pregnancy and lactation Anesth Analg 1997851074-87
bull 77 Teratology society public affairs committee FDA classification of drugs for teratogenic risk Teratology 199449446-7
bull 78 Moore PA Selecting drugs for the pregnant dental patient J Am Dent Assoc 19981291281-6
bull 79 Haas DA An update on analgesics for the management of acute postoperative dental pain J Can Dent Assoc 200268476-82
bull 80 Haas DA Pynn BR Sands TD Drug use for the pregnant or lactating patient Gen Dent 20004854-60
bull 81 Committee on Drugs American Academy of Pediatrics The transfer of drugs and other chemicals into human milk Pediatrics 199493137-50
bull 82 Nielsen GL Sorensen HT Larsen H Pedersen L Risk of adverse birth outcome and miscarriage in pregnant users of nonsteroidal anti-inflammatory drugs population based observational study and case-control study BMJ 2001322266-70
bull 83 Janssen N Genta M The effects of immunosuppressive and anti-inflammatory medications on fertility pregnancy and lactation Arch Intern Med 200016610-9
bull 84 Ostensen M Nonsteroidal anti-inflammatory drugs during pregnancy Scand J Rheumatol Suppl 1998107128-32
bull 85 USPDI -Drug information for the health care professional 22nd ed Greenwood Village CO Micromedex 2002 p 152-79
bull 86 Denson DD Coyle DE Thompson GA Santos D Turner PA Myers JA et al Bupivacaine protein binding in the term parturient effects of lactic acidosis Clin Pharmacol Ther 198435702-9
bull 87 Dillon DE Wagner CL Wiest D Newman RB Drug therapy in the nursing mother Obstet Gynecol Clin North Am 199724 675-96
bull 88 Dashe JS Gilstrap LC Antibiotic use in pregnancy Obstet Gynecol Clin North Am 199724617-29
bull 89 American College of Rheumatology Ad hoc Committee on Clinical Guidelines Guidelines for monitoring drug therapy in rheumatoid arthritis Arthritis Rheum 199639723-31
bull 90 Ng PC The fetal and neonatal hypothalamic-pituitary-adrenal axis Arch Dis Child Fetal Neonatal Ed 200082F250-4
bull 91 Crowley P Antenatal corticosteroidsmdashcurrent thinking BJOG 2003110(Suppl 20)77-8
bull 92 ACOG committee opinion antenatal corticosteroid therapy for fetal maturation Obstet Gynecol 200299871-3
bull 93 Ost L Wettrell G Bjorkhem I Rane A Prednisolone excretion in human milk J Pediatr 19851061008-11
bull 94 Rowland AS Baird DD Shore DL Weinberg CR Savitz DA Wilcox AJ Nitrous oxide and spontaneous abortion in female dental assistants Am J Epidemiol 1995141531-8
bull 95 McGlothlin JD Jensen PA Fischbach TJ Hughes RT Jones JH Control of anesthetic gases in dental operatories Scand J Work Environ Health 199218(Suppl 2)103-5
bull ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY Volume 97 Number 6 Suresh and Radfar 681
bull 96 Rosen MA Nitrous oxide for relief of labor pain a systematic review Am J Obstet Gynecol 2002186(Suppl Nature)S110-6
bull 97 Sands TD Pynn BR Management considerations for the pregnant or nursing emergency patient Ont Dent 199875 17-9
bull 98 Daya S Recurrent spontaneous early pregnancy loss and low dose aspirin Minerva Ginecol 200355441-9
bull 99 Sinclair C Handbook of obstetrical emergencies 1st ed Philadelphia WB Saunders 1996 p 29-39 69
bull 100 Tarsitano BF Rollings RE The pregnant dental patient evaluation and management Gen Dent 199341226-34
bull 101 Livingston MH Dlllinger TM Holder R Consideration in the management of the pregnant patient SCD Special Care in Dentistry 199818183-8
Thank you
- A Review on the principle of Dental Management of the Pregnant patient
- Slide 2
- Questions that a dentist may ask
- Stages of Pregnancy
- Slide 5
- Slide 6
- Physiologic Changes in Pregnancy
- Systemic changes in pregnancy
- FLAT SUPINE POSITIONING
- SUPINE HYPOTENSION SYNDROME (Vena Cava Compression)
- Supine Hypotension Syndrome
- Slide 12
- Supine Hypotension Syndrome
- Prevention of Supine Hypotensive Syndrome
- Treatment of Supine Hypotensive Syndrome
- How should the pregnant woman be positioned
- Slide 17
- Slide 18
- Slide 19
- Slide 20
- Slide 21
- Slide 22
- Slide 23
- Pregnancy Related Oral Health Problems
- Oral Problems in Pregnancy
- Pregnancy Gingivitis Pathophysiology
- Pregnancy Gingivitis
- Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Gum Problems - Pregnancy Granuloma
- Slide 31
- Gum Changes - Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Candidiasis
- Pregnancy Myths
- Other Oral Conditions in Pregnancy
- Changes During Pregnancy that Affect Oral Health
- Saliva changes
- Increased Bacteria
- Slide 40
- Enamel erosion caused by frequent vomiting
- Treatment for Acid Exposure
- Oral Diseases Can Effect Pregnancy
- Periodontal Disease and Preterm Labor
- Periodontal Disease and Low Birth Weight
- Periodontal Disease and Preeclampsia
- Periodontitis and Pre-eclampsia
- Dental Considerations
- Treatment Timing
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Slide 52
- Use of Radiation on Pregnant Patient
- Radiographs during Pregnancy
- Risks of Dental X-Rays
- FDA drug classification for pregnancy
- Slide 57
- FDA drug classification for pregnancy
- Slide 59
- Slide 60
- Slide 61
- Common Analgesics
- Analgesics
- Analgesics - continued
- Analgesics to Use During 1st and 2nd Trimester
- Analgesics to Avoid During the Third Trimester
- Sedation in Pregnancy
- Common Antibiotics
- Antibiotics
- Antibiotics To Use During Pregnancy
- Antibiotics to Avoid during Pregnancy
- The Problem With Tetracycline
- Other Antimicrobial Agents
- Local Anesthetic Use in Pregnancy
- Use of Local Anesthetics
- Ulcer healing drugs
- Slide 77
- Slide 78
- Slide 79
- Use of Nitrous Oxide Gas
- Common Preventives
- Are topical agents safe
- Pre-natal Fluoride
- Is it safe to use mercury restorations
- References
- REFERENCES
- Slide 87
- Slide 88
- Slide 89
- Slide 90
- Slide 91
- Slide 92
- Slide 93
- Slide 94
- Slide 95
- Slide 96
- Slide 97
- Slide 98
- Thank you
-
bull 40 Davidson JM Renal disorders in pregnancy Curr Opin Obstet Gynecol 200113109-14
bull 41 Dafnis E Sabatini S The effect of pregnancy on renal function physiology and pathophysiologyAmJMedSci 1992303184-205
bull 42 Davison JM Shiells EA Philips PR Lindheimer MD Serial evaluation of vasopressin release and thirst in human pregnancy Role of human chorionic gonadotrophin in the osmoregulatory changes of gestation J Clin Invest 198881798-806
bull 43 Glinoer D de Nayer P Bourdoux P Lemone M Robyn C van Steirteghem A et al Regulation of maternal thyroid during pregnancy J Clin Endocrinol Metab 199071276-87
bull 44 Wilson SG Retallack RW Kent JC Worth GK Gutteridge DH Serum free 125-dihydroxyvitamin D and the free 125- dihydroxyvitamin D index during a longitudinal study of human pregnancy and lactation Clin Endocrinol 199032613-22
bull 45 Rasmussen N Frolich A Hornnes PJ Hegedus L Serum ionized calcium and intact parathyroid hormone levels during pregnancy and postpartum Br J Obstet Gynaecol 199097857-9
bull 46 Guyton AC Textbook of medical physiology 8th ed Philadelphia W B Saunders 1991 p 915e28
bull 47 Trainer PJ Corticosteroids and pregnancy Semin Reprod Med 200220375-80
bull 48 Soory M Hormonal factors in periodontal disease Dent Update 200027380-3
bull 49 Hugoson A Gingivitis in pregnant women A longitudinal clinical study Odontol Revy 19712265-84
bull 50 Neville BW Damm DD Allen CM Bouquot JE Oral amp Maxillofacial Pathology 3rd ed Philadelphia W B Saunders 2002 p 329-30 447-9
bull 51 Tilakaratne A Soory M Ranasinghe AW Corea SM Ekanayake SL de Silva M Periodontal disease status during pregnancy and 3 months post-partum in rural population of Sri-Lankan women J Clin Periodontol 200027787-92
bull 52 Laine M Tenovuo J Lehtonen OP Ojanatko-Harri A Vilja P Tuohimaa P Pregnancy e related changes in human whole saliva Arch Oral Biol 198833913-7
