Dentistry and the Pregnant Patient

By Daniel Ninan

To err on the side of caution, some dentists may hesitate to perform necessary procedures on pregnant patients. However, good oral health is essential to a healthy pregnancy and can help reduce prenatal complications, including preterm delivery and fetal loss. This book serves as an easy-to-use guide to help dentists of all specialties provide safe, effective care for their patients during pregnancy. The book is broken down into chapters on general treatment guidelines, pregnancy-related conditions in each organ system that may impact care, and the safety of the use of common dental drugs, including anesthetics, during pregnancy. With over 50 quick-reference charts and tables and a breakdown of treatment recommendations by trimester, this book is a must-have for any dental office.

• Language: English
• Publisher: Quintessence Publishing Co, Inc
• Release date: Oct 1, 2019
• ISBN: 9780867159134

Book preview

Preface

My Introduction to the Treatment of Pregnant Women

Early in life, I became aware of the fear and caution that can envelop health care practitioners when they are placed in a situation where they have to evaluate and treat a pregnant woman. My mother, a labor and delivery nurse, told me stories about her experiences. One time, the emergency room staff immediately transferred a patient to the labor and delivery unit upon finding out she was pregnant—without even assessing the chief complaint that brought her to the emergency room in the first place. It is likely that the emergency room staff had reservations about treating a pregnant woman without first obtaining a specialist’s opinion. I have observed what appears to be a similar fear from dental professionals who are reluctant to treat pregnant patients. Many dentists may fear that they may cause harm to the unborn baby or the expectant mother.¹

The Role of Dentistry During Pregnancy

As dental professionals, our duty is to find ways to provide necessary dental care as safely as possible. Our ideal role is to work with a woman to help her get to a state of ideal oral health before she becomes pregnant. This way, the need for invasive treatments during pregnancy is minimized or prevented altogether. Researchers keep uncovering evidence that untreated oral disease has the potential to be detrimental to both the expectant mother and the baby. Poor oral health is associated with a number of pregnancy-related complications, including the following:

•  Preterm delivery ²

•  Low birth weight ² , ³

•  Preeclampsia ² , ⁴

•  Gestational diabetes ³

•  Fetal loss ⁵

•  Childhood caries as a result of maternal cariogenic bacterial load ⁶

Unfortunately, there is a large proportion of pregnant women who have significant unmet oral health care needs. Many women either fail to seek or are unable to receive dental treatment based on concerns regarding its safety during pregnancy.

It is understandable for providers to have reservations about treating patients in need, and careful consideration should be given to every circumstance. Currently, there is limited clinical trial evidence to support or refute the premise that providing dental care is totally safe for the pregnant woman. And while dental procedures have not been directly linked to fetal loss, it may be of importance to note that most dental procedures induce bacteremias, and subgingival bacteria has been reported to travel to the placenta and cause fetal demise.⁵,⁷

Even if all dental needs are addressed prior to pregnancy, unforeseen dental emergencies may arise that require invasive and sometimes extensive treatment during pregnancy. It is also important to note that nearly 50% of women have at least one unplanned pregnancy during the course of their life. It is possible that a dentist may treat some patients who do not realize they are already pregnant. Because of this, dental professionals should always consider the possibility of adverse fetal effect when treating a woman of childbearing age.

This book is a quick reference guide on how to maximize the safety of the pregnant woman and her unborn child while providing dental care. Ultimately, my hope is that this will result in better outcomes for both the expectant mother and her unborn baby.

Acknowledgments

I would first like to thank Quintessence Publishing for this opportunity. I would also like to say thank you to everyone who helped. As with any list of people, there are always more whose names are inadvertently omitted. I am very grateful to Dan Fischer and the many suggestions he provided during this project. I do want to say thank you to Alexander Bahn, Natalie Barton, Richard Lynch, Cathy Presland, and Penny Swift, as well as my family for their support and guidance while writing this book.

References

1.  California Dental Association Foundation; American College of Obstetricians and Gynecologists, District IX. Oral health during pregnancy and early childhood: Evidence-based guidelines for health professionals. J Calif Dent Assoc 2010;38:391–403, 405–440.

2.  Sanz M, Kornman K, Working group 3 of joint EFP/AAP workshop. Periodontitis and adverse pregnancy outcomes: Consensus report of the Joint EFP/AAP Workshop on Periodontitis and Systemic Diseases. J Periodontol 2013;84(4 suppl):S164–S169.

