Dental

Management of
the Pregnant
patient
• Pregnancy has been considered an
impediment to dental treatment
• However, preventive, emergency, and
routine dental procedures are all suitable
during various phases of a pregnancy,
with some treatment modifications and
initial planning
 Introduction
 Pregnancy is a major event in any woman's life.

 A pregnant patient is not consideredmedically

compromised but consists of a unique set of
management for the dentist.
 Dental care should be given in such a way that it does not
adversely affect the fetus .

 Hormonal changes during the period ofpregnancy causes

changes in the body as well as the oral cavity.

 All elective dental procedures can be delayed till

postpartum to avoid any risk to the developing fetus.
It is still very important to maintain the
pregnant woman's current state of dental
health and pregnancy is the ideal
opportunity to begin a preventive dental
program.
Its also important to educate the pregnant patient about
the common problems noticed duringpregnancy.
Stages of
Pregnancy

•1st Trimester (1-12

weeks)
•Fetal organ formation
and differentiation.
•Most susceptible to
adverse effects of
teratogens.
•Avoid all elective care
but provide care as
needed.
Stages of Pregnancy

•2nd Trimester (13-24

weeks)
•Fetal growth and
maturation.
•Safest period to provide
dental care.
Stages of Pregnancy

•3rd Trimester (25-40 weeks)

•Fetal growth continues.
•Focus of concern is risk to
upcoming birth process and
safety and comfort of the
pregnant woman.
Physiologic Changes in Pregnancy

• Complex hormonal interactions cause

profound physiologic changes
• Increase estrogen by 10 fold and
progesterone by 30 folds
• Increased hormonal secretion and fetal
growth causes several systemic as well as
physical changes in a pregnant women
Systemic changes in pregnancy:
Cardiovascular system
 ↑ in blood volume by an average of 45%
• Anemia due to increased blood volume
(20% of women)
 ↓ in pulse by 10-15 beats per minute
 Systemic murmur occurs in 90% of
pregnancies, disappears shortly after
delivery
 ↑cardiac output
 Supine hypotension syndrome may
occur .
 FLAT SUPINE POSITIONING

•Negatively impacts: mother and infant

SUPINE HYPOTENSION
SYNDROME (Vena Cava Compression)

• Supine position after 5th month

• Uterus compresses the inferior
vena cava
• ↑Vol. Blood in the l.E.’S
• ↓Return to the heart
• Reduced perfusion of uterus
• Fetal hypoxia
Supine Hypotension Syndrome

• Obstruction of inferior vena cava and

aorta from pressure of the large fetus.
Symptoms:
Sweating
Nausea
Weakness
Sense of lack of air
Supine Hypotension Syndrome

Other symptoms:
• Drop in blood pressure
• Bradycardia
• Possible loss of consciousness
Prevention of Supine Hypotensive
Syndrome

•Elevate right hip 10-12

cm.
•Weight is taken off the
major vessels
 Treatment of Supine Hypotensive
Syndrome

•Roll patient onto her

left side.
How should the pregnant
woman be positioned?
• Flat position may
cause hypotension
and hypoxia

• Place a small pillow

under right hip - left
lateral displacement

• Head above feet

Systemic changes in pregnancy:

Respiratory system
 Diaphragm rises about 4 cm.
 ↓ residual volume
 ↑ awareness of a desire to breath is
common-may be interpreted as dyspnea.
 Increased estrogen in blood causes
engorgement of the nasal capillaries and
rhnitis in pregnant women.
 Frequent nosebleeds & predisposition to
upper respiratory infection.
Systemic changes in pregnancy:

Gastrointestinal system
 Gastric emptying & intestinal transit times
are delayed.

 Heart burn / reflux common

 Nausea and vomiting common

Systemic changes in pregnancy:

 For pregnant patient with Hyper-emesis

gravidarium ( excessive and uncontrolled
vomiting) , morning appointments should
be avoided.

 They should be seated in a semi-supine or

comfortable position
 In case of vomiting , the procedure should
be stopped immediately & the patient
should be repositioned upright
 When vomiting is over rinsing mouth with
cold water or mouthwash is recommended.
Systemic changes in pregnancy:
• Urinary System
 ↑ GFR & renal plasma flow by as much as
50%
 Nocturia –to mobilize the dependent
edema which accumulate during the day.
 ↑ Frequency from ↑ renal flow plus reduced
bladder capacity from uterine growth
 It is advisable to ask the patient to void the
bladder just prior to starting the dental
procedure.
Systemic changes in pregnancy:
Endocrine Changes:
 ↑Estrogen, ↑ progesterone, ↑human
gonadotropin
 ↑ thyroxin, steroid and insulin level
 Estrogen & progesterone are insulin
antagonists. ↑ level of these hormones lead to
insulin resistance. Thus insulin levels are
elevated in pregnant in pregnant patient to
compensate this resistance
 About 45 %of women fail to produce sufficient
amount of insulin to overcome this antagonist
action & thus develop gestational diabetes.
Systemic changes in pregnancy:

