Clinical Guideline -19 Version 1

Valid to: July 2012

Dental management of pregnant patients

Purpose
The aim of this Clinical Guideline is to provide advice to public oral health clinicians about
the issues that arise when treating a pregnant patient. Recently pregnant women have
been identified as a priority group as studies have shown a link between the level of
periodontitis in pregnant women and preterm birth, low birth weight, or both (Clothier, et al
2007). In addition an association between moderate to severe periodontitis in early
pregnancy and an increased risk of spontaneous preterm birth, independent of other
traditional risk factors (Jeffcoat et al, 2001) (Offenbacher et al, 2006) has been
demonstrated. More recently an association has been shown between maternal periodontal
health and higher incidence of preeclampsia (Canakci et al, 2004). Considering these
findings a new course of care within the public dental system in Victoria has identified
pregnant women as a high priority group for access to public dental services. This is also an
opportunity to begin a lifetime of preventive dental treatment for the baby.

Guideline
2.0 Preventative messages
The literature demonstrates Streptococci Mutans are vertically transmitted from mother to
child. Therefore an individualised preventive plan for an expectant mother needs to be
implemented as part of her treatment plan. This would include oral hygiene instructions,
diet counselling, the regular use of oral rinses and CPPACP in the form of tooth mousse or
recaldent gum and/or xylitol gum in an effort to improve the oral health of the expectant
mother and decrease the likelihood of transmission of cariogenic bacteria postpartum
(American Academy of Paediatric Dentistry, 2007)(Yost et al, 2008). An adequate Dental
history should form part of the routine early pregnancy care. If concerns regarding dental
health are recognized by the supervising Obstetric team early Dental referral should be
facilitated. Any concerns regarding the safety of the pregnancy or impact of proposed
treatment should always be discussed with the responsible Obstetric team.
Mothers need adequate calcium and Vitamin D for optimal development of their baby's
teeth and bones. Calcium can be found in common foods such as milk, cheese, dried beans,
and leafy green vegetables. Furthermore, cheese has shown pH neutralising benefits if
eaten after a meal (Cappelli, 2008). Oral Vitamin D supplements may be needed if serum
levels are low.
Early Childhood Caries is a serious dental disease. The result of this disease is cavities,
pain, infection, speech problems, early tooth loss, dental phobia and loss of self esteem
(Cameron et al, 2006)(Yost et al, 2008).
Mothers should be advised to avoid putting baby to bed with a bottle. Should the mother be
breast-feeding, the mother should be advised against letting baby nurse continuously
during sleep. Baby feeding should always be supervised, i.e. the mother should finish
feeding the baby before putting him or her to sleep. If the mother insists on baby sucking
something while sleeping, advise the use of a pacifier (dummy) (Cameron et al, 2006)
(Yost et al, 2008).
Advise mother that once baby is 1 year old its time for the first dental visit (Yost et al,
2008). Children should visit a dentist for the first time within 6 months of the eruption of
the first primary tooth, and no later than age 12 months. The goals of the visit are to
assess risk for tooth decay, provide anticipatory guidance, respond to questions parents

