Dental Care Throughout Pregnancy:

Dos and Donts

Alexandre Khairallah - BDS, PGD, DESS, FEADMFR, MBAIRD
Oral Biologist, Oral Radiologist, Oral Surgeon | Fellow of the European Academy of Oral And Maxillo-Facial Radiologist |
Head Of Service of Oral & Maxillo-Facial Imaging Dpt, Lebanese University | Founder & Manager Of CLIR center | Beirut, Lebanon
[email protected]

ABSTRACT
Pregnancy is a special period in a womans lifetime. Good oral health during pregnancy is important to the overall
health of both the expectant mother and her baby. Oral health assessment should be part of comprehensive prenatal
care for all women and obstetrician should consider referral of a newly pregnant woman to a dentist as routine.
Unfortunately, in most of the times pregnant women, obstetricians and dentists are skeptical of dental care during
pregnancy owing to prejudices about the safety of dental treatment, resulting in delay of the dental treatment.
The aim of this paper is to review the literature for evidence-based answers with regard to the frequent dilemmas of
dentists concerning dental treatment of pregnant women. From this review it can be concluded that most dental work
is safe during pregnancy. Dentists and health agencies should provide and distribute information to women about the
importance of maintaining oral health during pregnancy.
KEYWORDS
Pregnancy, Dental treatment, Precautions.

INTRODUCTION
Dentists have to face a pregnant womans anxiety along with her familys anxiety1 due to a series of wrong
assumptions that have been made and perpetuated
by the lack of proper information, as well as by some
dental professionals who consider dental treatment to
be possibly dangerous for the fetus.2,3 However, it is
beyond doubt that dental treatment during pregnancy
is not only safe, but also necessary. Ideally, during
prenatal testing, the pregnant woman should be referred
to a dentist. Unfortunately, up to now, there have been
no such official guidelines in any country. Maintaining
the expectant mothers oral health is important both
for her own health and for that of the fetus. A typical
example, which has been the subject of much research,
is the relationship between periodontal disease and the
increased risk of pre-term birth and low birth weight.4-8
The relationship between Early Childhood Caries (ECC)
and the transmission of bacteria from the maternal oral
flora to the baby has increased efforts to promote oral
health during pregnancy and the perinatal period.9
Although there has been improvement in the dental
care of pregnant women during the past decades,
inequalities and erroneous perceptions concerning the
importance of dental care during pregnancy still exist,
affecting mainly the socio-economically deprived part
of the population.10,11 Many organizations, including
the American Dental Association (ADA), the American
Academy of Pediatrics (AAP), and the American Academy
of Pediatric Dentistry (AAPD), have developed protocols

| 16 | Smile Dental Journal | Volume 10, Issue 1 - 2015

and norms in order to improve the oral health of

pregnant women and babies. They stress that pregnancy
is not a disease, thus pregnant women should not be
treated differently than the general population. Health
care professionals (physicians and dentists) should
collaborate to develop comprehensive prenatal testing
protocols, including complete treatment plans, which
aim to prevent any problems and restore the pregnant
womans oral health. These protocols should also aim to
inform the pregnant woman appropriately so that she will
be able to look after the newborn babys oral health.12
PURPOSE AND METHODOLOGY
In order to help the dentist make the right decisions, a
search for documented answers on issues he often has
to face regarding the treatment of pregnant women was
done. The sources included PubMed, from which we
collected the relevant bibliography using the following
search criteria: dental, treatment, therapy, pregnancy
(MeSH terms). We also used PubMed to search for
reviews, clinical and experimental studies reported within
the last five years, as well as the most important older
publications that were highly cited. Additionally, we
searched for guidelines from major accredited agencies,
such as the ADA, the World Health Organization
(WHO), the Food and Drug Administration (FDA), and
international dental associations. Our search focused
on the dental treatment of healthy pregnant women. But
what are the difficulties a dentist may face when treating
a pregnant woman?

DENTAL RADIOGRAPHY
Dental radiography is a controversial area in the
management of the pregnant patient. In pamphlets widely
supported by most dental professional organizations, no
alteration of recommendation was given for prescribing
radiographs to a pregnant patient, as the amount of
radiation given during standard dental radiographic
examination is so trivial that it could not cause gross
anatomic malformations in the developing fetus.
The American Dental Association (ADA) recommends
every precaution should be taken to minimize radiation
exposure to the pregnant patient. The National
Commission of Radiation Protection (NCRP) reports that
production of congenital defects is negligible from fetal
exposures of 50 mSv.13 Yet, in a questionnaire study of
552 dentists, almost all saw pregnancy as contradictory
for bitewing radiographs, thus showing the need for
clinician education using evidence-based dentistry.
The estimated fetal doses from typical radiographic
examinations lend support to the conclusion that fetal
risks are minimal and, therefore, radiologic examinations
that may provide significant diagnostic information
should not be withheld from pregnant women. This is the
position advocated by the International Commission on
Radiation protection, American College of Radiology,12
and American College of Obstetrics and Gynecology.
Needless to say, any potentially harmful factors that may
affect the unborn child should be avoided, especially
during the first trimester, and the As Low As Reasonably
Achievable (ALARA) concept should be used as with all
other patients.9,14