bull 53 Yuan K Wing LY Lin MT Pathogenetic roles of angiogenic factors in pyogenic granulomas in pregnancy are modulated by female sex hormones J Periodontol 200273701-8
bull 54 Evans RD Briggs PF Tooth-surface loss related to pregnancyinduced vomiting Prim Dent Care 1994124-6
bull 55 Salvolini E Di Giorgio R Curatola A Mazzanti L Fratto G Biochemical modifications of human whole saliva induced by pregnancy Br J Obstet Gynaec 1998105656-60
bull 56 Mauldin JG Newman RB Preterm birth risk assessment Semin Perinatol 200125215-22
bull 57 Heine RP McGregor JA Goodwin TM Artal R Hayashi RH Robertson PA et al Serial salivary estriol to detect an increased risk of preterm birth Obstet Gynecol 200096490-7
bull 58 Kauh YC Zachian TF Melasma Adv Exp Med Biol 1999455 491-9
bull 59 Wong RC Ellis CN Physiologic skin changes in pregnancy J Am Acad Dermatol 198410929-40
bull 60 Errickson CV Matus NR Skin disorders of pregnancy Am Fam Physician 199449605-10
bull 61 Lopez NJ Smith PC Gutierrez J Periodontal therapy may reduce the risk of preterm low birth weight in women with periodontal disease a randomized controlled trial J Periodontol 200273911-24
bull 62 McGaw T Periodontal disease and preterm delivery of lowbirth- weight infants J Can Dent Assoc 200268165-9
bull 63 Richards AG Dental x-ray protection Dent Clin North Am 1968631-41
bull 64 1990 Recommendations of the International Commission on Radiological Protection Ann ICRP 1991211-201
bull 65 Hall EJ Radiation the two-edged sword cancer risks at high and low doses Cancer J 20006343-50
bull 66 Diethelm L Xu H Diagnostic imaging of the lung during pregnancy Clin Obstet Gynecol 19963936-55
bull 67 Brent RL The effects of embryonic and fetal exposure to x-rays microwaves and ultrasound ClinObstetGynecol 198326484-510
bull 68 National Council on Radiation Protection NCRP report no128 1998 Bethesda Md Author
bull 69 Wasylko L Matsui D Dykxhoorn SM Reider MJ Weinberg S A review of common dental treatments during pregnancy implications for patients and dental personnel J Can Dent Assoc 199864434-9
bull 70 Freeman JP Brand JW Radiation doses of commonly used dental radiographic surveys Oral Surg Oral Med Oral Pathol 199477285-9
bull 71 Kircos LTAngin LL Lorton LOrder ofmagnitude dose reduction in intraoral radiography J Am Dent Assoc 1987114344-7
bull 72 Updegrave WJ Simplified and standardized intraoral radiography with reduced tissue irradiation J Am Dent Assoc 197285861-9
bull 73 Wood RE Harris AM van der Merwe EJ Nortje CJ The leaded apron revisited does it reduce gonadal radiation dose in dental radiology Oral Surg Oral Med Oral Pathol 199171642-6
bull 74 An update on radiographic practices information and recommendations ADA Council on Scientific Affairs J Am Dent Assoc 2001132234-8
bull 75 Rayburn WF Recommending medications during pregnancy an evidence based approach Clin Obstet Gynecol 2002451-5
bull 76 Rathmell JP Viscomi C Ashburn MA Management of nonobstetric pain during pregnancy and lactation Anesth Analg 1997851074-87
bull 77 Teratology society public affairs committee FDA classification of drugs for teratogenic risk Teratology 199449446-7
bull 78 Moore PA Selecting drugs for the pregnant dental patient J Am Dent Assoc 19981291281-6
bull 79 Haas DA An update on analgesics for the management of acute postoperative dental pain J Can Dent Assoc 200268476-82
bull 80 Haas DA Pynn BR Sands TD Drug use for the pregnant or lactating patient Gen Dent 20004854-60
bull 81 Committee on Drugs American Academy of Pediatrics The transfer of drugs and other chemicals into human milk Pediatrics 199493137-50
bull 82 Nielsen GL Sorensen HT Larsen H Pedersen L Risk of adverse birth outcome and miscarriage in pregnant users of nonsteroidal anti-inflammatory drugs population based observational study and case-control study BMJ 2001322266-70
bull 83 Janssen N Genta M The effects of immunosuppressive and anti-inflammatory medications on fertility pregnancy and lactation Arch Intern Med 200016610-9
bull 84 Ostensen M Nonsteroidal anti-inflammatory drugs during pregnancy Scand J Rheumatol Suppl 1998107128-32
bull 85 USPDI -Drug information for the health care professional 22nd ed Greenwood Village CO Micromedex 2002 p 152-79
bull 86 Denson DD Coyle DE Thompson GA Santos D Turner PA Myers JA et al Bupivacaine protein binding in the term parturient effects of lactic acidosis Clin Pharmacol Ther 198435702-9
bull 87 Dillon DE Wagner CL Wiest D Newman RB Drug therapy in the nursing mother Obstet Gynecol Clin North Am 199724 675-96
bull 88 Dashe JS Gilstrap LC Antibiotic use in pregnancy Obstet Gynecol Clin North Am 199724617-29
bull 89 American College of Rheumatology Ad hoc Committee on Clinical Guidelines Guidelines for monitoring drug therapy in rheumatoid arthritis Arthritis Rheum 199639723-31
bull 90 Ng PC The fetal and neonatal hypothalamic-pituitary-adrenal axis Arch Dis Child Fetal Neonatal Ed 200082F250-4
bull 91 Crowley P Antenatal corticosteroidsmdashcurrent thinking BJOG 2003110(Suppl 20)77-8
bull 92 ACOG committee opinion antenatal corticosteroid therapy for fetal maturation Obstet Gynecol 200299871-3
bull 93 Ost L Wettrell G Bjorkhem I Rane A Prednisolone excretion in human milk J Pediatr 19851061008-11
bull 94 Rowland AS Baird DD Shore DL Weinberg CR Savitz DA Wilcox AJ Nitrous oxide and spontaneous abortion in female dental assistants Am J Epidemiol 1995141531-8
bull 95 McGlothlin JD Jensen PA Fischbach TJ Hughes RT Jones JH Control of anesthetic gases in dental operatories Scand J Work Environ Health 199218(Suppl 2)103-5
bull ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY Volume 97 Number 6 Suresh and Radfar 681
bull 96 Rosen MA Nitrous oxide for relief of labor pain a systematic review Am J Obstet Gynecol 2002186(Suppl Nature)S110-6
bull 97 Sands TD Pynn BR Management considerations for the pregnant or nursing emergency patient Ont Dent 199875 17-9
bull 98 Daya S Recurrent spontaneous early pregnancy loss and low dose aspirin Minerva Ginecol 200355441-9
bull 99 Sinclair C Handbook of obstetrical emergencies 1st ed Philadelphia WB Saunders 1996 p 29-39 69
bull 100 Tarsitano BF Rollings RE The pregnant dental patient evaluation and management Gen Dent 199341226-34
bull 101 Livingston MH Dlllinger TM Holder R Consideration in the management of the pregnant patient SCD Special Care in Dentistry 199818183-8
Thank you
- A Review on the principle of Dental Management of the Pregnant patient
- Slide 2
- Questions that a dentist may ask
- Stages of Pregnancy
- Slide 5
- Slide 6
- Physiologic Changes in Pregnancy
- Systemic changes in pregnancy
- FLAT SUPINE POSITIONING
- SUPINE HYPOTENSION SYNDROME (Vena Cava Compression)
- Supine Hypotension Syndrome
- Slide 12
- Supine Hypotension Syndrome
- Prevention of Supine Hypotensive Syndrome
- Treatment of Supine Hypotensive Syndrome
- How should the pregnant woman be positioned
- Slide 17
- Slide 18
- Slide 19
- Slide 20
- Slide 21
- Slide 22
- Slide 23
- Pregnancy Related Oral Health Problems
- Oral Problems in Pregnancy
- Pregnancy Gingivitis Pathophysiology
- Pregnancy Gingivitis
- Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Gum Problems - Pregnancy Granuloma
- Slide 31
- Gum Changes - Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Candidiasis
- Pregnancy Myths
- Other Oral Conditions in Pregnancy
- Changes During Pregnancy that Affect Oral Health
- Saliva changes
- Increased Bacteria
- Slide 40
- Enamel erosion caused by frequent vomiting
- Treatment for Acid Exposure
- Oral Diseases Can Effect Pregnancy
- Periodontal Disease and Preterm Labor
