Dent Clin N Am 50 (2006) 677–697

Dent Clin N Am 50 (2006) 677–697

Pregnancy: Physiologic Changesand Considerations for Dental Patients

Tracy M. Dellinger, DDS, MSa,b,*,H. Mark Livingston, DDS, MSb,c

aAdvanced Education in General Dentistry Residency Program, University of Mississippi

School of Dentistry, 2500 North State Street, Jackson, MS 39216, USAbDepartment of Advanced General Dentistry, University of Mississippi School of Dentistry,

2500 North State Street, Jackson, MS 39216, USAcGeneral Practice Residency Program, University of Mississippi School of Dentistry,

2500 North State Street, Jackson, MS 39216, USA

Pregnancy is a dynamic physiological state evidenced by several transientchanges. These can develop into various physical signs and symptoms thatcan affect the patient’s health, perceptions, and interactions with others inher environment. Patients may not always understand the relevance of theirbodies’ ongoing adaptations or how they relate to either her or her fetus’shealth. A gestational woman requires various levels of support throughoutthis time, such as medical monitoring or intervention, preventative care, andphysical and emotional assistance.

Practitioners with minimal training in gestational medicine may be hesi-tant to treat their pregnant patients. Because of a fear of injuring either themother or unborn child, some practitioners may withhold care or medica-tions from their patients, inadvertently causing harm. An understandingof the patient’s physiologic changes, the effects of chronic infection or illicitdrug and alcohol usage, and the risks or benefits of medications is necessaryto adequately advise a patient on her options regarding medical care.

Occasionally, the patient’s underlying medical conditions or status of herpregnancy may limit the comprehensive care options available. Dentists, forexample, may delay certain elective procedures to coincide with periods ofpregnancy devoted to maturation versus organogenesis. Other times, dentalcare professionals need to alter their normal pharmacologic armamentarium

* Corresponding author. Department of Advanced General Dentistry, University of

Mississippi School of Dentistry, 2500 North State Street, Jackson, MS 39216, USA.

E-mail address: [email protected] (T.M. Dellinger).

0011-8532/06/$ - see front matter � 2006 Elsevier Inc. All rights reserved.

doi:10.1016/j.cden.2006.06.001 dental.theclinics.com

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678 DELLINGER & LIVINGSTON

to address patient needs versus fetal demands. By being better informedabout the physiological changes of pregnancy, medical and dental providerswill be more comfortable and, hence, willing to treat their pregnant patients.

Physiologic changes during pregnancy

This 9-month period of a woman’s life is not only defined by the devel-opment of her unborn child, but also the adaptive changes that she un-dergoes to support the pregnancy. Many women complain of varioussymptoms that develop during this time. The most common complaints in-clude nausea and vomiting, nasal congestion, heartburn, alteration in tasteand food cravings, hyperventilation and shortness of breath, and fatigue.These symptoms are often caused by the physiologic changes of various sys-tems, including the cardiovascular, respiratory, gastrointestinal, musculo-skeletal, and hematological systems.

Respiratory system

The oxygen demand during pregnancy consistently increases. The grow-ing fetus presses the gravid uterus upwards on the diaphragm by as much as4 cm, which decreases the functional residual capacity of the lungs by ap-proximately 18% [1,2]. To overcome this change, various physiologicalcompensations develop to increase the availability of oxygen. Anatomically,the lower ribs flare and the chest’s transverse diameter increases approxi-mately 2 cm [3–8]. A progesterone hormone drive causes an increase inthe central ventilation drive and a resulting hyperventilation [4,9,10]. Pro-gesterone also lowers the carbon dioxide content of alveolar air by promot-ing transfer of carbon dioxide and oxygen [4,10,11]. These adaptations assistwith up to a 20% increase in oxygen consumption as the pregnancy prog-resses [1]. Even with these temporary physiologic changes, approximately60% of women still report a shortness of breath at some time during theirpregnancies [12–14].

Due to the ongoing changes during pregnancy, dyspnea and hyperventi-lation are common sequalae [9]. The hyperventilation may be from eitherthe oxygen demands of the mother or lessened residual capacity of the lungs.Dyspnea may be related to this or by the hormonal changes to the mucosalvasculature of the respiratory tract. Elevated progesterone levels lead to cap-illary engorgement and swelling of the lining in the nose, oropharynx, lar-ynx, and trachea [12].

Gastrointestinal system

Multiple changes occur throughout the gastrointestinal tract during preg-nancy. Beginning in the first trimester, women present with decreased gastricperistalsis and intestinal motility [15]. This is in part a result of reducedmuscular tone and decreased frequency and strength of peristalsis. Primarily

679PREGNANT PATIENTS

due to the effect of progesterone, reduced peristaltic activity and diminishedtone are evident in bowel function, resulting in constipation, which is aggra-vated by vitamins containing iron [12]. The constipation, in turn, may leadto an increase in hemorrhoids as the pregnancy progresses [12].

