The Safety and Necessity of Dental Care During Pregnancy

KATIE THORNE, RDH, BS

As dental professionals, we play a unique and critical role in our pregnant patients’ team of healthcare providers. There is a consensus among medical professional groups that oral health contributes to a healthy pregnancy, delivery and infant.3 Despite this consensus, the majority of pregnant women in the US do not receive dental treatment.3 In order to rectify this situation, it is imperative we understand the causative factors. With data and knowledge about current guidelines, we can take concrete action to treat more pregnant women and positively impact pregnancy outcomes in our communities.

Research indicates the percentage of pregnant individuals receiving dental care is significantly lower than non-pregnant individuals.6 In fact, according to the American Public Health Association (APHA), just 46% of pregnant women in the US receive oral prophylaxis during their pregnancy.3 Furthermore, socioeconomically disadvantaged pregnant women and those without dental insurance are less likely to receive oral prophylaxis or other dental care.3

There appears to be several contributing factors leading to the low percentage of pregnant women receiving dental care.3 Low health literacy and cultural beliefs among pregnant patients and low cultural competency of dental providers are barriers to oral healthcare.3 Geographic location and lack of providers who accept Medicaid are additional barriers. Research indicates that a shocking 77% of OB/GYNs have patients who have been refused dental care by a dental professional due to their pregnancy status.3 According to the APHA, dental professionals may fear litigation or be unaware of or not understand the guidelines for caring for pregnant individuals.3 Furthermore, OB/GYNs often do not feel adequately trained to educate their patients on oral health and where to access dental care.3

Several of these barriers require large-scale industry changes, including better training in medical and dental schools and legislative changes at the state and federal levels.3 Fortunately, we can immediately ensure we are personally knowledgeable about the latest guidelines and recommendations regarding the treatment of pregnant individuals so we can confidently care for our pregnant patients. So, what are the current recommendations?

1. Oral prophylaxis: Routine oral prophylaxis is safe at any time during pregnancy.4 It is often most comfortable for the pregnant patient during the second trimester.4 There is a higher likelihood a pregnant patient will experience nausea during the first trimester making treatment difficult.8 During the third trimester, the patient may require a partially reclined position and turning slightly to their left side to avoid impingement of the vena cava by the uterus.8

2. Restorative, endodontic, and periodontal treatment and extractions: Treatment is considered safe at any time during pregnancy.5

3. Radiograph: Radiographs with abdominal and thyroid shields are safe at any time during pregnancy.5

4. Local anesthetic: The following local anesthetics with epinephrine may be used at any time during pregnancy: bupivacaine, lidocaine and mepivacaine.2

5. Nitrous oxide: As a category C drug, nitrous oxide is considered unsafe for use during pregnancy as there is a risk of fetal harm.2

In addition to reassuring our pregnant patients of the safety of dental care, we can provide education on how oral health contributes to their systemic health and the health of their child. Important topics to discuss with patients include:

1. Periodontal disease: Periodontal disease during pregnancy has been linked to an increased risk of preterm birth and low-birth weight.7 These conditions can lead to developmental dental defects such as hypoplastic enamel of the primary and permanent teeth in addition to the myriad of other health concerns associated with preterm birth and low-birth weight.7 The risk of preeclampsia and gestational diabetes mellitus also increases for pregnant women with periodontal disease.3

2. Caries: The vertical transmission of mutans streptococci can occur prior to the eruption of the child’s primary teeth.7 Fortunately, studies have demonstrated that pregnant individuals may reduce or even stave off the transfer of mutans streptococci to their infant by decreasing the level of the bacteria in their own oral microbiome.7 By treating decay prior to delivery, pregnant women can decrease their levels of cariogenic bacteria. Recommend pregnant patients use fluoride toothpaste and drink fluoridated water as well to reduce their caries risk.7 Pregnant women should also be counseled on the importance of an anti-cariogenic diet to reduce their caries risk.7

Before initiating care, motivational interviewing can be utilized to understand your patient’s priorities and goals.1 This allows our recommendations to be tailored to them.1 For instance, the patient may be especially concerned about pre-term birth because their last pregnancy did not reach full term. This information provides a segue to discuss the importance of oral health and positively reinforces the initiative they are taking to receive dental care during this pregnancy.

