Pediatric Dentistry

Prenatal dental care: A review

Homa Amini, DDS, MPH, MS n Paul S. Casamassimo, DDS, MS

Good oral health during is necessary for the health of during pregnancy. Oral health professionals should promote the both the mother and the baby. Dental care during pregnancy is safety of dental care during pregnancy. safe, effective, and recommended, yet many dental professionals Received: January 21, 2010 delay treatment due to concerns for fetal safety. This article Accepted: February 25, 2010 discusses common dental findings and treatment considerations

he identified link between early including the American Academy depends on her nutritional status.7 childhood caries (ECC) and the of Pediatric Dentistry (AAPD), the Poor oral health has also been linked Tmaternal transmission of bacte- ADA, and the American Academy to adverse pregnancy outcomes. ria has increased efforts to promote of Pediatrics (AAP), have developed Some studies suggest an association the oral health of women during the statements and recommendations between maternal periodontal dis- perinatal period.1 Pregnancy is an for improving the oral health of ease and ; in addition, important time in a woman’s life, pregnant women and young chil- evidence indicates that a child can and good oral health is essential for dren.6 In 2006, the New York State acquire oral biofilm from the mother the health of both the mother and Department of Health developed and/or caretaker, and poor maternal the baby.1,2 The Surgeon General’s practice guidelines for dental care oral health may be a potential risk 2000 report on oral health empha- during pregnancy to assist health factor for ECC.1,2,6 Oral health is an sized dental treatment during preg- care professionals make appropri- integral part of general health, and nancy as a way to improve maternal ate care decisions; the California pregnancy by itself is not a reason to and infant health; however, few Foundation issued similar practice defer dental care.1,6,8 women visit a dentist during preg- guidelines four years later. These nancy.1,3,4 In addition, oral health guidelines were developed by an Common dental findings assessment and referral are not expert panel of health professionals Hormonal changes during preg- routinely incorporated into prenatal based on review of current scientific nancy can result in changes in the visits.1,2 Also, patients, physicians, evidence and consensus.1,6 oral cavity. The most common and dentists can be overly cautious The guidelines indicate that oral oral disease is , which about dental care, often delaying health professionals should develop has been reported in 30–100% of treatment of dental disease due to comprehensive treatment plans .9 During pregnancy, concerns for fetal safety and liabil- for pregnant women that include the inflammatory response to oral ity.1,5 Among women in low-income preventive, restorative, and mainte- bacteria is exacerbated by fluctua- populations, lack of dental insurance nance services.1,2,6 Untreated dental tions in estrogen and progesterone is a major barrier to accessing dental disease can lead to pain, infections, levels, changes in oral flora, and services. Nonetheless, pregnancy and unnecessary exposure to medica- a decreased immune response.5,8,9 is a time when women are more tions, any of which might be harm- Although gingivitis is transient in receptive to oral health promotion ful to the developing fetus. Many many cases, severe cases require messages; for many low-income women may self-medicate with professional cleaning and use of women, pregnancy may be the only potentially unsafe OTC medications chlorhexidine mouthrinse. Appro- time that they are eligible to receive to alleviate dental pain.1,6 priate home care measures (such as dental coverage.1,4,5 Poor oral health can also affect proper toothbrushing and flossing) Dental care during pregnancy is the nutritional intake of expectant should be emphasized.5,8 safe, effective, and recommended, mothers. The mother’s ability to Tooth mobility may be a sign despite the lack of national provide the nutrients that are neces- of .8 However, guidelines. Several organizations, sary for fetal growth and survival increased levels of progesterone

