Dental and stomatological care in pregnant and breastfeeding women
Plan:
Introduction
I. Pregnant woman
1. Definition of pregnancy
2. Physiological changes in pregnant women
3. Oral manifestations
4. Support
5. Potential problems in daily practice related to pregnancy
6. General precautions:
II. The breastfeeding woman
Conclusion
Introduction
Pregnancy is not a pathological state but is accompanied by a certain number of concomitant changes, both physiological and psychological, which should be taken into account when exercising
odonto-stomatology
The care of pregnant women, particularly in ondontostomatology, requires a certain number of precautions in order to intervene without endangering the health of the patient and the proper development of the embryo and then the fetus.
These precautions concern the prescription of medication, the taking of X-rays, anesthesia, as well as restorative and endodontic procedures, with specific features of care during the different trimesters of pregnancy.
In addition, certain precautions must also be taken when breastfeeding, given the passage of most medications into breast milk.
I. Pregnant woman:
1. Definition:
Pregnancy: according to WHO:
“The approximately 9 months during which a woman carries the embryo and then the fetus which develops in her uterus”
For most women it is a time of great happiness and fulfillment.
However, during pregnancy, both the woman and her unborn child
are faced with various health risks. For this reason, it is
important that all pregnancies are monitored by qualified health workers.
Pregnancy is classically divided into 3 phases, we speak of trimester to designate these three phases. Each trimester is associated with certain physical changes for the mother and for her child.
First quarter: The most critical period in terms of fetal sensitivity. It corresponds to embryogenesis and organogenesis.
It is during this period that the vast majority of the organism’s structures will form according to a well-defined chronology and that the risks of morphological damage are the greatest.
Second quarter : Maturation of the organs.
Third quarter : end of maturation of organs.
The toxicity of drugs during this period is based, among other things, on the particularity of the fetus’s circulatory system.
2. Physiological changes in pregnant women
During these different phases, certain modifications can be observed:
ENDOCRINE CHANGES
They are mainly the result of the endocrine activity of the placenta which secretes three major types of hormones: estrogens, progesterone and chronic gonadotropins.
NEUROLOGICAL CHANGES
They are most common during the first trimester. They mainly include: fatigue, dizziness, nausea and vomiting, anxiety, postural hypotension and syncope (due to compression of the inferior vena cava)
Dental and stomatological care in pregnant and breastfeeding women
CARDIOVASCULAR CHANGES
From the 24th week of amenorrhea (approximately 6 months of pregnancy), in the supine position, compression of the inferior vena cava by the uterus can reduce venous return and therefore cause maternal hypotension. This phenomenon is called “vena cava syndrome”. Pregnancy-induced hypertension
can also be observed during pregnancy . HEMATOLOGICAL CHANGES – An increase in the volume of red blood cells. – Thrombopenia at the end of pregnancy – Neutropenia. – Iron deficiency can cause anemia
Pulmonary changes
There is an increase in pulmonary blood flow and an increase in oxygen uptake per minute.
LIVER AND DIGESTIVE CHANGES
Appetite increases from the end of the first trimester, which leads to an increase in food intake of 200 kcal/day. The “cravings” of pregnant women are often described. Their cause is unknown: hormonal factor, prevention of deficiencies, psychological origin.
Nausea and vomiting are common between 4 and 12 weeks of gestation. The general condition is generally preserved and the course is spontaneously resolved.
DERMATOLOGICAL CHANGES:
Endocrine, metabolic, immunological and circulatory changes during pregnancy are responsible for physiological dermatological changes which are often the cause of complaints from women (body hyperpigmentation nevus, etc.)
OPHTHALMOLOGICAL CHANGES
Physiological changes related to hormonal impregnation may appear. These are:
● Moderate ptosis
● Refractive disorders with myopization at the end of pregnancy which regresses postpartum
● Corneal hypoesthesia, changes in corneal thickness and a change in tear composition that causes intolerance to contact lenses
● Accommodation disorders with transient presbyopia.
PSYCHOLOGICAL CHANGES
Pregnancy and the birth of a child are accompanied by emotional changes resulting from bodily transformations and psychological changes linked to the puerperium.
This period of development involves many factors: hormonal, neuropsychological, sociological, ethnological contributing to the conscious and unconscious rearrangements of the woman becoming a mother.
