A dental student’s guide to…pregnant patients

Hannah Hook discusses the considerations and understandings needed when working with pregnant patientsHannah Hook discusses the considerations and understandings needed when working with pregnant patients.

During pregnancy a variety of anatomical and physiological changes are induced, therefore special consideration is required when managing the pregnant patient. Understanding how to identify and manage oral changes that a pregnant patient may undergo is important in providing effective care for your patient.

Some dentists may feel slightly reluctant to perform dental treatment on a pregnant patient due to the uncertainty of its effects. Therefore, it is vital to understand the effects that dental treatment may have during pregnancy, and recognise what is safe and what should be avoided.

Trimesters

  • First trimester (1 – 12 weeks)
  • Second trimester (13 – 27 weeks)
  • Third trimester (28 – 40+ weeks).

Oral manifestations

Pregnancy gingivitis

Whilst pregnancy does not directly cause gingivitis or periodontitis the increased levels of circulating oestrogen result in amplified capillary permeability which can exacerbate a pre-existing condition.

Pregnancy granuloma/epulis

  • A benign overgrowth of gingival tissue and capillaries most commonly found at the area of the interdental papilla on the labial surface
  • Occurrence rate is between 1-5%, and they most often arise in the third trimester
  • Thought to be due to an increase in sex hormones such as progesterone, angiogenesis, and gingival irritation such as the present of plaque deposits.

Salivary changes

  • During pregnancy some changes have been noted in the composition of saliva
  • Decreased pH and sodium concentration, increased potassium and oestrogen levels
  • Amplified salivary oestrogen levels lead to proliferation and desquamation of the oral mucosa, with the desquamated cells providing nutrition to oral bacteria
  • Alongside the drop in pH and buffering effect of the saliva a suitable environment for cariogenic bacteria to thrive is created, in turn increasing the risk of caries.

Heartburn

  • Present in 30-70% of pregnant women
  • Due to a reduction in the muscle tone of the lower oesophageal sphincter and increased intragastric pressure.

Morning sickness

  • Around 66% of pregnant women experience nausea and vomiting
  • An increase in HGC (human chorionic gonadotrophin) is thought to be the cause of morning sickness
  • Frequent vomiting can lead to erosion of the palatal surfaces of teeth.

Oral hygiene

  • Excellent oral hygiene is key in maintaining oral health and preventing gingivitis, periodontitis, and dental decay
  • Patients should be shown how to effectively use interproximal cleaning aids such as Tepe and floss
  • Brushing frequency and technique should be checked and corrected as necessary
  • Diet advice relating to the consumption of refined carbohydrates should be given
  • Morning sickness can lead to numerous acid attacks on the teeth; therefore, patients should be advised to thoroughly rinse their mouth with water or a fluoridated mouthwash.

Drugs

Fluoride

  • Whilst many studies have noted that fluoride crosses the placenta, it has been found that it is not a teratogen
  • Despite this, there is not enough evidence to say that the use of 5,000ppm sodium fluoride toothpaste or 22,600ppm fluoride varnish is safe for use in pregnant or breast feeding women
  • Fluoride toothpaste with a concentration of 2,800ppm has been found to be safe during pregnancy and lactation.

Local anaesthetic

  • All local anaesthetics will cross the placenta; however, the extent will vary depending on the type of local anaesthetic
  • Local anaesthetic containing a vasoconstrictor such as adrenaline should be used, along with careful aspiration
  • Information regarding the effects of articaine use during pregnancy is limited, therefore its use should be avoided unless any potential benefit outweighs the risk
  • Avoid local anaesthetics containing felypressin, such as prilocaine with felypressin. Felypressin is related to oxytocin which, whilst highly unlikely, may have the potential to cause uterine contractions
  • Lidocaine with adrenaline is safe to use for most pregnant women.

Antibiotics

  • As with all drugs all antibiotics will cross the placenta to a certain degree, therefore antibiotics should only be prescribed if deemed that the potential benefit outweighs the risk
  • Antibiotics safe for use in pregnant women (providing no allergies) include penicillins, cephalosporins, erythromycin and clindamycin
  • Tetracyclines should be avoided due to their irreversible effects on the teeth and bones of the developing foetus
  • Check guidance from sources such as the BNF before prescribing!

Analgesics

  • Paracetamol has been shown to demonstrate efficacy and safety during all stages of pregnancy
  • The use of ibuprofen in the pregnant patient is not advised as studies have highlighted an association between the use of the NSAID and an increased risk of premature closure of the ductus arteriosus in the third trimester.

Positioning

  • Patients in their third trimester are at an increased risk of supine hypertensive syndrome
  • This is thought to occur in approximately 8% of pregnant patients
  • When laying horizontally the weight of the foetus puts pressure on the inferior vena cava
  • Compression of the inferior vena cava causes a sudden drop in blood pressure leading to dizziness, nausea, and also fainting
  • To prevent this, elevate the patient’s right hip by 10-12cm.

Radiography

  • Often there is substantial concern regarding radiography during pregnancy due to the possible risk to the developing foetus
  • During the majority of dental radiographs, it is rare that the X-ray beam would be pointed towards the abdomen. If, in the rare case that an essential radiograph is required and the angle of the X-ray beam is directed towards the abdomen, then a lead apron should be used to protect the foetus
  • For all standard radiographs which don’t require angulation of the X-ray beam towards the abdomen, there is no requirement to postpone until after the birth of the baby
  • However due to radiographs and pregnancy being an emotive topic, the FGDP recommends that practitioners offer pregnant patients the option of delaying non-urgent radiographs.

Summary

  • Pregnancy is a unique time in which a woman undergoes a multitude of physiological changes to support the development of new life
  • Every pregnant patient should be encouraged to see their dentist to enable treatment or stabilisation of any current disease
  • The importance of excellent oral hygiene should be reinforced, and measures should also be put in place aimed at prevention of future disease
  • Due to the sensitive nature of a developing foetus the prescribing of medications should be done so with caution and double checked using national guidance such as the BNF.

References

Babb M, Koren G, Einarson A (2010) Treating pain during pregnancy Canadian Family Physician 56: 25–27

Chaveli López B, Sarrión Pérez G, Soriano YJ (2011) Journal section: Oral Medicine and Pathology J Clin Exp Dent 3: 135–179

Gajendra S, Kumar J V (2004) Oral health and pregnancy: a review The New York State Dental Journal 70: 40–44

Hemalatha VT, Manigandan T, Sarumathi T, et al (2013) Dental considerations in pregnancy – a critical review on the oral care Journal of Clinical and Diagnostic Research 7: 948–953

Scully C (2014) Age and gender issues Scully’s Medical Problems in Dentistry Elsevier, 627–651

Turner M, Aziz SR (2002) Management of the pregnant oral and maxillofacial surgery patient J Oral Maxillofac Surg 60: 1479–1488.


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