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may have about oral health and development, initiate prevention practices, and schedule
the next visit. During a childs early visits to the dentist, the oral health practitioner can
also assess tooth and jaw development and check for problems. By taking their child to the
dentist early, parents learn how to care for their childs teeth. Children, in turn, learn the
importance of good oral health care and view visiting the dentist as a positive experience.
Additionally the pregnant patient should be advised of the associations between poor
periodontal health and possible adverse effects on the pregnancy and foetus.
3.0 Treatment
When treating a pregnant patient it is important to obtain the following information when
recording their history:
History taking:
Questions regarding the patients medical history should included any current or previous
pregnancy complications, previous spontaneous abortions, or pernicious vomiting, present
or past tobacco use and contact should be made to the obstetrician to discuss medical
status, periodontal and dental needs and the proposed treatment plan. Furthermore the
patients dental history should include any symptoms of pre-existing oral conditions, current
oral hygiene homecare practice, and previous radiographic exposures. Lastly the patients
dietary history should be noted and include exposure to carbohydrates, especially due to
increased snacking and acidic beverages/foods (Carranza et al, 2006) (American Academy
of Pediatric Dentistry, 2007).
Pregnant women who are at risk of infective endocarditis
Primary prophylaxis is with amoxicillin 2.0 g given orally 1 hour before the procedure.
Penicillin-allergic women can be treated with clindamycin 600mg orally (Therapeutic
Guideline LTD, 2007).
General care of the pregnant patient
When treating the pregnant patient in a dental chair a few considerations need to be made
for both mother and foetus:
Conservative treatment
There is no increased risk of preterm (<37 weeks gestation) deliveries, spontaneous
abortions or still births, or foetal abnormalities associated with essential dental treatment,
defined as presence of moderate to severe caries or fractured or abscessed teeth
(Michalowicz et al, 2008). There is also no association between maternal general dental
care during pregnancy and gestational age, birth weight, or neurodevelopment (Hujoel et
al, 2006) (Daniels et al, 2007).
The most comfortable and safest time for the pregnant patient is during the 14th to 20th
weeks of gestation. (Rosen, 1999) (Creasy et al, 2004). During the first trimester elective
dental treatment should be avoided as the foetus is very susceptible to environmental
influences, as this is when organogenesis occurs. Additionally during the second half of the
third trimester premature delivery is a risk, as the uterus is sensitive to external stimuli and
prolonged chair time may need to be avoided because the patient is most uncomfortable at
this time (Carranza et al, 2006).
Supine hypotensive syndrome
Supine hypotensive syndrome is a condition that affects up to 8% of pregnant women and
occurs mainly in the third trimester (Lanni et al, 2002) (Carranza et al, 2006). This
syndrome occurs when the patient is in a semi reclining or supine position, as the great
vessels, particularly the inferior vena cava, are compressed by the gravid uterus. This
compression will cause maternal hypotension by interfering with venous return to the heart,

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decreasing cardiac output. This leads to hypotension, nausea, dizziness, fainting and
eventually loss of consciousness. This syndrome can usually be reversed by turning the
patient on her left side, allowing blood to return from the lower extremities and pelvic area
by alleviating the pressure on the vena cava (Carranza et al, 2006) (Little et al, 2002).
Clinical Tip: A preventive 10 12 cm soft wedge (rolled towel) should be placed on the
patients right side when she is reclined for clinical treatment to limit the pressure placed on
the vena cava thus allowing the blood to continue circulating (Carranza et al, 2006) (Little
et al, 2002).
Radiography
The Australian governments Australian Radiation Protection and Nuclear Safety Agency
published a Code of Practice and Safety Guide outlining Radiation Practice in Dentistry in
2005.
Radiation Protection Series Publication No. 1 (ARPANSA 2002) recommends:
care should be taken to lower the radiation exposure of the pelvic and abdomen
regions of women
precautions should be taken to avoid irradiation of the foetus wherever practical
when taking a radiograph of an area distant form the foetus, such as dental
radiography, this can be taken at anytime with insignificant dose to the foetus any
time during pregnancy
Use of a lead protective drape is recommended when the radiation beam is directed
towards the patients body, for example when taking occlusal views of the maxilla.
(Radiation Health Committee, 2005).
There is no need to defer dental radiography during pregnancy on the grounds of radiation
protection, however if treatment is to be deferred, radiation should be deferred.
Should the patient require consecutive radiation exposure, such as when having endodontic
treatment, the foetus should be afforded the same level of protection as a member of the
public, which is set at the rate of 1 mSv per year.
(Radiation Health Committee, 2005) (American Academy of Paediatric Dentistry, 2007).
Amalgam and pregnancy
When handling dental amalgam appropriately, amalgam restorations are considered safe
for pregnant patients and their baby (Daniels et al, 2007) (Luglie et al, 2005) (DHSV,
Amalgam Policy, 2007).
4.0 Considerations
4.1 Oral conditions associated with pregnancy
Pregnancy granuloma
Pregnancy oral tumour occurs in up to 5 percent of pregnancies and is indistinguishable
from pyogenic granuloma. Pregnancy tumours are most common after the first trimester,
grow rapidly, and typically recede after delivery. Management is usually observational
unless the tumours bleed, interfere with mastication, or do not resolve after delivery.
Lesions surgically removed during pregnancy are likely to recur (Sills et al, 1996).
Loose teeth
Teeth can loosen during pregnancy, even in the absence of gum disease, because of
increased levels of progesterone and oestrogen affecting the periodontium (Scheutz et al,