The organs of the abdominal cavity are also altered during female gesta-tion. Gallbladder emptying time is increased during pregnancy, affecting thepatient’s digestion and increasing the risk of gallstone formation [16]. Theliver has increased hepatic production of hormone-binding globulins and de-creased albumin, resulting in significant impact on the pharmacokinetics ofcertain medications [17]. There are also elevations of the liver-dependentclotting factors, such as fibrinogen, as well as the liver’s production of alka-line phosphatase, which can be elevated to a level two to four times that fornongestational women [17].

Nausea and vomitingmay also be related to physiologic changes of the gas-trointestinal tract. First, an unknown pathway leads to hypersalivation inpregnant women. Next, the decreasedmuscle tone of the gastrointestinal tractleads to delays in gastric emptying [12]. Additionally, the soft tissues of thenose, oral cavity, and larynx become edematous during pregnancy [15]. Thismay lead to widely varied symptoms, such as nasal congestion, altered taste,altered sense of smell, or a bothersome cough [12,18]. Any of these alterationsmay lead to an increase in nausea or vomiting. However, studies have alsofound an increase in free thyroxine and human chorionic gonadotropin,with a resulting increase in thyroid function, in patients suffering from thenau-sea and vomiting associated with ‘‘morning sickness’’ [12,19–22].

Women often mention increased hunger and strange food cravings, alsoknown as ‘‘pregnancy pica,’’ during pregnancy [23]. Common myths andcolloquialisms, such as ‘‘eating for two’’ and ‘‘pickles and ice cream,’’have aggravated tendencies to gain weight [12]. However, women are nowencouraged to increase their low-impact aerobic activities and to limit theirtotal gain to a total of 12 to 14 kg (approximately 26–30 lb) [24].

Circulatory system

Multiple changes of the circulatory system are characteristic during preg-nancy. Vasodilatation and an increase in vascular proliferation along withincreased venous pressure in lower extremities can lead to varicosities [12].The bone marrow becomes hyperplastic, which can result in a slight increasein leukocytes or erythrocytes. Many coagulation factors are increased, in-cluding factors V, VII, VIII, X, and X [25]. Serum protein concentrations,serum lipids, and fibrinogen concentrations also rise during pregnancy.These changes result in a hypercoagulable state [1].

There is a 40% to 50% increase in total blood volume, resulting froma threefold increase in plasma volume, usually between 4 and 7 L, versusa more mild increase in red blood cell counts or hemoglobin [1,9,24]. Thered cell mass may increase by upwards of 500 mg, leading to a corresponding


rise in maternal demand for iron. This is why dietary iron supplements areoften recommended for pregnant women [9]. Increased blood volume duringpregnancy serves two purposes. First, higher blood volumes help facilitatethe maternal and fetal exchanges of respiratory gases, nutrients, and metab-olites. Second, higher blood volumes help offset maternal blood loss duringbirth when anywhere from 500 mL, in the case of vaginal birth, to 1000 mL,in the case of cesarean section, may be lost [26,27].

The disparity between the fluid and the cellular elements of the bloodis responsible for the dilution anemia, which usually stabilizes at around32 weeks of gestation [9]. The anemia is evidenced by a decrease in overallpercentage concentrations of red blood cells, plasma proteins, and plasmacolloid osmotic pressures [28].

This increase in the plasma volume parallels the curve of increase in car-diac output [28]. Cardiac output is a product of heart rate and stroke vol-ume, which can gradually increase by as much as 30% to 50% duringgestation with a concurrent total blood volume increase of 40% to 50%[1,24]. This leads to an increase in total stroke volume, a transient tachycar-dia in most gestational women, and the development of a systolic ejectionmurmur noted over the pericordium in over 50% of pregnant patients[1,9]. This type of heart murmur typically is not a result of subacute bacte-rial endocarditis, and disappears shortly after the end of the pregnancy[1,29]. However, there are usually no physical changes to the heart exceptfor a shifting toward a more anterior and left placement due to its displace-ment from the enlarging uterus and, also, a slight ventricular mass increaseduring the first trimester [9,28].

Blood pressures are also affected during pregnancy. While systemic arte-rial pressure never increases during normal gestation, a slight decrease in di-astolic pressure can be recognized during midpregnancy [24]. Meanwhile,pulmonary arterial pressure remains constant [28]. Most patients’ hypoten-sive complaints occur late in normal pregnancy. These complaints are oftenattributed to the impeded venous return to the heart as the heavy, graviduterus falls on the inferior vena cava when the patient is either in a supineposition or reclined [9]. For this reason, many women in their third trimestermay elevate their right hip when reclining for long periods of time, thusshifting their gravid uterus toward the left and alleviating pressure on theinferior vena cava (Fig. 1).

