Pediatric Dentistry Prenatal dental care: A review Homa amini, DDS, MPH, MS n Paul S. Casamassimo, DDS, MS good oral health during pregnancy 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 preterm birth; 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 gingivitis, 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 pregnancies.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 periodontal disease.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 saliva production) may be birth weight.6,8 Pyogenic granuloma (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.