3- ORAL REPERCUSSIONS
Several oral pathologies can be observed during pregnancy, which are mainly the consequence of:
An increase in the level of progesterone, which induces general vasodilation and therefore an increase in capillary permeability, making the oral cavity more sensitive to mucosal attacks.
Changes in the diet of pregnant women, qualitatively and quantitatively: food intake is greater with a particular appetite for sugars and acids.
Dental and stomatological care in pregnant and breastfeeding women
- Pregnancy gingivitis:
-It constitutes the most common oral manifestation.
-It is characterized by gingival inflammation associated with hyperplasia in phase with peaks of hormonal secretion
-It manifests itself during the second month with a peak in the 8th month, the severity is correlated with oral hygiene.
-It is reversible and disappears after childbirth.
- Epulis gravidarum:
– Observed in 5% of pregnant women.
-It is a soft, red, hemorrhagic mass that is generally located in the papillary region.
-Generally painless, it appears during the 2nd trimester of pregnancy and disappears spontaneously.
-The treatment which consists of surgical excision in case of pain or functional discomfort, is often followed by recurrence. This is why this treatment will preferably be carried out after childbirth.
- Dental caries and abrasions:
-The increase in the incidence of carious lesions does not result directly from pregnancy but rather from diet and hygiene, particularly due to the intake of foods rich in sugar to prevent nausea during the first trimester.
– Abrasions caused by vomiting particularly affect the palatal surfaces of the upper incisors. To limit these abrasions, fluoride mouthwashes will be offered to patients suffering from vomiting.
- Dental mobility:
– Generalized tooth mobility without evidence of periodontal disease resulting from mineral changes within the lamina dura, the attachment system is reported during some pregnancies. This mobility spontaneously recedes.
- Salivary changes
– Salivary flow increases especially during the first three months, and may be related to digestive disturbances common during pregnancy.
-The salivary pH changes towards a slight acidity; it goes from 6.7 to 6.2. This decrease leads to a reduction in the buffering capacity and can worsen an already defective oral condition and lead, due to its acidity, to the appearance of dental caries.
-On the other hand, this oral acidification which promotes the erosion of enamel is reinforced by the frequent occurrence of nausea, vomiting and gastroesophageal reflux which will also increase the cariogenic risk.
- Periodontitis
– Untreated during pregnancy could have significant repercussions, including risks of prematurity and low birth weight.
-There are two possible explanations:
On the one hand, it has been shown that host inflammatory mediators such as prostaglandin (PGE2) and interleukin (IL-6 and IL-8), whose levels systematically increase in periodontitis, can trigger contractions prematurely.
On the other hand, it is assumed that periodontal germs can enter the fetal environment as a pathogen through bacteremia and cause vaginosis.
Dental and stomatological care in pregnant and breastfeeding women
4. ODONTOSTOMATOLOGICAL CARE OF PREGNANT WOMEN
Pregnancy does not contraindicate dental care and does not justify postponing it until after childbirth; on the contrary, abstention can have repercussions on the pregnant woman and the fetus. The majority of these can be carried out if certain precautions are taken. Prescriptions, anesthesia, and intraoral X-rays are entirely possible, but require certain knowledge on the part of practitioners. Prevention remains the best way to avoid emergency situations, for this reason oral hygiene and dietary advice must be known and given by health professionals working in contact with pregnant women.
II.1. RADIOGRAPHY: WHAT ARE THE RISKS?
X-rays are said to have an action:
– embryolethal (risk of death of the embryo);
– or teratogenic (risk of malformations).
This action would be maximal during the first two months (embryonic period during which most of the organogenesis takes place).
In reality, the exposure of the fetus would be 0.004 rads for a skull X-ray and 0.00001 rads for a retro-alveolar dental assessment carried out under protection by a lead apron. For a retro-alveolar X-ray, the dose delivered (50 mgrays) would be 500 times lower than the limit dose and the dose for a panoramic X-ray would be 50 times lower.
Thus, it would seem that taking one or more intra-oral or even exoral X-rays has no consequences for the fetus, because the irradiation is very low and the source is far from the pelvis.
However, for safety reasons, taking X-rays is only justified in pregnant women when it is absolutely necessary for diagnosis or treatment, particularly in emergencies (acute pulpitis, acute early apical periodontitis, established periodontitis, abscess, cellulitis). In addition, the images must be taken under protection of a lead apron.