Hematological change
• ↑ red RBC , ↑ESR, ↓Hb
• ↑WBC
• ↑ circulatory catecholamin & cortisol lead
to leucositosis
• ↑ Coagulation factors except factor XI &
XIII (anticloting factor)
• so pregnancy is a hypercoagulable state &
↑ risk for thromboembolism
Systemic changes in pregnancy:

• Pregnant women with anti-phospholipid

syndrome are at ↑ risk for thrombo-
embolisim.
• They are placed on subcutaneous low
molecular weight heparin (LMWH)
• These patients must be hospitalized for
dental care.
 Pregnancy Related
Oral Health Problems

• Pregnancy Gingivitis
• Pregnancy Epulis
• Increased Tooth Mobility
• Dental Caries
• Erosion
• Dental Problems in relation to Labor
and Delivery
Oral Problems in Pregnancy

•Pregnancy Gingivitis
•Most common oral
manifestation (50-
100% of women)
•Caused by hormonal
and vascular changes
of pregnancy
Pregnancy Gingivitis
Pathophysiology

• Elevated circulating estrogen increases

capillary permeability.

• Preexisting gingivitis may predispose to

pregnancy gingivitis.
Pregnancy Gingivitis

•Occurs commonly in the

2nd to 8th months
•Tendency to bleed very
easily
•Treatment: Scaling, root-
planing, currettage, OHI
Pregnancy Granuloma

•Occurs in up to 5% of
women.
•Most common in
buccal maxillary
anterior areas.
•Usually starts in an
area of gingivitis.
Pregnancy Granuloma (continued)

•Rapid growth up to 2 cm.

•Single tumor-like growth
•usually in interdental
papillae
•Purplish to bluish in color,
may be ulcerated- bleeds
easily
Gum Problems - Pregnancy
Granuloma
Gum Problems - Pregnancy
Granuloma
Gum Changes - Pregnancy
Granuloma
Pregnancy Granuloma (continued)

Treatment

• Scaling and root planing

• Excision if it is too large or bleeds too
easily
• May regress spontaneously after
pregnancy
Candidiasis

•Wipes off
•Usually
asymptomatic, but
may burn
•Treatment topical or
systemic antifungals
Pregnancy Myths
•“A mother loses a
tooth for every baby”
•No evidence that
aphthous ulcers are
any more common in
pregnancy
Other Oral Conditions in Pregnancy

• Dry mouth
• Excessive salivation
• Tooth erosions associated with
severe GERD or hyperemesis
Changes During Pregnancy that
Affect Oral Health

• Hormonal Affects
– Increased tooth mobility
– Saliva changes
– Increased bacteria
– Gingival problems
Saliva changes
• Decreased buffers
• Decreased minerals

• Decreasing flow first and last

trimester
• Increased flow second trimester
• More acidic
Increased Bacteria
• Increased acidity
– Increase in decay-causing bacteria
• Increased Snacking
– Morning sickness/low blood sugar
– Between-meal snacks
• Increase in amount and frequency of
starches/carbohydrates
– Crackers are commonly recommended
– Promotes decay-causing bacteria
Changes During Pregnancy that
Affect Oral Health
• Morning sickness
– Difficulty with hygiene
• Gingival disease
• Tooth decay
– Vomiting
• Esophogeal Reflux (heartburn)
• Acid exposure
– Irritation of the gums
– Weakening of tooth enamel
– Dental erosion
Enamel erosion caused by
frequent vomiting
Treatment for Acid Exposure

• Do NOT brush immediately after

vomiting
• Rinse
– Water with baking soda
– Antacid
– Plain water
• Eat some cheese
Oral Diseases Can Effect
Pregnancy

• Preterm, low birth weight (LBW) linked

to periodontal disease

• Thorough calculus (tartar) removal in

pregnant women with periodontitis
may reduce pre-term births
Periodontal Disease and Preterm
Labor
•Maternal periodontal
disease is associated
with increased risk of
preterm labor
•Anaerobic oral gram-
negative bacteria cause
inflammatory response
•Inflammatory response
stimulates prostaglandin
and cytokine production
to stimulate labor
 Periodontal Disease and Low
Birth Weight

• Periodontal disease is associated with

low birth weight
• Evidence is not conclusive
• Biochemical mechanism similar cascade
as in preterm labor leading to placental
blood flow restriction and necrosis
 Periodontal Disease and
Preeclampsia

• Emerging data
• Mechanism unclear
• Proposed mechanism:
– Periodontal infection leads to
inflammatory vascular damage
– Triggers cell damage in placenta
Periodontitis and Pre-eclampsia

• Periodontal disease may be associated with

pre-eclampsia (Boggess, 2003)
• PGE2, IL-1 and TNF-α from gingival
crevicular fluid were higher in women with
preeclampsia compared with healthy
matched pregnant women (Oettinger-Barak,
2003).
Dental Considerations

• timing of treatment for pregnant

patients
• dental radiation exposure
• use of local anesthetics
• prescription of common antibiotics and
analgesics
• nitrous oxide gas administration
Treatment Timing