Hypertension may be present either pregestation or develop during thepregnancy itself. While chronic hypertension may be of general concern, de-velopment of hypertension in the second or third trimester could be an initialsign of preeclampsia, which is present in approximately 5% of all pregnanciesworldwide [2]. Severe hypertension may lead to both maternal and fetalmortality through placental abruption, stroke risks, or eclampsia [2]. Ofmost concern is any symptomology that can be a precursor for eclampsia.

Hypertension control during pregnancy commonly requires frequentmonitoring. When medications are warranted, physicians often favor


medications with a proven record of hypertensive success as well as safetyduring pregnancy. This means physicians rule out angiotension convertingenzyme inhibitors, which the US Food and Drug Administration (FDA)has given a category X pregnancy risk rating due to multiple reports of fetaldeath or renal problems in live births [2].

Preeclampsia affects 5% to10% of pregnancies after they have progressed20 weeks [29]. Unfortunately, the etiology of preeclampsia is unknown, butit is imperative that the condition is closely monitored once it develops. Thissyndrome causes diffuse vasospasm in the liver, kidneys, lungs, heart, orbrain, which may lead to eclampsia. Signs of eclampsia include renal dys-functions, edema, proteinuria, hypertension, thrombocytopenia, seizures,and even sudden death [2,30].

Patients should be queried frequently during their pregnancy about anyrapid weight gain, visual problems, migraine-type headaches, or epigastricpain associated with the liver [2]. Physical exams should include bloodpanels to see if platelet levels are falling, as well as observations and testswatching for developing hypertension, increased tendon reflexes, or retinalchanges [30]. If preeclampsia is suspected, common treatments include hos-pitalization to enable close monitoring and to reduce the patient’s activitylevel, hypertension therapy with magnesium sulfate, and delivery of the fetusat 37 weeks or as soon as the fetus may be delivered safely [2,31].

Preeclampsia conditions can rapidly deteriorate, causing serious medicalconsequences for the mother, including maternal death. Signs of elevatedmaternal and fetal risk are hemolysis, elevated liver enzymes, and low

Fig. 1. Gravid women may be more comfortable and less inclined to develop postural

hypotension when reclined in a dental chair if the fetus is displaced from the inferior vena

cava. Placing a pillow or folded blanket under the patient’s right hip will aid in this placement.


platelet counts, which together are known as the HELLP syndrome [2].HELLP may predict cerebral hemorrhage, disseminated coagulopathy,acute renal failure, pulmonary edema, and seizures [2,32]. If seizures occur,the patient has progressed to eclampsia and a higher risk of death.

Once delivery of the baby is complete, most signs and symptoms of pre-eclampsia resolve. However, some cases of preeclampsia and eclampsia maypersist or present postpartum up to 3 months following delivery of the child[2]. Preeclampsia is difficult to prevent and has an 18% chance of recurrencewith additional pregnancies [2,33].

Musculoskeletal system

Musculoskeletal changes are common in the later stages of pregnancy.Painful leg cramps, or ‘‘charley horses,’’ are common complaints of late preg-nancy. Changes in calcium and phosphate metabolism lead to leg cramps[12,34]. Increases in both vascular dilation and venous stasis have both beenattributed as causes of leg-muscle cramps and lower extremity edema [9].

The venous drainage from the pelvic region may also relate to pelvis andsacroiliac pain. Hormonal changes can increase the mobility of the sacroiliac,sacrococcygeal, and pubic joints, and cause lower back pain and pelvic dis-comfort [12,35]. Increases in weight may also result in a larger strain on the in-tervertebral disks, leading to generalized back pain. The increase in the size ofthe gravid uterus leads to lordosis, which causes muscle strain and pain of thelower back. Studies reveal that close to 49% of pregnant women experiencesome back pain during gestation [12,35]. A woman’s changing body contoursand center of gravitymay lead to a transient decrease of coordination and pos-sibly a chance of minor traumas, such as contusions and bruising, from falls.

Endocrine system

As fetal requirements increase, so does the need for nutrients. Thus, ges-tational changes are made to alter maternal metabolism to ensure nutritionto the developing fetus [36]. Changes in the release of systemic hormones,which alter cellular responses to insulin, and thyroid hormone are mecha-nisms that allow for elevated glucose, lipid, and triglyceride levels in theblood, which are needed to better nourish the developing fetus [36].

The thyroid undergoes several physiologic changes during pregnancy. Ele-vated estrogens increase the response of pituitary thyrotropin to thyrotropin-releasing hormone and thyroxine-binding globulin [20,37–39]. Hyperplasia ofglandular elements, new follicular formation, and increased thyroid vascular-ity are also temporary effects of maternal gestation [20].

