Safely caring for pregnant patients

The American Dental Association (ADA) states that preventive, diagnostic, and restorative dental treatment are safe throughout pregnancy.¹ There is “ample evidence that shows oral health care during pregnancy is safe and should be recommended to improve the oral and general health of the woman.”² However, confusion still surrounds the topic of treating patients during pregnancy for both providers and patients. The Centers for Disease Control and Prevention (CDC) reports that in 2019, only 46% of pregnant women in the United States received an oral prophylaxis during pregnancy; the percentage was even lower among socially disadvantaged women.³

There are many barriers to oral health care for pregnant women: cost, geographical location, family commitments, job commitments, other health care appointments, myths that dental care is not safe, and difficulty finding a dental office that is willing to provide care.

The top reason reported for not visiting the dentist more frequently is cost. Among Americans without a dental visit in the past 12 months, 59% reported that it was due to cost.⁴

According to the American Public Health Association (APHA), pregnancy may qualify women for public health insurance that includes dental benefits.⁵ As of May 2021, there are 36 states, and the District of Columbia, that provide Medicaid dental services for pregnant women.⁶ However, the extent of coverage varies from state to state and only 33 percent of all dentists in the US accept Medicaid.⁷

Oral health changes during pregnancy

The are many physiological changes that take place during pregnancy. The oral cavity is not excluded. The most common oral health conditions that occur during pregnancy are:

• Pregnancy gingivitis
• Periodontitis
• Tooth mobility
• Decay
• Erosion
• Pyogenic granuloma

For some women, oral health problems begin during pregnancy. Perhaps the patient is suffering with morning sickness and nausea throughout the day; it has prevented her from keeping up with home care and she sucks on lemon drops all day to help reduce the nausea. The result: for the first time in her life, the patient is diagnosed with cavities.

While the patient may attribute this to her pregnancy, as dental professionals we know that not keeping up with home care and sucking on sugar candy throughout the day is what caused the decay.

Another patient, who has teetered on the cusp of gingivitis for years, is now presenting with pregnancy gingivitis. With good home-care practices and routine dental care, this patient will likely see the pregnancy gingivitis resolve after the baby is delivered.

There are several hormonal changes that take place during pregnancy that contribute to oral health changes. Some women may temporarily experience tooth mobility because of high levels of progesterone and estrogen.⁸ Elevated progesterone levels can contribute to inflammation and bleeding of the gingival tissue.⁹ Neutrophil suppression is a relevant factor in the association between periodontal disease and pregnancy.¹⁰ Capillary permeability, defined as high levels of estrogen in the blood, predispose pregnant women to gingivitis and hyperplasia.¹¹

Preexisting oral health conditions

Preexisting oral health conditions can be problematic during pregnancy. A patient who enters pregnancy with untreated oral health issues is at risk of irreversible dental conditions such as periodontitis and tooth loss.

According to the CDC, nearly 60% 75% of pregnant women have gingivitis.¹² As dental professionals we know that when treated gingivitis is reversible. However, when left untreated, gingivitis leads to periodontitis, which can lead to tooth loss. Periodontitis has also been associated with poor pregnancy outcomes, including preterm birth and low birth weight.¹³

When left untreated, dental caries can lead to pain, abscess, and/or tooth loss. Untreated dental caries can have a negative impact beyond dental health for both the mother and the child. Children born to women with untreated dental caries are three times as likely to have higher levels of caries compared with children whose mother has no untreated caries.¹⁴

As a result of dental pain, the patient can also experience an increase in blood pressure.¹⁵ High blood pressure during pregnancy can lead to preeclampsia, stroke, placental abruption, preterm delivery, and low birth weight.¹⁶ It is imperative that pain be managed properly to avoid the potential harm high blood pressure can have on the pregnancy.

Untreated dental caries can lead to an abscess, and an untreated abscess can result in infection that spreads to the jaw, neck, head, or may result in sepsis—a life-threatening infection that spreads throughout the whole body.¹⁷ Oral infections have been implicated in adverse pregnancy outcomes such as preeclampsia, premature delivery, and miscarriage.¹⁸

Gram-negative anaerobes, which play an important role in maxillofacial infections, may serve as a source for endotoxins and lipopolysaccharides, which then increase local inflammatory mediators, leading to such complications.¹⁹ As a result of the systemic inflammatory response, the growing child is also at risk of serious complications.²⁰

When possible, patients should be encouraged to address dental health issues prior to starting a family to prevent complications with oral health during pregnancy. However, dental professionals can rest assured that it is safe to provide care when a pregnant patient presents with an oral health condition that requires treatment.^1,2

Oral health care during pregnancy

It is not necessary to postpone dental treatment during pregnancy. According to the American College of Obstetricians and Gynecologist (ACOG) and the ADA, oral health care during pregnancy is safe and should be recommended to improve the oral and general health of the woman.^1,2 To provide optimal care to patients during pregnancy, there are some considerations:

Morning sickness: 70% to 80% of women experience nausea and vomiting during the first trimester.²¹ Some women may opt to postpone routine dental care until they reach the second trimester. If the patient has pain or issues that cannot wait to be addressed, dental care providers should do their best to accommodate the patient. Offering an appointment during the time of day that the patient feels her best can help facilitate the opportunity to provide treatment.