Furthermore, X-ray examinations should be postponed whenever possible beyond the first trimester.
Finally, among the X-ray examinations formally contraindicated during pregnancy: sialographic examination of the salivary glands, because iodine causes thyroid insufficiency responsible for the death of the fetus by asphyxia.
II.2.ANESTHESIA AND PREGNANCY
Which molecule to choose?
Once in the bloodstream, the anesthetic molecules are fixed by plasma proteins and more precisely: α-l glycoprotein (for anesthetics with amide function) which allows their hepatic detoxification. During pregnancy, the level of α-l glycoprotein becomes significantly reduced which has the effect of increasing the free fraction (not bound to proteins) of the anesthetic molecules. However, the increase in the free fraction of anesthetics is accompanied by an increase in their maternal and fetal toxicity (because this fraction crosses the placental barrier).
Although no teratogenic effects of anesthetics have been described and the toxic dose of analgesic is significantly higher than the doses administered during dental treatments, the
choice will be made on the least toxic molecules. Thus, it is preferable to choose a molecule presenting both a strong binding to plasma proteins and a reduced liposolubility therefore fixing less at the level of the embryonic or fetal organism.
We distinguish in ascending order of toxicity according to Gaudy JF et al. (2005):
• articaine: this is the least toxic molecule for the fetus, due to its low placental passage rate (< 25%); which makes it the molecule of choice in pregnant women;
• followed by lidocaine: with a placental passage rate around 55%;
• bupivacaine presents a risk of cardiac toxicity for the fetus, it can therefore only be administered at low doses to limit this risk, we therefore prefer the preceding molecules;
• spartocaine (combination of lidocaine and sparteine) is associated with a risk of premature delivery;
• mepivacaine cannot be metabolized by the fetus;
• prilocaine is associated with a risk of fetal (with anoxia and cyanosis) and maternal methemoglobinemia;
Thus, spartocaine, mepivacaine and prilocaine are totally contraindicated during pregnancy due to their toxicity.
Finally, the molecule of choice during pregnancy is: articaine; lidocaine can also be used.
Should vasoconstrictors be used?
Vasoconstrictors are authorized for pregnant women, to reduce the amount of solution injected and reduce the toxicity of anesthetic molecules. However, the use of vasoconstrictors could be accompanied by a reduction in uterine blood flow triggering uterine contractions that remain, however, close to physiological uterine contractions. In order to limit this phenomenon, it is recommended: to aspirate before injecting to avoid any intravascular injection and to prefer a concentration of 1/100000.
Under these conditions, the use of vasoconstrictors becomes safe and does not seem to significantly affect uterine blood flow. The benefit of vasoconstrictors then justifies their use during pregnancy.
II.3. ORAL AND DENTAL MANAGEMENT: A QUARTERLY APPROACH
Blood pressure measurement is necessary in pregnant women before each treatment session. In the event of a maximum above 15 mmHg, it is advisable to postpone the procedure to a later session according to Gaudy JF et al. (2005). During the 1st trimester:
During the first 3 months (organogenesis period), the embryo’s susceptibility to teratogenic influences and the risk of abortion is increased.
(1 in 5 pregnancies ends in spontaneous abortion). It is therefore preferable to limit any intervention at this stage, especially since the pregnant woman is subject to nausea, discomfort and often has intense fatigue. Also, it is preferable to postpone any dental treatment until the 2nd trimester.
On the other hand, the 1st trimester can be used to assess the oral health and needs of the patient. A clinical examination is carried out, followed by motivation for dental hygiene which has some particularities in pregnant women.
Indeed, repeated vomiting can cause erosions. Rinsing (immediately afterwards) with a solution of sodium bicarbonate 1 teaspoon in a glass promotes the rise of the oral pH. On the other hand, brushing immediately after vomiting should be avoided to reduce the risk of damage to the demineralized enamel. In addition, a soft toothbrush will be prescribed during this period.
Thus, demineralizations often appear during pregnancy. They would be due to a decrease in oral pH, caused by vomiting but also by frequent snacking (especially sugary products). Fluorinated mouthwashes may be prescribed to limit demineralization and promote remineralization. Professional
scaling and/or prophylactic cleaning can be performed and dietary advice given. We will emphasize the importance of: reducing snacking, limiting the consumption of sugary drinks and foods by preferring neutral or protective foods (especially dairy products, especially yogurts, cheeses).
