Pregnancy

Oral health care, including having dental radiographs taken and being given local anesthesia, is safe at any point during pregnancy.^{1, 2} Further, the American Dental Association and the American College of Obstetricians and Gynecologists (ACOG) agree that emergency treatments, such as extractions, root canals or restorations can be safely performed during pregnancy and that delaying treatment may result in more complex problems.^{1, 2} Although ACOG has a statement regarding postponing elective nonobstetric general surgery and some invasive procedures (e.g., cardiac catheterization or colonoscopy) until after delivery,³ their statement on oral care during pregnancy and through the lifespan¹ states that oral conditions requiring immediate treatment, such as periodontal or endodontic treatment, extractions, or restoration of untreated caries can be managed at any time during pregnancy.

When treating pregnant patients, it might be helpful to reach out to the obstetrician to develop a working relationship should consultation be needed later. Questions to ask might include:⁴

• When is the expected delivery date?
• Is this a high-risk pregnancy? If so, are there any special concerns or contraindications?
• Is there a recommended medication for pain control?

During pregnancy, several oral health conditions are more common:

• Gingivitis may result from hormonal changes that exaggerate the response to bacteria in the gum tissue⁴
• Dental caries may occur due to changes in diet such as increased snacking due to cravings, increased acidity in the mouth due to vomiting, dry mouth or poor oral hygiene stemming from nausea and vomiting.^{1, 4}
• Pyogenic granuloma (also known as granuloma gravidarum) is a round growth, usually connected to the gingivae by a thin cord of tissue, that may develop due to hormonal changes.^5,6
• Erosion stemming from vomiting as a result of morning sickness may be detected.⁵ Patients should be encouraged to avoid toothbrushing immediately after vomiting, which exposes the teeth to stomach acids. Instead, they should opt for rinsing with a diluted solution of 1 cup water and 1 teaspoon of baking soda to neutralize the acid.⁵
  
  

Due to the increased risk of gingivitis and caries, the importance of good daily oral hygiene should be emphasized to these patients. Brushing twice a day with a soft-bristled brush for two minutes, using a fluoride-containing toothpaste, and cleaning between the teeth once a day should be encouraged. If it is determined that a topical fluoride treatment is needed to minimize the effects of erosion, fluoride varnish may be preferred over gel treatments due to nausea.⁷

Periodontitis and Adverse Pregnancy Outcomes

Much has been written in recent years about the relationship between maternal periodontitis and pregnancy outcomes. While findings of individual studies have been mixed, an overview of 23 systematic reviews conducted through 2016 concluded that associations exist between periodontitis and pre-term birth, low birthweight babies, low birthweight babies born prematurely and the development of pre-eclampsia. ⁸

More research is needed to determine the relationship between periodontitis and pregnancy outcomes, however, should periodontitis develop during pregnancy, scaling and root planing is recognized as safe to perform.^{1, 4} The ACOG statement on oral care during pregnancy and through the lifespan1 states that “despite the lack of evidence for a causal relationship between periodontal disease and adverse pregnancy outcomes, the treatment of maternal periodontal disease during pregnancy is not associated with any adverse maternal or birth outcomes,” and “prenatal periodontal therapy is associated with the improvement of maternal oral health.”

Medication Safety Labeling

Historically, manufacturers have relied on an alphabetical system to communicate the safety of medications for use with pregnant patients. In 2015, the U.S. Food & Drug Administration began phasing out that system for prescription drugs, replacing it with a narrative section in the package insert that discusses the benefits and risks of using a particular medication with this population.^{9, 10} The new system will be phased-in, with a full compliance date of 2020.

The alphabetical system (Table) will continue to be used for over-the-counter (OTC) medications.¹¹

Table. Pregnancy Risk Categories¹² for OTC Medications

Medication Selection

Questions about use of local anesthetics or antibiotics in pregnant individuals are common. Options considered safe for use in these situations include:

• Local anesthesia (with or without epinephrine)^{1, 13, 14}
• Antibiotics^13-15
  
  • Penicillin
  • Amoxicillin
  • Cephalosporins
  • Clindamycin
  • Metronidazole

Use of other medications calls for consultation with the patient’s obstetrician to weigh risks and benefits. An example of a situation that may benefit from consultation is pain relief. Several analgesics have been placed in pregnancy Category B, which indicates that they are typically safe to use; however, in 2015, the U.S. Food & Drug Administration backed off that classification, stating that the published research is “too limited to make any recommendations” on pain reliever use in this population.¹⁶ This suggests that decisions made about medications for pain relief should be arrived at after consultation with the obstetrician. That said, emergencies call for immediate implementation of standard emergency protocols.