• First Trimester
– Spontaneousmiscarriages naturally occur
more often in 1st trimester
– Avoid elective treatment that can be delayed
– Offer anticipatory guidance
• Second Trimester
– The optimal timefor dental treatment
– Organogenesis complete, fetus not large
– Easier to prevent than treat established disease
• Third Trimester
– Late in term very uncomfortable (short visits)
– Position slightly on left side
Timing of Dental Treatment During
Pregnancy - From Little and Fallace

First Trimester

• Plaque control
• Oral hygiene instruction
• Scaling, polishing, curettage
• Avoid elective treatment; urgent care
only
Timing of Dental Treatment During
Pregnancy - From Little and Fallace

Second Trimester

• Plaque control
• Oral hygiene instruction
• Scaling, polishing, curettage
• Routine dental care
Timing of Dental Treatment During
Pregnancy - From Little and Fallace

Third Trimester

• Plaque control
• Oral hygiene instruction
• Scaling, polishing, curettage
• Routine dental care (after middle of third
trimester, elective care should be avoided)
Treatment Timing

• Plaque Control oral hygiene instructions,

FIRST TRIMESTER scaling, polishing curettage
• Avoid elective treatment urgent careonly.

• Plaque Control oral hygiene instructions,

SECOND TRIMESTER scaling, polishing curettage
• Routine dental care.

• Plaque Control oral hygiene instructions,

THIRD TRIMESTER scaling, polishing curettage.
• Routine dental care.
Use of Radiation on Pregnant Patient
• Dose given and time of gestation are
important
• doses < 5-10 rads (cGy) not teratogenic
• fetus is most susceptible to radiation
between the 2nd and 6th week of gestation
• single dental x-ray exposes patient to 0.01
millirads of radiation. In relative terms, this
amount is 40 times less than daily dose
acquired from cosmic radiation. Therefore,
diagnostic radiation should not be
withheld during pregnancy
 Radiographs during Pregnancy

• Take as needed with optimal methods for

reducing secondary radiation and exposure
time.
• Always use a lead apron.
• Exposure to fetus (with apron use) is .00001
centiGray.(rad)
• Daily cosmic radiation - .0004 centiGray (rad)
Risks of Dental X-Rays

• X-ray only if necessary (i.e. root

canal therapy, trauma)
• When x-rays are indicated, radiation
exposure is extremely low
• Exposure can be limited by:
– Lead apron shielding
– Modern fast film
– Avoiding retakes
Drug
Administration
Ideally, no drug should be administered duringpregnancy
especially 1st trimester.

ALL DRUGS SHOULD BE AVOIDED UNLESS

POTENIAL BENEFIT OUT WEIGHS
POTENTIAL RISKS.
Principles of prescribing during pregnancy –
Whenever possible use non drug therapy.
Prescribe drugs only when definitely needed choose
the drug having best safety record over time.
Avoid newer drugs.
As far as possible, avoid medication in initial 1o
weeks of gestation
Use the lowest effective dose.
Use drug for the shortest period necessary.
If possible give drug intermittently.
 PHARMACOKINETICSIN PREGNANCY–

>Drug Absorption –
1. Slower drug absorption
2. Parenteral drug administration
3. Drug compliance poor

>Drug Metabolism –
1. Hepatic drug metabolizing enzymes are induced
2. Rapid metabolic degradation

>Drug Excretion –
1. Renal plasma flow increases by 100% & glomerular filtration rate by70%
2. Rapid elimination

Most commonly used drugs in dental practice can be given during

pregnancy with relativesafety.
Food and Drug Admistration

Classification System
Controlled studies showed no risk to the fetus. This group limited to
multivitamins and prenatal vitamins , not megavitamins.

Either animal studies have shown no fetal effects , but there is no

controlled human studies during pregnancy, or animal studies have
shown adverse effect that was not confirmed in controlled studies
during first trimester. Penicillins are in thisfamily.

There are no adequate studies, or animal studies have shown adverse

effect , but controlled studies in women are not available. Potential
benefit must be greater than the risk to the fetus if these medications
are used.
Evidence of fetal risk is proven, but potential benefit must be
thought to be outweigh therisks.

Proven fetal risk clearly outweighs any potential benefits.

FDA drug classification for
pregnancy
• Combines risk statements including
congenital anomalies, fetal effects,
perinatal risks, and therapeutic risk-
benefit ratio
• Untreated disease or condition may
pose more serious risks to both
mother and fetus than any theoretical
risks from the medication
• Category A thru D and X
FDA drug classification for
pregnancy

• A = Controlled Studies in women fail

to demonstrate a risk to the fetus in
the first trimester and the possibility
of fetal harm appears remote
FDA drug classification for
pregnancy

• B = Animal studies show no risk,

or if risk shown in animals, controlled
trials in women showed no risk
FDA drug classification for
pregnancy

• C = Studies in animals with adverse

effects and no human studies,
OR no animal or human studies, but
benefits of use may outweigh
potential harms
FDA drug classification for
pregnancy