Elevated levels of progesterone, estrogen, cortisol, and chorionic somato-mammotropin are all related to increased insulin resistance amonga mother’s cells [36,40]. Thus, there is a significant risk for pregnant womento develop diabetes. Gestational diabetes mellitus (GDM) is found in


approximately 4% of cases, though more frequently in Hispanic and Cauca-sian women [41,42]. Women with GDM often have children with 4 kg orhigher birth weights [41]. The fetal macrosomia makes the children moresusceptible to trauma during vaginal births as well as more likely to havecongenital deformities [40]. The newborns also have an increased risk of hy-pocalemia, hypoglycemia, and polycythemia [41,43].

Gestational control of diabetes requires a combination of monitoring, di-etary control, and human insulin supplements [40]. Only 15% to 20% ofGDM mothers require human insulin supplements, and most cases resolvefollowing the end of the pregnancy. However, patients have an increasedrisk of developing type-2 diabetes over their lifetime, as well as a 30%-to-60% likelihood of developing GDM during subsequent pregnancies [44].

Effects of alcohol, drug, or tobacco use

Social habits of tobacco or substance abuse are of great concern, not onlyfor the patient’s health but also for the health of her unborn child. Medicalprofessionals must screen all of their patients for use of tobacco, alcohol, orillegal drugs. Studies estimate that from 1.8% to 32% of pregnant womenhave used an illicit drug sometime during their gestation [45–47]. In somestates, medical professionals are required by law to report suspicion of ille-gal drug use. Thus, medical professionals should be familiar with local lawsas well as with their professional and ethical guidelines.

When suggesting to patients that they stop using tobacco, alcohol, orother drugs, the health professional should be aware of the available treat-ment options as well as other factors that may relate to success. First, pa-tient motivation and desire for change are essential to success. Such issuesas underlying medical or psychological conditions need to be addressedfor the patient’s overall health and effective management. Additionally, con-sideration for treatment or counseling options, finances, and family orhousehold obligations should be addressed [45].

Tobacco

Premature and lower birth weights associated with tobacco use were firstreported in the 1950s [48,49]. Since the 1970s, cigarette packages have in-cluded warnings related to the harmful effects of tobacco on both thepopulation in general and pregnant women specifically. Tobacco cessationis of extreme importance as the known consequences of smoking includelow birth weight, risks of spontaneous abortions or preterm deliveries,and increased risk of sudden infant death syndrome [50]. Animal studieshave proven that both nicotine and carbon monoxide cross the placentaand cause direct effects on developing fetuses [49,51,52]. Long-term effectsof tobacco have also been reported as increased risks for mental retardation


and attention-deficit/hyperactivity disorder in children who were exposed tosmoking in utero [50].

While tobacco cessation is difficult for most patients, 25% to 40% ofsmokers report strong motivation to quit while pregnant. Of those who quitsmoking, only 21% to 35%ofwomen reported relapse during their pregnancy[50]. Successful methods for tobacco cessation include patient motivation aswell as behavioral and coping counseling or the availability of educationalma-terials [49,53–55]. If this is insufficient, bupropion has been used with successfor nonpregnant patients. The FDAhas given bupropion a B classification forpregnancy risk [50]. Nicotine concentrates in the fetal circulation after passingthe placental barrier and causes vasoconstriction of both placental and uterineblood vessels [50,56]. As such, it is an FDA category C medication and nico-tine patches should only be used when their benefits clearly outweigh the riskof smoking or other cessation methods [50].

Alcohol

Alcohol abuse among pregnant women is of such concern that the Centerfor Substance Abuse Treatment has required that alcohol treatment centersthat receive federal substance abuse block grants must give priority to preg-nant women [50,57]. Health professionals should ask all their pregnant pa-tients about alcohol use. However, many do not because only about 65% ofgestational women report being queried regarding their alcohol consump-tion [50,58]. To aid this discussion, various standardized questionnaireshave been developed to identify alcoholic tendencies.

Women who abuse alcohol while pregnant are at high risk for miscar-riage or spontaneous abortion [49]. Alcohol abuse can also lead to fetal al-cohol syndrome (FAS), which is characterized by several physical andcognitive birth defects. Cleft palate, visual defects, thin upper lips with ab-sent philtrums, epicanthal folds, and flat midfaces are just some of the facialdeformities associated with FAS [49,59]. Heart defects, such as ventricularseptal defects, vertebral defects, and hip defects are also reported as physicalanomalies [50,60]. Lower intelligence, attention-deficit/hyperactivity disor-der and other behavioral problems, along with decreased growth potentialand failure to thrive, have been correlated with FAS [50].

Cocaine and opiate abuse

Cocaine has been a common recreational drug since the 1980s and is stillof concern today. Cocaine is a stimulant associated with hypertension andperipheral vasoconstriction [49,61]. Cocaine also has multiple effects onboth the mother and the fetus, as the drug easily crosses the placentalbarrier. It is known to cause uterine arteries to constrict and to inhibit themetabolism of epinephrine and norepinephrine at neural junctions[45,49,62–64]. Cocaine also increases the contractility of the pregnant


woman’s uterus, which may lead to uterine rupture [45,65]. Additionally,cocaine-related hypertension can be associated with a preeclampsia-likesyndrome. Congenital anomalies include heart and vision defects, hydroen-cephaly, cerebral infarcts, and other neurological defects [63]. Childrenwith in utero cocaine exposure have been found to have attention deficit dis-orders during childhood and unknown effects toward their maturation[45,66].