- Periodontal Disease and Low Birth Weight
- Periodontal Disease and Preeclampsia
- Periodontitis and Pre-eclampsia
- Dental Considerations
- Treatment Timing
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Slide 52
- Use of Radiation on Pregnant Patient
- Radiographs during Pregnancy
- Risks of Dental X-Rays
- FDA drug classification for pregnancy
- Slide 57
- FDA drug classification for pregnancy
- Slide 59
- Slide 60
- Slide 61
- Common Analgesics
- Analgesics
- Analgesics - continued
- Analgesics to Use During 1st and 2nd Trimester
- Analgesics to Avoid During the Third Trimester
- Sedation in Pregnancy
- Common Antibiotics
- Antibiotics
- Antibiotics To Use During Pregnancy
- Antibiotics to Avoid during Pregnancy
- The Problem With Tetracycline
- Other Antimicrobial Agents
- Local Anesthetic Use in Pregnancy
- Use of Local Anesthetics
- Ulcer healing drugs
- Slide 77
- Slide 78
- Slide 79
- Use of Nitrous Oxide Gas
- Common Preventives
- Are topical agents safe
- Pre-natal Fluoride
- Is it safe to use mercury restorations
- References
- REFERENCES
- Slide 87
- Slide 88
- Slide 89
- Slide 90
- Slide 91
- Slide 92
- Slide 93
- Slide 94
- Slide 95
- Slide 96
- Slide 97
- Slide 98
- Thank you
-
bull 49 Hugoson A Gingivitis in pregnant women A longitudinal clinical study Odontol Revy 19712265-84
bull 50 Neville BW Damm DD Allen CM Bouquot JE Oral amp Maxillofacial Pathology 3rd ed Philadelphia W B Saunders 2002 p 329-30 447-9
bull 51 Tilakaratne A Soory M Ranasinghe AW Corea SM Ekanayake SL de Silva M Periodontal disease status during pregnancy and 3 months post-partum in rural population of Sri-Lankan women J Clin Periodontol 200027787-92
bull 52 Laine M Tenovuo J Lehtonen OP Ojanatko-Harri A Vilja P Tuohimaa P Pregnancy e related changes in human whole saliva Arch Oral Biol 198833913-7
bull 53 Yuan K Wing LY Lin MT Pathogenetic roles of angiogenic factors in pyogenic granulomas in pregnancy are modulated by female sex hormones J Periodontol 200273701-8
bull 54 Evans RD Briggs PF Tooth-surface loss related to pregnancyinduced vomiting Prim Dent Care 1994124-6
bull 55 Salvolini E Di Giorgio R Curatola A Mazzanti L Fratto G Biochemical modifications of human whole saliva induced by pregnancy Br J Obstet Gynaec 1998105656-60
bull 56 Mauldin JG Newman RB Preterm birth risk assessment Semin Perinatol 200125215-22
bull 57 Heine RP McGregor JA Goodwin TM Artal R Hayashi RH Robertson PA et al Serial salivary estriol to detect an increased risk of preterm birth Obstet Gynecol 200096490-7
bull 58 Kauh YC Zachian TF Melasma Adv Exp Med Biol 1999455 491-9
bull 59 Wong RC Ellis CN Physiologic skin changes in pregnancy J Am Acad Dermatol 198410929-40
bull 60 Errickson CV Matus NR Skin disorders of pregnancy Am Fam Physician 199449605-10
bull 61 Lopez NJ Smith PC Gutierrez J Periodontal therapy may reduce the risk of preterm low birth weight in women with periodontal disease a randomized controlled trial J Periodontol 200273911-24
bull 62 McGaw T Periodontal disease and preterm delivery of lowbirth- weight infants J Can Dent Assoc 200268165-9
bull 63 Richards AG Dental x-ray protection Dent Clin North Am 1968631-41
bull 64 1990 Recommendations of the International Commission on Radiological Protection Ann ICRP 1991211-201
bull 65 Hall EJ Radiation the two-edged sword cancer risks at high and low doses Cancer J 20006343-50
bull 66 Diethelm L Xu H Diagnostic imaging of the lung during pregnancy Clin Obstet Gynecol 19963936-55
bull 67 Brent RL The effects of embryonic and fetal exposure to x-rays microwaves and ultrasound ClinObstetGynecol 198326484-510
bull 68 National Council on Radiation Protection NCRP report no128 1998 Bethesda Md Author
bull 69 Wasylko L Matsui D Dykxhoorn SM Reider MJ Weinberg S A review of common dental treatments during pregnancy implications for patients and dental personnel J Can Dent Assoc 199864434-9
bull 70 Freeman JP Brand JW Radiation doses of commonly used dental radiographic surveys Oral Surg Oral Med Oral Pathol 199477285-9
bull 71 Kircos LTAngin LL Lorton LOrder ofmagnitude dose reduction in intraoral radiography J Am Dent Assoc 1987114344-7
bull 72 Updegrave WJ Simplified and standardized intraoral radiography with reduced tissue irradiation J Am Dent Assoc 197285861-9
bull 73 Wood RE Harris AM van der Merwe EJ Nortje CJ The leaded apron revisited does it reduce gonadal radiation dose in dental radiology Oral Surg Oral Med Oral Pathol 199171642-6
bull 74 An update on radiographic practices information and recommendations ADA Council on Scientific Affairs J Am Dent Assoc 2001132234-8
bull 75 Rayburn WF Recommending medications during pregnancy an evidence based approach Clin Obstet Gynecol 2002451-5
bull 76 Rathmell JP Viscomi C Ashburn MA Management of nonobstetric pain during pregnancy and lactation Anesth Analg 1997851074-87
bull 77 Teratology society public affairs committee FDA classification of drugs for teratogenic risk Teratology 199449446-7
bull 78 Moore PA Selecting drugs for the pregnant dental patient J Am Dent Assoc 19981291281-6
bull 79 Haas DA An update on analgesics for the management of acute postoperative dental pain J Can Dent Assoc 200268476-82
bull 80 Haas DA Pynn BR Sands TD Drug use for the pregnant or lactating patient Gen Dent 20004854-60
bull 81 Committee on Drugs American Academy of Pediatrics The transfer of drugs and other chemicals into human milk Pediatrics 199493137-50
bull 82 Nielsen GL Sorensen HT Larsen H Pedersen L Risk of adverse birth outcome and miscarriage in pregnant users of nonsteroidal anti-inflammatory drugs population based observational study and case-control study BMJ 2001322266-70
bull 83 Janssen N Genta M The effects of immunosuppressive and anti-inflammatory medications on fertility pregnancy and lactation Arch Intern Med 200016610-9
bull 84 Ostensen M Nonsteroidal anti-inflammatory drugs during pregnancy Scand J Rheumatol Suppl 1998107128-32
bull 85 USPDI -Drug information for the health care professional 22nd ed Greenwood Village CO Micromedex 2002 p 152-79
bull 86 Denson DD Coyle DE Thompson GA Santos D Turner PA Myers JA et al Bupivacaine protein binding in the term parturient effects of lactic acidosis Clin Pharmacol Ther 198435702-9
bull 87 Dillon DE Wagner CL Wiest D Newman RB Drug therapy in the nursing mother Obstet Gynecol Clin North Am 199724 675-96
bull 88 Dashe JS Gilstrap LC Antibiotic use in pregnancy Obstet Gynecol Clin North Am 199724617-29
bull 89 American College of Rheumatology Ad hoc Committee on Clinical Guidelines Guidelines for monitoring drug therapy in rheumatoid arthritis Arthritis Rheum 199639723-31
bull 90 Ng PC The fetal and neonatal hypothalamic-pituitary-adrenal axis Arch Dis Child Fetal Neonatal Ed 200082F250-4
bull 91 Crowley P Antenatal corticosteroidsmdashcurrent thinking BJOG 2003110(Suppl 20)77-8
bull 92 ACOG committee opinion antenatal corticosteroid therapy for fetal maturation Obstet Gynecol 200299871-3
bull 93 Ost L Wettrell G Bjorkhem I Rane A Prednisolone excretion in human milk J Pediatr 19851061008-11
bull 94 Rowland AS Baird DD Shore DL Weinberg CR Savitz DA Wilcox AJ Nitrous oxide and spontaneous abortion in female dental assistants Am J Epidemiol 1995141531-8
bull 95 McGlothlin JD Jensen PA Fischbach TJ Hughes RT Jones JH Control of anesthetic gases in dental operatories Scand J Work Environ Health 199218(Suppl 2)103-5
bull ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY Volume 97 Number 6 Suresh and Radfar 681
bull 96 Rosen MA Nitrous oxide for relief of labor pain a systematic review Am J Obstet Gynecol 2002186(Suppl Nature)S110-6
bull 97 Sands TD Pynn BR Management considerations for the pregnant or nursing emergency patient Ont Dent 199875 17-9