• D = There is evidence of human fetal

risk, but benefits may outweigh risks
FDA drug classification for
pregnancy

• X = Contraindicated
Common Analgesics

• paracetamol (B)
• Ibuprofen (B/D*)
• Oxycodone (B/D*)
• Hydrocodone and codeine
(C/D*)

*avoid in third trimester

Analgesics

• Paracetamol is the analgesic of choice for

all stages of gestation
• used to treat mild to moderate pain and
fevers
• short term usage is believed to be safe
• avoid chronic and large doses of
paracetamol
Analgesics - continued
• Aspirin is nonteratogenic but may cause
maternal and fetal hemorrhage
• large and chronic doses during last trimester
may result in premature closure of ductus
arteriosus, fetal hypertension, anemia, and
low birth weight
• avoid ibuprofen in 3rd trimester because of
possible adverse circulatory effects
• short term use of codeine seems safe
• avoid codeine late in gestation because of
possible fetal respiratory depression and
withdrawal symptoms
Analgesics to Use During
1st and 2nd Trimester
• Category B (for best!)
• Paracetamol, Ibuprofen,
• Naproxen
• Category C (use with caution):
• Paracetamol with codeine or
hydrocodone
• Paracetamol with oxycodone
Analgesics to Avoid During the
Third Trimester

• Causes delivery problems:

• Aspirin (C/ 3D)
• Ibuprofen (B/3D)
• Naproxen (B/3D)
• Causes neonatal respiratory
depression and opioid withdrawal:
• Codeine (C/3D)
• Hydrocodone (C/3D)
• Oxycodone(C/3D)
Sedation in Pregnancy

• Sedatives/Anxiolytics (e.g. Diazepam ) are

rated D and can cause oral clefts with
prolonged exposure.
• Nitrous oxide should not be used in 1st
trimester (If used in 2nd and 3rd, do not go
below 50% O2)
 Common Antibiotics
• To treat oral abscess or cellulitis
– Penicillin (B)
– Amoxicillin (B)
– Cephalexin (B)
– Erythromycin base* (B) (Not estolate, as it
cause cholestatic hepatitis)
– Clindamycin (B)
 Antibiotics

• penicillin V and amoxicillin is preferred drug

for mild to moderate infections
• widely used for many years with no ill effects
• no studies show penicillin to be teratogenic
• amoxicillin extensively used without harming
the fetus
• Drug classes:
B: penicillin, cephalosporins, erythromycin,
clindamycin, Azithromycin
D: Tetracycline
Antibiotics To Use During Pregnancy

• Penicillin V
• Amoxicillin
• Erythromycin (base form)
• Cephalexin, cephalosporin
• Clindamycin
• Metronidazole
Antibiotics to Avoid during
Pregnancy

• Doxycycline
• Tetracycline
• Erythromycin (estolate form)
• Vancomycin
 The Problem With Tetracycline

• Accumulates in bones and chelates

calcium
• Inhibits bone growth
• Discolors teeth
Other Antimicrobial Agents
• OK to use:
• Nystatin (B)
• Chlorhexidine rinse (B)
• Use with caution:
• Clotrimazole (C)
• Ketoconazole (C)
• Fluconazole (C)
• Do not use:
• Doxycycline (D)
Drug Administration During
Pregnancy

DRUG FDA Use During Risk Use During

Category Pregnancy Breast-
feeding

1. Local
Anesthetics

Lidocaine B Yes - Yes

Prilocaine B Yes - Yes

Mepivacainet C Use with caution Fetal Yes

consult bradycardia
physician
DRUG FDA Use During Risk Use
Category Pregnancy During
Breast-
feeding
1.Analgesics

Asprin C/D3 Avoid in 3rd Post partum Avoid

trimester hemorrhage
constriction
ductus
arteriosuss

Acetaminophen B Yes - Yes

Ibuprofen B Caution avoid in Delayed Yes

second half of labour
pregnancy
DRUG FDA Use During Risk Use
Category Pregnancy During
Breast-
feeding
1.Antibiotics

Penicillin B Yes
Erythromycin B
Yes avoid estolate - Yes
B form
Cephalosporin Yes -
Tetracycline D
Avoid Tooth
discoloration
bone Avoid
deformities

Metronidazole B Yes Mutagenic Yes

DRUGs FDA Use During Risk Use During
Category Pregnancy Breast-
feeding

1.Sedatives/Hy
pnotics
Avoid Avoid
Barbiturates D Neonatal
Respiratory
Depression
Avoid Avoid
Benzodiazepines D/X Oral clefts

2.Corticosteroids

Yes Yes
Prednisone B Delay labour
Local Anesthetic Use in
Pregnancy

• Class B:
• Lidocaine (Xylocaine)
• Etidocaine
• Prilocaine
• Class C:
• Procaine
• Bupivicaine
• Mepivicaine
 Use of Local Anesthetics

