Care of pregnant women in odontostomatology

Care of pregnant women in odontostomatology

Introduction

There are many questions that a dentist might ask when seeing a pregnant woman or a woman of childbearing age.

How should I behave to ensure his care? Can I take an X-ray? What anesthetic should I use? What medication should I prescribe? What procedure should I perform and what should I postpone until after delivery?

It is useful to highlight:

The physiological characteristics during each of the three trimesters of gestation on the one hand

The therapeutic possibilities and limits on the other hand, in order to eliminate any ambiguity regarding the care of pregnant women.

Pregnancy is a physiological state characterized by a major endocrine upheaval.

This rather complex set of hormones causes vascular changes in the oral mucosa, the alveolar-dental ligament and the dental organ.

1. HORMONAL CHANGES

The physiological changes that occur in pregnant women result mainly from the endocrine activity of the placenta, which secretes estrogens and progesterones.

The secretion of these hormones increases during pregnancy up to 10 times the normal concentration for progesterone and 30 times the normal concentration for estradiol.

2. IMMUNOLOGICAL CHANGES:

*certain hormones associated with pregnancy, such as progesterone, have immunosuppressive properties.

*Also, polymorphonuclear chemotaxis, phagocytosis and antibody response are affected in the presence of high hormone levels.

*Pregnant women have a higher risk of infections.

3. CHANGES IN THE ORAL ENVIRONMENT

*Saliva

During pregnancy, we witness qualitative and quantitative changes in saliva. Salivary flow increases especially during the first three months. There is currently no explanation for this phenomenon. This hypersalivation generally decreases over the months. Salivary pH evolves towards a slight acidity; it goes from 6.7 to 6.2. This drop in pH leads to a decrease in buffering capacity. In addition, we witness a passage of pregnancy hormones into saliva. Studies have shown that estradiol and progesterone can substitute certain bacterial growth factors, which increases the number of microorganisms and modifies the composition of bacterial plaque.

4. ORAL PATHOLOGIES RELATED TO PREGNANCY:
   1. Mucosal pathology: Hormonal action on the oral mucosa is demonstrated experimentally and clinically.
5. Pregnancy gingivitis : This is an inflammatory response frequently observed during pregnancy, exacerbated by the presence of bacterial plaque, aggravated by increased estrogen and progesterone levels.

Support:

*Achieving appropriate plaque control, combining personal mechanical control (rigorous oral hygiene) with professional control (careful scaling) with a frequency adapted to the context, remains the main preventive measure.

* The practitioner may, if necessary, prescribe agents which act on the development of bacterial plaque (alcohol-free 0.12% Chlorhexidine mouthwashes, for example).

2. Epulis gravidarum : This is a benign hyperplastic tumor, generally appearing during the 3rd month. It presents in the form of gingival hyperplasia, red in appearance, often nodular or ulcerative and pedunculated, preferentially located in the interproximal spaces at the level of the mandibular incisors.

It disappears spontaneously after childbirth.

Its surgical excision is considered when it interferes with chewing or when it hinders brushing.

2. Periodontitis and its possible systemic repercussions:

The ANAES (National Agency for Accreditation and Evaluation in Health) working group on periodontal diseases recommends special monitoring of pregnant women (professional agreement).

According to them, the discovery of periodontitis requires increased obstetrical management and monitoring because periodontal disease appears to be significantly associated with a risk of prematurity: birth before the 37th ^week of gestation of a newborn weighing less than 2.5 kg.

Armitage GC recommends screening for periodontitis before any pregnancy. If this screening occurs during pregnancy, only minimal treatment can be undertaken, Lopez NJ et al .

3. Dental injuries

Cavities (One child, one tooth)

This belief is explained by the modification of:

*eating behavior of expectant mothers

*Due to the frequent occurrence of nausea and vomiting

*In addition, the presence of gingivitis responsible for gingival bleeding during brushing frequently leads to inadequate hygiene, which aggravates the phenomenon.

Furthermore, the pregnant woman may complain of diffuse pain, never localized. This pain would be due to intrapulpal circulatory changes causing compression of the nerve fibers against the inextensible wall of the pulp chamber.

This pain is not related to the presence of cavities.

If the pain occurs in healthy teeth, it will disappear after one or two weeks.

