PREGNANCY

 Pregnancy
 Although not a disease state, pregnancy is still a
situation in which special considerations are
necessary when oral surgery is required, to
protect the mother and the developing fetus. The
primary concern when providing care for a
pregnant patient is the prevention of genetic
damage to the fetus. Two areas of oral surgical
management with potential for creating fetal
damage are (1) dental imaging and (2) drug
administration. It is virtually impossible to perform
an oral surgical procedure properly without using
radiography or medications; therefore, one option
is to defer any elective oral surgery until after
delivery to avoid fetal risk.
 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.
 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.
Symptoms and signs are caused by impaired
venous return to the heart resulting from
compression of the inferior vena cava by the
gravid uterus. This leads to decreased blood
pressure, reduced cardiac output, and impairment
or loss of consciousness.
 The remedy for the problem is for the patient to
roll over onto her left side, which lifts the uterus
off the vena cava. Blood pressure should rapidly
return to normal.
 ----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.
Although changes in platelets are usually clinically
insignificant, most studies show a mild decrease
in platelets during pregnancy.
 Several blood clotting factors, especially
fibrinogen and factors VII, VIII, IX, and X, are
increased. As a result of the increase in many of
the coagulation factors, combined with venous
stasis, pregnancy is associated with a
hypercoagulable state. Interestingly, however, the
prothrombin time, activated partial
thromboplastin time, and thrombin time all fall
slightly but remain within the limits of normal
nonpregnant values.
 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. This increase in neutrophils may complicate the
interpretation of the complete blood count during infection.
Also, during pregnancy, the immune system shifts from
helper T cell type 1 (TH1) dominance to TH2 dominance.
This shift leads to immune suppression. Clinically, the
decrease in cellular immunity leads to increased
susceptibility to intracellular pathogens such as
cytomegalovirus virus, herpes simplex virus, varicella virus.
The decrease in cellular immunity may explain why
rheumatoid arthritis frequently improves during gestation,
since it is a cell-mediated immunopathologic disease.
 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%. Of interest,
the respiratory rate and vital capacity remain
unchanged. These ventilator changes produce
an increased rate of respiration (tachypnea)
and dyspnea that is worsened by the supine
position.
 Common complications include infection,
enhanced inflammatory response, glucose
abnormalities, and hypertension.. Each of these
entities increases the risks for preterm delivery,
perinatal mortality, and congenital anomalies.
Insulin resistance is a contributing factor to the
development of gestational diabetes mellitus
(GDM), which occurs in 2% to 6% of pregnant
women. GDM increases the risks for infection and
large birth weight babies.
 Hypertension is of particular interest because it
can lead to end organ damage or preeclampsia, a
clinical condition of pregnancy that manifests as
hypertension, proteinuria, edema, and blurred
vision. Preeclampsia, defined as hypertension
with proteinuria, progresses to eclampsia if
seizures or coma develop. The cause of eclampsia
is unknown but appears to involve sympathetic
overactivity associated with insulin resistance, the
renin-angiotensin system, lipid peroxidation, and
inflammatory mediators.
 Complications of pregnancy that are unresponsive
to diet modification and palliative care ultimately
require drugs or hospitalization for adequate
control.
 Gestational diabetes (or gestational diabetes
mellitus, GDM) is a condition in which women
without previously diagnosed diabetes exhibit high
blood glucose (blood sugar) levels
during pregnancy (especially during their third
trimester). Gestational diabetes is caused
when insulin receptors do not function properly.
This is likely due to pregnancy-related factors such
as the presence of human placental lactogen that
interferes with susceptible insulin receptors. This
in turn causes inappropriately elevated blood
sugar levels.
 ---Another consideration related to fetal growth is
spontaneous abortion (miscarriage). The most
common causes of spontaneous abortion are
morphologic or chromosomal abnormalities which
prevent successful implantation. It is most
unlikely that any dental procedure would be
implicated in spontaneous abortion, provided fetal
hypoxia and exposure of the fetus to teratogens
are avoided. Febrile illness and sepsis also can
precipitate a miscarriage; therefore, prompt
treatment of odontogenic infection and
periodontitis is advised.

 Dental management:

 1--Before performing any oral surgery on a pregnant patient, the
clinician should consult the patient’s obstetrician.