• Lidocaine + vasoconstrictor: most common

local anesthetic used in dentistry
• extensively used in pregnancy with no proven ill
effects
• accidental intravascular injections of lidocaine
pass through the placenta but the
concentrations are too low to harm fetus
• prilocaine might cause methemoglobinemia
Ulcer healing drugs
Cimetidine
•FDA category B
Famotidine
•FDA category B
Ranitidine
•FDA category B
• not known to be harmful
Ulcer healing drugs
Omeprazole
• FDA category B.Not known to be
harmful
Esomeprazole
•FDA category B
Lansoprazole
•FDA category B
Pantoprazole
• Avoid unless potential benefit
outweighs risk—fetotoxic in animals
Ulcer healing drugs

Misoprostol
• First, second, third trimesters: Avoid—
potent uterine stimulant (has been used to
induce abortion) and may be teratogenic
Ulcer healing drugs

Antacids
• Almunium hydroxide/Magnesium
hydroxide—FDA category B
 Calcium carbonate—FDA category C

 Simethecone—FDA category C
Use of Nitrous Oxide Gas

• used over 150 years

• safety is being debated
• SHORT TERM exposure do not cause
birth defects or spontaneous abortion
• CHRONIC exposure may result in fetal
loss and infertility
• literature suggests that nitrous oxide
should be avoided until more conclusive
research is available
• FDA Drug class: not yet assigned
Common Preventives

• Fluoride
– No increased risk during pregnancy
• Xylitol
– No studies; no harm reported
• Chlorhexidine
– No increased risk during pregnancy
Are topical agents safe?

• Fluoride
• Toothpaste & mouthrinse
• Xylitol chewing gum
• Chlorhexidine (11% alcohol)
• No over the counter mouthrinses
with alcohol (Listerine 20% alcohol)
Pre-natal Fluoride

• Daily 2.2 mg tablet of sodium fluoride

during 3rd through 9th months
• decreases caries rate in offspring.
• Safe and effective.

Glenn, FB, 1982

Is it safe to use
mercury restorations?

• No evidence of harmful effect

• Benefits outweigh risks
• Canada, Germany, and New
Zealand have some restrictions
• Determine the best option
In conclusion…..

• Can I take x-rays?