Long-term narcotic exposure to the fetus is of concern, too. Maternal nar-cotic dependency has been associated with low birth weights and increasedneonatal mortality rates [49]. Additionally, fetal dependency on narcoticshas been associated with long-term maternal usage. Neonatal symptomsmay also include irritability, gastrointestinal problems, tremors, and even sei-zures [45].Marijuana is another frequently abuseddrug, though few long-termeffects have been noted for the fetus, newborn, or children [49].

Infection

Pregnant women may be more susceptible than other women to infection[67]. This vulnerability can be traced in part to the physiological effects thatcan precipitate infections, as well as the alterations in pharmacokinetics. Theincreased total blood volume and vasodilation increases the disseminationof bacteria throughout the body. Also, pregnancy may alter the cell-medi-ated immune function, resulting in a delayed immune response to infection[15]. Diminished gastrointestinal motility can delay peak concentration oforal medications and the increased blood volume, when combined with anincreased cardiac output and glomerular filtration rate, can cause rapid dif-fusion, but also rapid metabolism and excretion of water soluble medica-tions [9]. For example, ampicillin suffers this fate, so that patientsreceiving lower dosages may not obtain therapeutic levels of the drug [9].

Pharmacology

Medications may be either a boon or liability during a woman’s preg-nancy. This determination can only be made if the weight of her medicalcondition, the fetus’s exposure risk, and the need for medical treatment isevaluated and balanced [63]. Physicians, dental professionals, or patientsmay have an irrational belief that all medications may be harmful to the un-born child. However, some medical conditions, left untreated, may be moredetrimental to the fetus. This may lead to progressive maternal diseasestatus, teratogenesis, impaired fetal growth or development, prematurebirth, spontaneous miscarriage, or abortion [68]. While some medicationsmay be harmful to a fetus, safe alternatives are often available to treatmany of these medical conditions. Both the patient and medical professionalneed to make an informed choice.


Once the decision for medical management has been made, selection ofa medication must be balanced by the therapeutic options available, the de-gree of control required for a medical condition, the potential and degree offetus exposure, the maternal and fetus risks of various medications, dosagesnecessary for control and safety, and long-term effects of the medication onthe fetus [68]. Due to ethical concerns, there are few controlled studiesrelated to adverse effects of medications on either human fetuses or futuredevelopment and maturation of the child and adult. While there may bevarious anecdotal reports on adverse effects of medication, these maynot adequately reflect a drug’s safety status. A reliable rule of thumb mayinclude reviewing nonpharmacologic treatments, becoming familiar withcurrent pharmacologic standards of care, and considering older pharmaceu-tical treatments that have a longer record of safety [68].

The medical professional must use scientific literature and study reviews;confer with the patient’s obstetrician, physicians, or pharmacists familiarwith pregnancy interactions; or make use of reliable published referencesources. In the United States, the FDA has developed a five-category systemto determine fetal risks of medications [69]. Categories range from A, thesafest listing, to the final category, X, which is completely contraindicatedduring pregnancy [70] (Table 1).

Many factors play roles in determining fetal risk of medications. First, itshould be determined if a drug is tetragenic in nature. Most fetal organogen-esis occurs during the first trimester, which is the period of most concern formany medication effects on the fetus. Next of concern would be the degree

Table 1

FDA Drug Categories During Pregnancy: Level and outcome of testing required to determine

a pregnancy risk factory category

Category Outcome of testing

Percentage

of drugs in category

A Controlled studies in humans have failed to

demonstrate a risk to the fetus, and the possibility

of fetal harm appears remote.

!0.7

B Animal studies have not indicated fetal risk, and

human studies have not been conducted; or

animal studies have shown a risk, but

controlled human studies have not.

19

C Animal studies have shown a risk, but controlled

human studies have not been conducted;

or studies are not available in humans or animals.

66

D Positive evidence of human fetal risk exists,

but in certain situations the drug may be

used despite its risk.

7

X Evidence of fetal abnormalities and fetal risk exists

based on human experience, and the risk

outweighs any possible benefit of use during pregnancy.

7

Data from Refs. [63,70,73].


of fetus exposure to a medication. Not all drugs readily pass through the pla-cental barrier. Those that do not thus spare the unborn child from exposure.For example, drugs with little or no fetal contact are those that bind to proteinor aremade up of largemolecules that cannot transfer through the barrier [68].Drugs that would readily go across the placental barrier include lipid-bindingdrugs, acidic medications, or those that depend on renal clearance [71].