bull 98 Daya S Recurrent spontaneous early pregnancy loss and low dose aspirin Minerva Ginecol 200355441-9
bull 99 Sinclair C Handbook of obstetrical emergencies 1st ed Philadelphia WB Saunders 1996 p 29-39 69
bull 100 Tarsitano BF Rollings RE The pregnant dental patient evaluation and management Gen Dent 199341226-34
bull 101 Livingston MH Dlllinger TM Holder R Consideration in the management of the pregnant patient SCD Special Care in Dentistry 199818183-8
Thank you
- A Review on the principle of Dental Management of the Pregnant patient
- Slide 2
- Questions that a dentist may ask
- Stages of Pregnancy
- Slide 5
- Slide 6
- Physiologic Changes in Pregnancy
- Systemic changes in pregnancy
- FLAT SUPINE POSITIONING
- SUPINE HYPOTENSION SYNDROME (Vena Cava Compression)
- Supine Hypotension Syndrome
- Slide 12
- Supine Hypotension Syndrome
- Prevention of Supine Hypotensive Syndrome
- Treatment of Supine Hypotensive Syndrome
- How should the pregnant woman be positioned
- Slide 17
- Slide 18
- Slide 19
- Slide 20
- Slide 21
- Slide 22
- Slide 23
- Pregnancy Related Oral Health Problems
- Oral Problems in Pregnancy
- Pregnancy Gingivitis Pathophysiology
- Pregnancy Gingivitis
- Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Gum Problems - Pregnancy Granuloma
- Slide 31
- Gum Changes - Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Candidiasis
- Pregnancy Myths
- Other Oral Conditions in Pregnancy
- Changes During Pregnancy that Affect Oral Health
- Saliva changes
- Increased Bacteria
- Slide 40
- Enamel erosion caused by frequent vomiting
- Treatment for Acid Exposure
- Oral Diseases Can Effect Pregnancy
- Periodontal Disease and Preterm Labor
- Periodontal Disease and Low Birth Weight
- Periodontal Disease and Preeclampsia
- Periodontitis and Pre-eclampsia
- Dental Considerations
- Treatment Timing
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Slide 52
- Use of Radiation on Pregnant Patient
- Radiographs during Pregnancy
- Risks of Dental X-Rays
- FDA drug classification for pregnancy
- Slide 57
- FDA drug classification for pregnancy
- Slide 59
- Slide 60
- Slide 61
- Common Analgesics
- Analgesics
- Analgesics - continued
- Analgesics to Use During 1st and 2nd Trimester
- Analgesics to Avoid During the Third Trimester
- Sedation in Pregnancy
- Common Antibiotics
- Antibiotics
- Antibiotics To Use During Pregnancy
- Antibiotics to Avoid during Pregnancy
- The Problem With Tetracycline
- Other Antimicrobial Agents
- Local Anesthetic Use in Pregnancy
- Use of Local Anesthetics
- Ulcer healing drugs
- Slide 77
- Slide 78
- Slide 79
- Use of Nitrous Oxide Gas
- Common Preventives
- Are topical agents safe
- Pre-natal Fluoride
- Is it safe to use mercury restorations
- References
- REFERENCES
- Slide 87
- Slide 88
- Slide 89
- Slide 90
- Slide 91
- Slide 92
- Slide 93
- Slide 94
- Slide 95
- Slide 96
- Slide 97
- Slide 98
- Thank you
-
bull 58 Kauh YC Zachian TF Melasma Adv Exp Med Biol 1999455 491-9
bull 59 Wong RC Ellis CN Physiologic skin changes in pregnancy J Am Acad Dermatol 198410929-40
bull 60 Errickson CV Matus NR Skin disorders of pregnancy Am Fam Physician 199449605-10
bull 61 Lopez NJ Smith PC Gutierrez J Periodontal therapy may reduce the risk of preterm low birth weight in women with periodontal disease a randomized controlled trial J Periodontol 200273911-24
bull 62 McGaw T Periodontal disease and preterm delivery of lowbirth- weight infants J Can Dent Assoc 200268165-9
bull 63 Richards AG Dental x-ray protection Dent Clin North Am 1968631-41
bull 64 1990 Recommendations of the International Commission on Radiological Protection Ann ICRP 1991211-201
bull 65 Hall EJ Radiation the two-edged sword cancer risks at high and low doses Cancer J 20006343-50
bull 66 Diethelm L Xu H Diagnostic imaging of the lung during pregnancy Clin Obstet Gynecol 19963936-55
bull 67 Brent RL The effects of embryonic and fetal exposure to x-rays microwaves and ultrasound ClinObstetGynecol 198326484-510
bull 68 National Council on Radiation Protection NCRP report no128 1998 Bethesda Md Author
bull 69 Wasylko L Matsui D Dykxhoorn SM Reider MJ Weinberg S A review of common dental treatments during pregnancy implications for patients and dental personnel J Can Dent Assoc 199864434-9
bull 70 Freeman JP Brand JW Radiation doses of commonly used dental radiographic surveys Oral Surg Oral Med Oral Pathol 199477285-9
bull 71 Kircos LTAngin LL Lorton LOrder ofmagnitude dose reduction in intraoral radiography J Am Dent Assoc 1987114344-7
bull 72 Updegrave WJ Simplified and standardized intraoral radiography with reduced tissue irradiation J Am Dent Assoc 197285861-9
bull 73 Wood RE Harris AM van der Merwe EJ Nortje CJ The leaded apron revisited does it reduce gonadal radiation dose in dental radiology Oral Surg Oral Med Oral Pathol 199171642-6
bull 74 An update on radiographic practices information and recommendations ADA Council on Scientific Affairs J Am Dent Assoc 2001132234-8
bull 75 Rayburn WF Recommending medications during pregnancy an evidence based approach Clin Obstet Gynecol 2002451-5
bull 76 Rathmell JP Viscomi C Ashburn MA Management of nonobstetric pain during pregnancy and lactation Anesth Analg 1997851074-87
bull 77 Teratology society public affairs committee FDA classification of drugs for teratogenic risk Teratology 199449446-7
bull 78 Moore PA Selecting drugs for the pregnant dental patient J Am Dent Assoc 19981291281-6
bull 79 Haas DA An update on analgesics for the management of acute postoperative dental pain J Can Dent Assoc 200268476-82
bull 80 Haas DA Pynn BR Sands TD Drug use for the pregnant or lactating patient Gen Dent 20004854-60
bull 81 Committee on Drugs American Academy of Pediatrics The transfer of drugs and other chemicals into human milk Pediatrics 199493137-50
bull 82 Nielsen GL Sorensen HT Larsen H Pedersen L Risk of adverse birth outcome and miscarriage in pregnant users of nonsteroidal anti-inflammatory drugs population based observational study and case-control study BMJ 2001322266-70
bull 83 Janssen N Genta M The effects of immunosuppressive and anti-inflammatory medications on fertility pregnancy and lactation Arch Intern Med 200016610-9
bull 84 Ostensen M Nonsteroidal anti-inflammatory drugs during pregnancy Scand J Rheumatol Suppl 1998107128-32
bull 85 USPDI -Drug information for the health care professional 22nd ed Greenwood Village CO Micromedex 2002 p 152-79
bull 86 Denson DD Coyle DE Thompson GA Santos D Turner PA Myers JA et al Bupivacaine protein binding in the term parturient effects of lactic acidosis Clin Pharmacol Ther 198435702-9
bull 87 Dillon DE Wagner CL Wiest D Newman RB Drug therapy in the nursing mother Obstet Gynecol Clin North Am 199724 675-96
bull 88 Dashe JS Gilstrap LC Antibiotic use in pregnancy Obstet Gynecol Clin North Am 199724617-29
bull 89 American College of Rheumatology Ad hoc Committee on Clinical Guidelines Guidelines for monitoring drug therapy in rheumatoid arthritis Arthritis Rheum 199639723-31
bull 90 Ng PC The fetal and neonatal hypothalamic-pituitary-adrenal axis Arch Dis Child Fetal Neonatal Ed 200082F250-4
bull 91 Crowley P Antenatal corticosteroidsmdashcurrent thinking BJOG 2003110(Suppl 20)77-8
bull 92 ACOG committee opinion antenatal corticosteroid therapy for fetal maturation Obstet Gynecol 200299871-3
bull 93 Ost L Wettrell G Bjorkhem I Rane A Prednisolone excretion in human milk J Pediatr 19851061008-11
bull 94 Rowland AS Baird DD Shore DL Weinberg CR Savitz DA Wilcox AJ Nitrous oxide and spontaneous abortion in female dental assistants Am J Epidemiol 1995141531-8
