Dental treatment for the pregnant patient: Part 1

Everything I tell you today is based on the latest research and medical opinion found  in   articles  available online, from reliable sources.  Many of these articles are written for healthcare professionals, and I have tried  to translate their findings and recommendations into lay terms.  The articles I used to prepare this guide are listed at the end of the article.

Please, if you are doing your own internet searches for health information, use trusted sources only.  There is a lot of strange medical advice out there on the web on any given topic.  A  few  examples of trusted sources for dental information are:  The Canadian Dental Association, The American Dental Association, The Mayo Clinic and Health Canada.

I would also like to add that I was surprised by the lack of information on this topic  at our local big box bookstore.  They only had a few books on pregnancy, and each of those books only devoted a few paragraphs to dentistry and the pregnant patient.

One of the best articles that I came across on the web when preparing for this topic is entitled: 

Oral Health During Pregnancy and Early Childhood:  Evidence-Based Guidelines for Health Professionals.  

This article is written for dentists, physicians and other healthcare workers, and  is available for free online at:

www.cdafoundation.org/library/docs/poh_guidelines.pdf

The article was written by a group of  U.S. state and national  medical, dental and public health experts, in 2010. They reviewed all of the current research in the area of dental care and dental health for the pregnant patient and developed a set of guidelines for dentists to follow.  Most importantly, their findings and recommendations  are fully endorsed by the American College of Obstetricians and Gynecologists, who oversaw the entire project.

The American College  of Obstetricians and Gynecologists (ACOG) is a professional association of  medical doctors  specializing in obstetrics  and gynecology in the United States.  It has a membership of over 55,000 and represents 90 percent of U.S. board-certified obstetrician-gynecologists.  So the U.S. Ob-GYN college felt this issue was important enough to do a very extensive report and study.   (From Wikepedia).

I will be referring to their article quite a few times during our talk, so I will call it the 2010 OB-GYN article.

So let’s get started…

Dental health changes a woman may notice during pregnancy:

During pregnancy there is an increase in estrogen production which has many effects on the mother to be:

• Increased estrogen can cause the small blood vessels in the nose to swell, which can cause a stuffed up nose.  This can  make it difficult to breath through the nose, especially at night.   This will force the patient to breath through the mouth while they sleep, which can dry the teeth and gums and cause dry mouth.
• Since there is  less saliva on the teeth to wash off  bacteria from the teeth this can cause  cavities and/or gum inflammation.

During pregnancy  some women can also develop gum problems due  to an increase in the hormone progesterone that circulates in the body during pregnancy.

One such problem is called pregnancy gingivitis.

• In this condition, the gums become  swollen,  red , tender and sore to touch and can bleed when the teeth are brushed.
• Pregnancy gingivitis  affects about one half of pregnant women, starts in the second or third month of pregnancy and can get worse throughout the pregnancy.

In some  patients with pregnancy gingivitis, the gums can have an exaggerated reaction to the build up of bacteria or plaque  at or under the gum line.  This can cause the inflamed gums to develop a  large, usually painless lump in the gums in between the teeth.  


This lump is called a pregnancy tumor.

•  This is a  harmless condition despite the scary sounding name.
• Pregnancy tumors can grow quite quickly and large, and can cause discomfort during meals.
• They sometimes can bleed and swell.
• They often will shrink in size after delivery, however sometimes they have to be removed during pregnancy if they are bothering the patient.
• They can recur if removed during pregnancy so if it is not bothering the patient it is reasonable to try to wait it out till after the baby comes.
• If they don’t shrink on their own they will usually need to be removed surgically after the baby is born.

A way to prevent and treat pregnancy gingivitis is to  keep a regular check up and cleaning schedule with your dentist and to do a very good job of brushing and flossing at home.

It is widely agreed by physicians that dental cleanings are safe and important during pregnancy.  During dental cleanings we are removing not only soft plaque from the teeth but also tartar, which are hard calcium deposits that form on the teeth above and below the gum line.   If tarter is allowed to accumulate it attracts more bacteria or plaque on the teeth, making the swelling and bleeding of the gums even worse.

