Tooth extraction is a common and largely safe dental procedure. However, the popular opinion in society suggests that any dental work for expectant mothers should be solely directed at prevention and essential restorations, while surgical procedures, including tooth removal, should ideally be delayed until delivery.
During pregnancy, women experience various changes in their bodies, including hormonal changes that may affect their dental health. For instance, increased sensitivity of gums to irritation may lead to advanced gum disease and severe tooth cavities that necessitate tooth extraction.
Under normal circumstances, tooth extraction is a simple surgical procedure that doesn’t cause much concern. After all, everyone goes through the process of losing 20 primary teeth in the early years. But removing a permanent tooth is a different story, especially for pregnant women, due to the potential risks on the developing baby brought about by dental X-rays and the use of medication.
Considerations for oral surgery during pregnancy
For any dental professional, it would be difficult to perform an oral surgical procedure successfully without using X-rays or administering medication and anesthesia. So, they prefer to defer any elective oral surgeries until after delivery to prevent fetal risks.
But in the event that surgery cannot be postponed until after delivery, dental professionals will strive to reduce fetal exposure to teratogenic factors.
Risks during the first trimester
During the first eight weeks of pregnancy, the baby’s organs are rapidly forming (organogenesis), which makes this time the most critical time.
Exposure to harmful substances or stress during this period can increase the risk of miscarriage or cause severe birth defects. In fact, about 50 to 75% of all miscarriages happen during this time.
Taking certain medications or getting an infection during the first trimester can interfere with the baby’s development and cause serious birth defects.
If a pregnant woman needs to have oral surgery during the first trimester, the safest choice would be to use a local anesthetic if possible.
Risks during the second trimester
At this point, the process of organogenesis is complete, and the risk of harm to the fetus is much lower. This means that it is generally safe to provide dental care during the second and third trimesters of pregnancy. In fact, the second trimester is the safest period for providing dental care during pregnancy.
Local anesthesia can also be safely used during this period to manage any pain or discomfort that may occur during dental procedures.
Risks during the third trimester
From about the thirtieth week, the blood volume of a pregnant woman is at its highest, and it remains elevated until delivery. And although there is usually no risk to the developing baby during this period, it can be quite uncomfortable for the expectant mother.
When a pregnant woman lies on her back, the weight of the uterus can put pressure on major blood vessels, which may reduce blood flow to the brain and result in a drop in blood pressure (a condition known as supine hypotension).
Therefore, dental appointments during this time should be kept short, and the mother positioned appropriately in the dental chair to avoid this condition.
Routine dental treatments can be performed safely in the early part of the third trimester, but should be avoided in the middle of the third trimester.
Safety of dental x-rays during pregnancy
Dental X-rays for pregnant women can be a controversial issue. The main concern is that radiation exposure may harm the developing fetus, especially during the first trimester when the fetus is most susceptible to radiation damage.
However, sometimes X-rays are necessary to accurately diagnose and treat dental problems during pregnancy. In such cases, the dentist should follow certain safety measures to reduce the amount of radiation exposure.
These may include:
- Fast Exposure Techniques: Involves the use of high-speed film or digital imaging systems that allow for shorter exposure times, reducing the amount of radiation exposure to the patient.
- Filtration: Involves the use of filters in the X-ray machine to remove low-energy X-rays that are not useful for imaging but can contribute to radiation exposure.
- Collimation: This refers to the use of a collimator, a device that limits the size and shape of the X-ray beam to only the area of interest, further reducing unnecessary radiation exposure.
- Protective Lead: This refers to the use of a lead apron or thyroid collar to shield sensitive areas of the body, such as the abdomen and thyroid gland, from unnecessary radiation exposure during dental radiography.
The National Commission for Radiation Protection recommends that the cumulative fetal dose should not exceed 0.005 Gy, and exposure to more than 0.20 Gy can cause microcephaly and mental retardation.
Dental X-rays, such as the panoramic and full mouth intraoral series, are generally safe during pregnancy.
Nonetheless, dentists should use X-rays selectively and only when necessary and appropriate to aid in diagnosis and treatment, both during pregnancy and at other times.
Risks associated with drugs used for oral surgery during pregnancy
The use of drugs in dentistry during pregnancy is a concern because some drugs administered during pregnancy may cross the placenta and harm the fetus. Additionally, drugs that are respiratory depressants can cause maternal hypoxia, resulting in fetal hypoxia, injury, or death.
