Dental considerations and drugs in pregnant and lactating

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DENTAL CONSIDERATIONS AND DRUGS IN PREGNANT AND LACTATING MOTHER

-SUNAYANA SHRESTHA

4TH YEAR, ROLL: 44

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CONTENTS:

• INTRODUCTION• MAJOR ORAL CHANGES• MINOR ORAL CHANGES• SYSTEMIC CHANGES DUE TO ORAL CONDITIONS• DENTAL TREATMENT DURING PREGNANCY• DENTAL TREATMENT GUIDELINE• DRUGS DURING PREGNANCY AND LACTATION PERIOD

• FDA CLASSIFICATION• ANALGESICS• ANTIBIOTICS• SEDETIVES AND ANXIOLYTICS• ANESTHETICS• EMERGENCY MEDICATION

• CONCLUSION• REFERENCES

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INTRODUCTION• Physiological condition starting from conception till delivery

of fetus.• Characterized by various changes in female body• Divided into 3 trimesters1st Trimester (1-12 weeks)Fetal organ formation and differentiation.Most susceptible to adverse effects of teratogens.•2nd Trimester (13-24 weeks) Fetal growth and maturation•3rd Trimester (25-40 weeks) Fetal growth continues with final weight gain

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• Changes evident in oral cavity as well.• Few major and minor changes are seen.considered an impediment to dental treatment• with some treatment modifications and initial planning; preventive, emergency, and routine dental procedures are all suitable during various phases of a pregnancy.1ST TRIMESTER: Avoid all elective care but provide care as needed.2ND TRIMESTER: Safest period to provide dental care.

3RD TRIMESTER: Focus of concern is risk to upcoming birth process and safety and comfort of the pregnant woman.

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MAJOR ORAL CHANGES• PREGNANCY TUMOR:Also known as ‘pyogenic granuloma’ due to its high vascular nature.• Occurs in up to 5% of women.• Most common in buccal maxillary anterior areas.• Usually starts in an area of gingivitis• Rapid growth up to 2 cm.• Single tumor-like growth• usually in interdental papillae• Purplish to bluish in color, may be ulcerated- bleeds easily• HISTOLOGICAL: Atrophic stratified squamous epithelium

with edematous connective tissue and thin walled vascular channels.

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Treatment

• Scaling and root planing• Excision in 2nd trimester if it is too large or bleeds

too easily• May regress spontaneously after pregnancy

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PREGNANCY INDUCED GINGIVITIS AND PERIODONTITIS:

• Occurs in about 50% of pregnant women• Caused by hormonal and vascular changes of pregnancy• Elevated circulating estrogen increases capillary permeability.• Preexisting gingivitis may predispose to

pregnancy gingivitis• Occurs commonly in the 2nd to 8th months

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• Tendency to bleed very easily• Tooth mobility• Presence of periodontal pockets (may be false

due to enlargement)

Treatment: Scaling, root-planing, currettage, OHI

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DENTAL CARIES:• Usually seen in women with poor oral hygiene

and preexisting carious status• Mainly due to myths like to avoid brushing and

dental treatment• Accelerated due to decreased salivary flow and

change in diet

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Treatment:Restoration of carious teeth(amalgam avoided)Oral hygiene maintainence

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MINOR CHANGES• Xerostomia in 1st and 3rd trimester• Sialorrhoea in 2nd trimester• Oral infections due to increased bacterial count• Erosion• Apthous ulcer• Telangectasia

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Systemic changes due to oral disease in pregnancy

• Low birth weight (LBW)

• Pre term labor and pre term birth: Inflammatory response stimulates prostaglandin and cytokine production to stimulate labor Thorough calculus (tartar) removal in pregnant women with periodontitis may reduce pre-term births

• Pre eclapsia :Periodontal infection leads to inflammatory vascular damage Triggers cell damage in placenta

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DENTAL TREATMENT IN PREGNANCY1st TRIMESTER:Plaque controlOral hygiene instructionScaling, polishing, curettageAvoid elective treatment; urgent care only

2ND TRIMESTER:Plaque controlOral hygiene instructionScaling, polishing, curettageRoutine dental care

3RD TRIMESTER:Plaque controlOral hygiene instructionScaling, polishing, curettageRoutine dental care (after middle of third trimester, elective care should be avoided)

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DENTAL MANAGEMET GUIDELINES

• Developing rapport with patient reduces anxiety• Detailed medical history with medical

consultation.• Monitoring of vital signs and blood examination

anemia and folate deficiency• Proper preventive programs can reduce caries

incidence in child• Prenatal fluoride 2.2mg/day• Short appointments• Patient advised to change position frequently

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CHAIR POSITION IN PREGNANCY

• SUPINE POSITION CONTRAINDICATED increased size of uterus can obstruct vena cava and aortasemi reclined position adviced

return to the heart reduced perfusion of uterus fetal hypoxiaSupine hypotension Syndrome:• Obstruction of inferior vena cava and aorta from pressure

of the large fetus. Symptoms: Sweating Nausea Weakness Sense of lack of air

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PREVENTION:•Elevate right hip 10-12 cm Use of soft pillow on right side•Weight is taken off the major vessels

TREATMENT:Roll patient onto her left side.