Patient positioning: Dental providers should avoid lying the patient in the supine position during the third trimester. This is because patients in their third trimester are at risk of hypotensive supine syndrome (HSS). HSS occurs because the enlarged uterus presses against the vena cava, which carries blood to the heart, and pressure exerted by the fetus causes a sudden drop in blood pressure.²¹

To prevent patients from experiencing dizziness and fainting, guide them to a semi-reclined position. Patients can also be instructed to move to their left side, or a pillow can be placed under the right side of patients’ lower back; this allows the uterus to be closer to the aorta to prevent disruption of blow flow.²¹

X-rays: According to the ACOG and the ADA, dental x-rays are safe during pregnancy. Concern for taking dental x-rays during pregnancy stems from the risk associated with fetal exposure to ionizing radiation.^1,2 In order for radiation to be harmful to the child, there would have to be a high-dose exposure; however, high-dose levels are not used in diagnostic imaging.²²

Dental professionals should use clinical judgment when recommending dental x-rays for pregnant patients. The Food and Drug Administration (FDA) recommends that patients only be exposed to x-rays that are necessary to yield a diagnosis.²³ Routine x-rays can usually be postponed until after the baby is born. The ACOG, ADA, and FDA all recommend proper shielding to cover the patient’s abdomen and neck during exposure.^1,22,23

Local anesthesia: Per the ADA and the ACOG, lidocaine with or without epinephrine is considered safe to use during pregnancy.^1,2 Up to five tubes containing epinephrine with a concentration of 1:100,000 (or 10 tubes of anesthetic with 1:200,000 concentration of epinephrine) can be administered to pregnant patients.²¹

Favero et al. state that, “epinephrine-induced vasoconstriction delays the absorption of the anesthetic and, therefore, the level of lidocaine in the blood increases gradually and without peaks. The anesthetic is transferred to the fetus just as slowly, with a wider safety margin.”²¹

Nitrous oxide: Nitrous oxide has the potential risk for fetal harm and therefore is not recommended during pregnancy.¹ Other anesthetic and anxiety management options should be offered to ensure that the pregnant patient is comfortable during dental procedures.

Medication: Antibiotics may be used during pregnancy.²⁴ If the patient requires an antibiotic, the following medications are considered safe:

• Penicillin
• Amoxicillin
• Cephalosporins
• Metronidazole

Pain medications may also be used during pregnancy. When possible, it is best to manage oral pain with nonopioid medications, such as acetaminophen.²⁴ If it is necessary to prescribe an opioid, it is recommended to prescribe the lowest dose, for the shortest duration, and avoid any refills to reduce risk of dependency.²⁴ Additionally, the ADA recommends consulting with the patient’s obstetrician when prescribing medications for pain relief.¹

Sidebar: Tips for pregnant clinicians

To reduce occupational hazards, notify your employer of your pregnancy as early as possible. This will allow safety measures to be put into action to protect you throughout your pregnancy. The ADA states that special consideration should be given to dental personnel whose job duties involve direct exposure to nitrous oxide and radiation.¹

According to the National Institute for Occupational Safety and Health, dental workers are exposed to nitrous oxide during the administration to patients.²⁵ Therefore, the ADA recommends that pregnant dental staff avoid exposure to nitrous oxide due to its potential for fetal harm.¹

Additionally, pregnant dental care providers need to take precautions to ensure that they are minimizing radiation exposure. If possible, x-rays should be taken by an employee who is not pregnant.

According to the ADA, pregnant providers should wear a dosimetry badge to track exposure to radiation.²⁶ Pregnant dental care providers should also have barrier protection; this may include shielding and standing at least two meters from the tube head and out of the path of the primary beam.²⁶ Dental hygienists’ schedules are often very busy. You must make sure to take care of your body during pregnancy.

Steps to help care for your body during pregnancy include:

• Drink plenty of water
• Take a lunch break and pack healthy snacks
• Stretch
• Prenatal massage therapy
• Try to get at least eight hours of sleep at night

Home care education

Hormone changes, nausea, vomiting, dietary changes, and lifestyle changes can all increase a women’s risk of oral health problems during pregnancy. Therefore, daily oral hygiene must be emphasized to all pregnant patients. While brushing twice a day for two minutes and flossing once a day are standard oral care practices, additional recommendations may be necessary to help pregnant patients prevent, or manage, oral health problems.

With an increased risk for periodontal disease during pregnancy, it is important to discuss interdental cleaning with pregnant patients and to help them find the right interdental device to suit their personal preferences and needs. Dental floss, interdental brushes, floss handles, or a water flosser (e.g., Waterpik) are just a few of the options available to help patients improve or maintain gingival health.

When the patient is at risk for dental decay, additional home-care education beyond brushing and flossing are necessary. Dental hygienists can provide pregnant patients with nutritional counseling and recommend a fluoride mouth rinse be used daily to help prevent decay.

Patients who are experiencing morning sickness have a high risk for erosion and decay. These patients should be instructed to not brush immediately after vomiting as this can be harmful to the enamel surface. Instead, patients should be instructed to rinse with a diluted solution of one cup of water and one teaspoon of baking soda.²⁷

When discussing home-care regimens, dental hygienists should consider struggles the patient is experiencing that may have a negative consequence on oral health. For example, some women may find their gag reflex is easily triggered by brushing and/or flossing during pregnancy. Suggestions that may help reduce the gag reflex:

• Wait until after eating breakfast to brush
• Change the flavor of toothpaste
• Eliminate toothpaste and brush with water instead
• Use a mouth rinse instead of toothpaste to provide antimicrobial or decay prevention benefits
• Use an interdental cleaning device that does not require putting hands inside of the mouth to clean interproximally, such as floss handles, interdental brushes, or a Waterpik water flosser

Summary

The oral cavity is not excluded from the many physiological changes that take place during pregnancy. According to the ACOG and the ADA, dental professionals can feel confident that it is safe to deliver diagnostic, preventive, and restorative care to patients during pregnancy.^1,2 If any questions remain, a consultation with the patient’s obstetrician is recommended to ensure the patient’s oral health needs are met.

Editor's note: This article appeared in the October 2022 print edition of RDH magazine. Dental hygienists in North America are eligible for a complimentary print subscription. Sign up here.

References

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