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Doctor, I'm pregnant

I'm guessing the title caught your eye and, before you consider all possible scenarios, let me provide some background. I have received several requests from members asking for editorials about clinically relevant topics—such as how to manage dental care during pregnancy. While the WSDA News (the journal of the Washington State Dental Association) has never been a clinical journal, dental care during pregnancy is a common concern for patients and dentists. Using this topic as an example, I will demonstrate how to determine the best approach to care.

So, back to the title: "Doctor, I'm pregnant." The reference is to a female patient informing you, her dentist, that she is pregnant. She has concerns about risk to the fetus and how her pregnancy will affect her dental treatment. How should you respond?

First, accept that there is no simple answer that meets the needs and situation for every patient; that's why they call you "doctor." Otherwise, any staff member could provide an answer and, given the chance, many likely will. Second, many myths about the safety of dental care during pregnancy, including the belief that treatment may harm the fetus or poor oral health is normal during pregnancy, cloud the science and impede acceptance of necessary care. Regardless, it is your responsibility, as the dentist, to educate and advise the patient using an evidence-based approach to care.

The ADA defines evidence-based dentistry as: "An approach to oral health care that requires the judicious integration of systematic assessments of clinically relevant scientific evidence, relating to the patient's oral and medical condition and history, with the dentist's clinical expertise and the patient's treatment needs and preferences." In other words, using the best available science and clinical judgment to determine the most appropriate treatment for each individual patient.

Before you respond, you likely will need more information from the patient: "Have you seen a physician? How far along are you? Are you aware of any potential complications?" Then, reflecting on the patient's medical and dental history, you can resource the evidence to provide your answer. But what's the evidence and how can it be quickly and easily accessed?

The most efficient and effective method I have found for researching the evidence is to conduct an online PubMed search. In this case, using the keywords "dental treatment and pregnancy outcomes," I encountered 106 citations—a rather large field to review. However, adding the keywords "clinical trials" yielded 21 citations, thereby narrowing the field and focusing on the more substantive evidence of clinical studies versus anecdotal reports. By conducting a similar search at ADA.org and comparing these to the focused PubMed search, the following evidence-based recommendations can be made:

  • Most pregnant patients can be treated in a similar manner as other patients.
  • Periodontal treatment and essential dental care, including amalgams, multiple restorations, extractions, and the use of topical and local anesthetics during the second trimester of pregnancy appear to be safe.
  • Avoid local delivery agents to treat periodontal disease as most contain tetracycline.
  • Prescriptions, if necessary, should be limited to drugs with a track record of safety, especially during the first trimester. A consultation with the patient's physician and/or pharmacist is advised.
  • Intra-oral radiographs, if necessary to assist diagnosis and treatment, should be taken using both abdominal aprons and thyroid collars, whenever practical, to minimize radiation exposure.
  • Untreated periodontal disease is associated with premature birth and low birthweight and periodontal treatment appears to reduce these adverse outcomes.
  • A high level of cariogenic bacteria in mothers is associated with increased infant decay.
  • This is an excellent opportunity to inform and educate the expectant mother that maintaining good oral health during pregnancy can be critical to the overall health of both herself and her baby.

In summary, women should be encouraged to visit their dentist during pregnancy, because the benefits of achieving and maintaining oral health during pregnancy far outweigh any risk. Acute dental problems should be treated promptly—regardless of the stage of pregnancy—and elective care should be scheduled during the second trimester.

It is estimated that less than half of women receive dental care during pregnancy. Although some women have limitations of access to care, many pregnant women choose to avoid dental care due to fear of harm to the fetus. However, by conducting a quick and simple Internet search, evidence-based recommendations can be made. Using a similar approach to research other topics will yield similar, evidence-based results.

Dr. Phipps is the editor of the WSDA News, the journal of the Washington State Dental Association. His comments, reprinted here with permission, originally appeared in the December 2008 issue of that publication.