Dentistry and the Pregnant Patient
Dentistry
and the
Pregnant
Patient
Assistant Professor
Dental Education Services
School of Dentistry
Loma Linda University
Loma Linda, California
With contributions from
R. Leslie Arnett, DDS, MS
Sheila Bahn, MD
Brinda Grapin, PharmD
Bates D. Moses, MD
This book is dedicated to my amazing family: Priscilla, Norman, Pat, Bonnie, Ben, Barbara, David, Stacy, Debbie, Kayli, and Khloe. Thank you for always supporting my pursuits. I also extend this dedication to those who have touched my life and inspired me to make this world a better place.
Library of Congress Cataloging-in-Publication Data
Names: Ninan, Daniel, author.
Title: Dentistry and the pregnant patient / Daniel Ninan.
Description: Hanover Park, IL : Quintessence Publishing Co Inc, [2018] |
Includes bibliographical references and index.
Identifiers: LCCN 2017058024 (print) | LCCN 2017059740 (ebook) | ISBN
9780867159134 (ebook) | ISBN 9780867157796 (softcover)
Subjects: | MESH: Dental Care | Pregnant Women
Classification: LCC RK56 (ebook) | LCC RK56 (print) | NLM WU 29 | DDC
617.6--dc23
LC record available at https://lccn.loc.gov/2017058024
© 2018 Quintessence Publishing Co, Inc
Quintessence Publishing Co, Inc
4350 Chandler Drive
Hanover Park, IL 60133
www.quintpub.com
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All rights reserved. This book or any part thereof may not be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, or otherwise, without prior written permission of the publisher.
Editor: Marieke Zaffron
Design: Sue Zubek
Production: Angelina Schmelter
Contents
Preface
1 Perceptions About Dental Treatment During Pregnancy
2 Considerations for Treating Pregnant Patients
3 Complications and the Impact on Dental Care
4 Procedures and Treatment Guidelines
5 Administration of Drugs During Pregnancy
6 Medications
7 Anesthetic Use
Appendices
Preface
My Introduction to the Treatment of Pregnant Women
Early in life, I became aware of the fear and caution that can envelop health care practitioners when they are placed in a situation where they have to evaluate and treat a pregnant woman. My mother, a labor and delivery nurse, told me stories about her experiences. One time, the emergency room staff immediately transferred a patient to the labor and delivery unit upon finding out she was pregnant—without even assessing the chief complaint that brought her to the emergency room in the first place. It is likely that the emergency room staff had reservations about treating a pregnant woman without first obtaining a specialist’s opinion. I have observed what appears to be a similar fear from dental professionals who are reluctant to treat pregnant patients. Many dentists may fear that they may cause harm to the unborn baby or the expectant mother.1
The Role of Dentistry During Pregnancy
As dental professionals, our duty is to find ways to provide necessary dental care as safely as possible. Our ideal role is to work with a woman to help her get to a state of ideal oral health before she becomes pregnant. This way, the need for invasive treatments during pregnancy is minimized or prevented altogether. Researchers keep uncovering evidence that untreated oral disease has the potential to be detrimental to both the expectant mother and the baby. Poor oral health is associated with a number of pregnancy-related complications, including the following:
• Preterm delivery2
• Low birth weight2,3
• Preeclampsia2,4
• Gestational diabetes3
• Fetal loss5
• Childhood caries as a result of maternal cariogenic bacterial load6
Unfortunately, there is a large proportion of pregnant women who have significant unmet oral health care needs. Many women either fail to seek or are unable to receive dental treatment based on concerns regarding its safety during pregnancy.
It is understandable for providers to have reservations about treating patients in need, and careful consideration should be given to every circumstance. Currently, there is limited clinical trial evidence to support or refute the premise that providing dental care is totally safe for the pregnant woman. And while dental procedures have not been directly linked to fetal loss, it may be of importance to note that most dental procedures induce bacteremias, and subgingival bacteria has been reported to travel to the placenta and cause fetal demise.5,7
Even if all dental needs are addressed prior to pregnancy, unforeseen dental emergencies may arise that require invasive and sometimes extensive treatment during pregnancy. It is also important to note that nearly 50% of women have at least one unplanned pregnancy during the course of their life. It is possible that a dentist may treat some patients who do not realize they are already pregnant. Because of this, dental professionals should always consider the possibility of adverse fetal effect when treating a woman of childbearing age.