One example of fetal harm secondary to medication is thalidomide,a drug that falls into fetal risk category X. This drug resulted in multiple re-ports of malformations of the musculoskeletal system and extremity forma-tion, and led to a revision in the United States food-and-drug laws [63].Tetracycline and minocycline, though effective antibiotics, are known tobe associated with abnormalities in both bone and dental development.These drugs are thus not advised for pregnant patients [70]. Alcohol isalso contraindicated during gestation as it has been proven to cause neuro-developmental defects after repeated or high-dose exposure [49].

The pharmacokinetics of a drug may be altered by pregnancy. For exam-ple, vasodilation leads to increased hepatic metabolisms and renal clearancerates. The increase in blood volume causes a larger volume of distribution ofa given medication [1]. Pregnancy is also associated with slower peristalsisand gastric emptying, as well as increased cardiac output, blood volume,body fat, and glomerular filtration [24,68]. Thus, unbound free drugs maytransfer across the placenta and drugs that are usually cleared by the kidneydo so at a faster rate. This leads to lower serum drug concentrations, thuslower effectiveness unless the dosage is adjusted [68].

Fortunately,manydrugs in a dental office’s armamentariumare consideredgenerally safe for both pregnant patients and their unborn children.Most den-tal professionals shouldhave access to amedication reference if questions ariseregarding a proposed drug’s efficacy or safety. However, if a dental profes-sional has any doubts about either dental medication choices or risk factorsfor pregnant patients, he or she should refer to the patient’s obstetrician.

Local anesthetics are among of the most commonly used medications bydentists. Lidocaine and prilocaine have been given an FDA category B rat-ing when given in a therapeutic range, and should be first-line choices forlocal anesthesia for pregnant women who do not have any contraindication,such as allergy [70,72]. Bupivicaine, mepivicaine, and articaine have eachbeen given FDA category C ratings. Bupivicaine’s rating stems from animalstudies demonstrating embryo death with higher-than-therapeutic dosages.Mepivicaine and articaine are category C drugs because of insufficient ani-mal studies [73]. None of the above listed local anesthetic agents have beenassociated with poor fetal outcomes when given in dental therapeutic doseranges [72,73]. Additionally, the use of vasoconstrictors, such as epinephrineor levonorderfrin, is not contraindicated when part of the commerciallyavailable local anesthetics. Though given a C rating, these vasoconstrictors,when used in low concentrations in pre-packaged local anesthetic cartridges,cause no fetal harm as long as normal precautions are taken. These


precautions include avoiding injection within blood vessels and maintainingtotal dosages at or below therapeutic ranges, such as 0.04 mg for epineph-rine and 0.2 mg for levonorderfrin [72,73].

Frequently, the best treatment option for a patient is to immediately ad-dress pain or infections at the source [73–75]. However, there are occasionswhen infections cannot be treated immediately with invasive dental care andantibiotics may be a necessary course of action. Many of a dentist’s first lineantibiotics are rated by the FDA as category B for pregnancy risk. Theseinclude the penicillin family, the erythromycins (except for the estolateform), azithromycin, clindamycin, metronidazole, and the cephalosporins[70]. However, tetracycline, minocycline, and doxycycline are given D rat-ings due to their likelihood of chelating in bones and teeth. Thus, tetracy-cline, minocycline, and doxycycline should normally avoided [70]. Fungalinfections may be treated with nystatin, which is the best topical choice be-cause it has received a category B rating based on animal studies. Insufficientanimal testing for the oral use of fluconazole and ketoconazole have resultedin category C ratings, although these drugs are still considered generally safefor gestational women [70].

When discussing pain, the dental professional should be aware of manypotential pitfalls. Not all nonsteroidal anti-inflammatory drugs are safefor the fetus. Neither aspirin nor diflusinal are recommended for a pregnantwoman. Aspirin and diflusinal have both been associated with prolongedgestation and labor, anemia, increased bleeding potential, and prematureclosure of the ductus arteriosus of the heart [73]. Even ibuprofen, ketopro-fen, and naproxen are contraindicated in the third trimester of pregnancy,where they are considered FDA category D choices, due to their risks ofprolonged labor, hemorrhage risk during delivery, and premature closureof the ductus arteriosus. However, these three analgesics are given a categoryB rating for the first two trimesters of pregnancy [73]. Instead, the first-linenonsteroidal anti-inflammatory of choice should be acetaminophen. Acet-aminophen has earned an FDA B rating for all three trimesters of preg-nancy [70]. If stronger pain medication is necessary, most narcoticcombinations are relatively safe for short durations, despite their risks forfetal growth retardation or fetal dependency if prescribed for long periods.Oxycodone has received B ratings for short-term usage, while meperidine,hydrocodone, propoxyphene, and codeine are FDA category C narcoticmedications, though still considered reasonably safe for short-durationpain control [70]. However, long-term narcotic usage is ill-advised as thefetus may develop either neonatal depression or withdrawal symptoms [69].