3.  Kentucky Cabinet for Health and Family Services. Kentucky Pregnancy Risk Assessment Monitoring System (PRAMS) Pilot Project: 2008 Data Report. http://chfs.ky.gov/NR/rdonlyres/888F8BBC-3DF7-47A4-B34E-8BD-7BABA1E09/0/PRAMSREPORT08finalwithcovers.pdf . Accessed 15 January 2018.

4.  Strafford KE, Shellhaas C, Hade EM. Provider and patient perceptions about dental care during pregnancy. J Matern Fetal Neonatal Med 2008;21:63–71.

5.  Han YW, Fardini Y, Chen C, et al. Term stillbirth caused by oral Fusobacterium nucleatum . Obstet Gynecol 2010;115:442–445.

6.  Chaffee BW, Gansky SA, Weintraub JA, Featherstone JDB, Ramos-Gomez FJ. Maternal oral bacterial levels predict early childhood caries development. J Dent Res 2014;93:238–244.

7.  Hilgers KK, Douglass J, Mathieu GP. Adolescent pregnancy: A review of dental treatment guidelines. Pediatr Dent 2003;25:459–467.

CHAPTER 1

Perceptions

About Dental

Treatment During

Pregnancy

Key Points

•  Prenatal care providers often do not discuss oral health with their patients or provide dental referrals. ¹

•  Dentists do not always provide treatment during pregnancy because of poor perceptions of treatment safety. ²

•  Pregnant women often do not seek dental care because they believe it is unsafe. ³, ⁴

Most women do not see a dentist during their pregnancy, but the consequence of not treating oral pathologies can be devastating.¹,⁵ Perceptions of the safety of dental treatment during pregnancy by patients, dental providers, and prenatal providers may all contribute to the lack of oral health care during pregnancy.¹,⁶

Prenatal Care Provider Perceptions

In 1992, it was reported that 91% of obstetricians did not want to be consulted before dental treatment unless the treatment might induce a bacteremia.⁷ If they believed a bacteremia might occur, 79% of the obstetricians wanted to be consulted prior to treatment.⁷ The conflict, which suggests insufficient understanding of dental treatment, is that most routine dental procedures have been well documented to induce a transient bacteremia. Examples of procedures that induce bacteremia include tooth extraction, gingivectomy, supra- and subgingival scaling, ultrasonic scaling, and subgingival irrigation.⁸

In a 2012 study, it was reported that obstetricians were well informed on the relationship between periodontal disease and pregnancy outcomes.¹ However, at the same time, many prenatal general practitioners and midwives may not understand the link between oral health and overall health.¹ The authors of the study also found that most of the time, prenatal care providers did not discuss oral health with their patients and that dental referrals were often only made when the patient self-identified an oral health problem.¹ Other researchers reported that only 26% of women were advised by their prenatal care provider to see a dentist.² While there has been an improvement in awareness of how oral health may affect pregnancy, there is still a significant lack of dental referrals.

Dental Provider Perceptions

Many dentists are reluctant, or simply refuse, to see pregnant patients.¹ In 2004, in response to the increasing evidence that periodontal disease may contribute to preterm birth and low–birth weight babies, the American Academy of Periodontology began recommending that all women who were pregnant or planning to become pregnant should undergo a periodontal examination.⁹ In 2006, the New York State Department of Health published guidelines for oral health care during pregnancy.¹⁰ Despite this, researchers in 2008 found that 90% of dentists did not provide all necessary treatment to pregnant patients.² Reasons dentists reported for withholding or delaying treatment included fear of injuring the woman or fetus and fear of litigation.²

In 2010, the California Dental Association published evidence-based guidelines for oral health care during pregnancy¹¹ (see Appendix E). There is still room for the dental profession to improve the delivery of oral health care to pregnant patients.

Patient Perceptions

In the United States, only 25% to 50% of women will receive any dental care while pregnant, including prophylaxis.¹¹ This is true even though 50% of pregnant women have dental problems.¹² Pregnant women do not seek dental care during pregnancy for a number of reasons, including the following¹³:

•  They do not realize they have an oral disease. ⁴

•  They believe poor oral health is normal during pregnancy. ³ , ⁴

•  They believe dental treatment may harm the fetus. ³ , ⁴

•  They are not informed that they should seek care. ⁴

Pregnancy may be the only time women in the lower socioeconomic strata are eligible for dental benefits.³ At the same time, however, these women are less likely to utilize services to receive dental care. For example, only 20% of the pregnant women enrolled in California’s Medi-Cal Program in 2007 had a dental visit during their pregnancy.¹⁴

Conclusion

As these facts suggest, the main barrier to proper dental care during pregnancy is the poor perception of patients, prenatal providers, and dental providers, all of whom contribute to the lack of proper oral health care during pregnancy.