This book is a quick reference guide on how to maximize the safety of the pregnant woman and her unborn child while providing dental care. Ultimately, my hope is that this will result in better outcomes for both the expectant mother and her unborn baby.
Acknowledgments
I would first like to thank Quintessence Publishing for this opportunity. I would also like to say thank you to everyone who helped. As with any list of people, there are always more whose names are inadvertently omitted. I am very grateful to Dan Fischer and the many suggestions he provided during this project. I do want to say thank you to Alexander Bahn, Natalie Barton, Richard Lynch, Cathy Presland, and Penny Swift, as well as my family for their support and guidance while writing this book.
References
1. California Dental Association Foundation; American College of Obstetricians and Gynecologists, District IX. Oral health during pregnancy and early childhood: Evidence-based guidelines for health professionals. J Calif Dent Assoc 2010;38:391–403, 405–440.
2. Sanz M, Kornman K, Working group 3 of joint EFP/AAP workshop. Periodontitis and adverse pregnancy outcomes: Consensus report of the Joint EFP/AAP Workshop on Periodontitis and Systemic Diseases. J Periodontol 2013;84(4 suppl):S164–S169.
3. Kentucky Cabinet for Health and Family Services. Kentucky Pregnancy Risk Assessment Monitoring System (PRAMS) Pilot Project: 2008 Data Report. http://chfs.ky.gov/NR/rdonlyres/888F8BBC-3DF7-47A4-B34E-8BD-7BABA1E09/0/PRAMSREPORT08finalwithcovers.pdf. Accessed 15 January 2018.
4. Strafford KE, Shellhaas C, Hade EM. Provider and patient perceptions about dental care during pregnancy. J Matern Fetal Neonatal Med 2008;21:63–71.
5. Han YW, Fardini Y, Chen C, et al. Term stillbirth caused by oral Fusobacterium nucleatum. Obstet Gynecol 2010;115:442–445.
6. Chaffee BW, Gansky SA, Weintraub JA, Featherstone JDB, Ramos-Gomez FJ. Maternal oral bacterial levels predict early childhood caries development. J Dent Res 2014;93:238–244.
7. Hilgers KK, Douglass J, Mathieu GP. Adolescent pregnancy: A review of dental treatment guidelines. Pediatr Dent 2003;25:459–467.
CHAPTER 1
Perceptions
About Dental
Treatment During
Pregnancy
Key Points
• Prenatal care providers often do not discuss oral health with their patients or provide dental referrals.1
• Dentists do not always provide treatment during pregnancy because of poor perceptions of treatment safety.2
• Pregnant women often do not seek dental care because they believe it is unsafe.3,4
Most women do not see a dentist during their pregnancy, but the consequence of not treating oral pathologies can be devastating.1,5 Perceptions of the safety of dental treatment during pregnancy by patients, dental providers, and prenatal providers may all contribute to the lack of oral health care during pregnancy.1,6
Prenatal Care Provider Perceptions
In 1992, it was reported that 91% of obstetricians did not want to be consulted before dental treatment unless the treatment might induce a bacteremia.7 If they believed a bacteremia might occur, 79% of the obstetricians wanted to be consulted prior to treatment.7 The conflict, which suggests insufficient understanding of dental treatment, is that most routine dental procedures have been well documented to induce a transient bacteremia. Examples of procedures that induce bacteremia include tooth extraction, gingivectomy, supra- and subgingival scaling, ultrasonic scaling, and subgingival irrigation.8
In a 2012 study, it was reported that obstetricians were well informed on the relationship between periodontal disease and pregnancy outcomes.1 However, at the same time, many prenatal general practitioners and midwives may not understand the link between oral health and overall health.1 The authors of the study also found that most of the time, prenatal care providers did not discuss oral health with their patients and that dental referrals were often only made when the patient self-identified an oral health problem.1 Other researchers reported that only 26% of women were advised by their prenatal care provider to see a dentist.2 While there has been an improvement in awareness of how oral health may affect pregnancy, there is still a significant lack of dental referrals.