For invasive treatments, only emergency treatments will be carried out, which should not be postponed because the harmful effects caused by pain (release of algogenic substances) and/or infection (release of toxins) may be greater than those caused by care. Given the patient’s condition, the sessions should be short. During the 2nd trimester: This period is the most appropriate to carry out the treatment because the fetus has developed and the patient is in better condition. However, it is not a question of carrying out a complete restoration of the oral cavity: complex treatments (surgical and prosthetic in particular) should preferably be postponed until after delivery. The same applies to endodontic treatments, which should only be considered in emergencies. When endodontic treatment is required, the use of an apex locator is recommended to determine the working length. It would not only reduce the radiation dose but also reduce the total duration of the treatment.
In any case, restorative treatments will be preferred.
Concerning amalgam, it is established that mercury crosses the placental barrier.
In fact, the release of mercury from dental amalgams would be approximately 2µg/day, while the WHO in 2007, sets the dose not to be exceeded at 10µg/kg/day. Furthermore, according to the study by Hujoel PP et al. 2005, there would be no risks (in particular of low birth weight) linked to the placement of amalgam during pregnancy. Even if no study proves its pathogenic effects on fetal development, it is better to avoid any placement or removal of amalgam during pregnancy. Removal is only indicated for a restoration harmful to the tooth and the periodontium and whose removal cannot be postponed until after childbirth. In this case, the removal is carried out under a dam to minimize the risk of absorption of mercury vapors.
However, the use of bleaching agents based on hydrogen peroxide should be avoided because it would lead to an increase in the release of mercury from the amalgams present in the mouth according to Al Salehi SK et al (2007).
Furthermore, chewing gum should be avoided in pregnant women with numerous amalgam restorations (because it increases the release of mercury).
Simple extractions as well as scaling and surfacing can also be carried out. They would be safe for pregnant women according to several studies, including that of Michalowicz (2008) on pregnant women, between 13 and 32 weeks, who had received dental treatments such as: cleaning of caries with the creation of temporary or permanent restorations, endodontic treatment, extraction or even periodontal treatment involving scaling and surfacing. The risks of abortion, premature delivery or fetal abnormalities were not increased compared to the untreated group.
Dental and stomatological care in pregnant and breastfeeding women
During the 3rd quarter:
In the first part of this last trimester, essentially restorative dental care can still be considered. However, the risk of premature delivery becomes high during the last 2 months of pregnancy. Intervention should therefore be avoided after 7 and a half months except in emergencies, especially since from this stage there is a risk of compression of the inferior vena cava by the pregnant uterus. This results in a sudden drop in blood pressure with loss of consciousness of the patient. The patient should then be placed on her left side, which is usually enough to make the symptoms disappear. In order to avoid this risk of syncope, it is advisable (when dental treatment is necessary) to take precautions concerning: the duration of the intervention, which should be as short as possible and especially the position of the patient, who should be placed in a semi-seated position, in a slight left lateral decubitus. A cushion can be placed under the hip to raise the uterus so that it no longer compresses the vena cava.
Finally, oral care during pregnancy involves, depending on the patient’s needs, professional scaling or prophylactic cleaning and possibly root planing, procedures that can be performed at any time during pregnancy. Restorative treatments should preferably be performed during the 2nd trimester. Emergencies, whether endodontic treatments or selective extractions, will be treated regardless of the stage of pregnancy.
MEDICATIONS: PRESCRIBE OR PROHIBIT?
Medications used during pregnancy have been classified into 5 categories by the FDA (Food and Drug Administration in 2001) according to their teratogenic risk:
♣ Category A: includes medications and substances tested through controlled studies on pregnant women that have demonstrated the absence of risk to the fetus.
♣ Category B: includes medications and substances tested through:
– studies carried out on animals having demonstrated the absence of risk for the animal fetus with the absence of studies on humans to confirm this;
– or products associated with a risk for the animal fetus while controlled studies on pregnant women have demonstrated the absence of risk for the human fetus.
♣ Category C: includes medications and substances associated with a teratogenic or toxic risk for the fetus demonstrated through studies carried out on animals without controlled studies on pregnant women;
– or products for which there are no studies on pregnant women or animals.