• Can I inject local anesthesia with
epinephrine?
• What medications can I prescribe?
• Are topical agents safe?
• When should I perform necessary
procedures?
• Can I use mercury restorations?
References
• Wasylko L, Matsui D, Dykxhoorn SM, Rieder MJ, Weinberg
S. A Review of Common Dental Treatments During
Pregnancy. J Canadian Dental Association. 64:434-439 1998
• Little JW, Donald AF, Craig SM, Rhodus NL. Dental
Management of the Medically Compromised Patient - 5th
edition. Mosby, Toronto. Pp.434-442. 1997.
• Livingston HM, Dellinger TM, Holder R. Considerations in the
management of the pregnant patient. Special Care in
Dentistry. 18:5 pp183-188. 1998.
• Larimore WL, Petrie KA. Drug use during pregnacy and
lactation. Primary Care; Clinics in Office Practice. 27:1 35-
53. 2000
• Health Canada. The Safety of DentalAmalgam. Minister Of
Supply and Services Canada. 1996.
REFERENCES
• 1. Weiss G. Endocrinology of parturition. J Clin
Endocrinol Metab 2000;85:4421-5.
• 2. Theunissen IM, Parer JT. Fluid and electrolytes in
pregnancy. Clin Obstet Gynecol 1994;37:3-15.
• 3. Duvekot JJ, Peeters LLH. Renal hemodynamics and
volume homeostasis in pregnancy. Obstet Gynecol
Surv 1994;49:830-9.
• 4. Barron WM, Lindheimer MD. Medical disorders
during pregnancy. 2nd ed. St Louis: Mosby; 1995. p.
129.
• 5. Thornburg KL, Jacobson SL, Giraud GD, Morton MJ.
Hemodynamic changes in pregnancy. Semin Perinatol
2000;24:11-4.
• 6. Fiese R, Herzog S. Issues in dental and surgical
management of the pregnant patient. Oral Surg Oral
Med Oral Pathol 1988;65:292-7.
• 7. Martin C, Varner MW. Physiologic changes in
pregnancy:surgical implications. Clin Obstet Gynecol
1994;37:241-55.
• 8. Clark SL, Cotton DB, Lee W, Bishop C, Hill
T, Southwick J, et al. Central hemodynamic
assessment of normal term pregnancy. Am J
Obstet Gynecol 1989;161:1439-42.
• 9. Mabie WC, Di Sessa TG, Crocker LG, Sibai
BM, Arheart KL. A longitudinal study of
cardiac output in normal human pregnancy.
Am J Obstet Gynecol 1994;170:849-56.
• 10. Clapp JF 3rd, Capeless E. Cardiovascular
function before, during, and after the first and
subsequent pregnancies. Am J Cardiol
1997;80:1469-73.
• 11. Duvekot JJ, Peeters LL. Maternal
cardiovascular hemodynamic adaptation to
pregnancy. Obstet Gynecol Surv
1994;49(Suppl): S1-14.
• 12. Bhagwat AR, Engel PJ. Heart disease and pregnancy. Cardiol Clin
1995;13:163-78.
• 13. Lanni SM, Tillinghast J, Silver H. Hemodynamic changes and
baroreflex gain in the supine hypotensive syndrome. Am J Obstet
Gynecol 2002;187:1636-41.
• 14. Little JW, Falace DA, Miller CS, Rhodus NL. Dental management of
the medically compromised patient. 6th ed. St Louis: Mosby; 2002. p.
303.
• 15. Garcia-Rio F, Pino JM, Gomez L, Alvarez-Sala R, Villasante C,
Villamor J. Regulation of breathing and perception of dyspnea in healthy
pregnant women. Chest 1996;110:446-53.
• 16. McAuliffe F, Kametas N, Costello J, Rafferty GF, Greenough A,
Nicolaides K. Respiratory function in singleton and twin pregnancy. BJOG
2002;109:765-9.
• 17. Clapp JF 3rd, Seaward BL, Sleamaker RH, Hiser J. Maternal
physiologic adaptations to early human pregnancy. Am J Obstet Gynecol
1988;159:1456-60.
• 18. O’Day MP. Cardio-respiratory physiological adaptation of pregnancy.
Semin Perinatol 1997;21:268-75.
• 19. Contreras G, Gutierrez M, Beroiza T, Fantin A, Oddo H, Villarroel L, et
al. Ventilatory drive and respiratory muscle function in pregnancy. Am
Rev Respir Dis 1991;144:837-41.
• 20. Turner M, Aziz SR. Management of the pregnant oral and maxillofac
• 21. Sifakis S, Pharmakides G. Anemia in pregnancy. Ann N Y Acad Sci
2000;900:125-36.
• 22. Branch DW. Physiologic adaptations of pregnancy. Am J Reprod Immunol
1992;28:120-2.
• 23. Burrows RF, Kelton JG. Incidentally detected thrombocytopenia in healthy
mothers and their infants. N Engl J Med 1988;319: 142-5.
• 24. Hanly JG. Antiphospholipid syndrome: an overview. CMAJ
2003;24(168):1675-82.
• 25. Heilmann L, von Tempelhoff GF, Pollow K. Antiphospholipid syndrome in
obstetrics. Clin Appl Thromb Hemost 2003;9: 143-50.
• 26. Sherman P, Flaxman SM. Nausea and vomiting of pregnancy in an
evolutionary perspective. Am J Obstet Gynecol 2002; 185(Suppl):s190-7.
• 27. Koch KL. Gastrointestinal factors in nausea and vomiting of pregnancy.
Am J Obstet Gynecol 2002;185(Suppl):s198-203.
• 28. Koch KL, Frissora CL. Nausea and vomiting during pregnancy.
Gastroenterol Clin N Am 2003;32:201-34.
• 29. Baron TH, Ramirez B, Richter JE. Gastrointestinal motility disorders during
pregnancy. Ann Intern Med 1993;118: 366-75.
• 30. Richter JE. Gastroesophageal reflux disease during pregnancy.
Gastroenterol Clin N Am 2003;32:235-61.
• 31. Marrero JM, Goggin PM, de Caestecker JS, Pearce JM, Maxwell
JD. Determinants of pregnancy heartburn. Br J Obstet Gynaecol