176 May/June 2010 General Dentistry www.agd.org and estrogen may affect the perio- after vomiting should be avoided high-speed films, collimation, and dontium, and mobility may be to prevent further damage to the lead aprons with a thyroid collar can observed in the absence of perio- demineralized enamel, while a fluo- minimize radiation exposure. How- dontal disease; in such cases, the ride mouthwash can help with tooth ever, it should be noted that lead condition will resolve after delivery.5 sensitivity resulting from enamel aprons without thyroid collars are A comprehensive assessment is erosion/dentin exposure.1,5,6,9 not protective, and thyroid exposure required and immediate periodontal Nausea and vomiting are common to radiation during pregnancy has treatment is indicated when disease among pregnant woman. Ptyalism been associated with low offspring is present.6,8 (excessive production) may be birth weight.6,8 (also known observed in women who experience The second trimester is an ideal as pregnancy tumor) is a benign, nausea; this condition typically time for routine general dentistry, painless, vascular lesion that occurs resolves when the nausea improves as the risk of spontaneous abortion in up to 5% of pregnancies associ- (at approximately 12–14 weeks is lower and organogenesis is com- ated with hormonal fluctuations gestation).8 It should be noted plete.6,8,9 Recent evidence indicates in combination with local irritants that excessive saliva may be due to that there is no association between and bacteria.5 Pyogenic granulomas the expectant mother’s inability to dental treatment and an adverse are most commonly located on swallow a normal quantity of saliva, pregnancy outcome or an increased the gingiva. They also may occur instead of resulting from a true risk for adverse medical event at on the palate, tongue, or buccal increase in production.8,9 13–23 weeks’ gestation.1 Generally, mucosa and appear as erythematous, nausea has stopped by the end of smooth, and lobulated lesions.5 The Treatment considerations the first trimester, and the size of the lesions usually appear after the first As with all patients, informed uterus has not increased to the point trimester and typically resolve after consent should be obtained prior that reclining in a dental chair is delivery. Surgical removal of these to dental procedures in accordance uncomfortable for the patient.6 lesions may be required when they with the standard of care; preg- During the third trimester, lying bleed, interfere with mastication, or nancy by itself does not necessitate back in the dental chair can be do not resolve after delivery. Other- a special consent.1 Dental treatment uncomfortable due to the increased wise, local debridement, chlorhexi- can be delivered safely at any time size of the uterus; in addition, the dine rinse, and observation is the during the pregnancy with no uterus can push on the inferior vena management treatment of choice.8 more fetal or maternal risk when cava, impeding venous return to A woman’s dental caries risk compared to the risk of not provid- the heart and decreasing the oxygen may increase due to changes in ing care.1 One of the most common flow to the brain. Dizziness and/or the oral cavity associated with the complications of pregnancy is nausea may be observed; these con- consumption of small, frequent, spontaneous abortion; however, ditions can be resolved by placing a carbohydrate-rich meals; increased there is no evidence linking early pillow under the patient’s right hip acid in the mouth from vomiting; spontaneous miscarriage to first or having her lean on her left side to and a lack of attention to proper trimester oral health care or dental move the uterus off the vena cava. hygiene during pregnancy.5,9,10 procedures.1 Dental appointments should be Limiting snacking to small amounts There is no need to obtain kept short, allowing for frequent of nutritious food throughout the approval from prenatal care provid- changes in position and making sure day should help women who experi- ers to deliver routine dental care to to keep the head above the feet.1,5,6 ence frequent nausea and vomiting. a healthy patient.1 During the first Pregnant women also have delayed Dental erosion may be seen due to trimester, a comprehensive exami- gastric emptying and an impaired gastric acid exposure as the result of nation is recommended to diagnose lower esophageal sphincter, allowing morning sickness early in pregnancy disease processes that need immedi- acidic stomach contents to escape and a lax esophageal sphincter ate treatment.1,6 Dental radiographs into the esophagus and creating during the later stages of pregnancy. are safe at any time during preg- a risk for aspiration. It is recom- To neutralize acid after vomiting, nancy as long as the dental team mended to keep the patient in a pregnant women should rinse with a follows good radiologic practices semi-seated position to avoid aspira- teaspoon of baking soda mixed in a and ALARA (as low as reason- tion. Elective dental procedures can cup of water. Brushing immediately ably achievable) principles. Use of be deferred until after delivery.5

www.agd.org General Dentistry Special Pediatrics Section 177 Pediatric Dentistry Prenatal dental care

