Clinical Scenario

A 24‐year‐old pregnant patient attends her routine dental check‐up complaining that her gums feel swollen, with associated sensitivity and bleeding when brushing her teeth.

Structured Learning

1. Apart from the poor oral hygiene, what could have caused the change in gingival appearance?
   • Pregnancy gingivitis, also known as gingivitis gravidarum, may present in the first trimester of pregnancy
     

     

   • This form of gingivitis results from increased levels of progesterone and oestrogen causing an exaggerated gingival inflammatory reaction to local irritants
2. What factors are considered important in assessing the risk of managing this patient?
   • Social
     • Drives to appointments (not suitable if dental sedation is considered)
   • Medical
     • Still in the first trimester of pregnancy when elective dental treatment should be avoided
     • There can be an increased tendency to nausea and sickness
     • Selective drugs prescription
     • Risk of peripheral dizziness when reclined in the dental chair (car accident sequela)
   • Dental
     • Using a soft toothbrush which is likely to be ineffective at removing oral deposits
     • Gingival recession can occur if the gingival inflammation persists
     • Vomiting related to pregnancy increases the risk of dental erosion
     • Cariogenic dietary habits
     • Potential for anaemia and related oral manifestations due to poor oral intake
     • Dental anxiety may reduce compliance for treatment
     • Only strictly necessary radiographs should be undertaken
3. When is it most appropriate to schedule her dental appointments for periodontal treatment?
   • The patient is taking an antiemetic (doxylamine/pyridoxine) because of her hyperemesis gravidarum; it is preferable to wait a few weeks to see if she progresses favourably once the second trimester of pregnancy is under way, particularly as she is also anxious about dental treatment
   • Elective dental procedures are also usually safer in the second trimester
   • Avoid scheduling the patient when she usually feels the most tired (generally early in the morning)
4. Following oral hygiene advice, the patient returns for periodontal treatment when she is 14 weeks pregnant. In order to assess her level of anxiety, you ask her to complete a Modified Dental Anxiety Scale questionnaire (see Chapter 15.1). Her score is 20 which means that she is extremely anxious. She requests dental sedation. What sedation technique do you choose?
   • Close liaison with the patient’s physician is required before providing sedation
   • One option which the physician could assist with is diphenhydramine, although consideration would need to be given to the fact she is already taking doxylamine, an antihistamine with sedative activity
   • Avoid benzodiazepines, since they are not recommended in pregnancy or hypothyroidism
   • Nitrous oxide may be employed with strict restrictions and a hospital setting may be preferable (the sessions should not exceed 30 minutes, and the oxygen concentration should not be lower than 50%)
5. What considerations are there regarding the patient’s position in the chair?
   • Place the backrest of the chair in the semi‐reclined position to promote respiration and prevent gastro‐oesophageal reflux
   • Remember the patient’s history of peripheral dizziness and vertebral fractures
   • Supine hypotensive syndrome occurs starting in the second trimester
6. What factors may increase the risk of bleeding as the result of the periodontal treatment?
   • The interproximal papillae in pregnancy gingivitis are oedematous and bleed easily but this can be controlled with local measures
   • Hypothyroidism can cause vascular endothelial disorders but not in its subclinical form
7. Unfortunately, the patient subsequently presents with a periodontal abscess in relation to #14. What antibiotics should be avoided in pregnancy?
   • Do not prescribe metronidazole in the first trimester of pregnancy
   • Clarithromycin is contraindicated throughout pregnancy and during breastfeeding
   • Quinolones and tetracyclines should also be avoided during pregnancy

General Dental Considerations