In decayed teeth, the symptoms persist, indicating pulp damage and therefore requiring emergency treatment.

1. Hyperesthesia :

Pregnancy has been found to predispose to changes in tooth sensitivity in the direction of dentin hypersensitivity.

2. Dental erosion: Erosion is defined as the dissolution of mineralized tissues under the action of chemical substances.

During pregnancy, cases of dental erosion have been observed, especially at the level of the necks of the palatal surfaces of the antero-superior group.

Erosions are caused by food acidity AND repeated vomiting. These erosions cause brief pain occurring after meals.

5. ODONTOSTOMATOLOGICAL CARE OF PREGNANT WOMEN

There are no contraindications to dental care, on the contrary, abstention can have repercussions for the pregnant woman and the fetus.

However, certain precautions need to be taken. These concern in particular:

• Stress
• The use of ionizing radiation
• Anesthesia
• Drug prescriptions
• Filling materials
• The presence of concomitant pathologies
• The most appropriate time to perform the treatment.

1. Stress : Stress and anxiety will be minimized by establishing a good practitioner-patient relationship. Dialogue will be essential to building the mother’s confidence. It will aim to explain our actions and their safety for the fetus.
2.  Ionizing radiation : The position of the American College of Radiology is formal:

Exposure of pregnant women to ionising radiation for dental diagnosis does not pose any risk to the normal development of the embryo or foetus (HALL 1991, cited in 8).

However, the German Association of Stomatology and Dentistry recommends:

• The use of the long cone
• Protection of the pregnant woman by a lead apron,
• And reducing the number of shots to the bare minimum.

It is true that these precautions reduce the irradiation of the fetus, but wisdom dictates that X-ray examinations, particularly during the first trimester, should only be carried out if absolutely necessary.

3. Anesthesia:

In pregnant women, no analgesic technique used in the dental office is contraindicated.

*The anesthetic product

-Local anesthetics are substances capable of crossing the placental barrier.

-Their diffusion rate depends on their affinity for plasma proteins, since only the free fraction can enter the fetal circulation.

Therefore, in dentistry, it is recommended to use substances with a high plasma protein binding rate (more than 90%). This is the case of articaine.

• Other molecules such as lidocaine and mepivacaine have a binding rate of approximately 70%.
• For lidocaine : Clinical analysis of a large number of pregnancies has apparently revealed no malformative or fetotoxic effects. However, lidocaine should be used with caution.
• Mepivacaine: Animal studies have shown fetotoxicity . Bradycardia sometimes accompanied by acidosis in the fetus. In the newborn, there is a risk of cyanosis and a transient decrease in neurobehavioral responses at birth. These effects are all the more evident when anesthesia is administered in the last days of pregnancy. This is why the use of mepivacaine is not recommended .
• The addition of vasoconstrictors such as adrenaline or noradrenaline slows the passage of the anesthetic into the general circulation and thus ensures the prolonged maintenance of an active tissue concentration, allowing for a low-hemorrhagic surgical field.
• They do not normally cause fetal tachycardia, since they are not metabolized into biologically active molecules in the placenta.
• However, preference should be given to the lowest possible adrenaline concentrations (e.g. 1:200,000).

5-5-Medicinal prescription :

Dental care or emergency treatment provided may be supplemented by a prescription medication when an infection has set in.

• Pregnancy should not delay treatment of oral cavity conditions.
• However, certain antibiotics, anti-inflammatories or analgesics should be avoided either during the gestation period or only at certain times of the pregnancy.
• Antibiotics :

*Any systemic bacterial infection of the mother carries a high risk of fetal malformations, regardless of the child’s stage of development.

*In this case, antibiotic treatment is indicated.

*Antibiotic therapy should never be under-dosed, otherwise effective plasma levels will not be achieved due to the 40 to 55% increase in circulating blood volume in pregnant women.

• Beta-lactams: can be prescribed without restriction during pregnancy (penicillin, ampicillin
• Use of clavulanic acid: authorized
• the administration of tetracyclines is contraindicated:

Risks of dental and skeletal malformations during pregnancy. In addition, cases of acute pancreatitis and hepatic steatosis (the accumulation of fat in the liver) have been reported in the mother.