Brushing at least twice a day, especially at the gum line, and flossing once a day are also important in keeping the gums healthy during pregnancy and even if there is bleeding this should still be done daily.

There is a chlorhexidine mouth rinse which is safe to use during pregnancy and is very helpful in reducing gum inflammation and bleeding if used twice daily.  It is only available by prescription.

Gingivitis, if untreated can lead to more progressive gum disease which can cause tooth loosening and bone loss around one or more teeth.  This can certainly be avoided by following the brush/floss/professional cleanings and chlorhexidine  combination I just spoke about.

In severe cases of pregnancy gingivitis we would recommend cleanings by your dentist or hygienist every three months.

During pregnancy, the immune system may not work as efficiently as it usually does, meaning that the pregnant patient may not be able to fight off a gum or tooth infection as well as they normally would.

So, there may be an increased need for an antibiotic to fight a tooth or gum infection. Dental infections in the pregnant patient have to be treated more  aggressively to keep the infection from getting worse.
 
There has been some controversy whether poor gum health in the pregnant mother can cause her baby to have  low birth weight or a cause premature birth.  The most recent research is showing this is not the case.  However, healthy
gums are important for a pregnant woman’s overall health and quality of life.

Morning sickness and your teeth

Nausea and vomiting common in the first trimester can lead to gastric reflux during this time.  Stomach acids in the mouth can cause erosion  of teeth and cause considerable tooth wear and sensitivity.  Your dentist can paint fluoride varnish  on the teeth, which can strengthen the enamel and exposed roots and may decrease sensitivity.  Brushing with toothpaste like Sensodyne Pronamel can reharden softened enamel and can help remedy and prevent tooth sensitivity caused by acid reflux.
 
For mothers that have morning sickness, after vomiting, rinsing your mouth with water or a fluoride mouth rinse can ensure acidic stomach acid doesn’t remain on the teeth, which can, over time damage enamel.  You should  avoid brushing the teeth right after exposure to stomach acid as the teeth are at their softest at this time.

Chewing Trident Xtra Care gum can rebuild weakened enamel .  It contains the ingredient recaldent, which is a derived from the protein casein (pronounced kay-seen found in cow’s milk.  Recaldent is made up of calcium and phosphate.

 The calcium from Trident Xtra Care gum is absorbed into tooth enamel, strengthening it.

Mint flavoured chewing gum is also said to help with morning sickness. Incidentally, Recaldent, although derived from a milk protein is safe for people with lactose intolerance.

Another change that pregnant women may notice is a change in their  sense of taste, called dygeusia (pronounced  dis-gew-zee-?).  It usually will be a sour or metallic taste and it can affect women in their first trimester. It is caused by increased estrogen levels. It often is gone by  the second trimester.

Acidic foods like orange juice or lemonade or foods marinated in vinegar such as pickles can help take away the metallic taste.

Here’s a real life example of altered taste in pregnancy.  When my wife Adi was pregnant with our first child many years ago, one night, when it was getting a little late, my wife announced she was craving red pickled  peppers, something I had never seen her eat before in the several years we had been together.  She was in her first trimester and she suddenly wanted them really bad.  Obviously I asked no questions and went straight out to find a store that would still be open that sold them.  I was in luck.  I found a store and I procured the pickled peppers and  my wife Adi was appreciative.

About a week later while doing some grocery shopping I had a brilliant idea:  I would buy a few more large jars of pickled  red peppers, so I wouldn’t have to go on any more late night red pickled  pepper runs.   So when I arrived homewith the groceries I proudly announced to my wife that I brought home  a few more large jars of the peppers she craved.  Adi then informed me:  “oh…I am not into those anymore”.

The two jars of pickled red peppers sat in our fridge for the next two years, unopened.  Once they started to turn green I got rid of them. 

Looking back, my wife was probably entering her second trimester by then and lost her need or enthusiasm for vinegary foods. 

If you’re not into marinated peppers another way to help rid the metallic or sour taste is to scrape your tongue  each time you brush your teeth, or rinse your mouth with a mild salt solution (a teaspoon of salt in eight ounces of water) or a baking soda solution (1/4 teaspoon baking soda in eight ounces of water) as needed.