♣ Category D: substances associated with a risk to the fetus, but which constitute the only possible treatment in certain clinical situations that may justify their use during pregnancy.
♣ Category X: includes medications and substances associated with a risk of alterations to the fetus demonstrated through studies carried out on animals or humans; this risk being greater than any benefit which contraindicates their use whatever the clinical situation.
We will only deal here with the main medications used in dentistry and which can be prescribed to pregnant women or which are controversial.
Dental and stomatological care in pregnant and breastfeeding women
1. Analgesics:
Paracetamol
This is the analgesic of choice that has proven its safety in pregnant women. It belongs to category B of the FDA classification. However, it is important to avoid exceeding the dose of 4g/day.
Paracetamol-codeine combination
It is part of category C of the FDA classification. In fact, the data currently available suggest an absence of teratogenic or cytotoxic risk for the fetus. However, a withdrawal syndrome has been described in newborns whose mothers have repeatedly taken this combination at high doses. Its prescription is therefore controversial. For DESCROIS (2005), it could be prescribed as a one-off, short-term treatment, only if the indication for level 2 analgesia arises. On the other hand, BAUSER (2002) and ROCHE (1996) prefer to avoid this prescription.
2. Salicylates and NSAIDs:
These molecules present a risk of fetotoxicity, especially at the end of pregnancy with:
♣ disruption of fetal development (by constriction of the ductus arteriosus leading to cardiopulmonary and renal effects);
♣ lengthening of labor time;
♣ risk of placental and neonatal hemorrhages.
Anti-inflammatories belong to category C of the FDA classification when prescribed in the first and second trimesters of pregnancy and to Category D in the third trimester. For AFSSAPS (2003), NSAIDs should be avoided during the first two trimesters of pregnancy and formally contraindicated during the third.
3. Antibiotics:
According to the recommendations of AFSSAPS (French Agency for the Safety of Health Products) in 2002. Concerning the indications and choice of antibiotics in odonto-stomatology: if a prescription of antibiotics is justified during pregnancy, amoxicillin will be prescribed first, then macrolides, metronidazole and finally the amoxicillin-clavulanic acid combination and this at all stages of pregnancy.
ß lactams
They are classified in category B of the FDA classification. The use of penicillins and cephalosporins is generally safe during pregnancy. We usually opt for group A penicillins, in particular amoxicillin which is the antibiotic of choice during pregnancy.
Macrolides
In a pregnant woman with a penicillin allergy, the choice is oriented towards macrolides with a preference for certain molecules. Indeed, spiramycin or erythromycin (category B) will be safely prescribed.
Metronidazole
Its prescription during pregnancy (usually in combination with amoxicillin or spiramycin) is controversial in relation to its carcinogenic effect in certain rodents.
Although this effect has not been demonstrated in humans, BAUSER (2002), CASAMAJOR and HUGLY (1997), MORAND (1996) and ROCHE (1996) prefer to avoid its prescription during pregnancy. For LODI, this prescription should be prohibited during the first trimester of pregnancy. The American College of Obstetricians and Gynecologists (1998) also contraindicates its use (in the United States) during the first trimester of pregnancy. On the other hand, in France, the AFSSAPS (2002) and the transparency commission (2004) authorize its use during pregnancy and the FDA classifies it as category B. 4. Corticosteroids: The prescription of corticosteroids is controversial. BAUSER (2002) and ROCHE (1996) prefer to avoid their prescription. On the other hand, DESCROIS (2005)(22), TIMOUR (1999), CASAMAJOR AND HUGLY (1997) estimate that in treatment of a few days (5 on average), the adverse effects of these products would be negligible. Consequently, the use of prednisone or prednisolone could be considered during pregnancy, as a short course. 5. Antifungals: The treatment of oral candidiasis involves the prescription of local antifungals: amphotericin B, miconazole and nystatin. Although these molecules hardly cross the placental barrier, so their use should theoretically be safe, in the absence of sufficient data on their safety, their use is only considered when absolutely necessary. 6. Anxiolytics: The prescription of benzodiazepines in pregnant women could be accompanied in particular by teratogenic risks (category D). 7. Fluoride: Its prescription in pregnant women is currently being questioned, because it does not appear to have any effect on the maturation of the dental tissues of the future baby.