When treating anxiety in the dental setting, nonpharmaceutical methodsare preferred because they reduce the fetus’s exposure to medication. Mostbenzodiazepines for anxiolytic relief must be administered with extreme cau-tion and consultations with the patient’s physician because most drugs inthis class are classified in categories C or D for pregnancy risk [1,73]. Tria-zolam, listed by the FDA in category X, is absolutely contraindicated in


gestational patients [73]. Intranasal nitrous oxide use is very controversialbecause there is risk of reduced uterine blood flow or tetratogenic effectswhen used in high concentrations [1]. Short-term (ie, %30 minutes) use ofnitrous oxide when used in combination with O50% oxygen for nonelectivedental procedures may be warranted if patient management is not possiblewithout anxiolytic management. However, anecdotal reports have indicatedrisks of cleft palate development associated with short-tern use of nitrousoxide in combination with oxygen [1,76].

Herbal medications have been used throughout human history and areonce again gaining popularity in Western cultures. While physicians com-monly prescribe vitamin supplements for their pregnant patients, theymay be unaware or uncomfortable discussing other natural products withpatients. Americans are more frequently adding dietary supplements to theirdaily routine and may be using these agents during their pregnancies. Be-cause herbs are considered natural products, patients may not perceivethem as risky [68]. The FDA, in conjunction with the Dietary SupplementHealth and Education Act of 1994, has recently begun reviewing the efficacyand safety of herbs. Controlled scientific studies related to herbs are needed.

The effects and risks associated with most natural substances are dose re-lated. For example, garlic and ginger have been used as spices for genera-tions without reported effects on pregnancy. Yet, high doses of garlic mayincrease the risk of heavy bleeding by its antiplatelet aggregation properties[63]. Other herbs, such as blue cohosh and passionflower, may alter uterinecontraction patterns, which then affect labor [63]. Table 2 lists some com-mon herbal medications.

Dental providers need to become comfortable with routinely queryingtheir patients about herbal and supplement usage above and beyond theuse of vitamins (Fig. 2). Dentists should also reference available scientific lit-erature regarding the risks and benefits of natural products. Unfortunately,locating controlled scientific studies can be difficult due to the sparse litera-ture on their safety during pregnancy.

Dental treatment during pregnancy

Many dental professionals may be apprehensive about providing dentalcare to their gestational patients due to fears of inadvertently harming thefetus. However, few dental procedures are contraindicated during noncom-plicated pregnancies. The need to minimize systemic infection and disease isof utmost importance during this period [29,75]. Multiple studies have re-ported that the bacteria associated with periodontal disease have been asso-ciated with low birth weights and premature birth [77–83]. Porphyromonasgingivalis, Actinobacillus actinomycetemcomitans, Bacteroides forsythus,and Treponema denticola are periodontal-associated pathogens that havebeen studied and found in higher levels in mothers of low–birth-weightchildren associated with preterm birth [77,79–81,84]. It is assumed that


the bacteria associated with periodontal disease increases prostaglandin E2,tumor necrosis factor a, and interleukin 1-B. These in turn set up an inflam-matory response that may stimulate cervical dilation and labor, leading topremature birth [84–88]. Thus, dental procedures that minimize the mother’soral bacterial load are beneficial for her unborn child.

Dental hygiene procedures, such as prophylaxis, deep scaling, or rootplanning are allowable in any trimester of a normal pregnancy [89]. Dentalprophylaxis is encouraged to not only minimize the bacterial load of peri-odontal pathogens, but also to reinforce good oral hygiene habits for the

Table 2

Common herbals and their uses, effects, and risks to pregnant women

Herb Uses and effects Pregnancy risk category

Blue cohosh Stimulate labor

Relieve menstrual cramps

Antirheumatic

Laxative

C

Echinacea Enhance wound healing

Immune system stimulant

Anti-inflammatory agent

C

Garlic Inhibit platelet aggregation

Antimicrobial

Lowers lipid levels

Antihypertensive

C

Ginger Antitussive

Antiemetic

Antimicrobial

Immune system stimulant

C

Ginkgo biloba Improve mentation

Antitussive

Expectorant

Digestive aid

C

Ginseng Immunoregulation B

Nutmeg Anticholinergic C

Passion flower Potential uterine stimulant

Sedative

Burn compress

Hemorrhoid treatment

C

St. John’s wort Management of anxiety

Management of depression

Enhance wound healing

Improve gastritis

C

Valerian Sedative

Hypnotic

Antihypertensive

Anticonvulsive

B

Data from Briggs GG, Freeman RK, Yaffe SJ. Drugs in pregnancy and lactation, 7th

edition. Philadelphia: Lippincott, Williams, & Wilkins; 2005. p. xiiii–xix, 168–71,362–77,714–7,

1249–51; and Wynn RL, Meiller TF, Crossley HL. Drug information handbook for dentistry.

