Pregnancy

 

Pregnancy          

 

   

       

  

Effect on diagnosis/ OH (direct/ indirect) Effect of condition/ medication on treatment/ management   Antibiotic prophylaxis Changes to current medication  Allergies Blood pressure issues – seating position, anaesthetics Bleeding problems Precautions in place Drug prescription/ interactions

-  most dental treatment can be carried out with safety during pregnancy -  problems can include blood pressure, pregnancy gingivitis, ‘sickness’, - 

-  - 

positioning, medications elective procedures requiring general anaesthesia or intravenous sedation should be deferred until after the baby is bone and, preferably, until breastfeeding has been been ceased. If the patient is unsure whether she is pregnant, the decision about whether to proceed should be deferred until this is known. In general, elective treatment is best performed performed in the second trimester (i.e. the fourth, fifth and sixth si xth months) of pregnancy. If dental radiographs are necessary for assessment or diagnosis of  infection or trauma, or for treatment of these conditions, there is no reason, on radiation protection grounds, to defer them ARPANSA guidelines state that there are no contraindications to the taking of intraoral radiographs during pregnancy - leaded drape is recommended when the X-ray beam is i s directed towards the patient’s trunk (e.g. occlusal views of maxilla)  - of all aids, the most protective for the pregnant patient is the protective lead apron – minimizes gonadal and fetal radiation

Effect on diagnosis/ OH -  pregnancy gingivitis – due to exaggerated inflammatory response to local irritants and less than meticulous oral hygiene during periods of  hormonal changes; thought to be largely due to the increased vascular blood flow associated with elevated elevated progesterone levels. levels. In its mild form, may simply manifest as profuse gingival bleeding on minor trauma such as tooth brushing or even when eating. More typically, the gingivae show increased swelling, redness, redness, and are extre extremely mely haemorrhagic. May manifest at any time during pregnancy, but in the absence of adequate management it will persist throughout the term of the pregnancy. -  gestational diabetes mellitus associated with increased risk of periodontal disease – perio. Disease increases risk of a low-birthweight low- birthweight baby therefore oral hygiene measures and plaque control programs should be offered to mothers during pregnancy

 

1

 

-  caries attributable to presence of cariogenic bacteria in mouth, a diet  containing fermentable carbs and poor OH – control through fluoride and chlorhexidine is important because maternal saliva is the primary vehicle for transfer of cariogenic cariogenic streptococci to the infant. Increased appetite appetite and food cravings – diet may be unbalanced, high in sugars or nonnutritious – may adversely affect mother’s dentition 

-

 

hypersensitive gag reflex and morning sicknesstotogether increase risk of  halitosis and enamel erosion advise patient rinse after regurgitation with a solution that neutralizes the acid e.g. baking soda or water

-  Pregnancy epulis – a localized pyogenic pyogenic granuloma. This is a localized inflammatory swelling that is extremely haemorrhagic and can often become quite large – for example, growing sufficiently to interfere with the occlusion. Management is a particular challe challenge nge because surgical removal during pregnancy results in considerable bleeding and is best  avoided until after the pregnancy term is complete, com plete, if possible. Occasionally, these lesions can alternatively be managed by cryosurgery or laser sx, but these techniques are not readily available in all centres. Again, the emphasis is on primary plaque control as the initial management tool. Following the birth of the infant, the pregnancy epulis will often become considerably more fibrous in a relatively short period of time, which may make it much more amenable to subsequent surgical removal.

Effect of condition on treatment   -  Basically, schedule short appointments, allowing the patient to assume a semi-reclined position, and encouraging frequent changes of position can minimize problems  problems  -  sit upright (hypotension due to pressure on vena cava) – during late pregnancy, a phenomenon known as supine hypotensive syndrome may occur that manifests as an abrupt fall in blood pressure, bradycardia, sweating, nausea, weakness and air hunger when the patient is in a supine position. Symptoms are ca caused used by impaired venous return to the heart that results from compression of the inferior vena cava by the gravid uterus (Note that the inferior vena cava is primarily a right-sided structure). This leads to decreased blood blood pressure, reduced cardiac cardiac output, and impairment or loss of consciousness. Furthermore, changes in respiratory function during pregnancy: increased rate of respiration (increased demand on lung for oxygen) and dyspnea that is aggravated by the supine position If supine hypotension develops, rolling the patient onto her left side affords return of circulation to the heart, because this lifts the uterus off the vena cava. This should rapidly return the blood pressure to normal.   normal. -  short appointments: fatigue common during pregnancy

 

2

 

-  taste alteration and increased gag response – may dictate delay in certain dental procedures Medication (drug prescription and management) -  Principal concern is that a drug may cross the placenta and be toxic or teratogenic to the fetus. Additionally, any drug that is a respiratory depressant may cause maternal hypoxia, resulting in fetal hypoxia, injury or death.

-  Postpartum, most drugs are only minimally transmitted from maternal -  -  - 

-  - 

-  - 

significant but  but dentist  dentist  serum to breast milk and infant’s exposure is not  significant  should avoid using any drug that is known to be harmful to patient  categories A, B, C, D, X a drug can have more than one harmful effect on the fetus individual effects depend on the time of fetal exposure to the drug - may not be aware of pregnancy until after early stages - drugs in the most severe category of risk (category X) should not be prescribed to a woman of childbearing potential avoid benzodiazepines in pregnancy Avoid category C drugs such as aspirin, diazepam, ibuprofen, methylprednisolone, temazepam temazepam and category D drugs such as doxycycline, fluconazole. fluconazole. Category C are are drugs which, owing to their pharmacological effects, have caused or may be suspected of causing, harmful effects on the human fetus or neonate without causing malformations. These effects effects may be reversible. Category D drugs are those which have caused, as suspected to have caused or may be expected to cause, an increased incidence of human fetal malformations or irreversible damage. damage. These drugs may also have adverse adverse pharmacological effects. Povidone-iodine should not be used during pregnancy or lactation as it  has the potential to cause hypothyroidism in the neonate. Oral contraceptive pill interacts with many antibiotics:   Enzyme-inducing abx (enzyme = cytochrome P450) which metabolises the pill and therefore serum levels of the circulating c irculating pill are reduced. reduced. Only one abx does this: rifampicin-type abx (use (used d in treatment of tuberculosis)   Non-enzyme inducing abx – these abx destroy colonic bacteria that  are required to cleave the conjugate off the oestrogen component  of the pill. Background: pill administered orally, undergoes first  pass metabolism by passing out of small intestine into liver, liver conjugates with glucaronic acid, pill excreted into bile and reabsorbed into small intestine, intestine, passes into large intestine intestine.. In the large intestine, colonal bacteria are expected to release enzymes that cleave the conjugate and allow the pill pi ll to be released into the enterohepatic circulation. circulation. However, abx such as penicillin, macrolides, tetracyclines and cephalosporins can reduce colonic bacteria and this theoretically reduces enterohepatic circulation of  the oestrogen component component of the oral contraceptive. (This

 

3

 

component prevents ovulation). Source: BDJ Abx and oral  contraceptives: new considerations for dental practice.  practice.    TG p. 20: Studies have failed to show a significant interaction between oral contraceptives and common antimicrobials used in dentistry. Additional contraceptive precautions are required required in pxs taking hormonal contraceptives who are treated with antimicrobials that are enzyme inducers e.g. rifampicin, some antiretrovirals.

 

4