Pregnancy and Breast Feeding
A pregnant patient, although not considered medically compromised, poses a unique set of management considerations for the dentist. Dental care must be rendered to the mother without adversely affecting the developing fetus, and although routine dental care generally is safe for the pregnant patient, the delivery of such care involves some potentially harmful elements, including the use of ionizing radiation and certain drugs. Thus, the prudent practitioner must balance the beneficial aspects of dentistry with potentially harmful procedures by minimizing or avoiding exposure of the patient (and the developing fetus).
Additional considerations arise during the postpartum period if the mother elects to breast feed her infant. Although most drugs are only minimally transmitted from maternal serum to breast milk, and the infant’s exposure is not significant, the dentist should avoid using any drug that is known to be harmful to the infant.
Endocrine changes are the most significant basic alterations that occur with pregnancy. They result from the increased production of maternal and placental hormones and from modified activity of target end organs.
Fatigue is a common physiologic finding during the first trimester that may have a psychologic impact. A tendency toward syncope and postural hypotension also has been noted. During the second trimester, patients typically have a sense of well-being and relatively few symptoms. During the third trimester, increasing fatigue and discomfort and mild depression may be reported. Several cardiovascular changes occur as well. Blood volume increases by 40% to 50%, cardiac output by 30% to 50%, but red blood cell volume increases by only about 15% to 20%, resulting in a fall in the maternal hematocrit.< ?xml:namespace prefix = "mbp" />
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.
Blood changes in pregnancy include anemia and a decreased hematocrit value. Anemia occurs because blood volume increases more rapidly than red blood cell mass. As a result, a fall in hemoglobin and a marked need for additional folate and iron occur. A majority of pregnant women have insufficient iron stores—a problem that is exaggerated by significant blood loss. However, there is disagreement over whether or not to routinely provide iron supplementation.
Several white blood cell (WBC) and immunologic changes occur. The WBC count increases progressively throughout pregnancy, primarily because of an increase in neutrophils, and is nearly doubled by term. The reason for the increase is unclear but may involve elevated estrogen and cortisol levels.
Changes in respiratory function during pregnancy include elevation of the diaphragm which decreases the volume of the lungs in the resting state, thereby reducing total lung capacity by 5% and the functional residual capacity (FRC), the volume of air in the lungs at the end of quiet exhalation, by 20%.
Pregnancy predisposes the expectant mother to an increased appetite and often a craving for unusual foods. As a result, the diet may be unbalanced, high in sugars, or nonnutritious. This can adversely affect the mother’s dentition and also contribute to significant weight gain. Taste alterations and an increased gag response are common as well. The pH and production of saliva are probably unchanged.
The general pattern of fetal development should be understood when dental management plans are being formulated. Normal pregnancy lasts approximately 40 weeks. During the first trimester, organs and systems are formed (organogenesis). Thus, the fetus is most susceptible to malformation during this period. After the first trimester, the major aspects of formation are complete, and the remainder of fetal development is devoted primarily to growth and maturation. Thus, the chances of malformation are markedly diminished after the first trimester. A notable exception to this relative protection is the fetal dentition, which is susceptible to malformation from toxins or radiation, and to tooth discoloration caused by administration of tetracycline.
Complications of pregnancy are infrequent when appropriate prenatal care is provided and the mother is healthy. Unfortunately, complications occur more often in expectant mothers who harbor pathogens (oral and extraoral) and smoke, and in nonwhites than in whites in the United States.
Another consideration related to fetal growth is spontaneous abortion (miscarriage). Spontaneous abortion is the natural termination of pregnancy before the 20th week of gestation, and occurs in approximately 15% of all pregnancies.
During the postpartum period, the mother may suffer from lack of sleep and postpartum depression. Also during the postpartum period, risks for the occurrence of autoimmune disease, particularly rheumatoid arthritis, multiple sclerosis, and thyroiditis, are increased.
Management recommendations during pregnancy should be viewed as general guidelines—not as definitive rules. The dentist should assess the general health of the patient through a thorough medical history. Information to ascertain includes current physician, medications taken, use of tobacco, alcohol, or illicit drugs, history of gestational diabetes, miscarriage, hypertension, and morning sickness. If the need arises, the patient’s obstetrician should be consulted. Of interest, in a 1992 survey of obstetricians,
Box 17-1 Dental Management
Considerations in Patients Who Are Pregnant
Patient Evaluation/Risk Assessment (see
|Antibiotics||If antibiotics are required, consult with the physician. Use those with FDA classification A or B, unless otherwise approved by the physician.|
|Analgesics||If analgesics are required, consult with the physician. Acetaminophen is the drug of choice. If other analgesics are required, use with approval of physician.|
|Anesthesia||The usual local anesthetics with vasoconstrictors are safe to use, provided that care is taken not to exceed the recommended dose.|
|Anxiety||Avoid most anxiolytics. Short-term use of nitrous oxide, if needed, is permissible, provided that 50% oxygen is used.|
|Breathing||Patient may have difficulty breathing in the supine position.|
|Blood pressure||Watch for supine hypotension if patient is in the supine position; most likely in late third trimester.|
|Chair position||Patient may not be able to tolerate a supine chair position in third trimester.|
|Cardiovascular||Elevated lood pressure could be a sign of preeclampsia.|
|Drugs||Avoid all drugs if possible. If drugs are needed, use FDA category A or B, if possible.|
|Equipment||Make only necessary x-ray exposures; use lead apron and thyroid collar.|
|Emergencies||Anticipate the possibility of supine hypotension if the pregnancy has reached third trimester.|
|Follow-up||Follow-up evaluation after delivery is recommended, to ensure resumption of needed dental care, with radiographic assessment, as appropriate.|
Pregnancy is a special event in a woman’s life; hence, it is an emotionally charged experience. Establishing a good patient-dentist relationship that encourages openness, honesty, and trust is an integral part of successful management. This kind of relationship greatly reduces stress and anxiety for both patient and dentist.
As with all patients, measuring vital signs is important for identifying undiagnosed abnormalities and the need for corrective action. At a minimum, blood pressure and pulse should be measured. Systolic pressure at or above 140 mm Hg and diastolic pressure at or above 90 mm Hg are signs of hypertension (see
An important objective in planning dental treatment for a pregnant patient is to establish a healthy oral environment and an optimum level of oral hygiene. This essentially consists of a plaque control program that minimizes the exaggerated inflammatory response of gingival tissues to local irritants that commonly accompany the hormonal changes of pregnancy.
Acceptable oral hygiene techniques should be taught, reinforced, and monitored. Diet counseling, with emphasis on limiting the intake of refined carbohydrates and carbonated soft drinks, should be provided. Coronal scaling and polishing or root curettage may be performed whenever necessary. Preventive plaque control measures should be provided and emphasized throughout pregnancy, including the first trimester, for benefit to the pregnant mother and the developing baby.
The benefits of prenatal fluoride are controversial. Early studies by Glenn and associates
Other than as part of a good plaque control program, elective dental care is best avoided during the first trimester because of the potential vulnerability of the fetus (
|First Trimester||Second Trimester||Third Trimester|
|Plaque control||Plaque control||Plaque control|
|Oral hygiene instruction||Oral hygiene instruction||Oral hygiene instruction|
|Scaling, polishing, curettage||Scaling, polishing, curettage||Scaling, polishing, curettage|
|Avoid elective treatment; urgent care only||Routine dental care||Routine dental care|