Dental and stomatological care in pregnant and breastfeeding women
II.3.THERAPEUTICS OF ORAL PATHOLOGIES RELATED TO PREGNANCY
II.3.1.Treatment of mucosal lesions :
* Epulis of pregnancy:
The epulis disappears after childbirth, its surgical excision during pregnancy will only be indicated if it interferes with chewing.
Our intervention will then be limited to a motivation for hygiene.
* Periodontal lesions:
In the case of pregnancy gingivitis, the practitioner must inform the patient about the importance of eliminating bacterial plaque: methods and brushing techniques. He may possibly perform scaling and prescribe mouthwashes based on 0.12% chlorhexidine.
In the case of periodontal lesions, only minimal treatment is carried out, periodontal therapy itself is postponed until after childbirth. II.3.2. Treatment of dental lesions: * Carious lesions: In order to reduce the bacterial load, prophylactic cleaning and sealing of the joints of defective restorations using glass ionomer cement or a flowable composite will be carried out. To support this procedure, the dental surfaces will be covered with chlorhexidine varnish (Cervitec®, VIVADENT). The application of fluoride, by fluoride varnish (Fluoroprotector®, VIVADENT) or by fluoridation trays, will prevent the appearance of new cavities and will combat dental hyperesthesia. The curettage of cavities will be followed by a temporary glass ionomer filling. The placement of amalgam will be postponed until after delivery. In the event of pulp involvement, pulpectomy will be performed with the placement of calcium hydroxide. This temporary root canal filling with calcium hydroxide will soothe the pain and maintain the state of disinfection. Complete root canal treatment will only be done during the second trimester or after childbirth. *Erosions: When the patient consults for erosions, it is wise to advise her to rinse the oral cavity with a sodium bicarbonate solution after vomiting and to avoid any brushing (3, 4). Dietary advice is essential; the diet must be free of acidic foods such as lemon, orange, and vinaigrette. The practitioner can support his action by making fluoridation and protection trays.
II. The breastfeeding woman:
Lactation is the act of feeding the offspring of mammals, thanks to the milk produced and secreted by the mammary glands of females. The young activate the secretion of milk by suckling on the nipple.
WHO recommends exclusive breastfeeding for babies up to 6 months of age, but for practical reasons, women often resort to mixed breastfeeding .
Dental care for breastfeeding women:
All oral care is possible for breastfeeding women. Precautions to be taken concern drug prescriptions.
Drug prescription
There is little literature on the passage of drugs into breast milk, and little data from clinical trials.
The rate of medication that passes into milk depends on many factors:
- passive diffusion and active transport.
- The physicochemical properties of the molecule
In general, drugs with high protein binding
plasma, low liposolubility , high molecular weight,
short half-life and a low degree of ionization (penicillins)
will be found in lower concentrations in breast milk.
frequency, dosage, duration of treatment, route
administration (general or topical).
Generally speaking, if a prescription is considered, it will be
asked the mother to take the medication immediately after breastfeeding to reduce the concentration as much as possible.
It would also be essential to ask the patient to monitor the occurrence of vomiting, diarrhea or skin signs (urticaria, erythema, etc.) in the breastfed child.
If such signs occur, stop treatment immediately and contact the child’s pediatrician or treating physician.
Regarding local anesthetics, Articaine is also the molecule of choice for breastfeeding patients, because it is degraded and eliminated
quickly.
Dental and stomatological care in pregnant and breastfeeding women
Dental and stomatological care in pregnant and breastfeeding women
Conclusion :
The dental care of pregnant women is never trivial and a neglected procedure or prescription can have particularly harmful consequences.
Any care must respect certain principles and must take certain precautions in order to treat and prescribe safely and protect against any complications for both the mother and her future child.
It also seems necessary to strengthen prevention by setting up an oral-dental examination. This examination would reduce the prevalence of gingival bleeding during pregnancy. Prevention will particularly concern tooth brushing and diet and addictive behaviors.
Dental and stomatological care in pregnant and breastfeeding women
Wisdom teeth can be painful if they are misplaced.
Composite fillings are aesthetic and durable.
Bleeding gums can be a sign of gingivitis.
Orthodontic treatments correct misaligned teeth.
Dental implants provide a permanent solution for missing teeth.
Scaling removes tartar and prevents gum disease.
Good dental hygiene starts with brushing twice a day.