on risks and benefits. Drugs in cat- Table 1. The FDA classifications for drugs in terms of their safety during egories D and X are contraindicated pregnancy.10 in pregnancy (see Table 2).6,8,9 Dentists should be aware of Class Definition co-morbid conditions that may A Adequate, well-controlled studies in pregnant women failed to demonstrate risk to fetus affect dental treatment and should initiate appropriate consultation B No evidence of risk in humans; animal studies show risk but human findings do not; or animal findings are negative and no adequate human studies have been performed with the obstetrician. For example, gestational diabetes is seen in 2–5% C Human studies are lacking and animal studies are either lacking or test positive for fetal risk; however, potential benefits may justify the risk of pregnancies, while 12–22% of pregnancies are associated with D Positive evidence of risk; investigational or post-marketing data show risk to fetus; 6 however, potential benefits may outweigh risks (as with some anticonvulsive hypertensive disorders. Pregnant medications) women with hypertensive disorders may be at an increased risk of bleeding during dental treatment.6 Pregnant women who have been diagnosed with thrombophilia may Table 2. Drugs used in dentistry (with FDA pregnancy risk category).6,8-10 receive daily heparin injections to improve the outcome of pregnancy; Analgesics Risk category Doxycycline D however, the heparin injections will Aspirin C Erythromycin B† increase the risk for bleeding during dental procedures.6 Antibiotics Acetaminophen B Metronidazole B‡ administered to prevent infective Acetaminophen Penicillin B endocarditis (IE) should be based with codeine C Tetracycline D on the American College of Cardi- Codeine C Local anesthetics ology guidelines for all individuals.6 Hydrocodone C Articaine C However, benign heart murmurs are Meperidine B Bupivicaine C common in pregnant women, since pregnancy results in an increased Morphine B Epinephrine C Ibuprofen B,D* cardiac output, plasma volume, and Lidocaine B heart rate. Benign systolic ejection Antimicrobials Mepivacaine C murmurs are caused by increased Amoxicillin B Prilocaine B blood flow across the pulmonic and Cephalexin B Anxiolytics aortic valves; these murmurs do Chlorhexidine rinse B Barbiturates D not require antibiotics prior to the dental procedure.6,8 Figure 1 illus- Ciprofloxacin C Benzodiazepines D Clindamycin B trates a sample consultation form Nitrous oxide not rated that may be used to facilitate com-

* Should be avoided in the first and third trimesters and used for only 24–72 hours munication between prenatal care 6 † Except for estolate form providers and dental care providers. ‡ Use with caution in the first trimester Future directions Oral health should be an essential part of prenatal care. Access to When treating pregnant women, belong in category C (66%) or B dental services during pregnancy dentists must understand which (19%).6 Drugs in category A and not only improves the overall health drugs can be prescribed and the majority of those in category B of pregnant women, it also provides administered. The FDA classifies can be used safely during pregnancy. an opportunity to counsel patients drugs into four categories (A–D) of Drugs in category C should be concerning harmful maternal behav- safety for use during pregnancy (see used only under the direction of a ior (for example, the use of tobacco, Table 1).10 The majority of drugs physician and with caution, based alcohol, and recreational drugs),

178 May/June 2010 General Dentistry www.agd.org Consultation Form for Pregnant Women to Receive Oral Health Care Table 3. Dentists and Referred to:______Date:______obstetricians (in %) who Patient Name: (Last) ______(First) ______consider specific procedures to 11 DOB:______Estimated delivery date: ______Week of gestation today: ______be safe during pregnancy.

KNOWN ALLERGIES: ______Procedure Dentists Obstetricians PRECAUTIONS: ❒ NONE ❒ SPECIFY (If any): ______Fillings 92 95 ______Root canal 90 86 Cleaning 99 95 This patient may have routine dental evaluation and care, including but not limited to: • oral health examination • root canal Abscess 95 100 • dental x-ray with abdominal and neck lead shield • Extraction drainage • dental prophylaxis • restorations (amalgam or composite) • Local anesthetic with epinephrine filling cavities Extractions 79 92 • Lidocaine 84 99 Patient may have: (Check all that apply) Sealants 91 73 • acetaminophen with codeine for pain control • Clindamycin • Penicillin • Cephalosporins X-rays 69 92 • amoxicillin • Erythromycin (Not estolate form) • alternative pain control medication: (Specify)______Nitrous oxide 10 34

Prenatal Care Provider: ______Phone: ______Antibiotics 73 99 Signature: ______Date: ______Periodontal 29 71 DO NOT HESITATE TO CALL FOR QUESTIONS surgery DENTIST’S REPORT (for the Prenatal Care Provider) Amalgams 74 26