10th edition. Hudson (OH): Lexi-Comp; 2005. p. 47–50, 145–8, 174–7, 294–6, 348–50, 369–71,

471–4, 562–3, 594–6, 603–5, 702–4, 783–5, 823–6, 870–2, 917–20, 931–4, 1003–4, 1027–8, 1118–20,

1136–8, 1280–2, 1555–6.


patient [74,90,91]. Dental hygiene should be encouraged during pregnancydue to the high incidence (from 30%–100% of study patients) of gingivitisin pregnant patients [92–94]. Estrogen analogs, such as estradiol, tend tosupplement a favorable environment of intra-oral Porphyromonas interme-dia [95]. This is found to increase gingival inflammation throughout theoral cavity or even contribute to the formation of pyogenic granulomas,also known as ‘‘pregnancy tumors’’ [1,29,96]. While benign, pregnancy tu-mors can be a painful, nonesthetic soft tissue growth that is frequently re-moved either during the patient’s pregnancy or recent postpartum period[29,89,95]. Also, most gestational women must increase their caloric intakeduring pregnancy. Frequently, this intake is in the form of multiple, smallmeals, or increased carbohydrate-based food, which exposes the patient’steeth to higher acid levels and caries risk [74,89,97]. Lowered pH createsan oral environment more favorable for dental decay development, whichreinforces the need for adequate dental hygiene habits and frequent recallsfor pregnant patients [98].

If dental caries is a source of pain or acute infection in an otherwisehealthy gestational woman, a dentist should provide invasive care no matterwhat the patient’s phase of pregnancy [74,75]. Dental decay also presents anadditional source of bacterial load on the patient. Oral-maxillofacial ab-scesses may release various exotoxins, cytolytic enzymes, as well as gram-positive and gram-negative bacteria [99].

As previously mentioned, most local anesthetics are acceptable for use forpregnant women. Additionally, there is no contraindication to using diag-nostic procedures deemed necessary, such as appropriate radiographs, dur-ing a patient’s pregnancy, as long as normal safety precautions are followed.These precautions includes beam collimation, high-speed film, limited

Fig. 2. Dental professionals should become accustomed to querying each pregnant patient

about her medications, about her use of herbal and natural supplements, about her health,

and about the health of the fetus. The best time to ask is during a brief medical update at

the beginning of each appointment.


exposures, and lead-apron protection for the patient [29]. It is estimated thatthe average full-mouth dental film series may expose the fetus to 1 � 10�5

rads of radiation, far below the tetragenic risk to the unborn child [1,74,100].The delivery of elective dental care during pregnancy is controversial, but

not necessarily contraindicated. It is best not to expose a pregnant womanto medical risks unnecessarily, which is why elective care is often postponeduntil gestation has concluded. However, as the second trimester of preg-nancy is usually devoted to maturation and not commonly associatedwith preterm birth in healthy pregnancies, many dentists feel comfortabledelivering elective dental care during this period [29,74,101]. Even thoughthe third trimester is also devoted to fetal maturation, gestational womenmay be more prone to muscle cramps, back pain, or positional hypotensionwhen reclined in the dental chair, which may lead to an uncomfortable en-vironment to deliver elective care [101].

Bouts of great joy, anxiety, or fear can be common during pregnancy[102]. When combined with dental fears or phobia, pregnant patients maydelay or avoid dental care. Anxiety may lead to transient increases in bloodpressure, gastrointestinal upset, hyperventilation, or uterine cramping.Often, counseling and addressing the causes of the patient’s fears help re-lieve the symptomology.

Benzodiazepines, as previously discussed, are contraindicated due to therisk of oral cleft developments during the first trimester and the risk of neo-natal toxicity and withdrawal symptoms during the third trimester [73,102].However, short-term nitrous oxide use for anxiolysis is usually deemedacceptable if nonpharmaceutical methods for anxiety reduction areunsuccessful [76].

Summary

Pregnancy is a unique period of various physiologic changes that supportthe formation and maturation of new life. Every gestational woman shouldbe encouraged to seek medical and dental care during her pregnancy, as fail-ure to treat developing problems affects the health of both the mother andthe unborn child. However, a network of health care professionals who aretrained and comfortable in treating patients during pregnancy is also re-quired for the overall well-being of these patients. Dental care professionalsshould educate themselves by gaining a basic understanding of the underly-ing physiologic changes of pregnancy, influences related to the use of med-ications or illicit drugs or substances during gestation, and how these mayinteract with the delivery of dental care. This understanding aids the devel-opment of a treatment plan and delivery of necessary medical, nutritional,and dental care, as well as prepare the professional for counseling theirpregnant patients on relevant issues, such as nutritional supplement usageor the need to avoid chemicals or substances that may be harmful to eitherthe mother or child.


Acknowledgments

The authors wish to acknowledge the assistance of Dr. Ray Holder andDr. Neeta Mehta for the preparation of this article.

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