- Before embarking a dental treatment the possibility of pregnancy should be considered.
- Considerations for dental treatment should be made throughout the phase of pregnancy and subsequent breast-feeding.
- Pregnancy represents a relative contraindication to elective dental care, especially during the first trimester.
- Consultation with the patient’s physician before commencing any treatment is indicated, especially if there are any problems with this or prior pregnancies.
The first trimester is when most of the baby’s organs are formed; this period is the most crucial for baby’s development, so if the treatment is urgent it is best to plan procedures during the second trimester to minimize any potential risk. Dental work is not recommended during the third trimester because the dental chair tends to be too uncomfortable for the mother. Furthermore, in certain positions the enlarged uterus may obstruct flow in the inferior vena cava.
The primary concern when providing care for a pregnant patient is the prevention of genetic damage to the fetus.
Two areas of dental treatment with potential for creating fetal damage are:
- Dental radiology
- Drug administration
Dental Radiology:
- Although radiographs in the region of the jaws don’t cause direct irradiation of the abdominal area, these should be restricted to clinical necessity, as should all radiographs. (Avoid X-Rays)
- (General dental treatment): Avoid dental radiographs unless information about tooth roots or bone is necessary for proper dental care. If radiographs must be taken, use proper shielding. use both abdominal aprons and thyroid collars, whenever practical, to minimize radiation exposure
- (Surgery) In case of imaging, use of protective aprons and taking digital periapical films of only the areas requiring surgery can accomplish this.
- Patients should be reassured that the risk is minimal. (When radiographs are necessary)
Drug administration:
Dental local anesthetics:
Local anesthetics and vasopressors are not teratogens and may be administered to pregnant patient’s during any trimester. However, it is prudent to be conservative in administering any drugs to pregnant women.
Citanest should be avoided as the vasoconstrictor, octopressin may induce labour. 
Lidocaine plus adrenaline (epinephrine) is an appropriate anesthetic and some clinicians prefer to avoid prilocaine with felypressin, which may (in theory) have a mild oxytocic effect.
Antibiotics
Such as penicillin, amoxicillin and clindamycine are acceptable, but avoid tetracyclines, which can cause discoloration of child’s deciduous & permanent dentition. Metronidazole has teratogenic potential and should be avoided in pregnant patients. 
Analgesics:
Paracetamol is the preferred analgesic for pregnant women, and products containing acetaminophen, such as tylenol, are approved. You should avoid NSAIDs which may induce allergy in the unborn fetus, and opioid/opiate medications for dental pain 
Anesthesia:
- Dental procedures requiring general anesthesia or sedation should also be avoided due to the risk of fetal hypoxia.
- Avoid sedatives and Hypnotics as there may have deleterious effects on the fetus.
- All sedative drugs are best avoided in pregnant patients.
Nitrous oxide should not be used during the first trimester but if necessary can be used in the second and third trimester as long as it is delivered with at least 50% oxygen, and not more that 9hr in a week
Surgical Treatment:
Although not a disease state, pregnancy is still a situation in which special considerations are necessary when oral surgery is required.
Before performing any oral surgery on a pregnant patient, the clinician should consult the patient’s obstetrician.
It is virtually impossible to perform an oral surgical procedure properly with neither radiographs nor the administration of medications; therefore, one option is to defer any elective oral surgery until after delivery to avoid fetal risk.
If surgery during pregnancy cannot be postponed, efforts should be made to lessen fetal exposure to teratogenic factors.
Pregnancy can be emotionally and physiologically stressful; therefore an anxiety-reduction protocol is recommended.
Patient vital signs should be obtained, with particular attention paid to any elevation in blood pressure (a possible sign of preeclampsia).
A patient nearing delivery may need special positioning of the chair during care, because if the patient is placed in a nearly supine position, the uterine contents may cause compression of the inferior vena cava, compromising venous return to the heart (Maternal Hypotension) and thereby cardiac output (decreased). Further, supine hypotensive syndrome may occur (Eventual Loss of Consciousness). The patient may be in a more upright position or have her torso turned slightly to one side during surgery.
Supine hypotensive syndrome can usually be reversed by turning the patient on her left side, thereby removing pressure on the vena cava and allowing blood to return from the lower extremities and pelvic area Frequent breaks to allow the patient to void are commonly necessary late in pregnancy because of fatal pressure on the urinary bladder.
Minor oral surgical procedures can be carried out during pregnancy, which, it should be remembered, is a physiological state. Necessary dental treatment should continue during pregnancy, especially such measures as extraction of unrestorable, grossly carious teeth where delay could lead to acute pain & spread of infection. Prompt treatment under LA may well avoid the need for later use of antibiotics and painkillers, and even the need for general anesthesia where gross infection precludes the use of LA. For less urgent surgery, such as removal of wisdom teeth or peri-radicular surgery, it is better that the surgical treatment is carried out during the middle trimester of pregnancy or deferred until after the pregnancy.
Sources:
- Contemporary Oral and Maxillofacial Surgery 5th edition (Hupp. Ellis. Tucker)
- Essential Human Disease for Dentists (Sproat. Burke. McGurk)
- Handbook of Local Anesthesia 5th edition (Malamed)
- Textbook of General and Oral Surgery (Wray. Stenhouse. Lee. Clark)
- Carranza’a Clinical Periodontology 10th edition (Newman. Takei. Klokkevold. Carranza)