bull 95 McGlothlin JD Jensen PA Fischbach TJ Hughes RT Jones JH Control of anesthetic gases in dental operatories Scand J Work Environ Health 199218(Suppl 2)103-5
bull ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY Volume 97 Number 6 Suresh and Radfar 681
bull 96 Rosen MA Nitrous oxide for relief of labor pain a systematic review Am J Obstet Gynecol 2002186(Suppl Nature)S110-6
bull 97 Sands TD Pynn BR Management considerations for the pregnant or nursing emergency patient Ont Dent 199875 17-9
bull 98 Daya S Recurrent spontaneous early pregnancy loss and low dose aspirin Minerva Ginecol 200355441-9
bull 99 Sinclair C Handbook of obstetrical emergencies 1st ed Philadelphia WB Saunders 1996 p 29-39 69
bull 100 Tarsitano BF Rollings RE The pregnant dental patient evaluation and management Gen Dent 199341226-34
bull 101 Livingston MH Dlllinger TM Holder R Consideration in the management of the pregnant patient SCD Special Care in Dentistry 199818183-8
Thank you
- A Review on the principle of Dental Management of the Pregnant patient
- Slide 2
- Questions that a dentist may ask
- Stages of Pregnancy
- Slide 5
- Slide 6
- Physiologic Changes in Pregnancy
- Systemic changes in pregnancy
- FLAT SUPINE POSITIONING
- SUPINE HYPOTENSION SYNDROME (Vena Cava Compression)
- Supine Hypotension Syndrome
- Slide 12
- Supine Hypotension Syndrome
- Prevention of Supine Hypotensive Syndrome
- Treatment of Supine Hypotensive Syndrome
- How should the pregnant woman be positioned
- Slide 17
- Slide 18
- Slide 19
- Slide 20
- Slide 21
- Slide 22
- Slide 23
- Pregnancy Related Oral Health Problems
- Oral Problems in Pregnancy
- Pregnancy Gingivitis Pathophysiology
- Pregnancy Gingivitis
- Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Gum Problems - Pregnancy Granuloma
- Slide 31
- Gum Changes - Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Candidiasis
- Pregnancy Myths
- Other Oral Conditions in Pregnancy
- Changes During Pregnancy that Affect Oral Health
- Saliva changes
- Increased Bacteria
- Slide 40
- Enamel erosion caused by frequent vomiting
- Treatment for Acid Exposure
- Oral Diseases Can Effect Pregnancy
- Periodontal Disease and Preterm Labor
- Periodontal Disease and Low Birth Weight
- Periodontal Disease and Preeclampsia
- Periodontitis and Pre-eclampsia
- Dental Considerations
- Treatment Timing
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Slide 52
- Use of Radiation on Pregnant Patient
- Radiographs during Pregnancy
- Risks of Dental X-Rays
- FDA drug classification for pregnancy
- Slide 57
- FDA drug classification for pregnancy
- Slide 59
- Slide 60
- Slide 61
- Common Analgesics
- Analgesics
- Analgesics - continued
- Analgesics to Use During 1st and 2nd Trimester
- Analgesics to Avoid During the Third Trimester
- Sedation in Pregnancy
- Common Antibiotics
- Antibiotics
- Antibiotics To Use During Pregnancy
- Antibiotics to Avoid during Pregnancy
- The Problem With Tetracycline
- Other Antimicrobial Agents
- Local Anesthetic Use in Pregnancy
- Use of Local Anesthetics
- Ulcer healing drugs
- Slide 77
- Slide 78
- Slide 79
- Use of Nitrous Oxide Gas
- Common Preventives
- Are topical agents safe
- Pre-natal Fluoride
- Is it safe to use mercury restorations
- References
- REFERENCES
- Slide 87
- Slide 88
- Slide 89
- Slide 90
- Slide 91
- Slide 92
- Slide 93
- Slide 94
- Slide 95
- Slide 96
- Slide 97
- Slide 98
- Thank you
-
bull 67 Brent RL The effects of embryonic and fetal exposure to x-rays microwaves and ultrasound ClinObstetGynecol 198326484-510
bull 68 National Council on Radiation Protection NCRP report no128 1998 Bethesda Md Author
bull 69 Wasylko L Matsui D Dykxhoorn SM Reider MJ Weinberg S A review of common dental treatments during pregnancy implications for patients and dental personnel J Can Dent Assoc 199864434-9
bull 70 Freeman JP Brand JW Radiation doses of commonly used dental radiographic surveys Oral Surg Oral Med Oral Pathol 199477285-9
bull 71 Kircos LTAngin LL Lorton LOrder ofmagnitude dose reduction in intraoral radiography J Am Dent Assoc 1987114344-7
bull 72 Updegrave WJ Simplified and standardized intraoral radiography with reduced tissue irradiation J Am Dent Assoc 197285861-9
bull 73 Wood RE Harris AM van der Merwe EJ Nortje CJ The leaded apron revisited does it reduce gonadal radiation dose in dental radiology Oral Surg Oral Med Oral Pathol 199171642-6
bull 74 An update on radiographic practices information and recommendations ADA Council on Scientific Affairs J Am Dent Assoc 2001132234-8
bull 75 Rayburn WF Recommending medications during pregnancy an evidence based approach Clin Obstet Gynecol 2002451-5
bull 76 Rathmell JP Viscomi C Ashburn MA Management of nonobstetric pain during pregnancy and lactation Anesth Analg 1997851074-87
bull 77 Teratology society public affairs committee FDA classification of drugs for teratogenic risk Teratology 199449446-7
bull 78 Moore PA Selecting drugs for the pregnant dental patient J Am Dent Assoc 19981291281-6
bull 79 Haas DA An update on analgesics for the management of acute postoperative dental pain J Can Dent Assoc 200268476-82
bull 80 Haas DA Pynn BR Sands TD Drug use for the pregnant or lactating patient Gen Dent 20004854-60
bull 81 Committee on Drugs American Academy of Pediatrics The transfer of drugs and other chemicals into human milk Pediatrics 199493137-50
bull 82 Nielsen GL Sorensen HT Larsen H Pedersen L Risk of adverse birth outcome and miscarriage in pregnant users of nonsteroidal anti-inflammatory drugs population based observational study and case-control study BMJ 2001322266-70
bull 83 Janssen N Genta M The effects of immunosuppressive and anti-inflammatory medications on fertility pregnancy and lactation Arch Intern Med 200016610-9
bull 84 Ostensen M Nonsteroidal anti-inflammatory drugs during pregnancy Scand J Rheumatol Suppl 1998107128-32
bull 85 USPDI -Drug information for the health care professional 22nd ed Greenwood Village CO Micromedex 2002 p 152-79
bull 86 Denson DD Coyle DE Thompson GA Santos D Turner PA Myers JA et al Bupivacaine protein binding in the term parturient effects of lactic acidosis Clin Pharmacol Ther 198435702-9
bull 87 Dillon DE Wagner CL Wiest D Newman RB Drug therapy in the nursing mother Obstet Gynecol Clin North Am 199724 675-96
bull 88 Dashe JS Gilstrap LC Antibiotic use in pregnancy Obstet Gynecol Clin North Am 199724617-29
bull 89 American College of Rheumatology Ad hoc Committee on Clinical Guidelines Guidelines for monitoring drug therapy in rheumatoid arthritis Arthritis Rheum 199639723-31
bull 90 Ng PC The fetal and neonatal hypothalamic-pituitary-adrenal axis Arch Dis Child Fetal Neonatal Ed 200082F250-4
bull 91 Crowley P Antenatal corticosteroidsmdashcurrent thinking BJOG 2003110(Suppl 20)77-8
bull 92 ACOG committee opinion antenatal corticosteroid therapy for fetal maturation Obstet Gynecol 200299871-3
bull 93 Ost L Wettrell G Bjorkhem I Rane A Prednisolone excretion in human milk J Pediatr 19851061008-11
bull 94 Rowland AS Baird DD Shore DL Weinberg CR Savitz DA Wilcox AJ Nitrous oxide and spontaneous abortion in female dental assistants Am J Epidemiol 1995141531-8
bull 95 McGlothlin JD Jensen PA Fischbach TJ Hughes RT Jones JH Control of anesthetic gases in dental operatories Scand J Work Environ Health 199218(Suppl 2)103-5
bull ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY Volume 97 Number 6 Suresh and Radfar 681
bull 96 Rosen MA Nitrous oxide for relief of labor pain a systematic review Am J Obstet Gynecol 2002186(Suppl Nature)S110-6
bull 97 Sands TD Pynn BR Management considerations for the pregnant or nursing emergency patient Ont Dent 199875 17-9