References

1.  George A, Shamim S, Johnson M, et al. How do dental and prenatal care practitioners perceive dental care during pregnancy? Current evidence and implications. Birth 2012;39:238–247.

2.  Michalowicz BS, DiAngelis AJ, Novak MJ, et al. Examining the safety of dental treatment in pregnant women. J Am Dent Assoc 2008;139:685–695.

3.  Stevens J, Iida H, Ingersoll G. Implementing an oral health program in a group prenatal practice. J Obstet Gynecol Neonatal Nurs 2007;36:581–591.

4.  Dasanayake AP, Gennaro S, Hendricks-Muñoz KD, Chhun N. Maternal periodontal disease, pregnancy, and neonatal outcomes. MCN Am J Matern Child Nurs 2008;33:45–49.

5.  Wong D, Cheng A, Kunchur R, Lam S, Sambrook PJ, Goss AN. Management of severe odontogenic infections in pregnancy. Aust Dent J 2012;57:498–503.

6.  Strafford KE, Shellhaas C, Hade EM. Provider and patient perceptions about dental care during pregnancy. J Matern Fetal Neonatal Med 2008;21:63–71.

7.  Shrout MK, Comer RW, Powell BJ, McCoy BP. Treating the pregnant dental patient: Four basic rules addressed. J Am Dent Assoc 1992;123:75–80.

8.  Achtari MD, Georgakopoulou EA, Afentoulide N. Dental care throughout pregnancy: What a dentist must know. Oral Health Dent Manag 2012;11:169–176.

9.  Task Force on Periodontal Treatment of Pregnant Women, American Academy of Periodontology. American Academy of Periodontology statement regarding periodontal management of the pregnant patient. J Periodontol 2004;75:495.

10.  New York State Department of Health. Oral Health Care During Pregnancy and Early Childhood: Practice Guidelines. Albany: New York State Department of Health, 2006. https://www.health.ny.gov/publications/0824.pdf . Accessed 13 November 2017.

11.  California Dental Association Foundation; American College of Obstetricians and Gynecologists, District IX. Oral health during pregnancy and early childhood: Evidence-based guidelines for health professionals. J Calif Dent Assoc 2010; 38:391–403, 405–440.

12.  American Academy of Pediatric Dentistry. Guideline on Oral Health Care for the Pregnant Adolescent. http://www.aapd.org/media/Policies_Guidelines/G_Pregnancy.pdf . Accessed 17 January 2018.

13.  Al Habashneh R, Guthmiller JM, Levy S, et al. Factors related to utilization of dental services during pregnancy. J Clin Periodontol 2005;32:815–821.

14.  California HealthCare Foundation. Denti-Cal Facts and Figures: A Look at California’s Medicaid Dental Program. Oakland: California HealthCare Foundation, 2007.

CHAPTER 2

Considerations

for Treating

Pregnant

Patients

Key Points

•  Bacteremia caused by dental treatment during pregnancy does not routinely require antibiotic prophylaxis.

•  Providing routine dental treatment during pregnancy can improve maternal oral health but does not necessarily improve pregnancy outcomes.

•  Perinatal provider consultation is not always necessary when providing routine dental care to a healthy pregnant woman.

•  The TPAL (term, premature, abortions, living children) recording system can be used to screen for women with a history of high-risk pregnancy.

•  Emergency and urgent dental treatment can be done at any time. (Depending on the clinical situation, care can either be provided in the traditional outpatient dental office or in a hospital.)

•  Necessary dental treatment is ideally provided early in the second trimester (weeks 14 to 20 of pregnancy).

•  Elective dental care is not expected to affect the health of the pregnant woman or fetus during the time course of pregnancy and can be deferred until after pregnancy.

•  Dental care provided during pregnancy (eg, definitive dental treatment to stabilize the dentition) may decrease the risk of aspiration of teeth or other materials during intubation if the patient undergoes general anesthesia during pregnancy or at delivery.

Because