Dental Provider Perceptions
Many dentists are reluctant, or simply refuse, to see pregnant patients.1 In 2004, in response to the increasing evidence that periodontal disease may contribute to preterm birth and low–birth weight babies, the American Academy of Periodontology began recommending that all women who were pregnant or planning to become pregnant should undergo a periodontal examination.9 In 2006, the New York State Department of Health published guidelines for oral health care during pregnancy.10 Despite this, researchers in 2008 found that 90% of dentists did not provide all necessary treatment to pregnant patients.2 Reasons dentists reported for withholding or delaying treatment included fear of injuring the woman or fetus and fear of litigation.2
In 2010, the California Dental Association published evidence-based guidelines for oral health care during pregnancy11 (see Appendix E). There is still room for the dental profession to improve the delivery of oral health care to pregnant patients.
Patient Perceptions
In the United States, only 25% to 50% of women will receive any dental care while pregnant, including prophylaxis.11 This is true even though 50% of pregnant women have dental problems.12 Pregnant women do not seek dental care during pregnancy for a number of reasons, including the following13:
• They do not realize they have an oral disease.4
• They believe poor oral health is normal during pregnancy.3,4
• They believe dental treatment may harm the fetus.3,4
• They are not informed that they should seek care.4
Pregnancy may be the only time women in the lower socioeconomic strata are eligible for dental benefits.3 At the same time, however, these women are less likely to utilize services to receive dental care. For example, only 20% of the pregnant women enrolled in California’s Medi-Cal Program in 2007 had a dental visit during their pregnancy.14
Conclusion
As these facts suggest, the main barrier to proper dental care during pregnancy is the poor perception of patients, prenatal providers, and dental providers, all of whom contribute to the lack of proper oral health care during pregnancy.
References
1. George A, Shamim S, Johnson M, et al. How do dental and prenatal care practitioners perceive dental care during pregnancy? Current evidence and implications. Birth 2012;39:238–247.
2. Michalowicz BS, DiAngelis AJ, Novak MJ, et al. Examining the safety of dental treatment in pregnant women. J Am Dent Assoc 2008;139:685–695.
3. Stevens J, Iida H, Ingersoll G. Implementing an oral health program in a group prenatal practice. J Obstet Gynecol Neonatal Nurs 2007;36:581–591.
4. Dasanayake AP, Gennaro S, Hendricks-Muñoz KD, Chhun N. Maternal periodontal disease, pregnancy, and neonatal outcomes. MCN Am J Matern Child Nurs 2008;33:45–49.
5. Wong D, Cheng A, Kunchur R, Lam S, Sambrook PJ, Goss AN. Management of severe odontogenic infections in pregnancy. Aust Dent J 2012;57:498–503.
6. Strafford KE, Shellhaas C, Hade EM. Provider and patient perceptions about dental care during pregnancy. J Matern Fetal Neonatal Med 2008;21:63–71.
7. Shrout MK, Comer RW, Powell BJ, McCoy BP. Treating the pregnant dental patient: Four basic rules addressed. J Am Dent Assoc 1992;123:75–80.
8. Achtari MD, Georgakopoulou EA, Afentoulide N. Dental care throughout pregnancy: What a dentist must know. Oral Health Dent Manag 2012;11:169–176.
9. Task Force on Periodontal Treatment of Pregnant Women, American Academy of Periodontology. American Academy of Periodontology statement regarding periodontal management of the pregnant patient. J Periodontol 2004;75:495.
