Leonie Callaway, professor of medicine at the University of Queensland, tackles the fear and uncertainty many dentists feel when treating pregnant patients, by advising on what level of care is required and what the key risks are
One of the main difficulties dentists struggle with is their fear around treating pregnant patients. It is an emotive time and everyone is aware of the need to ensure the very best outcomes for the foetus. As a result of this fear, and a lack of clear understanding, clinical care can often be more limited than it should be, with a series of unfortunate and unintended consequences for both mother and child. The purpose of writing this is to try to put your mind at ease and provide some clear guidelines about what is and is not okay during a patient’s pregnancy.
My area of expertise is as an obstetric physician. We care for women with medical disorders in pregnancy and therefore have particular expertise in the issues around radiation, drugs and surgery in pregnancy, the provision of pre-conception care, and the care of women with high risk pregnancies as a result of pre-existing illness or illness that arises during the pregnancy.
Globally, there are obstetric physicians in all of the major tertiary obstetric hospitals. We work in multidisciplinary teams with obstetricians, neonatologists, pharmacists, radiologists and specialists of all kinds with an interest in pregnancy (eg rheumatology, endocrinology, cardiology, nephrology and oncology).
If you ever have a tricky question regarding care for a pregnant woman, feel free to call your closest tertiary maternity hospital and ask to speak to the obstetric medicine registrar or physician who is on call for the maternity service. They should be able to provide you with advice, and if they do not know the answer to your question, they will be happy to point you in the direction of help. Pharmacists can also be invaluable in providing advice regarding drugs in pregnancy.
The level of care required
We know that pregnancy worries many healthcare providers and results in fear-based clinical decisions that are often not in the best interest of the mother or foetus. As a general observation, pregnant women often do not receive the care they need from a range of health professionals due to misconceptions about medications, radiology and surgery during pregnancy.
We have seen pregnant women hobbling around with undiagnosed fractures because their doctor was fearful of doing an x-ray during pregnancy, or struggle with a sudden deterioration in their asthma because their doctor thought their asthma medication was unsafe during pregnancy. And we see women with toothache and dental sepsis because dentists were afraid to treat them.
Most dentists find it reassuring to know that the care they might consider providing is quite minor in terms of risk, compared to what goes on for pregnant women on a day-to-day basis within Australia’s hospitals. For example, a dental radiograph results in a foetal radiation dose of 0.0001 rads, compared to a chest radiograph involving 0.001 rads.
We teach all medical students that if a pregnant woman requires a chest radiograph at any point during her pregnancy, the radiation dose to the foetus is so insignificant that the risk of not doing the radiograph and not assessing the lungs and heart properly may far outweigh any minor risk of extremely low doses of foetal radiation.
Pregnant women who develop cancer are often given multiple cycles of chemotherapy during pregnancy and women who develop appendicitis, cholecystitis or hypercalcaemia from parathyroid adenomas are all cared for with appropriately-timed surgery during pregnancy. So, in comparison to the kinds of medications, surgical procedures and radiation exposure that is required to care for pregnant women on a daily basis, dental procedures and dental radiation generally falls into the relatively minor category.
What you need to know
There are a few key messages for dentists providing care for pregnant women or women within the reproductive age range:
1. Women of reproductive age need excellent oral health prior to falling pregnant.
It is ideal for women considering a pregnancy to ensure that all major necessary dental work is undertaken prior to pregnancy if possible.
Dentists should ideally enquire about pregnancy plans when women of reproductive age have dental issues identified and encourage them to complete treatment plans prior to conception. This provides peace of mind for all involved. Adverse events such as miscarriage, congenital anomalies, growth restriction and premature delivery are common. People tend to associate adverse events with whatever happened to them recently. Providing excellent preconception dental care prevents women associating their dental care with common adverse pregnancy events in their own mind. It also reduces pregnancy associated anxiety for the dentist, which is a well-documented problem.
2. All required routine and emergency dental treatment is indicated at any time during pregnancy.
There are multiple guidelines to encourage and reassure dentists about providing regular and emergency dental care to pregnant women. References to these guidelines are included below.