1992;99:731-4.
• 32. Hamaoui E, Hamaoui M. Nutritional assessment and support
during pregnancy. Gastroenterol Clin N Am 2003;32:59-121.
• 33. King JC. Physiology of pregnancy and nutrient metabolism. Am J
Clin Nutr 2000;71(suppl):1218s-25s.
• 34. Casanueva E, Pfeffer F, Fernandez-Gaxiola AC, Gutierrez-
Valenzuela V, Rothenberg SJ. Iron and folate status before
pregnancy and anemia during pregnancy. Ann Nutr Metab 2003;
47:60-3.
• 35. Ch’ng CL, Morgan M, Hainsworth I, Kingham JG. Prospective
study of liver dysfunction in Southwest Wales. Gut 2002;51: 876-80.
• 36. Rahman TM, Wendon J. Severe hepatic dysfunction in
pregnancy. QJM 2002;95:343-57.
• 37. Knox TA, Olans LB. Liver disease in pregnancy. N Engl J Med
1996;335:569-76.
• 38. Saftlas AF, Olson DR, Franks AL, Atrash H, Pokras R.
Epidemiology of preeclampsia and eclampsia in the United States,
1979e1986. Am J Obstet Gynecol 1990;163:460-5.
• 39. Walker JJ. Pre-eclampsia. Lancet 2000;356:1260-5.
• 40. Davidson JM. Renal disorders in pregnancy. Curr Opin Obstet Gynecol
2001;13:109-14.
• 41. Dafnis E, Sabatini S. The effect of pregnancy on renal function: physiology and
pathophysiology.AmJMedSci 1992;303:184-205.
• 42. Davison JM, Shiells EA, Philips PR, Lindheimer MD. Serial evaluation of
vasopressin release and thirst in human pregnancy. Role of human chorionic
gonadotrophin in the osmoregulatory changes of gestation. J Clin Invest
1988;81:798-806.
• 43. Glinoer D, de Nayer P, Bourdoux P, Lemone M, Robyn C, van Steirteghem A,
et al. Regulation of maternal thyroid during pregnancy. J Clin Endocrinol Metab
1990;71:276-87.
• 44. Wilson SG, Retallack RW, Kent JC, Worth GK, Gutteridge DH. Serum free
1,25-dihydroxyvitamin D and the free 1,25- dihydroxyvitamin D index during a
longitudinal study of human pregnancy and lactation. Clin Endocrinol 1990;32:613-
22.
• 45. Rasmussen N, Frolich A, Hornnes PJ, Hegedus L. Serum ionized calcium and
intact parathyroid hormone levels during pregnancy and postpartum. Br J Obstet
Gynaecol 1990;97:857-9.
• 46. Guyton AC. Textbook of medical physiology. 8th ed. Philadelphia: W B
Saunders; 1991. p. 915e28.
• 47. Trainer PJ. Corticosteroids and pregnancy. Semin Reprod Med 2002;20:375-
80.
• 48. Soory M. Hormonal factors in periodontal disease. Dent Update 2000;27:380-3.
• 49. Hugoson A. Gingivitis in pregnant women. A longitudinal clinical study.
Odontol Revy 1971;22:65-84.
• 50. Neville BW, Damm DD, Allen CM, Bouquot JE. Oral & Maxillofacial
Pathology. 3rd ed. Philadelphia: W B Saunders; 2002. p. 329-30, 447-9.
• 51. Tilakaratne A, Soory M, Ranasinghe AW, Corea SM, Ekanayake SL, de
Silva M. Periodontal disease status during pregnancy and 3 months post-
partum in rural population of Sri-Lankan women. J Clin Periodontol
2000;27:787-92.
• 52. Laine M, Tenovuo J, Lehtonen OP, Ojanatko-Harri A, Vilja P, Tuohimaa
P. Pregnancy e related changes in human whole saliva. Arch Oral Biol
1988;33:913-7.
• 53. Yuan K, Wing LY, Lin MT. Pathogenetic roles of angiogenic factors in
pyogenic granulomas in pregnancy are modulated by female sex hormones. J
Periodontol 2002;73:701-8.
• 54. Evans RD, Briggs PF. Tooth-surface loss related to pregnancyinduced
vomiting. Prim Dent Care 1994;1:24-6.
• 55. Salvolini E, Di Giorgio R, Curatola A, Mazzanti L, Fratto G. Biochemical
modifications of human whole saliva induced by pregnancy. Br J Obstet
Gynaec 1998;105:656-60.
• 56. Mauldin JG, Newman RB. Preterm birth risk assessment. Semin Perinatol
2001;25:215-22.
• 57. Heine RP, McGregor JA, Goodwin TM, Artal R, Hayashi RH, Robertson
PA, et al. Serial salivary estriol to detect an increased risk of preterm birth.
Obstet Gynecol 2000;96:490-7.
• 58. Kauh YC, Zachian TF. Melasma. Adv Exp Med Biol 1999;455: 491-
9.
• 59. Wong RC, Ellis CN. Physiologic skin changes in pregnancy. J Am
Acad Dermatol 1984;10:929-40.
• 60. Errickson CV, Matus NR. Skin disorders of pregnancy. Am Fam
Physician 1994;49:605-10.
• 61. Lopez NJ, Smith PC, Gutierrez J. Periodontal therapy may reduce
the risk of preterm low birth weight in women with periodontal disease:
a randomized controlled trial. J Periodontol 2002;73:911-24.
• 62. McGaw T. Periodontal disease and preterm delivery of lowbirth-
weight infants. J Can Dent Assoc 2002;68:165-9.
• 63. Richards AG. Dental x-ray protection. Dent Clin North Am
1968;631-41.
• 64. 1990 Recommendations of the International Commission on
Radiological Protection. Ann ICRP 1991;21:1-201.
• 65. Hall EJ. Radiation, the two-edged sword: cancer risks at high and
low doses. Cancer J 2000;6:343-50.
• 66. Diethelm L, Xu H. Diagnostic imaging of the lung during pregnancy.
Clin Obstet Gynecol 1996;39:36-55.
• 67. Brent RL. The effects of embryonic and fetal exposure to x-rays,
microwaves and ultrasound. ClinObstetGynecol 1983;26:484-510.