 2---Treatment Timing
 Elective dental care is best avoided during the first trimester
because of the potential vulnerability of the fetus . The second
trimester is the safest period during which to provide routine
dental care. Emphasis should be placed on controlling active
disease and eliminating potential problems that could occur
later in pregnancy or during the immediate postpartum period,
because providing dental care during these periods often is
difficult. Extensive reconstruction or significant surgical
procedures are best postponed until after delivery. The early
part of the third trimester is still a good time to provide routine
dental care. After the middle of the third trimester, however,
elective dental care is best postponed.
 Pregnancy is a relative contraindication to
extractions; patients who are in the first or third
trimester should have their extractions deferred, if
possible. The latter part of the first trimester and
the first month of the last trimester may be as
safe as the middle trimester for a routine
uncomplicated extraction, but more extensive
surgical procedures requiring drugs other than
local anesthetics should be deferred until after
delivery.
 3--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, and hypertension. 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 .
 3--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, and hypertension. 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 .
 Also, clinical concern is appropriate if the
patient’s blood pressure increases 30 mm Hg or
more in systolic or increases 15 mm Hg in
diastolic blood pressure over prepregnancy
values, because these changes can be a sign of
preeclampsia. Confirmed hypertensive values
dictate that the patient be referred to a
physician to ensure that preeclampsia and other
cardiovascular disorders are properly diagnosed
and managed.

 4--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. 
 A patient nearing delivery may need special positioning of
the chair during care because if the patient is placed in
the fully supine position, the uterine contents may cause
compression of the inferior vena cava, compromising
venous return to the heart and, thereby, cardiac output.
The patient may need to be in a more upright position or
have her torso turned slightly to one side during surgery.
Frequent breaks to allow the patient to void are commonly
necessary late in pregnancy because of fetal pressure on
the urinary bladder.
 Prolonged time in the dental chair should be avoided, to
prevent the complication of supine hypotension. If supine
hypotension develops, rolling the patient onto her left side
affords return of circulation to the heart. Scheduling short
appointments, allowing the patient to assume a
semireclining position, and encouraging frequent changes
of position can help to minimize problems.

 6--Pregnancy can be emotionally and
physiologically stressful; therefore, an
anxiety-reduction protocol is
recommended. Patient vital signs should
be obtained, with particular attention paid
to any elevation in blood pressure (a
possible sign of pre-eclampsia).
 ----Dental Radiographs
Pregnant patients who require radiographs often 
have anxiety about the adverse effects of x-rays
on their baby. In some instances, their
obstetrician or primary care physician may
reinforce these fears. In almost all cases involving
dental radiography, these fears are unfounded.
The safety of dental radiography has been well
established, provided that features such as fast
exposure techniques (e.g., high-speed film or
digital imaging), filtration, collimation, lead
aprons, and thyroid collars are used. Of all aids,
the most important for the pregnant patient are
the protective lead apron and the thyroid collar.
 The traditional unit of the absorbed dose is the rad
(radiation absorbed dose). In recent years, however,
 there has been a move to use the metric-based Système
International (SI), and its unit of measurement for
 absorbed dose is the gray (Gy): 1 Gy equals 100 rads. Thus,
1 centigray (cGy) equals 1 rad.
 Available animal and human data support the conclusion
that no increase in gross congenital anomalies or intera
uterine growth retardation occurs as a result of exposures
during pregnancy totaling less than 5 cGy (5
 rad). Full-mouth dental series (18 intraoral radiographs, D
film, lead apron) is equal to 0.00001 cGy.
 It is obvious that exposures from typical dental radiographs
are less than natural daily background radiation.
 Despite the negligible risks of dental radiography, the
dentist should not be cavalier regarding its use during
 pregnancy . Radiographs should be obtained
selectively and only when necessary and appropriate
to aid in diagnosis and treatment. Bitewing,
panoramic, or selected periapical films are
recommended for minimizing patient dose. To further
reduce the radiation dose, the following measures
should be employed: rectangular collimation, E-speed
or F-speed film or faster techniques (digital imaging
reduces radiographic exposure by at least 50% in
comparison with E-speed exposures), lead shielding
(abdominal and thyroid collar), high-kilovoltage (kV) or
constant beams better to be used .
 Drug Administration
 During Pregnancy. Another controversial area in
the treatment of the pregnant dental patient is
drug administration. The principal concern is that
a drug may cross the placenta, with the potential
for toxic or teratogenic effects on the fetus.
Additionally, any drug that is a respiratory
depressant may cause maternal hypoxia, resulting
in fetal hypoxia, injury, or death.
 Before prescribing or administering a drug to a
pregnant patient, the dentist should be familiar
with the FDA categorization of prescription drugs
for pregnancy based on their potential risk of fetal
injury.
 In 2008, the FDA announced that it was eliminating the current
pregnancy risk classification
 System.