bull 98 Daya S Recurrent spontaneous early pregnancy loss and low dose aspirin Minerva Ginecol 200355441-9
bull 99 Sinclair C Handbook of obstetrical emergencies 1st ed Philadelphia WB Saunders 1996 p 29-39 69
bull 100 Tarsitano BF Rollings RE The pregnant dental patient evaluation and management Gen Dent 199341226-34
bull 101 Livingston MH Dlllinger TM Holder R Consideration in the management of the pregnant patient SCD Special Care in Dentistry 199818183-8
Thank you
- A Review on the principle of Dental Management of the Pregnant patient
- Slide 2
- Questions that a dentist may ask
- Stages of Pregnancy
- Slide 5
- Slide 6
- Physiologic Changes in Pregnancy
- Systemic changes in pregnancy
- FLAT SUPINE POSITIONING
- SUPINE HYPOTENSION SYNDROME (Vena Cava Compression)
- Supine Hypotension Syndrome
- Slide 12
- Supine Hypotension Syndrome
- Prevention of Supine Hypotensive Syndrome
- Treatment of Supine Hypotensive Syndrome
- How should the pregnant woman be positioned
- Slide 17
- Slide 18
- Slide 19
- Slide 20
- Slide 21
- Slide 22
- Slide 23
- Pregnancy Related Oral Health Problems
- Oral Problems in Pregnancy
- Pregnancy Gingivitis Pathophysiology
- Pregnancy Gingivitis
- Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Gum Problems - Pregnancy Granuloma
- Slide 31
- Gum Changes - Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Candidiasis
- Pregnancy Myths
- Other Oral Conditions in Pregnancy
- Changes During Pregnancy that Affect Oral Health
- Saliva changes
- Increased Bacteria
- Slide 40
- Enamel erosion caused by frequent vomiting
- Treatment for Acid Exposure
- Oral Diseases Can Effect Pregnancy
- Periodontal Disease and Preterm Labor
- Periodontal Disease and Low Birth Weight
- Periodontal Disease and Preeclampsia
- Periodontitis and Pre-eclampsia
- Dental Considerations
- Treatment Timing
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Slide 52
- Use of Radiation on Pregnant Patient
- Radiographs during Pregnancy
- Risks of Dental X-Rays
- FDA drug classification for pregnancy
- Slide 57
- FDA drug classification for pregnancy
- Slide 59
- Slide 60
- Slide 61
- Common Analgesics
- Analgesics
- Analgesics - continued
- Analgesics to Use During 1st and 2nd Trimester
- Analgesics to Avoid During the Third Trimester
- Sedation in Pregnancy
- Common Antibiotics
- Antibiotics
- Antibiotics To Use During Pregnancy
- Antibiotics to Avoid during Pregnancy
- The Problem With Tetracycline
- Other Antimicrobial Agents
- Local Anesthetic Use in Pregnancy
- Use of Local Anesthetics
- Ulcer healing drugs
- Slide 77
- Slide 78
- Slide 79
- Use of Nitrous Oxide Gas
- Common Preventives
- Are topical agents safe
- Pre-natal Fluoride
- Is it safe to use mercury restorations
- References
- REFERENCES
- Slide 87
- Slide 88
- Slide 89
- Slide 90
- Slide 91
- Slide 92
- Slide 93
- Slide 94
- Slide 95
- Slide 96
- Slide 97
- Slide 98
- Thank you
-
bull 75 Rayburn WF Recommending medications during pregnancy an evidence based approach Clin Obstet Gynecol 2002451-5
bull 76 Rathmell JP Viscomi C Ashburn MA Management of nonobstetric pain during pregnancy and lactation Anesth Analg 1997851074-87
bull 77 Teratology society public affairs committee FDA classification of drugs for teratogenic risk Teratology 199449446-7
bull 78 Moore PA Selecting drugs for the pregnant dental patient J Am Dent Assoc 19981291281-6
bull 79 Haas DA An update on analgesics for the management of acute postoperative dental pain J Can Dent Assoc 200268476-82
bull 80 Haas DA Pynn BR Sands TD Drug use for the pregnant or lactating patient Gen Dent 20004854-60
bull 81 Committee on Drugs American Academy of Pediatrics The transfer of drugs and other chemicals into human milk Pediatrics 199493137-50
bull 82 Nielsen GL Sorensen HT Larsen H Pedersen L Risk of adverse birth outcome and miscarriage in pregnant users of nonsteroidal anti-inflammatory drugs population based observational study and case-control study BMJ 2001322266-70
bull 83 Janssen N Genta M The effects of immunosuppressive and anti-inflammatory medications on fertility pregnancy and lactation Arch Intern Med 200016610-9
bull 84 Ostensen M Nonsteroidal anti-inflammatory drugs during pregnancy Scand J Rheumatol Suppl 1998107128-32
bull 85 USPDI -Drug information for the health care professional 22nd ed Greenwood Village CO Micromedex 2002 p 152-79
bull 86 Denson DD Coyle DE Thompson GA Santos D Turner PA Myers JA et al Bupivacaine protein binding in the term parturient effects of lactic acidosis Clin Pharmacol Ther 198435702-9
bull 87 Dillon DE Wagner CL Wiest D Newman RB Drug therapy in the nursing mother Obstet Gynecol Clin North Am 199724 675-96
bull 88 Dashe JS Gilstrap LC Antibiotic use in pregnancy Obstet Gynecol Clin North Am 199724617-29
bull 89 American College of Rheumatology Ad hoc Committee on Clinical Guidelines Guidelines for monitoring drug therapy in rheumatoid arthritis Arthritis Rheum 199639723-31
bull 90 Ng PC The fetal and neonatal hypothalamic-pituitary-adrenal axis Arch Dis Child Fetal Neonatal Ed 200082F250-4
bull 91 Crowley P Antenatal corticosteroidsmdashcurrent thinking BJOG 2003110(Suppl 20)77-8
bull 92 ACOG committee opinion antenatal corticosteroid therapy for fetal maturation Obstet Gynecol 200299871-3
bull 93 Ost L Wettrell G Bjorkhem I Rane A Prednisolone excretion in human milk J Pediatr 19851061008-11
bull 94 Rowland AS Baird DD Shore DL Weinberg CR Savitz DA Wilcox AJ Nitrous oxide and spontaneous abortion in female dental assistants Am J Epidemiol 1995141531-8
bull 95 McGlothlin JD Jensen PA Fischbach TJ Hughes RT Jones JH Control of anesthetic gases in dental operatories Scand J Work Environ Health 199218(Suppl 2)103-5
bull ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY Volume 97 Number 6 Suresh and Radfar 681
bull 96 Rosen MA Nitrous oxide for relief of labor pain a systematic review Am J Obstet Gynecol 2002186(Suppl Nature)S110-6
bull 97 Sands TD Pynn BR Management considerations for the pregnant or nursing emergency patient Ont Dent 199875 17-9
bull 98 Daya S Recurrent spontaneous early pregnancy loss and low dose aspirin Minerva Ginecol 200355441-9
bull 99 Sinclair C Handbook of obstetrical emergencies 1st ed Philadelphia WB Saunders 1996 p 29-39 69
bull 100 Tarsitano BF Rollings RE The pregnant dental patient evaluation and management Gen Dent 199341226-34
bull 101 Livingston MH Dlllinger TM Holder R Consideration in the management of the pregnant patient SCD Special Care in Dentistry 199818183-8
Thank you
- A Review on the principle of Dental Management of the Pregnant patient
- Slide 2
- Questions that a dentist may ask
- Stages of Pregnancy
- Slide 5
- Slide 6
- Physiologic Changes in Pregnancy
- Systemic changes in pregnancy
- FLAT SUPINE POSITIONING
- SUPINE HYPOTENSION SYNDROME (Vena Cava Compression)
- Supine Hypotension Syndrome
- Slide 12
- Supine Hypotension Syndrome
- Prevention of Supine Hypotensive Syndrome
- Treatment of Supine Hypotensive Syndrome
- How should the pregnant woman be positioned
- Slide 17
- Slide 18
- Slide 19
- Slide 20
- Slide 21
- Slide 22
- Slide 23
- Pregnancy Related Oral Health Problems
- Oral Problems in Pregnancy
- Pregnancy Gingivitis Pathophysiology
- Pregnancy Gingivitis
- Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Gum Problems - Pregnancy Granuloma
- Slide 31
- Gum Changes - Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Candidiasis
- Pregnancy Myths
- Other Oral Conditions in Pregnancy
- Changes During Pregnancy that Affect Oral Health
- Saliva changes
- Increased Bacteria
- Slide 40
- Enamel erosion caused by frequent vomiting
- Treatment for Acid Exposure
- Oral Diseases Can Effect Pregnancy