Lactation

Questions often arise about medication use by patients who are lactating. Most medication product inserts have information related to use during lactation. The National Library of Medicine also provides a searchable database (LactMed) on this topic.

Nitrous Oxide

Nitrous oxide is classified as a pregnancy risk group Category C medication, meaning that there is a risk of fetal harm if administered during pregnancy. It is recommended that pregnant individuals, both patients and staff, avoid exposure to nitrous oxide.¹⁷ The National Institute of Occupational Safety and Health (NIOSH), a federal agency affiliated with the Centers for Disease Control and Prevention, recommends use of a scavenging system and exposure limits of N₂O concentrations in dental operations to approximately 25 ppm during analgesia administration.¹⁸

Dental offices that use nitrous oxide-oxygen can review best management practices on the Nitrous Oxide Oral Health Topic page.

Radiographs are considered safe for the pregnant patient, at any stage during pregnancy, when abdominal and thyroid shielding is used.¹

Dental professionals who take radiographs should inform their employer in writing that they are pregnant as soon as they are aware of the pregnancy. The employee should be provided with a personal dosimetry badge and the manufacturer’s instructions should be followed to ensure that the occupational radiation exposure does not exceed 0.5 millisieverts (mSv) per month.¹⁹ Provision of dosimetry badges and limiting exposure to 0.5 mSv/month are recommendations for good practice; to determine whether there are related regulations in your state, contact your radiation protection program.

During pregnancy, individuals may be at increased risk for oral conditions such as gingivitis and dental caries, and should be counseled by both their obstetrician and dentist on the importance of good oral hygiene throughout the pregnancy. Regular and emergency dental care, including the use of local anesthetics and radiographs, is safe at any stage during pregnancy.

Statement on Alcohol and Other Substance Use by Pregnant and Postpartum Patients
(Trans.2005:330)

Resolved, that the following ADA Statement on Alcohol and Other Substance Use by Pregnant and Postpartum Patients be adopted.

Statement on Alcohol and Other Substance Use by Pregnant and Postpartum Patients

1. Dentists are encouraged to inquire about pregnant or postpartum patients’ history of alcohol and other drug use, including nicotine.

2. As healthcare professionals, dentists are encouraged to advise these patients to avoid the use of these substances and to urge them to disclose any such use to their primary care providers.

3. Dentists who become aware of postpartum patients’ resumption of tobacco or illegal drug use, or excessive alcohol intake, are encouraged to recommend that the patient stop these behaviors. The dentist is encouraged to be prepared to inform the woman of treatment resources, if indicated.

American Dental Association
Adopted 2005; Reviewed 2017

Dental Examinations for Pregnant Women and Women of Child-Bearing Age
(Trans.2014:508)

Resolved, that the ADA urge all pregnant women and women of child-bearing age to have a regular dental examination.

American Dental Association
Adopted 2014

Dental Treatment During Pregnancy
(Trans.2014:508)

Resolved, that the ADA acknowledges that preventive, diagnostic and restorative dental treatment to promote health and eliminate disease is safe throughout pregnancy and is effective in improving and maintaining the oral health of the mother and her child.