• clindamycin​

The use should be limited to infections by anaerobic germs, due to the side effects of this antibiotic in the mother: nausea and vomiting

• Metronidazole​

Shows mutagenic effects in vitro and its use during pregnancy is controversial

• Pain relievers

Paracetamol is the substance of choice for analgesic treatments during pregnancy. However, high doses should be avoided for prolonged periods to avoid possible liver damage to the fetus.

• Analgesics of the acetylsalicylic acid (ASA) group

• Several cases of early closure of the ductus arteriosus in the fetus have been reported
• During the last trimester, ASA intake greater than or equal to 500 mg per dose per day may expose the fetus to cardiopulmonary toxicity and renal dysfunction and the mother to a risk of prolonged bleeding time.

Any medication containing ASA is contraindicated during the last trimester.

• Codeine derivatives:

Should be rejected given the postpartum respiratory distress they can cause in the newborn.

• nonsteroidal anti-inflammatory drugs (NSAIDs): diclofenac, ibuprofen

• They can cause pulmonary toxicity by partial closure of the ductus arteriosus in the fetus.
  • Corticosteroids
• They are only administered when life is at risk; in cases of anaphylactic shock, for example.
• may cause fetal growth retardation, as well as possible action on lung maturation and certain regions of the brain

		Pregnancy	Breastfeeding
Antibiotics	Authorized	Amoxicillin Amoxicillin + Ac. clavulanicClindamycin Josamycin Erythromycin Spiramycin Metronidazole	Amoxicillin Amoxicillin + Ac. clavulanicJosamycin
	Not recommended	Azithromycin	Cyclines Spiramycin Metronidazole Azithromycin
	Contraindicated	Cyclines	Clindamycin
Analgesics and anti- inflammatories	Authorized	Paracetamol Paracetamol/codeine (occasionally) Short-term corticosteroid	Paracetamol Ibuprofen Short-term corticosteroid
	Not recommended	NSAIDs in the 1st and 2nd trimesters Tramadol	Paracetamol/codeine (except occasionally and under supervision) Tramadol
	Contraindicated	Paracetamol + opium NSAID from the beginning of the 6th month of pregnancy	Paracetamol + opium
Antifungals	Authorized	Topical amphotericin B Topical nystatin Topical miconazole	Nystatin under surveillance
	Not recommended	Amphotericin B orally
	Contraindicated	Oral nystanine Fluconazole	Fluconazole
Others	Authorized	Aciclovir	Topical aciclovir
	Not recommended	Intraoral iodine Hydroxyzine (in agreement with the treating gynecologist)	Hydroxyzine
	Contraindicated		Oral aciclovir

BIBLIOGRAPHY

1. Bahl R. Local anesthesia in dentistry. Anesth prog, 2004; 51:138–142.
2. Agbo-Godeau S. Stomatology and pregnancy. Encycl Méd Chir (Elsevier scientific and medical editions, SAS, Paris, all rights reserved), Stomatology, 22-050-F-10, Gynecology – Obstetrics, 5-045-A-10, 2002, 4p.
3. Roche Y. Dental surgery and patients at risk. Flammarion Medicine-Sciences, Paris, 1996.
4. Morand JM The pregnant woman at the dental office (2nd part). Dental information, 1996; (44): 3539-3541.
5. Benyahia I. Pregnancy and the oral cavity. Medical hope, 1996; 3(21): 649-652.
6. Bauser A. The pregnant woman in the dental office. Editorial notebook, dental information, 2000: 1-12.
7. Gaudy JF et al. The practice of analgesia in dentistry. Editions CdP, Paris, 2005.
8. Giglio A. et al. Oral health care for the pregnant patient. JCDA, 2009; 75 (1): 43-48 . www.cda-adc.ca/jcda/vol-75/issue-1/43.html

Care of pregnant women in odontostomatology

  Untreated cavities can cause painful abscesses.
Untreated cavities can cause painful abscesses.
Dental veneers camouflage imperfections such as stains or spaces.
Misaligned teeth can cause digestive problems.
Dental implants restore chewing function and smile aesthetics.
Fluoride mouthwashes strengthen enamel and prevent cavities.
Decayed baby teeth can affect the health of permanent teeth.
A soft-bristled toothbrush protects enamel and sensitive gums.
 

Care of pregnant women in odontostomatology