10. New York State Department of Health. Oral Health Care During Pregnancy and Early Childhood: Practice Guidelines. Albany: New York State Department of Health, 2006. https://www.health.ny.gov/publications/0824.pdf. Accessed 13 November 2017.
11. California Dental Association Foundation; American College of Obstetricians and Gynecologists, District IX. Oral health during pregnancy and early childhood: Evidence-based guidelines for health professionals. J Calif Dent Assoc 2010; 38:391–403, 405–440.
12. American Academy of Pediatric Dentistry. Guideline on Oral Health Care for the Pregnant Adolescent. http://www.aapd.org/media/Policies_Guidelines/G_Pregnancy.pdf. Accessed 17 January 2018.
13. Al Habashneh R, Guthmiller JM, Levy S, et al. Factors related to utilization of dental services during pregnancy. J Clin Periodontol 2005;32:815–821.
14. California HealthCare Foundation. Denti-Cal Facts and Figures: A Look at California’s Medicaid Dental Program. Oakland: California HealthCare Foundation, 2007.
CHAPTER 2
Considerations
for Treating
Pregnant
Patients
Key Points
• Bacteremia caused by dental treatment during pregnancy does not routinely require antibiotic prophylaxis.
• Providing routine dental treatment during pregnancy can improve maternal oral health but does not necessarily improve pregnancy outcomes.
• Perinatal provider consultation is not always necessary when providing routine dental care to a healthy pregnant woman.
• The TPAL (term, premature, abortions, living children) recording system can be used to screen for women with a history of high-risk pregnancy.
• Emergency and urgent dental treatment can be done at any time. (Depending on the clinical situation, care can either be provided in the traditional outpatient dental office or in a hospital.)
• Necessary dental treatment is ideally provided early in the second trimester (weeks 14 to 20 of pregnancy).
• Elective dental care is not expected to affect the health of the pregnant woman or fetus during the time course of pregnancy and can be deferred until after pregnancy.
• Dental care provided during pregnancy (eg, definitive dental treatment to stabilize the dentition) may decrease the risk of aspiration of teeth or other materials during intubation if the patient undergoes general anesthesia during pregnancy or at delivery.
Because many changes occur in the expectant mother and the baby during pregnancy, the timing may affect what dental treatment should be done and how it should be provided. There are always risks, benefits, and alternatives to dental treatments. In addition to the risk to the mother, there is also the risk to the baby. However, providing treatment that benefits the mother may also benefit the baby.
Categories of Dental Treatment
There are four categories of dental treatment: emergency, urgent, necessary, and elective.
Emergency dental treatment
Emergency dental treatment is defined as treatment for conditions that require immediate attention for the oral and/or systemic well-being of the patient. A dental emergency is an acute injury or illness in which there is an immediate risk to a patient’s life or long-term dental health. Examples include:
• Oral hemorrhage: This must be controlled or the patient may bleed to death.
• Ludwig angina: This is a potentially life-threatening infection of the floor of the mouth that can compromise the patient’s ability to breathe.
• Traumatic injury: Depending on the severity, the patient may seek treatment in an emergency room or urgent care center. However, patients who perceive the injury as minor (eg, an avulsed tooth) may go to a dental office. In the case of an avulsed tooth, there is a limited amount of time in which the tooth may be able to be reimplanted.
Urgent dental treatment
Urgent dental treatment would be considered treatment for conditions where the patient is experiencing significant symptoms. A small delay in treatment is not expected to significantly affect the treatment outcome. Examples include:
• Symptomatic irreversible pulpitis
• Cracked tooth syndrome
• Dental abscess (Note: Severe abscess and infection may require emergency treatment.)