How dental treatment is modified to keep both expectant mother and her developing baby safe:

The 2010 article by the American College of Obstetricians and Gynecologists states:

“Prevention, diagnosis and treatment of oral diseases, including needed dental x-rays and use of local anesthesia (or freezing),  is  highly beneficial and can be undertaken during pregnancy with no additional fetal or maternal risk when compared to the risk of not providing care. Good oral health and control of oral disease protects a woman’s health and quality of life and has the potential to reduce the transmission of pathogenic bacteria from mothers to their children. 

Dental care can improve a pregnant woman’s overall health and the health of her developing fetus…”

Because this is a Canadian based podcast, I will also provide  a quote from  Motherisk, which is an organization run by the Hospital for Sick Children in Toronto, Canada.  Motherisk  provides advice to pregnant women and health  care professionals regarding risks to fetus from exposure to drugs, chemicals, diseases, radiation and environmental agents.  They are a good resource for pregnant and breast feeding women and their website is www.motherisk.org

Motherisk states on their website:

“Appropriate and timely dental care can lead to improved pregnancy outcomes as well as greater comfort for the woman. The treatment of periodontitis (or gum disease), as well as the use of local anesthetics, amalgams, and x-ray scans, does not pose an increased risk to the developing fetus and is, in fact, important in contributing to maintaining optimal health for the mother.” 

When I see pregnant patients they are obviously very concerned about the health of their developing baby, and as dentists we are trained to keep the health of the both the developing baby and expectant mother first and foremost.
 
It is important to maintain dental health throughout the pregnancy.  A sore tooth or sore gums may affect the ability or desire of the expectant mother to eat.  An infected tooth or infected gums can have a negative effect on the health of the expectant mother  and the developing baby. 

So experts widely agree that dental treatment is very safe for the pregnant patient.  There are guidelines that do make the delivery of dental treatment more comfortable for the mother, and  there  are certainly procedures that are ideally best done when a woman is not pregnant. 

In an ideal world, women who are contemplating getting pregnant ideally should have a dental checkup and have necessary dental treatment done  before they get pregnant.

• For example, if a woman is thinking of getting some dental implants placed or are in need of getting her wisdom teeth removed, ideally this would be best done before she gets pregnant, or postponed till after the baby arrives.  Again, in an ideal world this is good advice.   However, consider the following statistics:
• Less than 50% of women know they are pregnant by 4th week of their pregnancy.
• About 20% of women  still don’t know they are pregnant  by 8th week.
• And about one half of pregnancies are unplanned
• So planning to have dental work done before you become pregnant is often  not an option.

As well, in light of these stats, there are many women receiving dental treatment early in their pregnancies without knowing they are pregnant. 

So what are the American College of Obstetricians and Gynecologists recommendations about receiving dental treatment during pregnancy?  They state:

1.  Routine dental treatment does not need to be postponed until after pregnancy.

2.  A healthy patient need not get approval from her MD for routine dental treatment.

3.  Necessary dental x-rays and use of freezing or local anesthetic is safe and will not harm the mother or developing fetus.

4.  Emergency treatment can and should be carried out at any time during pregnancy.
 
5.  Consultation with the patients physician should be made when there are health complications in the pregnant patient,  or when sedation is being considered for use in any pregnant patient, such as nitrous oxide, intravenous sedation or general anaesthesia.

6.  An untreated dental problem can lead to more serious health concerns for the expectant mother if they have a dental condition left untreated.

7.  The pregnant patient’s physician should ideally fill out an oral health referral form, which would reassure both the patient and the dentist that dental care is safe during pregnancy.  This form should be given to all pregnant patients by their physician at their first obstetrics appointment.  There is a copy of this form at the bottom of this article.

The form includes the name of the treating physician, and it informs the patient that they should see their dentist for a dental check-up and cleaning.  It assures the patient right on the form that they can have the following treatment done:

• X-rays (as long as abdominal and shield is used.
• Cleanings
• Fillings
• Extractions
• Freezing
• Tylenol (with codeine as necessary)
• Antibiotics (provided there is no allergy: i.e. penicillin, amoxicillin, cephalosporin, clindamycin, erythromycin (not estolate form)

8.  the 2010 report from the US college of obstetricians stressed that doctors caring for pregnant patients should recommend at the first prenatal appointment that their patients make sure they schedule a dental exam and reassure the patient that dental care during pregnancy is safe. 

