Pregnancy & Breast Feeding

Are dental radiographs safe during pregnancy?

yes

Is dental treatment safe during pregnancy?

yes

T/F: Pregnancy is not a medical complication per se, it does, however, it imposes specific physiologic stressors on the gravid patient

true

Pregnancy is often associated with changes in the ... systems

cardiovascular, endocrine, hematological, respiratory,

gastrointestinal and genitourinary

Clinicians have an obligation to provide safe and effective dental care to the mother without ___

adversely affecting the

developing fetus

Although routine dental care generally is safe for the pregnant patient, the delivery of such care involves some potentially harmful elements, including the use of ___ and ___

ionizing radiation

drug administration

Additional considerations may arise during the postpartum period of the mother elects to ___ her infant

breastfeed

First Trimester: Symptoms

fatigue

tendency toward syncope and postural hypotension

Second Trimester: Symptoms

sense of well-being

relatively few symptoms

Third Trimester: Symptoms

increased fatigue and discomfort

___ changes are the most significant alterations that occur with pregnancy

Endocrine

Endocrine changes result from increased production of ___ and ___

hormones and from modified activity of target end ___

maternal

placental

organs

For instance, sensitivity to ___ may diminish, increasing the risk of gestational diabetes

insulin

Another example: elevated ___ may lead to vascular permeability manifesting as increased gingival inflammation

estrogen

In a pregnant woman, blood volume and cardiac output tend to (increase/decrease)

increase

Blood volume increases by a lot, but ___ volume increases only by a little

RBC

This contradictory level of increase results in ___

a fall in the maternal hematocrit

(dilution)

Despite the increase in cardiac output, BP tends to fall during which trimester?

second

However, BP usually tends to increase in the other trimesters.... What is this increase associated with?

a benign systolic ejection murmur

This occurs in ___% of pregnant women and is (normal/not normal)

90

normal — not bad at all

___ occurs in late pregnancy, mainly during the third trimester

Supine Hypotensive Syndrome

SHS is caused by ___

compression of the inferior vena

cava by the uterus

This leads to ___

impaired venous return to the heart

What are some signs and symptoms of SHS?

• Abrupt fall in BP

• Bradycardia

• Sweating

• Nausea

• Weakness

• Air hunger

• Impairment/loss of consciousness

How do you manage SHS in the dental chair?

prevention: place rolled blanket

under patient's right side to tip the uterus off the inferior vena cava

treatment: roll patient onto left side, which lifts the uterus off the vena cava

Pregnancy may worsen pre-existing ___, especially the ___ type

anemias

sickle cell

Pregnancy is associated with a (hyper/hypo)coagulable state

hyper

The risk of ___ increases during pregnancy, in correlation

thromboembolism

Elevation of the diaphragm, during pregnancy, (increases/decreases) the volume of the lungs in the resting state

decreases

This leads to (increased/reduced) total lung capacity by ___%

reduced

5%

This leads to (increased/decreased) rate of respiration

increased

= tachypnea

Dental consideration: dyspnea is worsened by ___ position, which a patient may be in in the dental chair... need to adjust accordingly

supine (laying back)

___ affects up to 70% of women and usually lasts from weeks 4-8 until week 16

Morning sickness

Pregnant women often have increased appetite and craving for ___

unusual foods

Alterations in ___, increased ___ reflex, and gastric ___ are also commonly experienced

taste

gag

reflux

Normal pregnancy lasts approximately ___ weeks

40

During the first trimester, ___ and ___ are formed

organs

systems

(organogenesis)

During the ___ trimester, the fetus is especially at risk from developmental defects and is most

susceptible to malformation

first

The fetal dentition is susceptible to malformation from ___ or ___, and to tooth ___ caused by admin of tetracycline

toxins

radiation

discoloration

Pregnancy complications are infrequent when appropriate ___ is provided

prenatal care

Common pregnancy complications include:

• Infection

• Glucose abnormalities

• Hypertension

Each complication increases the risks for/of ..

preterm delivery, perinatal mortality, and congenital anomalies

Glucose abnormalities lead to ___ occurring in 2-6% of pregnant women

gestational diabetes mellitus

What is a contributing factor to the

development of gestational diabetes mellitus?

insulin resistance

GDM increases the risks for ___ and ___

infection

high birth weight babies

Another pregnancy complication is hypertension, which can lead to ___ or ___

end-organ damage

preeclampsia

T/F: preeclampsia can be fatal

true

What is preeclampsia?

pregnancy induced persistent hypertension

may also occur postpartum

What are symptoms of preeclempsia?