American Dental Association
Adopted 2014

1. American College of Obstetricians and Gynecologists Committee on Health Care for Underserved Women. Oral Health Care During Pregnancy and Through the Lifespan (Number 569).  2013; Reaffirmed 2017. https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2013/08/oral-health-care-during-pregnancy-and-through-the-lifespan. Accessed May 4, 2021.
2. American Dental Association. ADA Current Policies, 1954-2020.  2021. https://www.ada.org/~/media/ADA/Member%20Center/Members/current_policies.pdf. Accessed May 4, 2021.
3. American College of Obstetricians and Gynecologists Committee on Obstetric Practice and the American Society of Anesthesiologists. Nonobstetric Surgery During Pregnancy (Number 775).  2017; Reaffirmed 2021. https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2019/04/nonobstetric-surgery-during-pregnancy.
4. Niessen LC. Women's Health. In: Patton LL, Glick M, editors. The ADA Practical Guide to Patients with Medical Conditions. Second ed. Hoboken NJ: John Wiley & Sons; 2016. p. 423-34.
5. Steinberg BJ, Hilton IV, Iida H, Samelson R. Oral health and dental care during pregnancy. Dent Clin North Am 2013;57(2):195-210.
6. Silva de Araujo Figueiredo C, Goncalves Carvalho Rosalem C, Costa Cantanhede AL, Abreu Fonseca Thomaz EB, Fontoura Nogueira da Cruz MC. Systemic alterations and their oral manifestations in pregnant women. J Obstet Gynaecol Res 2017;43(1):16-22.
7. Giglio JA, Lanni SM, Laskin DM, Giglio NW. Oral health care for the pregnant patient. J Can Dent Assoc 2009;75(1):43-8.
8. Daalderop LA, Wieland BV, Tomsin K, et al. Periodontal Disease and Pregnancy Outcomes: Overview of Systematic Reviews. JDR Clin Trans Res 2018;3(1):10-27.
9. U.S. Food and Drug Administration. Pregnancy & Lactation: Improved Benefit-Risk Information.  2015. https://www.fda.gov/downloads/Drugs/DevelopmentApprovalProcess/SmallBusinessAssistance/UCM431132.pdf. Accessed May 4, 2021.
10. U.S. Food and Drug Administration. Pregnancy and Lactation Labeling (Drugs) Final Rule. https://www.fda.gov/drugs/labeling-information-drug-products/pregnancy-and-lactation-labeling-drugs-final-rule. Accessed May 3, 2021.
11. U.S. Food and Drug Administration. Questions and Answers on the Pregnancy and Lactation Labeling Rule. https://www.fda.gov/Drugs/DevelopmentApprovalProcess/DevelopmentResources/Labeling/ucm093311.htm. Accessed May 4, 2021.
12. Mendia J, Cuddy MA, Moore PA. Drug therapy for the pregnant dental patient. Compend Contin Educ Dent 2012;33(8):568-70, 72, 74-6 passim; quiz 79, 96.
13. Oral Healthcare During Pregnancy Expert Workgroup. Oral Health Care During Pregnancy: A National Consensus Statement. Washington, DC: National Maternal and Child Oral Health Resource Center; 2012.
14. Bassiur JP, Boyd BC, Burrell KH, et al. ADA/PDR Guide to Dental Therapeutics. Fifth ed. Montvale NJ: Physicians' Desk Reference, Inc.; 2009.
15. California Dental Association Foundation; American College of Obstetricians and Gynecologists, District IX.
16. U.S. Food & Drug Administration. FDA Drug Safety Communication: FDA has Reviewed Possible Risks of Pain Medicine During Pregnancy.  2015. https://www.fda.gov/Drugs/DrugSafety/ucm429117.htm. Accessed May 4, 2021.
17. National Institute for Occupational Safety and Health. International Chemical Safety Cards: Nitrous Oxide. https://www.cdc.gov/niosh/docs/hazardcontrol/hc3.html. Accessed May 4, 2021.
18. The National Institute for Occupational Safety and Health (NIOSH). Control of Nitrous Oxide in Dental Operatories (DHHS/NIOSH Publication No. 96-107). U.S. Department of Health & Human Services. https://www.cdc.gov/niosh/docs/hazardcontrol/hc3.html. Accessed May 4, 2021.
19. National Council for Radiation Protection & Measurements. NCRP Report No. 145 - Radiation Protection in Dentistry. Bethesda: National Council on Radiation Protection and Measurement; 2003.

Professional Resources

• X-rays: Dental Radiography and Pregnancy
• Nitrous Oxide

Patient Resources

JADA “For the Patient” page:

• Pregnancy and oral health (March 2021)

ADA MouthHealthy:

• X-rays
• Pregnancy

• U.S. Centers for Disease Control and Prevention: Radiation and Pregnancy: A Fact Sheet for the Public
• Oral Healthcare During Pregnancy: A National Consensus Statement
• Recommendations on Oral Health Care for the Pregnant Adolescent
  
• Guideline on Oral Health Care for the Pregnant Adolescent
• LactMed (U.S. National Library of Medicine Toxicology Data Network drugs and lactation database)
• American Academy of Pediatrics: Oral Health Toolkit for Providers