Necessary dental treatment
Necessary dental treatment is treatment that may improve the health of the pregnant woman or fetus during the time course of pregnancy. Examples include:
• Minor pain due to a fractured tooth
• Periodontally compromised teeth that may be avulsed and aspirated during intubation if the woman undergoes general anesthesia at delivery
• Caries that is either symptomatic or suspected to become symptomatic during the time course of pregnancy
• Asymptomatic irreversible pulpitis
Elective dental treatment
Elective dental care is not expected to affect the health of the pregnant woman or the fetus during the time course of pregnancy. Elective dental treatment does not necessarily treat oral pathologies. For example, it may be cosmetic in nature. Consider deferring elective dental treatment until after pregnancy. Examples include:
• Oral pathologies that are difficult to treat during pregnancy and may spontaneously resolve after pregnancy
– For example, an asymptomatic pyogenic granuloma (of pregnancy) may recur if removed during pregnancy.1,2
• Cosmetic surgery
• Veneers (no caries)
• Tooth whitening
• Small cracks in composites and amalgam with no caries
• Tiny caries lesions
When to provide dental care
Ideally, all necessary dental treatment will have been completed prior to pregnancy. In general, the safest option is to defer dental treatment until after pregnancy, when there is no fetal risk. However, emergency and urgent dental care should be provided at any time during pregnancy. Examples include providing care for acute infections and abscesses.1,3–16 If treatment is necessary, give consideration to both the type of treatment and the phase of pregnancy.
Deferring elective, nonessential, and postponable treatment until after pregnancy eliminates the possibility that fetal risk may be associated with dental treatment.2 Pregnancy is finite and relatively short, lasting only 9 to 10 months in length, and most oral pathologies are slowly progressing, non–life-threatening, and benign.2,10 Dental care can often be postponed until either the second trimester or after delivery.10,17,18
Safety Considerations
Pregnancy itself is not a contraindication to dental care.19 According to the American College of Obstetricians and Gynecologists,20 “Evidence has failed to show any improvement in outcomes after dental treatment during pregnancy. Nonetheless, these studies did not raise any concern about the safety of dental services during pregnancy.” A healthy pregnant woman having a normal pregnancy should have her urgent and emergency dental needs taken care of at any time during pregnancy.3–16 The decision of whether to perform dental treatment in a hospital or an outpatient dental office setting will depend on the patient’s health and the type and extent of the oral pathology.15
Consequences of dental treatment
When it comes to a developing fetus, the full impact of treatment is potentially not known for many years. Severe complications of dental treatment can occur, though they are rare.21,22 At the extreme, death has occurred in the dental office.23,24 Some examples of severe iatrogenic-related complications include adverse reaction or allergy to a medication as well as aspiration.
Aspiration of dental instruments or dental materials is a life-threatening event and can cause significant medical complications. Treatment may require a hospital-based multidisciplinary team.21,22,25 Things as common as full-arch dental impressions may place the patient at risk for aspirating the impression material, and swallowed objects have the risk of causing perforation of the gastrointestinal tract.21,26,27
When treatment does not go as planned, additional treatment may be required. This additional treatment may also place the fetus at increased risk. In addition, there are psychologic risks that may affect both the patient and the dentist. For example, the expectant mother may reach the conclusion that dental treatment was the cause of an adverse pregnancy outcome. While uncommon, a woman may take legal action against the provider in the absence of scientific evidence supporting her belief.3,28
Determining needs for treatment
Severe odontogenic infection provides a small risk of death to the pregnant woman, and thereby the fetus. These cases require urgent referral and treatment in a hospital capable of multidisciplinary treatment, including surgical, anesthetic, and obstetric services.15 On the other hand, delaying elective treatment may prevent dental treatment from being correlated with fetal demise.6
Aspiration
One reason to provide dental treatment is to decrease the risk of aspiration that may occur if a pregnant woman needs to be placed under general anesthesia either at delivery or for some other reason during her pregnancy. Poor oral health may lead to conditions that cause aspiration during intubation.4 Some examples of objects that may be aspirated include:
• Tooth fragments from severely decayed or fractured teeth
• Periodontally compromised teeth that become dislodged
• Temporary crowns
• Other dental materials
Timing of treatment
In general, oral pathologies that may cause pain or infection during the time course of pregnancy should be treated during pregnancy.20 (See “Recommendations by Trimester” later in this chapter.) When possible, place definitive restorations during pregnancy to minimize aspiration risk should intubation become necessary.4 Some reasons to consider deferring dental treatment include the following:
• The patient has a medical condition that places her or the fetus at risk if she undergoes dental treatment.