 The current five pregnancy labeling categories are as follows:
 Category A: Controlled studies in humans have failed to
demonstrate a risk to the fetus, and the possibility of fetal
harm appears remote.
 Category B: Animal studies have not indicated fetal risk, and
human studies have not been conducted, or animal studies
have shown a risk, but controlled human studies have not.
 Category C: Animal studies have shown a risk, but controlled
human studies have not been conducted, or studies are not
available in humans or animals.
 Category D: Positive evidence of human fetal risk exists, but in
certain situations, the drug may be used despite its risk.
 Category X: Evidence of fetal abnormalities and fetal risk exists
based on human experience, and the risk outweighs any
possible benefit of use during pregnancy.
 Local Anesthetics.
 Local anesthetics administered with epinephrine
generally are considered safe for use during
pregnancy and are assigned to pregnancy risk
classification categories B and C. Although both
the local anesthetic and the vasoconstrictor cross
the placenta, subtoxic threshold doses have not
been shown to cause fetal abnormalities.
Because of adverse effects associated with high
levels of local anesthetics, it is important not to
exceed the manufacturer’s recommended
maximum dose.
Analgesics.
 The analgesic of choice during pregnancy is
acetaminophen (category B). Aspirin and
nonsteroidal antiinflammatory drugs convey risks
for constriction of the ductus arteriosus, as well
as for postpartum hemorrhage and delayed labor .
The risk of these adverse events increases when
agents are administered during the third
trimester. Risk also is more closely associated
with prolonged administration, high dosage, and
selectively potent anti-inflammatory drugs, such
as indomethacin. Codeine and propoxyphene are
associated with multiple congenital defects and
should be used cautiously and only if needed.
 Antibiotics.
 Penicillins (including amoxicillin), erythromycin,
cephalosporins, metronidazole, and clindamycin
are generally considered to be safe for the
expectant mother and the developing child.
 The use of tetracycline, including doxycycline (FDA
category D), is contraindicated during pregnancy.
Tetracyclines bind to hydroxyapatite, causing
brown discoloration of teeth, hypoplastic enamel,
inhibition of bone growth, and other skeletal
abnormalities.
 Anxiolytics.
 Few anxiolytics are considered safe to use during
pregnancy. However, a single, short-term exposure to
nitrous oxide–oxygen (N2O-O2) for less than 35 minutes is
not thought to be associated with any human fetal
anomalies.
 Accordingly, the following guidelines are recommended if
N2O-O2 is used during pregnancy:
 • Use of N2O-O2 inhalation should be minimized to 30
minutes.
 • At least 50% oxygen should be delivered to ensure
adequate oxygenation at all times.
 • Repeated and prolonged exposures to nitrous oxide are
to be avoided.
 • The second and third trimesters are safer periods for
treatment because organogenesis occurs during the
 first trimester.
 Oral Complications and Manifestations
 ---The most common oral complication of
pregnancy is pregnancy gingivitis . This condition
results from an exaggerated inflammatory
response to local irritants and less-than-
meticulous oral hygiene during periods of
increased secretion of estrogen and
progesterone and altered fibrinolysis.
---In approximately 1% of gravid women, the 
hyperplastic response may exacerbate in a
localized area, resulting in a pyogenic granuloma
or ―pregnancy tumor‖. The most common location
for a pyogenic granuloma is the labial aspect of
the interdental papilla. The lesion generally is
asymptomatic; however, toothbrushing may
traumatize the lesion and cause bleeding.
Surgical or laser excision occasionally is required
as dictated by symptoms, bleeding, or
interference with mastication.
 ---Pregnancy does not cause periodontal disease but
may modify and worsen what is already present.
Gestational diabetes mellitus, however, may be
associated with an increased risk for periodontal
disease.


 ----Many women are convinced that pregnancy causes

tooth loss (i.e., ―a tooth for every pregnancy‖), or that
calcium is withdrawn from the maternal dentition to
supply fetal requirements (i.e., ―soft teeth‖). Calcium
is present in the teeth in a stable crystalline form and
hence is not available to the systemic circulation to
supply a calcium demand. However, calcium is readily
mobilized from bone to supply these demands.
 Tooth mobility, localized or generalized, is an
uncommon finding during pregnancy. Mobility is a
sign of
 gingival disease, disturbance of the attachment
apparatus, and mineral changes in the lamina
dura. Because vitamin deficiencies may
contribute to this and other congenital problems
(e.g., folate deficiency,), the dentist, when
discussing oral hygiene, should take this
opportunity to educate the patient about the
benefits of the use of multivitamins. Daily removal
of local irritants, adequate levels of vitamin C, and
delivery of the newborn should result in reversal
of tooth mobility.
 Pregnant women often have a hypersensitive
gag reflex. This, in combination with morning
sickness, may
 contribute to episodes of regurgitation,
potentially leading to halitosis and enamel
erosion. The dentist should advise the patient
to rinse after regurgitation with a solution that
neutralizes the acid (e.g., baking soda, water)
 Postpartum
 Special considerations should be taken when
providing oral surgical care for the postpartum
patient who is breastfeeding a child. Avoiding
drugs that are known to enter breast milk and to
be potentially harmful to infants is prudent (the
child’s pediatrician can provide guidance).
However, in general, all the drugs common in oral
surgical care are safe to use in moderate doses;
the exceptions are corticosteroids,
aminoglycosides, and tetracyclines, which should
not be used.