Category C: includes the majority of drugs, such

as aspirin, which should be used with caution and
certainly according to the treating doctors orders.
Category D: includes drugs such as tetracycline,
which should be avoided during pregnancy16 (Tables 1
and 2). As far as antibiotics are concerned, amoxicillin
and penicillin V are the safest and the most common
ones to prescribe.18,19 Tetracyclines are contra-indicated
during pregnancy because they accumulate in fetal
dental tissue during the calcification stage, causing
discoloration of the teeth.19 The safest choice among
painkillers is paracetamol, as it is not teratogenic. The
absorption of the usual recommended dose in the
body does not seem to change during pregnancy.18,19
(Table 1) Drugs used in dentistry (with FDA pregnancy risk
category2)
Drug

The FDA has classified drugs into four categories, according

to how dangerous they are for the mother and the fetus
when prescribed during pregnancy.16 This classification
provides a useful guide with regard to what drugs should or
should not be prescribed for a pregnant woman.
Category A: includes drugs that have been tested in
humans and there is evidence to support that they are
100% safe to use (e.g., folic acid).
Category B: includes drugs that are relatively safe to
use. Generally these drugs are considered safe to use
during pregnancy (e.g., paracetamol and amoxicillin).17

Considerations for use

Use with no risk

Amoxicillin

Use with no risk

Clindamycin

Use with no risk

Metronidazole

Use with no risk (After 1st

trimester for 24 to 72hrs
only)

Chlorhexidine rinse

Use with no risk

Non-steroidal
(NSAIDs)

C (most of them)

Consult with the antiinflammatory patients

obstetrician drugs

(Table 2) Class definition according to the FDA classifications

for drugs in terms of their safety during pregnancy2
A

Adequate, well-controlled studies in pregnant women failed to

demonstrate risk to fetus

No evidence of risk in humans; animal studies show risk but

human findings do not; or animal findings are negative and
no adequate human studies have been performed

Human studies are lacking and animal studies are either lacking or test positive for fetal risk; however, potential benefits
may justify the risk

Positive evidence of risk; investigational or post-marketing

data show risk to foetus; however, potential benefits may outweigh risks (as with some anti-convulsive medications)

PRESCRIPTION OF MEDICATION
When prescribing medication during pregnancy, the
main concern is the risk of teratogenesis, because
drugs cross the placenta by simple diffusion. Drugs
are administered during pregnancy only when they are
essential for the pregnant womans well-being, and the
drug of choice should always be the one that is the least
toxic. In practice, dentists mainly prescribe antibiotics
to control infections and painkillers to relieve the pain.
Any drug that is prescribed during pregnancy should
have the fewest possible side effects and it should aim to
improve the health of the mother or the fetus.15

Class

Paracetamol

LOCAL ANESTHESIA WITH VASOCONSTRICTOR

Usually dentists prefer to administer local anesthesia
with mepivacaine 3% without a vasoconstrictor. However,
according to the FDA classification, mepivacaine, as
well as articaine, are included in Category C, which
means that they are drugs that should be used with
caution while always weighing the risks and benefits
involved.16 According to the FDA classification, lidocaine,
prilocaine, and etidocaine are included in Category B,
so the administered dose to pregnant women (as well
as to the general population) should be well below the
maximum recommended dose. The above-mentioned
local anaesthetics (lidocaine, prilocaine, and etidocaine)
may be combined with vasoconstrictors and can
be administered during pregnancy. Their dosage is