- Periodontal Disease and Preterm Labor
- Periodontal Disease and Low Birth Weight
- Periodontal Disease and Preeclampsia
- Periodontitis and Pre-eclampsia
- Dental Considerations
- Treatment Timing
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Slide 52
- Use of Radiation on Pregnant Patient
- Radiographs during Pregnancy
- Risks of Dental X-Rays
- FDA drug classification for pregnancy
- Slide 57
- FDA drug classification for pregnancy
- Slide 59
- Slide 60
- Slide 61
- Common Analgesics
- Analgesics
- Analgesics - continued
- Analgesics to Use During 1st and 2nd Trimester
- Analgesics to Avoid During the Third Trimester
- Sedation in Pregnancy
- Common Antibiotics
- Antibiotics
- Antibiotics To Use During Pregnancy
- Antibiotics to Avoid during Pregnancy
- The Problem With Tetracycline
- Other Antimicrobial Agents
- Local Anesthetic Use in Pregnancy
- Use of Local Anesthetics
- Ulcer healing drugs
- Slide 77
- Slide 78
- Slide 79
- Use of Nitrous Oxide Gas
- Common Preventives
- Are topical agents safe
- Pre-natal Fluoride
- Is it safe to use mercury restorations
- References
- REFERENCES
- Slide 87
- Slide 88
- Slide 89
- Slide 90
- Slide 91
- Slide 92
- Slide 93
- Slide 94
- Slide 95
- Slide 96
- Slide 97
- Slide 98
- Thank you
-
bull 84 Ostensen M Nonsteroidal anti-inflammatory drugs during pregnancy Scand J Rheumatol Suppl 1998107128-32
bull 85 USPDI -Drug information for the health care professional 22nd ed Greenwood Village CO Micromedex 2002 p 152-79
bull 86 Denson DD Coyle DE Thompson GA Santos D Turner PA Myers JA et al Bupivacaine protein binding in the term parturient effects of lactic acidosis Clin Pharmacol Ther 198435702-9
bull 87 Dillon DE Wagner CL Wiest D Newman RB Drug therapy in the nursing mother Obstet Gynecol Clin North Am 199724 675-96
bull 88 Dashe JS Gilstrap LC Antibiotic use in pregnancy Obstet Gynecol Clin North Am 199724617-29
bull 89 American College of Rheumatology Ad hoc Committee on Clinical Guidelines Guidelines for monitoring drug therapy in rheumatoid arthritis Arthritis Rheum 199639723-31
bull 90 Ng PC The fetal and neonatal hypothalamic-pituitary-adrenal axis Arch Dis Child Fetal Neonatal Ed 200082F250-4
bull 91 Crowley P Antenatal corticosteroidsmdashcurrent thinking BJOG 2003110(Suppl 20)77-8
bull 92 ACOG committee opinion antenatal corticosteroid therapy for fetal maturation Obstet Gynecol 200299871-3
bull 93 Ost L Wettrell G Bjorkhem I Rane A Prednisolone excretion in human milk J Pediatr 19851061008-11
bull 94 Rowland AS Baird DD Shore DL Weinberg CR Savitz DA Wilcox AJ Nitrous oxide and spontaneous abortion in female dental assistants Am J Epidemiol 1995141531-8
bull 95 McGlothlin JD Jensen PA Fischbach TJ Hughes RT Jones JH Control of anesthetic gases in dental operatories Scand J Work Environ Health 199218(Suppl 2)103-5
bull ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY Volume 97 Number 6 Suresh and Radfar 681
bull 96 Rosen MA Nitrous oxide for relief of labor pain a systematic review Am J Obstet Gynecol 2002186(Suppl Nature)S110-6
bull 97 Sands TD Pynn BR Management considerations for the pregnant or nursing emergency patient Ont Dent 199875 17-9
bull 98 Daya S Recurrent spontaneous early pregnancy loss and low dose aspirin Minerva Ginecol 200355441-9
bull 99 Sinclair C Handbook of obstetrical emergencies 1st ed Philadelphia WB Saunders 1996 p 29-39 69
bull 100 Tarsitano BF Rollings RE The pregnant dental patient evaluation and management Gen Dent 199341226-34
bull 101 Livingston MH Dlllinger TM Holder R Consideration in the management of the pregnant patient SCD Special Care in Dentistry 199818183-8
Thank you
- A Review on the principle of Dental Management of the Pregnant patient
- Slide 2
- Questions that a dentist may ask
- Stages of Pregnancy
- Slide 5
- Slide 6
- Physiologic Changes in Pregnancy
- Systemic changes in pregnancy
- FLAT SUPINE POSITIONING
- SUPINE HYPOTENSION SYNDROME (Vena Cava Compression)
- Supine Hypotension Syndrome
- Slide 12
- Supine Hypotension Syndrome
- Prevention of Supine Hypotensive Syndrome
- Treatment of Supine Hypotensive Syndrome
- How should the pregnant woman be positioned
- Slide 17
- Slide 18
- Slide 19
- Slide 20
- Slide 21
- Slide 22
- Slide 23
- Pregnancy Related Oral Health Problems
- Oral Problems in Pregnancy
- Pregnancy Gingivitis Pathophysiology
- Pregnancy Gingivitis
- Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Gum Problems - Pregnancy Granuloma
- Slide 31
- Gum Changes - Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Candidiasis
- Pregnancy Myths
- Other Oral Conditions in Pregnancy
- Changes During Pregnancy that Affect Oral Health
- Saliva changes
- Increased Bacteria
- Slide 40
- Enamel erosion caused by frequent vomiting
- Treatment for Acid Exposure
- Oral Diseases Can Effect Pregnancy
- Periodontal Disease and Preterm Labor
- Periodontal Disease and Low Birth Weight
- Periodontal Disease and Preeclampsia
- Periodontitis and Pre-eclampsia
- Dental Considerations
- Treatment Timing
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Slide 52
- Use of Radiation on Pregnant Patient
- Radiographs during Pregnancy
- Risks of Dental X-Rays
- FDA drug classification for pregnancy
- Slide 57
- FDA drug classification for pregnancy
- Slide 59
- Slide 60
- Slide 61
- Common Analgesics
- Analgesics
- Analgesics - continued
- Analgesics to Use During 1st and 2nd Trimester
- Analgesics to Avoid During the Third Trimester
- Sedation in Pregnancy
- Common Antibiotics
- Antibiotics
- Antibiotics To Use During Pregnancy
- Antibiotics to Avoid during Pregnancy
- The Problem With Tetracycline
- Other Antimicrobial Agents
- Local Anesthetic Use in Pregnancy
- Use of Local Anesthetics
- Ulcer healing drugs
- Slide 77
- Slide 78
- Slide 79
- Use of Nitrous Oxide Gas
- Common Preventives
- Are topical agents safe
- Pre-natal Fluoride
- Is it safe to use mercury restorations
- References
- REFERENCES
- Slide 87
- Slide 88
- Slide 89
- Slide 90
- Slide 91
- Slide 92
- Slide 93
- Slide 94
- Slide 95
- Slide 96
- Slide 97
- Slide 98
- Thank you
-
bull 94 Rowland AS Baird DD Shore DL Weinberg CR Savitz DA Wilcox AJ Nitrous oxide and spontaneous abortion in female dental assistants Am J Epidemiol 1995141531-8
bull 95 McGlothlin JD Jensen PA Fischbach TJ Hughes RT Jones JH Control of anesthetic gases in dental operatories Scand J Work Environ Health 199218(Suppl 2)103-5
bull ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY Volume 97 Number 6 Suresh and Radfar 681
bull 96 Rosen MA Nitrous oxide for relief of labor pain a systematic review Am J Obstet Gynecol 2002186(Suppl Nature)S110-6
bull 97 Sands TD Pynn BR Management considerations for the pregnant or nursing emergency patient Ont Dent 199875 17-9
bull 98 Daya S Recurrent spontaneous early pregnancy loss and low dose aspirin Minerva Ginecol 200355441-9
bull 99 Sinclair C Handbook of obstetrical emergencies 1st ed Philadelphia WB Saunders 1996 p 29-39 69
bull 100 Tarsitano BF Rollings RE The pregnant dental patient evaluation and management Gen Dent 199341226-34
bull 101 Livingston MH Dlllinger TM Holder R Consideration in the management of the pregnant patient SCD Special Care in Dentistry 199818183-8
Thank you
- A Review on the principle of Dental Management of the Pregnant patient
- Slide 2
- Questions that a dentist may ask
- Stages of Pregnancy
- Slide 5
- Slide 6
- Physiologic Changes in Pregnancy
- Systemic changes in pregnancy
- FLAT SUPINE POSITIONING
- SUPINE HYPOTENSION SYNDROME (Vena Cava Compression)
- Supine Hypotension Syndrome
- Slide 12
- Supine Hypotension Syndrome
- Prevention of Supine Hypotensive Syndrome