• 68. National Council on Radiation Protection. NCRP report no.128,
1998. Bethesda, Md: Author.
• 69. Wasylko L, Matsui D, Dykxhoorn SM, Reider MJ. Weinberg S. A
review of common dental treatments during pregnancy: implications for
patients and dental personnel. J Can Dent Assoc 1998;64:434-9.
• 70. Freeman JP, Brand JW. Radiation doses of commonly used dental
radiographic surveys. Oral Surg Oral Med Oral Pathol 1994;77:285-9.
• 71. Kircos LT,Angin LL, Lorton L.Order ofmagnitude dose reduction in
intraoral radiography. J Am Dent Assoc 1987;114:344-7.
• 72. Updegrave WJ. Simplified and standardized intraoral radiography
with reduced tissue irradiation. J Am Dent Assoc 1972;85:861-9.
• 73. Wood RE, Harris AM, van der Merwe EJ, Nortje CJ. The leaded
apron revisited: does it reduce gonadal radiation dose in dental
radiology? Oral Surg Oral Med Oral Pathol 1991;71:642-6.
• 74. An update on radiographic practices: information and
recommendations. ADA Council on Scientific Affairs. J Am Dent Assoc
2001;132:234-8.
• 75. Rayburn WF. Recommending medications during pregnancy: an evidence
based approach. Clin Obstet Gynecol 2002;45:1-5.
• 76. Rathmell JP, Viscomi C, Ashburn MA. Management of nonobstetric pain
during pregnancy and lactation. Anesth Analg 1997;85:1074-87.
• 77. Teratology society public affairs committee. FDA classification of drugs for
teratogenic risk. Teratology 1994;49:446-7.
• 78. Moore PA. Selecting drugs for the pregnant dental patient. J Am Dent Assoc
1998;129:1281-6.
• 79. Haas DA. An update on analgesics for the management of acute
postoperative dental pain. J Can Dent Assoc 2002;68:476-82.
• 80. Haas DA, Pynn BR, Sands TD. Drug use for the pregnant or lactating
patient. Gen Dent 2000;48:54-60.
• 81. Committee on Drugs, American Academy of Pediatrics. The transfer of
drugs and other chemicals into human milk. Pediatrics 1994;93:137-50.
• 82. Nielsen GL, Sorensen HT, Larsen H, Pedersen L. Risk of adverse birth
outcome and miscarriage in pregnant users of nonsteroidal anti-inflammatory
drugs: population based observational study and case-control study. BMJ
2001;322:266-70.
• 83. Janssen N, Genta M. The effects of immunosuppressive and anti-
inflammatory medications on fertility, pregnancy, and lactation. Arch Intern Med
2000;16:610-9.
• 84. Ostensen M. Nonsteroidal anti-inflammatory drugs during pregnancy. Scand J
Rheumatol Suppl 1998;107:128-32.
• 85. USPDI -Drug information for the health care professional. 22nd ed. Greenwood
Village, CO: Micromedex; 2002. p. 152-79.
• 86. Denson DD, Coyle DE, Thompson GA, Santos D, Turner PA, Myers JA, et al.
Bupivacaine protein binding in the term parturient: effects of lactic acidosis. Clin
Pharmacol Ther 1984;35:702-9.
• 87. Dillon DE, Wagner CL, Wiest D, Newman RB. Drug therapy in the nursing
mother. Obstet Gynecol Clin North Am 1997;24: 675-96.
• 88. Dashe JS, Gilstrap LC. Antibiotic use in pregnancy. Obstet Gynecol Clin North
Am 1997;24:617-29.
• 89. American College of Rheumatology. Ad hoc Committee on Clinical Guidelines.
Guidelines for monitoring drug therapy in rheumatoid arthritis. Arthritis Rheum
1996;39:723-31.
• 90. Ng PC. The fetal and neonatal hypothalamic-pituitary-adrenal axis. Arch Dis
Child Fetal Neonatal Ed 2000;82:F250-4.
• 91. Crowley P. Antenatal corticosteroids—current thinking. BJOG 2003;110(Suppl
20):77-8.
• 92. ACOG committee opinion: antenatal corticosteroid therapy for fetal maturation.
Obstet Gynecol 2002;99:871-3.
• 93. Ost L, Wettrell G, Bjorkhem I, Rane A. Prednisolone excretion in human milk. J
Pediatr 1985;106:1008-11.
• 94. Rowland AS, Baird DD, Shore DL,
Weinberg CR, Savitz DA, Wilcox AJ. Nitrous
oxide and spontaneous abortion in female
dental assistants. Am J Epidemiol
1995;141:531-8.
• 95. McGlothlin JD, Jensen PA, Fischbach TJ,
Hughes RT, Jones JH. Control of anesthetic
gases in dental operatories. Scand J Work
Environ Health 1992;18(Suppl 2):103-5.
• ORAL SURGERY ORAL MEDICINE ORAL
PATHOLOGY Volume 97, Number 6 Suresh
and Radfar 681
• 96. Rosen MA. Nitrous oxide for relief of labor pain: a
systematic review. Am J Obstet Gynecol 2002;186(Suppl
Nature):S110-6.
• 97. Sands TD, Pynn BR. Management considerations for the
pregnant or nursing emergency patient. Ont Dent 1998;75: 17-
9.
• 98. Daya S. Recurrent spontaneous early pregnancy loss and
low dose aspirin. Minerva Ginecol 2003;55:441-9.
• 99. Sinclair C. Handbook of obstetrical emergencies. 1st ed.
Philadelphia: WB Saunders; 1996. p. 29-39, 69.
• 100. Tarsitano BF, Rollings RE. The pregnant dental patient:
evaluation and management. Gen Dent 1993;41:226-34.
• 101. Livingston MH, Dlllinger TM, Holder R. Consideration in
the management of the pregnant patient. SCD SpecialCare in
Dentistry 1998;18:183-8.
Thank you