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2002). Clinicians should assure these patients that these teeth are only temporarily mobile
and these teeth will not be lost due to this hormonal change (Silk et al, 2008).
Ptyalism and Perimylolysis
Ptyalism, which is excess saliva production during early pregnancy in women who
experience nausea, seems to subside when the nausea improvesat approximately 12 to
14 weeks gestation. Nausea and vomiting are very common in pregnancy and seem to
affect anywhere between 50% and 85% of pregnancies (Davis, 2004). Vomiting of the
gastric contents may lead to decreased pH in the oral cavity. Perimylolysis (acid erosion of
teeth) may occur during pregnancy if the gastric contents or the frequency and duration of
vomiting are excessive (Bartlett, 2006) (Harper et al, 1995) (Carranza et al, 2006). Rinsing
with a teaspoon of sodium bicarbonate (baking soda) and water after vomiting can
minimise affect on oral environment (Ritter, 2006).
Dry mouth and xerostomia
A confounding factor is that pregnancy associated hormonal changes may cause dryness of
the mouth. It has been found to effect up to 44% of pregnancies (Steinberg, 1999). There
are a number of salivary substitutes available to alleviate symptoms for patients who are
experiencing dry mouth during pregnancy. Additionally patients may stimulate salivary flow
with sugarless lollies or gum (Carranza et al, 2006).
4.2 Medication and pregnancy
Please refer to The Therapeutic Guidelines Oral and Dental or the Australian Government
website http://www.tga.gov.au/docs/html/medpreg.htm when prescribing medications to a
pregnant patient.
Nitrous oxide oxygen analgesia use during pregnancy
It is not recommended that nitrous oxide (N2O) oxygen be administered during pregnancy
as studies demonstrate increased congenital abnormalities, altered immune responses,
spontaneous abortions and increased birth defects when used during pregnancy (Darby et
al, 2003).
Nitrous oxide oxygen is considered safe for lactating women and therefore their nursing
infants (Darby et al, 2003).
Local anaesthetics
Although high-dose vasoconstrictors used to manage significant hypotension may be a
concern for pregnant patients, the doses of adrenalin used in local anaesthetic formulations
for dentistry are so low that they are unlikely to significantly affect uterine blood flow. The
benefits of adrenaline at the concentrations found in dental anaesthetic cartridges justify
their use. Aspiration must always be carried out (Haas, 2002).No specific disturbances to
the reproductive process have so far been reported with administration of prilocaine
hydrochloride 3% with felypressin 0.03 IU/ml (3% Citanest DENTAL with Octapressin),
e.g. an increased incidence of malformations or other direct or indirect harmful effects on
the foetus. With the dental dosage of prilocaine (1-5 mL 3% Citanest DENTAL with
Octapressin, i.e. 30-150 mg prilocaine hydrochloride 3% with felypressin 0.54 mcg/mL),
the occurrence of methaemoglobinaemia in dental practice appears remote. However, gross
overdosage in dental practice has been reported to cause methaemoglobinaemia.
Methaemoglobinaemia in the neonate has been reported after the administration of
prilocaine to the mother in doses exceeding 600 mg. Prilocaine may enter the mother's
milk, but in such small amounts that there is generally no risk of this affecting the neonate.
It is not known whether felypressin is excreted in breast milk. (Medsafe, 2009)

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4.3 Pregnant staff
Radiation
If a member of the dental staff is pregnant then the foetus should be afforded the same
level of protection as a member of the public which is set at the rate of 1 mSv per year.
(Radiation Health Committee, 2005).
Nitrous Oxide-Oxygen Analgesia
A properly functioning gas scavenging system should be used to provide protection to the
pregnant employee in a setting where nitrous oxide-oxygen is used. However if there is not
a scavenging system in place female employees of reproductive age should be removed
from non scavenged areas (Hoskins, 2003).

Definitions
Nil

Revision date

Policy owner

July 2012

Director of Clinical Leadership

Approved by

Date approved

Clinical Leadership Council

2 July 2009

References and related documents

American Academy of Dentistry. (2007). "Guideline on Oral Health Care for the
Pregnant Adolescent." Retrieved 26/06/2008, from
http://www.aapd.org/media/Policies_Guidelines/G_Pregnancy.pdf

Bartlett D (2006). "Intrinsic causes of erosion." Monographs in Oral Science 20:

119-39.

Cameron A and Widmer R (2006). Handbook of Pediatric Dentistry. Philadelphia,

Mosby

Canakci V, Canakci CF, et al. (2004). "Periodontal disease as a risk factor for
preeclampsia: a casecontrol study." Australian and New Zealand Journal of
Obstetrics and Gynaecology 44: 568-73.