• The patient has a history or elevated risk of miscarriage.
• Certain pathologies may recur when treated during pregnancy and resolve after pregnancy. An example is a pregnancy-related pyogenic granuloma.1,2
If the decision is made to defer dental treatment in the outpatient dental office setting until after pregnancy, consider referring any necessary dental treatment to be performed in a hospital setting.
Comprehensive dental treatment plan
Create a comprehensive dental treatment plan for the patient that includes3,4:
• Chief complaint
• Health history
• History of substance use, including tobacco and alcohol
• Clinical evaluation
• Caries risk assessment
• Periodontal disease risk assessment
• Comprehensive periodontal examination (with periodontal charting)
• Any maintenance therapy that may be needed during pregnancy
Perform diagnostic tests as needed to obtain definitive diagnoses as required for dental treatment.
Medical consults
To minimize risk, it is important to assess the health of the woman and her pregnancy.5 A physician consult is not required when providing routine dental treatment to a healthy pregnant woman, but it may serve as a tool to help educate the patient that it is safe to receive dental care during pregnancy.3,4,9,14,16 Consider a consultation with the patient’s prenatal care provider in the following situations:3,4,9,14,16
• When making the decision of whether or not to defer necessary dental treatment until after pregnancy.
• When treatment may require use of nitrous oxide, intravenous sedation, or general anesthesia.
• In the presence of comorbid medical conditions such as diabetes, pulmonary problems, heart or valvular disease, hypertension, bleeding disorders, and heparin-treated thrombophilia.
See Appendix A for sample physician consult forms.
Dental treatment–induced bacteremia
A transient bacteremia often follows dental treatment.3,6,29 It is not presently thought that dental treatment–induced bacteremia warrants antibiotic prophylaxis in pregnant patients. While the effects of this bacteremia have not been well studied, clinical trials have not reported adverse effects from a bacteremia that was induced by dental treatment (see page 64).
Pregnancy and Health Screening
Screening for pregnancy
About half of all pregnancies in the United States are unplanned.3,17,28,30,31 In fact, 48% of unintended pregnancies occurred in a month when contraception was being used.32
Because a dentist may treat a woman of childbearing age who is unaware of her own pregnancy, all women of childbearing age should be asked the following screening questions to assess the possibility of pregnancy6,17,33:
• Are you pregnant?
• Is there a possibility that you are pregnant and unaware of it?
• Are you trying to get pregnant?
Assessing reproductive history
Gravidity (gravida) refers to the number of times a woman has become pregnant, regardless of the outcome.1,34–37 Parity (para) is a number that refers to pregnancy outcomes. Parity is not always defined the same way. Two variations of parity are as follows:
• The number of births after 20 weeks’ gestation. (This can also be phrased as the number of births completed during the viable period.) When parity only refers to births during the viable period, it may be accompanied by the term abortus, which refers to the number of pregnancy losses prior to 20 weeks’ gestation. Abortus includes abortion, miscarriage, and ectopic pregnancy.1,37
• The total number of births, regardless of when they occurred during gestation. When this method is used, parity is broken up into four components.34–36
– Term births, which occur after 37 weeks’ gestation
– Preterm births, which occur between 20 and 37 weeks’ gestation
– Abortions, which occur prior to 20 weeks’ gestation
– Living children
Multiple births (eg, twins, triplets) count as a single event in the above terms because they occurred during a single pregnancy. This second method, known as TPAL, can be used as a screening tool to identify a woman who has a history of high-risk pregnancy.5,35,36
GTPAL
The GTPAL (gravida, term, premature, abortions, living children) system contains five numbers summarizing a woman’s reproductive history:
• G: Number of times a woman has become pregnant, regardless of the outcome
• T: Number of term births
• P: Number of premature births
• A: Number of abortions, miscarriages, or ectopic pregnancies
•