- Treatment of Supine Hypotensive Syndrome
- How should the pregnant woman be positioned
- Slide 17
- Slide 18
- Slide 19
- Slide 20
- Slide 21
- Slide 22
- Slide 23
- Pregnancy Related Oral Health Problems
- Oral Problems in Pregnancy
- Pregnancy Gingivitis Pathophysiology
- Pregnancy Gingivitis
- Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Gum Problems - Pregnancy Granuloma
- Slide 31
- Gum Changes - Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Candidiasis
- Pregnancy Myths
- Other Oral Conditions in Pregnancy
- Changes During Pregnancy that Affect Oral Health
- Saliva changes
- Increased Bacteria
- Slide 40
- Enamel erosion caused by frequent vomiting
- Treatment for Acid Exposure
- Oral Diseases Can Effect Pregnancy
- Periodontal Disease and Preterm Labor
- Periodontal Disease and Low Birth Weight
- Periodontal Disease and Preeclampsia
- Periodontitis and Pre-eclampsia
- Dental Considerations
- Treatment Timing
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Slide 52
- Use of Radiation on Pregnant Patient
- Radiographs during Pregnancy
- Risks of Dental X-Rays
- FDA drug classification for pregnancy
- Slide 57
- FDA drug classification for pregnancy
- Slide 59
- Slide 60
- Slide 61
- Common Analgesics
- Analgesics
- Analgesics - continued
- Analgesics to Use During 1st and 2nd Trimester
- Analgesics to Avoid During the Third Trimester
- Sedation in Pregnancy
- Common Antibiotics
- Antibiotics
- Antibiotics To Use During Pregnancy
- Antibiotics to Avoid during Pregnancy
- The Problem With Tetracycline
- Other Antimicrobial Agents
- Local Anesthetic Use in Pregnancy
- Use of Local Anesthetics
- Ulcer healing drugs
- Slide 77
- Slide 78
- Slide 79
- Use of Nitrous Oxide Gas
- Common Preventives
- Are topical agents safe
- Pre-natal Fluoride
- Is it safe to use mercury restorations
- References
- REFERENCES
- Slide 87
- Slide 88
- Slide 89
- Slide 90
- Slide 91
- Slide 92
- Slide 93
- Slide 94
- Slide 95
- Slide 96
- Slide 97
- Slide 98
- Thank you
-
bull 96 Rosen MA Nitrous oxide for relief of labor pain a systematic review Am J Obstet Gynecol 2002186(Suppl Nature)S110-6
bull 97 Sands TD Pynn BR Management considerations for the pregnant or nursing emergency patient Ont Dent 199875 17-9
bull 98 Daya S Recurrent spontaneous early pregnancy loss and low dose aspirin Minerva Ginecol 200355441-9
bull 99 Sinclair C Handbook of obstetrical emergencies 1st ed Philadelphia WB Saunders 1996 p 29-39 69
bull 100 Tarsitano BF Rollings RE The pregnant dental patient evaluation and management Gen Dent 199341226-34
bull 101 Livingston MH Dlllinger TM Holder R Consideration in the management of the pregnant patient SCD Special Care in Dentistry 199818183-8
Thank you
- A Review on the principle of Dental Management of the Pregnant patient
- Slide 2
- Questions that a dentist may ask
- Stages of Pregnancy
- Slide 5
- Slide 6
- Physiologic Changes in Pregnancy
- Systemic changes in pregnancy
- FLAT SUPINE POSITIONING
- SUPINE HYPOTENSION SYNDROME (Vena Cava Compression)
- Supine Hypotension Syndrome
- Slide 12
- Supine Hypotension Syndrome
- Prevention of Supine Hypotensive Syndrome
- Treatment of Supine Hypotensive Syndrome
- How should the pregnant woman be positioned
- Slide 17
- Slide 18
- Slide 19
- Slide 20
- Slide 21
- Slide 22
- Slide 23
- Pregnancy Related Oral Health Problems
- Oral Problems in Pregnancy
- Pregnancy Gingivitis Pathophysiology
- Pregnancy Gingivitis
- Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Gum Problems - Pregnancy Granuloma
- Slide 31
- Gum Changes - Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Candidiasis
- Pregnancy Myths
- Other Oral Conditions in Pregnancy
- Changes During Pregnancy that Affect Oral Health
- Saliva changes
- Increased Bacteria
- Slide 40
- Enamel erosion caused by frequent vomiting
- Treatment for Acid Exposure
- Oral Diseases Can Effect Pregnancy
- Periodontal Disease and Preterm Labor
- Periodontal Disease and Low Birth Weight
- Periodontal Disease and Preeclampsia
- Periodontitis and Pre-eclampsia
- Dental Considerations
- Treatment Timing
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Slide 52
- Use of Radiation on Pregnant Patient
- Radiographs during Pregnancy
- Risks of Dental X-Rays
- FDA drug classification for pregnancy
- Slide 57
- FDA drug classification for pregnancy
- Slide 59
- Slide 60
- Slide 61
- Common Analgesics
- Analgesics
- Analgesics - continued
- Analgesics to Use During 1st and 2nd Trimester
- Analgesics to Avoid During the Third Trimester
- Sedation in Pregnancy
- Common Antibiotics
- Antibiotics
- Antibiotics To Use During Pregnancy
- Antibiotics to Avoid during Pregnancy
- The Problem With Tetracycline
- Other Antimicrobial Agents
- Local Anesthetic Use in Pregnancy
- Use of Local Anesthetics
- Ulcer healing drugs
- Slide 77
- Slide 78
- Slide 79
- Use of Nitrous Oxide Gas
- Common Preventives
- Are topical agents safe
- Pre-natal Fluoride
- Is it safe to use mercury restorations
- References
- REFERENCES
- Slide 87
- Slide 88
- Slide 89
- Slide 90
- Slide 91
- Slide 92
- Slide 93
- Slide 94
- Slide 95
- Slide 96
- Slide 97
- Slide 98
- Thank you
-
Thank you
- A Review on the principle of Dental Management of the Pregnant patient
- Slide 2
- Questions that a dentist may ask
- Stages of Pregnancy
- Slide 5
- Slide 6
- Physiologic Changes in Pregnancy
- Systemic changes in pregnancy
- FLAT SUPINE POSITIONING
- SUPINE HYPOTENSION SYNDROME (Vena Cava Compression)
- Supine Hypotension Syndrome
- Slide 12
- Supine Hypotension Syndrome
- Prevention of Supine Hypotensive Syndrome
- Treatment of Supine Hypotensive Syndrome
- How should the pregnant woman be positioned
- Slide 17
- Slide 18
- Slide 19
- Slide 20
- Slide 21
- Slide 22
- Slide 23
- Pregnancy Related Oral Health Problems
- Oral Problems in Pregnancy
- Pregnancy Gingivitis Pathophysiology
- Pregnancy Gingivitis
- Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Gum Problems - Pregnancy Granuloma
- Slide 31
- Gum Changes - Pregnancy Granuloma
- Pregnancy Granuloma (continued)
- Candidiasis
- Pregnancy Myths
- Other Oral Conditions in Pregnancy
- Changes During Pregnancy that Affect Oral Health
- Saliva changes
- Increased Bacteria
- Slide 40
- Enamel erosion caused by frequent vomiting
- Treatment for Acid Exposure
- Oral Diseases Can Effect Pregnancy
- Periodontal Disease and Preterm Labor
- Periodontal Disease and Low Birth Weight
- Periodontal Disease and Preeclampsia
- Periodontitis and Pre-eclampsia
- Dental Considerations
- Treatment Timing
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Timing of Dental Treatment During Pregnancy - From Little and Fallace
- Slide 52
- Use of Radiation on Pregnant Patient
- Radiographs during Pregnancy
- Risks of Dental X-Rays
- FDA drug classification for pregnancy
- Slide 57
- FDA drug classification for pregnancy
- Slide 59
- Slide 60
- Slide 61
- Common Analgesics
- Analgesics
- Analgesics - continued
- Analgesics to Use During 1st and 2nd Trimester
- Analgesics to Avoid During the Third Trimester
- Sedation in Pregnancy
- Common Antibiotics
- Antibiotics
- Antibiotics To Use During Pregnancy
- Antibiotics to Avoid during Pregnancy
- The Problem With Tetracycline
- Other Antimicrobial Agents
- Local Anesthetic Use in Pregnancy
- Use of Local Anesthetics
- Ulcer healing drugs
- Slide 77
- Slide 78
- Slide 79
- Use of Nitrous Oxide Gas
- Common Preventives
- Are topical agents safe
- Pre-natal Fluoride
- Is it safe to use mercury restorations
- References
- REFERENCES
- Slide 87
- Slide 88
- Slide 89
- Slide 90
- Slide 91
- Slide 92
- Slide 93
- Slide 94
- Slide 95
- Slide 96
- Slide 97
- Slide 98
- Thank you
-