As a member of a pregnant person’s healthcare team, we must collaborate with the other members of the team. By establishing productive, working relationships with the OB/GYNs and midwives of our existing pregnant patients, we can provide safe, comprehensive oral healthcare and patient education consistent with the rest of the healthcare team. Consider reaching out to doctors and midwives in your area to establish a referral program early in a person’s pregnancy.1 A referral form indicating the safety of radiographs with proper shielding, appropriate local anesthesia and pain control, prophylaxis, and necessary dental treatment, patients can feel more at ease knowing their doctor or midwife approves and advocates for dental treatment. This also provides an opportunity for us to remind the medical team of the most recent recommendations and the importance of their patients’ dental care. Upon seeing the patient, positively reinforce their choice to seek dental care and reiterate why oral health is important for their health and the health of their unborn child.

In addition to in-office patient care, outreach to community organizations or programs such as WIC offices is another avenue to educate pregnant mothers on the importance of oral healthcare during pregnancy. As dental professionals, we also have a unique opportunity to advocate for pregnant mothers and their children in government. We know that uninsured pregnant women are less likely to receive preventive dental care than their insured counterparts.3 Meeting with and informing our elected representatives of the importance of oral health and dental insurance can lead to state and federal legislation that can drastically improve the health of our community.

The data shows there is a lot of work to be done to provide equitable care for pregnant individuals. This is an opportunity for the dental community to effect positive change, including financial, both in our own practices and at the societal level. Armed with the latest guidelines and education, we can confidently treat our pregnant patients and form working relationships with OB/GYN teams to increase access and contribute to improved pregnancy outcomes for our patients and community.

About The Author

Katie Thorne, RDH, BS practiced as a dental hygienist since 2011 in both private and public health settings. She is now a 3rd year DDS candidate at CU School of Dental Medicine.

She is the Advocacy Chair of the AAPHD CU Student Chapter and dedicates herself to increasing the number of first generation college graduates in dentistry. Outside of dentistry, Katie enjoys volunteering with animal welfare organizations.

References

1. American Academy of Pediatric Dentistry. Perinatal and infant oral health care. The Reference Manual of Pediatric Dentistry. Chicago, Ill.: American Academy of Pediatric Dentistry; 2016:216-20.

2. American Dental Association. Pregnancy. Available at https://www.ada.org/resources/research/science-andresearch-institute/oral-health-topics/pregnancy. Accessed February 2, 2023.

3. American Public Health Association. Improving Access to Dental Care for Pregnant Women through Education, Integration of Health Services, Insurance Coverage, an Appropriate Dental Workforce, and Research. Available at https://www.apha.org/policies-and-advocacy/public-health-policy-statements/policy-database/2021/01/12/ improving-access-todentalcareforpregnantwomen?tag=makemoney082120#:~:text=Improving%20Access%20 to%20Dental%20Care%20for%20Pregnant%20Women,Research%20Date%3A%20Oct%2024%202020%20 Policy%20Number%3A%2020203. Accessed February 2, 2023.

4. Anita M. Mark, Pregnancy and oral health, The Journal of the American Dental Association, Volume 152, Issue 3, 2021, Page 252, ISSN 0002-8177, https://doi.org/10.1016/j.adaj.2020.12.009. (https://www.sciencedirect.com/ science/article/pii/S0002817721000179)

5. Committee Opinion No. 569: oral health care during pregnancy and through the lifespan. Obstet Gynecol. 2013;122(2 Pt 1):417-422. doi:10.1097/01.AOG.0000433007.16843.10

6. Muralidharan, C., Merrill, R.M. Dental care during pregnancy based on the pregnancy risk assessment monitoring system in Utah. BMC Oral Health 19, 237 (2019). https://doi.org/10.1186/s12903-019-0921-3

7. Ramos-Gomez FJ. Clinical considerations for an infant oral health care program. Compend Contin Educ Dent. 2005 May;26(5 Suppl 1):17-23. PMID: 17036540.

8. Scherer, S. (2022, October 27) Safely caring for pregnant dental patients. RDH Magazine. https://www.rdhmag. com/patient-care/article/14279348/safely-caring-for-pregnant-dental-patients