3. Dental imaging should be used when required.
Fear of dental radiation during pregnancy is generally misplaced. The foetal exposure from dental radiation is vanishingly low. Therefore, if there is concern about dental infection during pregnancy and dental radiation is required to assist in determining an appropriate treatment plan, women should be strongly reassured about the risk benefit ratio of dental radiation.
Untreated dental sepsis can trigger pre-term birth and result in overwhelming maternal infection. High quality dental care, including appropriate dental imaging, can prevent these adverse outcomes.
4. Pregnant women from 28 weeks onward need careful positioning in a dental chair.
In advanced pregnancy, women are often very uncomfortable lying on their back and can develop hypotension from the foetus compressing the inferior vena cava. Therefore, from about 28 weeks onwards, a wedge or rolled up towel should be placed under one side of the woman’s back while in the dental chair, to ensure the foetus is not sitting on top of the vena cava.
5. Non-steroidal anti-inflammatory drugs need care during pregnancy.
In the third trimester (from 28 weeks gestation onwards), non-steroidal anti-inflammatory drugs (NSAIDs) should be avoided, due to significant foetal risks. These drugs are associated with persistent pulmonary hypertension of the newborn due to premature constriction of the patent ductus arteriosus, foetal renal injury, oligohydramnios (reduced amniotic fluid), necrotising enterocolitis and neonatal intracranial haemorrhage. Unfortunately, the constriction of the ductus arteriosus in the foetus can be related to even a single dose of NSAIDs.
For dental pain relief, we recommend paracetamol. If additional pain relief is required opioid based analgesia is safer, and we would suggest the use of codeine or oxycodone. NSAIDs can be considered in the second trimester (12-28 weeks) if absolutely required. If women have been taking over the counter NSAIDs for dental pain in the third trimester, encourage them to see their obstetrician so an ultrasound scan to assess foetal wellbeing can be arranged.
6. Individualised decision-making is often required, and communication with other healthcare professionals involved in the woman’s care is strongly recommended.
Each woman’s situation is unique. There are many variables in clinical decision-making for pregnant women who require medications, imaging and surgical procedures. These variables include the woman’s own preferences, the stage of pregnancy, delivery plans, foetal growth and wellbeing, weighing of risks and benefits, access to specialised services, newly published research, variations in guideline-based recommendations regarding the safety and acceptability of various medications (for example, local anaesthetics, nitrous oxide, antibiotics), decision-making in the context of limited information, and the skills of the healthcare providers involved.
All of the guidelines encourage communication between the dentist and the woman’s other healthcare providers. We strongly recommend good communication with the woman’s obstetrician, general practitioner or pregnancy healthcare team in cases where the best plan of action is unclear. We also recommend seeking expert, up-to-date guidance in situations where the published evidence and guidelines lack sufficient clarity to guide decision-making in a particular woman’s unique situation.
American Dental Association, Guidelines on Dental Care during Pregnancy
Oral health care during pregnancy and through the lifespan, Committee Opinion No. 723. American College of Obstetricians and Gynecologists, Obstet Gynaecol 2013 (Reaffirmed 2017);122:417 -22.
CDC National Consensus Statement regarding Oral Health Care During Pregnancy
Guidelines for diagnostic imaging during pregnancy and lactation, Committee Opinion No. 723, American College of Obstetricians and Gynecologists. Obstet Gynaecol 2017;130:e210 -6.
Lowe S, Diagnostic radiation in pregnancy: risks and reality, Aust N Z Journal, Obstet Gynaecol 2004. June; 44(3):191-6.
Lopes LM, Carrilho MC, Francisco RP, Lopes MA, Krebs VL, Zugaib M, Fetal ductur arteriosus constriction and closure: analysis of the causes and perinatal outcome related to 45 consecutive cases, J Matern Fetal Neonatal Med 2016; 29(4):638-45.
Ouanounou A, Hass DA, Drug therapy during pregnancy: implications for dental practice, Br Dent J 2016 Apr;22(8);413-417.
Kelaranta A, Ekholm M, Toroi P, Kortesniemi M, Radiation exposure to foetus and breasts from dental X-ray examinations: effect of lead shields, Dentomaxillofac Radiol 2016 Jan; 45(1):20150095.