Smile Dental Journal | Volume 10, Issue 1 - 2015 | 17 |

adjusted as follows: maximum dose of lidocaine 500mg,

prilocaine 600mg, etidocaine 400mg. Any concerns
regarding the vasoconstrictor effect on the uterine muscle
have proved to be speculative, as there is no clear
evidence to support this view.20,21 Moreover, according to
research, lidocaine appears to cause no increase in the
rates of malformations in infants13 (Tables 2 and 3).
ANTIBIOTIC PROPHYLAXIS PRIOR TO ANY DENTAL
PROCEDURE THAT INVOLVES BLEEDING
Pregnancy by itself is not an indication for administering
prophylactic antibiotics. Transient bacteremia may occur
as a result of certain dental procedures, such as tooth
extractions, supra gingival or sub gingival scaling, as
well as gingivectomy. However, there are no reports
to suggest that this transient bacteremia is harmful to
the fetus.13 Thus, the guideline that applies to pregnant
women is no different than the guideline that applies
to the general population according to American Heart
Association guidelines. Prophylactic antibiotics are
administered only if there is a risk of developing infective
endocarditis (IE).13
Optimal trimester of pregnancy for dental treatment:
Any dental treatment of an urgent nature can be
provided at any time during pregnancy.22 Traditionally,
dental treatment of any kind has been avoided during
the first trimester of pregnancy, so as not to harm the
fetus during the stage of organogenesis. However,
there is not enough evidence to forbid dental treatment
even during the first trimester of pregnancy. The ideal
period for a complete dental treatment of a pregnant
woman is the beginning of the second trimester (14-20
weeks of pregnancy).23 At this stage, there is no risk of
teratogenesis, nausea and vomiting have subsided, and
the uterus is not yet large enough to cause discomfort.
It is essential to treat all dental problems during the
second trimester, not only because the woman should
have a healthy mouth, but also because during labor
she might need to be intubated, in which case teeth with
a bad prognosis (e.g., tooth mobility due to periodontal
disease) may be damaged or lost.2
POSITIONING OF PREGNANT WOMEN IN THE
DENTAL CHAIR
During the third trimester of pregnancy, when the woman
is supine, the uterus may press on the inferior vena cava
and impede venous return to the heart, which may lead
to hypotensive syndrome (occurring at a rate of 15-20%)
and loss of consciousness.13 In order to prevent this
from happening during dental treatment, when seated
in the dentists chair the pregnant womans head should
always be higher than her feet, and, if necessary, a small
pillow (or a folded blanket) should be placed under her
right hip (left uterine displacement) so that the uterus is
moved away from the inferior vena cava.9,22
When should a dentist consult the patients obstetrician?
Provided that the pregnant woman is healthy, a dentist
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(Table 3) Local anesthetics used in dentistry (with FDA

pregnancy risk category2)
Local anaesthetic

FDA

Considerations for use

there are no extensive studies to prove the safety of the

aforementioned alternative materials during pregnancy,
compared to amalgam fillings. Furthermore, based on
studies in animals, bisphenol-A, a component found
in composite resin fillings, has been proven to cause
endocrine disruptions.30 Consequently, when a filling
is required during pregnancy, the patient needs to be
informed of the different options, and, together with the
dentist, they should decide on the best material to use.

Lidocaine (2%)

Use with no risk

Mepivacaine (3%)

Consult with the patient's obstetrician

Use only if it is needed

Prilocaine

Use with no risk

Bupivacaine

Consult with the patient's obstetrician

Use only if it is needed

Etidocaine

Use with no risk

PERIODONTAL THERAPY

Procaine

Consult with the patient's obstetrician

Use only if it is needed

Articaine

Consult with the patient's obstetrician

Use only if it is needed

Periodontal treatment is very important during pregnancy.

The hormones that are released in the pregnant womans
body make her more susceptible to plaque and in turn
gum bleeding.31,32 Many pregnant women mistakenly
think that gum bleeding is normal during pregnancy and
they do not seek dental care.13 The dentist has to inform
the pregnant woman and give her instructions on how
to improve her oral health. Furthermore, if necessary,
more frequent visits to the dentist should be scheduled.
Because infections (such as urinary tract infection) in
pregnant women are associated with preterm birth and
low birth weight, the hypothesis has been formulated
that periodontitis is possibly linked to pre-term birth.
This hypothesis was supported by experiments that
showed fetal growth restriction in pregnant women
who were affected by periodontitis.33-36 The hypothesis
is that periodontal pathogens, mainly those belonging
to the group of Gram-negative anaerobic rods, affect
fetal growth either through their toxins or through the
release of inflammatory mediators. This hypothesis has
been explored in numerous scientific publications.5-8,33,37
Because pre-term infants have significant health problems
that require costly medical treatment, if periodontal
treatment could prevent pre-term labor, the benefit would
be great both for the health of the infants and for the
reduction of medical costs. Thus, large scale studies have
been carried out, such as PIPS (Periodontal Infections and
Prematurity Study) and OPT (Obstetrics and Periodontal
Therapy), as well as other, small-scale studies, which
focus on the benefits of periodontal treatment and the
prevention of pre-term and low birth weight infants.38,39
So far, the results of these studies have been conflicting,
as, according to some researchers, it has been estimated
that periodontal treatment in pregnant women has not
reduced the risk of preterm low birth weight infants38,40-47
whereas others report positive results regarding the
prevention of such occurrences.48-52 A recent metaanalysis has suggested that pregnant women who
received successful periodontal treatment based on strict
criteria had a significantly lower risk of undergoing preterm labour. The same meta-analysis suggested that the
hormonal state of pregnant women makes the periodontal
therapy more challenging and that there should be more
studies that focus not only on the periodontal treatment
procedure, but also on its success as well as the time
that the treatment takes place.53,54 It is worth noting that
among the large number of pregnant women who took