The pregnant patient is much better off seeing a dentist and dealing with a dental problem such as a sore tooth, rather than taking  an over the counter pain killer like aspirin, for example, as this could cause unwanted side effects to the fetus and /or result in problems with the pregnancy if taken in the third trimester.

More on this in the next installment of this series. The reluctance amongst some dentists to treat pregnant patients is due to the fear of harming the developing fetus.  However there is no evidence that dental treatment during pregnancy can cause miscarriage or other pregnancy complications, even during the first trimester.

The reality is that 15 to 20 percent of   pregnancies will result in miscarriage before the 20th week and are usually not preventable.  The most common causes of spontaneous abortion are due to hormonal causes, problems with the 
uterus and genetic problems in the developing fetus.

As well,  according to recent research by  the American Dental Association,  many  women  do not visit the dentist during pregnancy, and this is due in large part to lack of information in the community about dental health and pregnancy.

Half of women who reported dental problems did not seek care because they believed poor oral health during pregnancy was normal or they feared dental treatments could harm the fetus.

Also, surprisingly, 49% of obstetricians rarely or never recommend a dental examination; and only 10% of dentists perform all  necessary treatment during pregnancy. 14% of dentists are against using local anesthetics during pregnancy.  Unfortunately there are apparently still some misinformed dentists practicing.

Dental x-ray safety during pregnancy:

Pregnant women and all patients for that matter should wear a lead apron that covers their entire abdomen and throat while dental x-rays are being taken.   By doing so the fetus or developing baby will receive virtually no radiation exposure from dental x-rays. 

The 2010 OB-GYN article states that:

“Dental x-rays are an important tool in the diagnosis and treatment of dental problems and are considered safe during pregnancy.  Dental x-rays are a very low source of radiation which makes the risk of harm extremely small. The number and type of x-rays needed will depend on the patient’s clinical condition and health history, and this number does not need to be altered because of pregnancy.”

The article on my website will have further points on this topic, including a fact sheet from the US Centre of Disease Control, that give further evidence of the safety of dental x-rays during pregnancy.

For interest, here are two final quick facts about dental x-rays during pregnancy, and again, this information is fro Motherisk, from Sick Kids Hospital in Toronto, 2009:

The amount of radiation that a fetus would receive from a single dental x-ray is 0.01 millirads.

To put this amount in perspective, each day, the amount of radiation each of us is exposed to from the sun and from natural  radioactivity in the earth is 1 mrad, which is 100 times the amount of the amount of radiation the fetus absorbs from a single dental x-ray.  So patients who are terrified about the notion of having a few dental x-rays taken during pregnancy have to realize that they and their developing baby are exposed to many, many times the amount of radiation each day, merely living on this planet from natural sources, so the additional amount of radiation from even several dental x-rays during pregnancy is insignificant.  

As well, according to Motherisk, birth defects will not occur as long as the x-ray dose that the fetus receives during the pregnancy is less than 5 rads.  So as long as the fetus doesn't receive a concentrated dose of 500 dental x-rays all at once

Motherisk points out that dental x-rays should not be a cause for a concern. Well, I think we’ll end it here for today.  Next time we will continue our discussion of dental treatment for the pregnant patient and there is a lot more important
information to cover.

The Oral Health Referral Form:

The pregnant patient’s physician should ideally fill out an oral health referral form for each patient.  This form is designed to give reassurance to both the patient and her treating dentist that dental care is safe for that patient during pregnancy.

This form should be given to all pregnant patients by their physician at their first obstetrics appointment.   Until this form is more commonly used, a patient could print this form out and ask their physician to fill it out. There is a copy of the form below. 

Note:  this form was found in the article:  Oral health During Pregnancy and Early Childhood:  Evidence Based Guidelines for Health Professionals, February 2010, California Dental Association and American college of Obstetricians and Gynecologists. 


Thank you to the California Dental Association for allowing the inclusion of this form in this article.  (Note the referral form below did not transfer well from the article but can be printed directly from the reference article and taken to your physician.