• Proteinuria

• Edema

• Blurred vision

What is a medical emergency symptom of preeclampsia?

eclampsia (makes sense)

What is eclampsia?

a complication of severe preeclampsia defined as new onset of grand-mal seizure activity and/or unexplained coma during pregnancy or postpartum

Eclampsia may result in the death of (mother/baby)

trick question: both

Another pregnancy complication is ___, also called "miscarriage"

spontaneous abortion

Spontaneous abortion is the natural termination of pregnancy before the ___ week of gestation

20th

Spontaneous abortion etiology is normally ___ and/or ___

febrile illness

sepsis

T/F: it is likely that a dental procedure is implicated in spontaneous abortion

false

However, it is important to avoid any ___ and ___ during treatment, just to be ultra safe

fetal hypoxia

teratogens

You should always check the ___ of a pregnant patient

blood pressure

Generally speaking, you should contact your patient's ___ if you have any consult questions

OBGYN

A ___ program needs to be established for a pregnant woman to ensure proper hygiene

preventive

Studies have shown that reduced oral streptococcal levels in a pregnant mother reduces the risk of ___ in her infant

caries

T/F: there is sufficient evidence that maternal prenatal fluoride reduces the caries risk of offspring

false

no evidence to support this claim.. but mother should still use fluoride for her own health

Let's talk about dental radiographs... a common area of concern in susceptible populations.. The teratogenicity of ionizing radiation is dependent upon the ___ and the ___ of the fetus

dose

gestational age

T/F: provided safety features are used, the safety of dental radiography is well established

true

Based on animal and human data, no increase in congenital anomalies or growth retardation occurs with exposure during pregnancy totaling less than __ cGy

5

The maximum risk attributable to 1cGy of in utero radiation exposure is estimated to be ___%

0.1

1cGy is more than ___ FMXs

1000

The gonadal dose to women after FMX using using a ___ for protection is less than 0.01µSv

lead apron

Overall, you are providing a very ___ level of radiation, as well as providing ___ protection

low

barrier

Also, this radiograph is obviously pointed at the ___, not at the baby

mouth

Dental radiographs are at least ___-fold below the threshold shown to cause congenital

damage to newborns

1000

Gonadal or fetus dose of 2 PAs (with use of lead apron) is 700 times less than 1 day of average exposure to ___ radiation in the US

natural background

Despite the extremely negligible risk, during pregnancy, radiographs should be

obtained ... to aid in diagnosis and treatment

selectively and only when necessary and appropriate

Radiographs should be taken only when ___

the information to be

obtained from them is necessary for the care of the patient

ALARA Principle

As Low As Reasonably Achievable

Indicated, bitewings, selected peri-apical films and panoramic radiographs are recommended. ___ are only recommended if necessary

Full mouth x-rays

What are some of the safety features associated with dental radiographs?

• Rectangular collimation

• Digital radiographs

• E-speed or F-speed film

• Lead shielding: abdominal and thyroid collar

• Ongoing quality assurance for equipment and technique

If the operator of the x-ray (the dental auxiliary or dentist) is pregnant, further safety measures should involve ...

• Wear a film badge

• Stand more than 6 feet from the tube head

• Position herself at between 90 and 130 degrees of the

beam, preferably behind a protective wall

Is amalgam safe for pregnant patients?

yes

Should dental amalgams with no decay below the filling/any errors be removed?

no

T/F: conditions that require immediate treatment, such as extractions, root canals, and restoration of untreated carry, may be managed at any time during pregnancy

true

T/F: delaying treatment may result in more complex problems, so you should just do it

true

T/F: oral health care including use of radiographs and local anesthesia is safe throughout pregnancy

true

T/F: emergency and acute care should be delayed until after pregnancy

false

can be provided at any time during the pregnancy

HOWEVER, if not NEEDED, these procedures probably should be delayed until after pregnancy:

reconstruction

crown and bridge procedures

extensive surgeries

Why?

comfort may be compromised if appointment takes a long time

Which trimester is often the most comfortable for treatment of pregnant patients?

second (early phase of it)

Why not the first trimester?

nausea and postural issues are more pronounced

same in the third, regarding posture

You need to position pregnant women appropriately during care:

• Keep the woman's head at a higher level than her feet

• Place woman in a semi-reclining position, as tolerated and allow frequent position changes

• Place a small pillow under the right hip or have the woman turn

slightly to the left as needed to avoid dizziness or nausea resulting from hypotension - Supine Hypotension Syndrome

During pregnancy, ___ can cause miscarriage, teratogenicity and low birth-weight babies

certain drugs

obviously want to avoid using these

___ may cause maternal hypoxia,

resulting in fetal hypoxia, injury or death

Respiratory depressants

The decision to administer a specific drug requires the ___ to outweigh the ___

benefit

risk

Category A

no risk to fetus

Category B

studies indicate no risk to the animal fetus; information for humans is not available

Category C

animal studies have shown an adverse effect on the fetus but there are no adequate studies in humans; the benefits from the use of the drug in pregnant women may be acceptable despite its potential risks, or there are no animal reproduction studies and no adequate studies in humans

Category D

there is positive evidence of human fetal risk based on adverse reaction data from investigational or marketing experience or studies in humans, but potential benefits may warrant use of the drug in pregnant women despite potential risks

Category E

the risks involved in use of the drug in

pregnant women clearly outweigh potential benefits

no go

T/F: Local anesthetics with epinephrine generally are considered safe for use during pregnancy

true

___ is generally considered the safest, as it falls under Category B

Lidocaine

These other dental anesthetics fall under Category C:

Mepivicaine

Articaine

Bupivicaine

(use with Caution)