does not normally need the obstetricians consent in

order to perform common dental procedures. However,
if for some reason the dentist thinks that the dental
treatment should be postponed or if there are any
co-morbid conditions for which the patient receives
medication (e.g., hypertension, diabetes, heparin
intake) that may affect dental treatment, the dentist
should inform and consult the obstetrician. Similarly, the
obstetrician should be informed if the dentist thinks it is
necessary that the pregnant woman should be treated
in a hospital setting, especially if the dental treatment
should be performed under general anesthesia.1
AMALGAM FILLINGS
Although lots of dentists are not using dental amalgam
in their daily practice, this type of restoration is still
present in most of our patients mouths. Dental
amalgam fillings release mercury vapor (a form of
inorganic mercury) in the mouth, especially during
chewing. As a result, mercury crosses the placenta
through blood circulation. This fact has concerned the
scientific community as to whether or not amalgam
fillings should be used in vulnerable populations, such
as pregnant women. Using a rubber dam and highspeed evacuation (suction) during amalgam placement
or removal may significantly reduce the inhalation
of mercury elements (mercury vapor).9 Although the
amalgam fillings contain mercury, which is toxic, the
amount of mercury released in the mouth is minimal
(estimated to be 10 g/d whereas, according to the
WHO, the total-mercury tolerable intake is 2 g/
kg/d).24,25 Even though the Public Health Agency
of Canada recommends that no dental amalgam
placement or removal take place during pregnancy,24 the
ADA, the FDA and the WHO consider dental amalgams
safe to use in dental restorations, because research
has shown that there is no relation between amalgam
fillings and complications during pregnancy.26-29 Filling
materials that can be used instead of amalgam include
glass-ionomer cement, composite resins, as well as gold
or porcelain. However, amalgam fillings last longer
than glass-ionomer fillings and composite resins; they
also cost less than gold or porcelain fillings. Moreover,

part in the studies and received periodontal treatment,

none experienced any problems due to the treatment.41,46
A periodontal lesion characteristic during pregnancy is the
pregnancy epulis. The lesion is estimated to affect 0.2-5%
of pregnant women and is more common in the maxillary
gingiva.55 It is a form of pyogenic granuloma that is
hormone related. Lesions may regress spontaneously after
birth. If not, they should be surgically removed. If they are
bleeding excessively and cause trouble in mastication they
may be removed with safety during pregnancy.55
THE ROLE OF THE DENTIST REGARDING THE ORAL
HEALTH OF A PREGNANT WOMAN
During pregnancy, the dentists role is to prevent oral
health problems, to inform, and to provide dental care to
the pregnant woman throughout the pregnancy period at
any time it is thought necessary. The reason for this is that
pregnancy is not a disease and, consequently, there is no
reason to postpone dental appointments and procedures.
In conclusion, a pregnant woman should receive
adequate information from her obstetrician so as to visit
the dentist early in her pregnancy. She should also look
after her oral health and, consequently, the oral health of
her newborn baby. The dental treatment that will deal with
any oral health problems should preferably be completed
during the second trimester of pregnancy, so that the
woman goes into labor with a fully restored mouth.
CONCLUSION
Good oral health during pregnancy is important because
the condition of a pregnant womans mouth can affect
her health and that of the fetus. It is vital that health
professionals collaborate to ensure pregnant women
receive proper oral assessment and intervention as well
as oral health education. Some oral health professionals
hesitate to treat pregnant women but there is sufficient
evidence to recommend that after consulting the general
medical practitioner and/or obstetrician and assessing
the potential risks of undergoing dental treatment
during pregnancy, routine dental visits can be safely
performed, including the use of radiographs, plaque
removal, treatment of periodontitis, local anesthesia,
and the provision of composite and amalgam fillings.
Prescribing of systemic drugs of any kind ideally should
be performed after consultation with the general medical
practitioner or obstetrician. Pregnancy is a life-changing
event and a particularly important time to access oral
health care because the consequences of poor oral
health may have a lifelong impact.
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