Ideally, no drugs should be administered during pregnancy, especially in the first trimester. However, adhering to this rule may sometimes be impossible
The FDA has categorized drugs based on their potential to cause birth defects, and some drugs are considered safe during pregnancy. That said, drugs should be used selectively and only when necessary and appropriate to aid in diagnosis and treatment, and the risks and benefits of drug use during pregnancy should be carefully considered.
Studies suggest that local anesthetics pass the placental barrier by passive diffusion. Fortunately, most of them are generally considered safe and non-teratogenic, but it’s best to avoid those with vasoconstrictors if possible. Epinephrine, a hormone commonly used in dental local anesthesia, is considered safe during pregnancy, but caution should be taken to avoid accidental intravenous administration.
Antibiotics with systemic effects cross the placenta and reach the fetus, so selection of an antibiotic for pregnant or nursing women must be made with equal consideration of the safety of both the mother and the baby. Also, changes that happen during pregnancy can affect how much of the antibiotic is in the mother’s blood (blood plasma increases by about 50% during pregnancy). To make sure the mother gets enough of the antibiotic, doctors may recommend a higher dose than usual.
Analgesics or painkillers
For pain relief, analgesics like acetaminophen are considered safe and useful for pain management during pregnancy and nursing, but caution should be taken when used in high doses, as they can cause problems for both the mother and the baby, such as anemia or damage to the baby’s kidneys.
Sedatives and hypnosis
The use of sedatives and hypnotics like nitrous oxide (laughing gas) during pregnancy is controversial because there is not enough evidence on how it might affect the mother and the baby. It can cause the blood vessels in the uterus to become narrower, which may reduce blood supply to the baby.
However, a single episode of exposure to nitrous oxide gas, for less than 35 minutes, is generally considered safe, but long-term exposure, for more than 3 hours, may cause decreased fertility and miscarriages.
Positioning pregnant patients for dental work to avoid hypotension
Hypotension (low blood pressure) must be avoided during pregnancy, as it can cause harm to both the mother and the baby. This can be achieved by placing pregnant dental patients in a semi-reclined or upright position for dental treatment.
Although the supine (lying flat on the back) position may be ideal for many dental procedures, it should be avoided during pregnancy, especially in the third trimester. This is because it can cause hypoxia (oxygen deprivation) and hypotension due to the weight of the uterus pressing against the spinal column and diaphragm, reducing blood flow. This could lead to hypotension and fainting, and cause fetal hypoxia (oxygen deprivation) and injury.
If a patient experiences hypotension or fainting during dental treatment in the third trimester, she should be placed with her head at or below the level of the heart and abdomen rolled to the left. This is best done in the dental chair with the patient’s right knee drawn up as the patient rolls to the left.
Supplemental oxygen is also recommended during such episodes to increase oxygen levels.
If hypotension is associated with sustained bradycardia (slow heart rate), administration of atropine (a medication that increases heart rate) may be necessary.
To avoid pulmonary response
- In the third trimester, the diaphragm elevates, leading to tachypnea (fast breathing) especially when lying down.
- Patients may prefer to sit up with hands on knees, leaning forward with legs parted, but this is not a good position for dental treatment.
- Sitting upright in the dental chair with legs hanging over either side in the third trimester offers the best position for ventilation.
To avoid hematologic response:
- Pregnancy causes a hypercoagulable state due to inhibited fibrinolysis. There is an increased risk of deep vein thrombosis and pulmonary embolism from the first trimester.
- Avoid compression of the inferior vena cava in the supine position, continuous flexing of the knees or pressure to the back of the calves in the dental chair.
- These can produce venous stasis which, when combined with the hypercoagulability state, can result in deep vein thrombosis.
In conclusion, dentists must be knowledgeable about the conditions that can occur during pregnancy, as well as the considerations that need to be made while performing tooth extraction and other dental work for pregnant patients.
The first trimester is the most delicate, as the fetus is more sensitive to stress and teratogenic agents. Antibiotics administered during this period can lead to congenital anomalies.
The second trimester is the safest period for dental care, while the third trimester requires careful attention due to the increased blood volume and physiological changes such as pre-eclampsia, hypotension, pulmonary reaction, and hematologic reactions.
Overall, dentists must consider the mother and child’s health equally while providing dental care to pregnant patients.