Diagnosis: ______Narcotics 16 95 ______

Treatment Plan: ______organization that insures 17,000 NAME: ______Date: ______Phone: ______dentists nationwide) has reported Signature of Dentist: ______only one such incidence of mal- practice in the past 15 years. The Fig. 1. A sample consultation form for pregnant women to receive oral health care.6 case involved a claim of miscarriage related to radiographs; however, the claim was not supported by scien- tific evidence.1 Oral health care professionals proper /diet, and infant A recent survey of Ohio dentists should promote the safety of dental oral health. and obstetricians revealed that care during pregnancy. Once the Prenatal care providers can play only 38% of dentists and 39% of baby is born, the mother may be an important role in emphasizing obstetricians agreed that there was too preoccupied to attend dental the importance of oral health good communication between appointments and may lose her and facilitating the referral of health professionals regarding dental insurance.1,6 pregnant women to oral health dental care during pregnancy. In care professionals. Engaging the same study, 92% of obstetri- Summary obstetricians in oral screenings, cians and 64% of dentists agreed Oral health assessment and treat- education, and referral is important that a fear of malpractice charges ment should be part of comprehen- in promoting prenatal oral health.1,6 should not be seen as a reason to sive prenatal care for all women. In However, effective communication delay dental treatment until after the U.S., only 22–34% of pregnant between prenatal providers and oral delivery; additional data from this women visit a dentist during preg- health care professionals is a key in study are presented in Table 3.11 The nancy.5 Common barriers include this process. Dentists Insurance Company (an the patient’s failure to perceive a

www.agd.org General Dentistry Special Pediatrics Section 179 Pediatric Dentistry Prenatal dental care

need for treatment, financial barri- and chair, Division of Pediatric health in pregnancy. Obstet Gynecol 2008; ers, dentists’ reluctance, misunder- Dentistry, Ohio State University 111(4):976-986. 5. Silk H, Douglass AB, Douglass JM, Silk L. Oral standings concerning the safety of College of Dentistry, chief of health during pregnancy. Am Fam Physician dental care during pregnancy, and dentistry at Nationwide Children’s 2008;77(8):1139-1144. a lack of referrals from prenatal Hospital, and a former president of 6. Oral health care during pregnancy and early childhood. Practice guidelines. Available at: care providers. These barriers may the AAPD. http://www.health.state.ny.us/publications/ be addressed by improving patient 0824.pdf. Accessed January 2010. and provider education and by References 7. Martin-Gronert MS, Ozanne SE. Maternal nutrition during pregnancy and health of the developing public policies that sup- 1. Oral health during pregnancy and early child- hood: Evidence-based guidelines for health pro- offspring. Biochem Soc Trans 2006;34(Pt 5): port and promote access to dental fessionals. Available at: http://www. 779-782. services during pregnancy.1 cdafoundation.org/library/docs/poh_policy_ 8. giglio JA, Lanni SM, Laskin DM, Giglio NW. Oral brief.pdf. Accessed March 2010. health care for the pregnant patient. J Can Dent 2. Access to oral health care during the perinatal Assoc 2009;75(1):43-48. Author information period: A policy brief. Available at: http://www. 9. russell SL, Mayberry LJ. Pregnancy and oral Dr. Amini is an associate profes- mchoralhealth.org/PDFs/PerinatalBrief.pdf. Ac- health: A review and recommendations to re- duce gaps in practice and research. Am J Ma- sor and director, Postdoctoral cessed January 2010. 3. Oral health in America: A report of the surgeon tern Child Nurs 2008;33(1):32-37. Education in Pediatric Dentistry, general. Rockville, MD: U.S. Department of 10. drugs in pregnancy. Available at: http://www. Ohio State University College of Health and Human Services, National Institute merck.com/mmpe/sec18/ch260/ch260c.html. Accessed March 2010. Dentistry, and chief of pediatric of Dental and Craniofacial Research, National Institutes of Health;2000. 11. Strafford KE, Shellhaas C, Hade EM. Provider dentistry at Nationwide Chil- 4. boggess KA; Society for Maternal-Fetal Medi- and patient perceptions about dental care dur- dren’s Hospital, Columbus, OH. cine Publications Committee. Maternal oral ing pregnancy. J Matern Fetal Neonatal Med 2008;21(1):63-71. Dr. Casamassimo is professor

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