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RADIOGRAPHS DURING

PREGNANCY

• Take as needed with optimal methods for reducing secondary radiation and exposure time.• Always use a lead apron.• Exposure to fetus (with apron use) is • .00001 centiGray.(rad)• Exposure can be limited by:

o Lead apron shielding o Modern fast film o Avoiding retakes

• X-ray only if necessary (i.e. root canal therapy, trauma)

Use of Radiation on Pregnant Patient• Dose given and time of gestation are important• doses < 5-10 rads (cGy) not teratogenic• fetus is most susceptible to radiation between the

2nd and 6th week of gestation• single dental x-ray exposes patient to 0.01 millirads

of radiation. In relative terms, this amount is 40 times less than daily dose acquired from cosmic radiation. Therefore, important diagnostic radiation should not be withheld during pregnancy

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TREATMENTS TO BE AVOIDED

• Radiographs requiring high dose of radiation eg. CBCT

• Stressful procedures requiring prolonged chair time

• Major surgical procedures• Amalgam restorations

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MEASURES TO PREVENT ORAL

CONSEQUENCES• Proper diet• Avoid smoking and drinking• Use of oral hygiene measures like brushing, flossing and Chlorhexidine mouth wash• Timely and occasional visit to dental clinic

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• Always safe to avoid drug during pregnancy esp in 1st trimester.

• Drugs may cross placental barrier and may be toxic to the child

• Considering drugs for group of patient like pregnant, trying to conceive and in patient with unknown pregnancy status limited group of mediations used.o Analgesics and anti inflammatoryo Antibiotico Local anesthesiao Sedativeso Emergency medication

DRUGS DURING PREGNANCY AND

LACTATION PERIOD

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FDA classification system based on potential for causing birth defects:• 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

• B = Animal studies show no risk, or if risk shown in animals, controlled trials in women showed no risk

• 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

• D = There is evidence of human fetal risk, but benefits may outweigh risks

• X = Contraindicated

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COMMONLY USED ANALGESICS

• Paracetamol (B)• Ibuprofen (B/D*) • Oxycodone (B/D*) • Hydrocodone and codeine (C/D*)• Aspirin(C/D*)

*avoid in third trimester

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Paracetamol • analgesic of choice for all stages of gestation• treat mild to moderate pain and fevers• avoid chronic and large doses • Maternal anemia and fetal renal disease Aspirinnonteratogenic but may cause maternal and fetal hemorrhage• large and chronic doses during last trimester may result

in premature closure of ductus arteriosus, fetal hypertension, anemia, and low birth weight

ibuprofen • Avoid in 3rd trimester• adverse circulatory effectscodiene• avoid codeine in late • fetal respiratory depression and withdrawal symptoms

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SEDATIVES/ANXIOLYTICS

rated D and can cause oral clefts with prolonged exposure.• Nitrous oxide should not be used in 1st trimester

(If used in 2nd and 3rd, do not go below 50% O2)• SHORT TERM exposure do not cause birth defects

or spontaneous abortion• CHRONIC exposure may result in fetal loss and

infertility

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ANTIBIOTICS• penicillin V and amoxicillin is preferred drug for mild to moderate infections• no studies show penicillin to be teratogenic• amoxicillin extensively used without harming the

fetus• Drug classes: B: penicillin, cephalosporins, erythromycin, clindamycin, Azithromycin D: Tetracycline

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TO USE:• Amoxicillin• Penicillin V• Erythromycin (base

form)• cephalosporin• Clindamycin• Metronidazole

TO AVOID:• Doxycycline•

Tetracycline•

Erythromycin (estolate form)

• Vancomycin

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OTHER ANTIMICROBIAL

to use:• Nystatin (B)• Chlorhexidine rinse (B)Use with caution:• Clotrimazole (C)• Ketoconazole (C)• Fluconazole (C)Do not use:• Doxycycline (D)

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Local Anesthetic Use in PregnancyClass B:• Lidocaine (Xylocaine)• Etidocaine• Prilocaine Class C:• Procaine• Bupivicaine• Mepivicaine • LidocaineWidely use without obvious sideeffectintravascular injections of lidocaine pass through the placenta but the concentrations are too low to harm fetus• prilocaine might cause methemoglobinemia

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TOPICAL AGENTS

• Fluoride

• Toothpaste & mouthrinse

• Xylitol chewing gum

• Chlorhexidine

• No over the counter mouthrinses with alcohol

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EMERGENCY MEDICATION

• ALBUTEROLcategory C, safe during pregnancy• EpinephrineCategory c, use with caution• Naloxone Category c, use with caution• NitroglycerinCategory c, use with caution

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MEDICATION DURING LACTATION

• Same drug dose as in pregnancy• Amount of drug excerted in breast milk is 2- 4%

of maternal dose.• Take drug just after breastfeeding and avoid

nursing for 4 hours.

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CONCLUSION• Hence all the oral change regress spontaneously in post

partum period after balance of hormonal level.• Only severe conditions require medical interventions. But it is

always better adopt preventive measures• Also dental radiography poses little, if any risk to fetus

provided use of filter, collimation, fast speed film and lead aprons.

• Finally, considering drugs , if the benefits to the mother exceed the risk to the fetus and a medication is required, it always be administered regardless of FDA’s pregnancy factor definitions.

• Thus even though with proper planning and treatment modifications most of dental procedures can be carried out without fear of complication, prevention of such condition is safest treatment option in pregnancy.

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REFERENCES:• BURKET’S ORAL MEDICINE

• MICHAEL GLICK, 12TH EDITION

• TEXTBOOK OF ORAL MEDICINE ORAL DIAGNOSIS AND ORAL RADIOLOGY

• RAVIKIRAN ONGOLE• PRAVEEN B N, 2ND EDITION

• CARRANZA’S CLINICAL PERIODONTOLOGY• 12TH EDITION

• 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 1998;64:434-9

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