Cappelli D (2008). Prevention in clinical oral health care. St. Louis, Mosby.

Carranza F, Newman M, et al. (2006). Carranza's Clinical Periodontology.

Philadelphia, Saunders.

Clothier B, Stringer M, et al. (2007). "Periodontal disease and pregnancy outcomes:

exposure, risk and intervention." Best Pract Res Clin Obstet Gynaecol 21(3): 451466.

Creasy RK and Resnik R (2004). Maternal-Fetal Medicine: Principles and Practice.

Philadelphia, WB Saunders.

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Daniels JL, Rowland AS, et al. (2007). "Maternal dental history, child's birth outcome
and early cognitive development." Paediatric and Perinatal Epidemiology 21: 44857.

Darby M and Walsh M (2003). Dental hygiene theory and practice. St Louis,
Saunders.

Davis M (2004). "Nausea and vomiting of pregnancy: An evidenced-based review."

The Journal of Perinatal and Neonatal Nursing 18: 312-28.

Dental Health Services Victoria (DHSV) (2007): Use of Dental Amalgam Policy POA041-02

Haas DA (2002). "An update on local anesthetics in dentistry." J Can Dent Assoc
68(9): 546-51.

Harper MA, McVeigh JE, et al. (1995). "Successful pregnancy in association with
Zollinger-Ellison syndrome." American Journal of Obstetrics and Gynecology 173:
863-4.

Hoskins I (2003). "Environmantal and occupational hazards to pregnancy." Prim

Care Update Ob/Gyns 10: 253-57.

Hujoel PP, Lydon-Rochelle M, et al. (2006). "Cessation of periodontal care during

pregnancy: effect on infant birthweight." Eur J Oral Sci 114: 2-7.

Jeffcoat MK, Geurs NC, et al. (2001). "Periodontal infection and preterm birth:
results of a prospective study." J Am Dent Assoc(132): 875-880.

Lanni SM, Tillinghast J, et al. (2002). "Hemodynamic changes and baroreflex gain in
the supine hypotensive syndrome." Am J Obstet Gynecol 187: 1636-41.

Little JW, Falace DA, et al. (2002). Dental management of the medically
compromised patient. St Louis, Mosby.

Luglie PF, Campus G, et al. (2005). "Effect of amalgam fillings on the mercury
concerntration in human amniotic fluid." Arch Gynecol Obstet 271: 138-42.

MedSafe (2004) . Information for Health Professionals. Data Sheet. 3% Citanest

Dental with Octapressin. New Zealand Medicine and Medical Devices Safety
Authority.
http://www.medsafe.govt.nz/profs/Datasheet/c/Citanestwithoctapressininj.htm (
Date accessed: 29 March 2009)

Michalowicz BS, DiAngelis AJ, et al. (2008). "Examining the Safety of Dental
Treatment in Pregnant Women " J Am Dent Assoc 139: 685-95.

Offenbacher S, Boggess KA, et al. (2006). "Progressive periodontal disease and risk
of very preterm delivery." Obstet Gynecol(107): 29-36.

Radiation Health Committee. (2005). Code of Practice and Safety Guide - Radiation
Protection in Dentistry, Australian Radiation Protection and Nuclear Safety Agency,
Australian Government
Ritter A (2006). "Talking with patients - eating disorders and ora health." Journal of
esthetic and restorative dentistry: 114.

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Rosen MA (1999). "Management of anesthesia for the pregnant surgical patient."

Anesthesiology 91(4): 1159-63.

Scheutz F, Baelum V, et al. (2002). "Motherhood and dental disease." Community

Dent Health 19(2): 67-72.

Silk H, Douglass A B, et al. (2008). "Oral health during pregnancy." Am Fam

Physician 77(8): 1139 -1144.

Sills ES, Zegarelli DJ, et al. (1996). "Clinical diagnosis and management of
hormonally responsive oral pregnancy tumor (pyogenic granuloma)." J Reprod Med
41(7): 467-70.

Steinberg BJ (1999). "Women's oral health issues." J Dent Educ 63(3): 271-5.

Therapeutic Guidelines: Oral and Dental, Version 1. Therapeutic Guideline LTD,

2007.

Yost J and Li Y (2008). "Promoting oral health from birth through childhood:
Prevention of early childhood caries." The American Journal of Maternal/Child
Nursing 33(1): 17-23.

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