Endodontic Management of the Pregnant Patient

 

Endodontic Management of the Pregnant Patient

Hello ruble Commission’s this is a Leonid, and I’m here at the Harvard School Dental, Medicine, postdoctoral me tonic program, and I’m joined with Dr. Ian Grayson, the postdoctoral fellow at the Harvard the post la kendo program, and thank you so much for joining me.

Thank you for inviting me absolutely great to have you here, and Ian has a case for us that we’re going to do in this new segment, which is the endodontic management of the medically compromised patient, and today’s case is just the pregnant patient.

Of course not medically compromised, but requires certain management requirements and in what do we listen to the case that you’ve done first and then from there we’re going to talk about the management issues that comes associated with it afterwards. So, let’s quickly go through the case.

First: okay: our case involves a 28 year old Caucasian female who presented to our office in pain in the upper right areas. When we reviewed her medical history, she was very healthy. She had no serious health concerns.

However, she was two months pregnant on our examination tooth number four was acutely tender to percussion, had apical tenderness, and that was swelling in the area.

The patient had previously been on two courses of amoxicillin to control the inflammation and the swelling, and our diagnosis was an acute apical abscess on a previously treated endodontic procedure.

Our treatment plan was to perform an incision and drainage that day using lidocaine 2%, one in a hundred thousand, and that was to prevent any kind of infection and relieve the pain.

After two to three days, we removed the drain, and we were going to monitor the patient in conjunction with her obstetrician. Our initial treatment plan was to reappoint her in the second trimester for apical surgery, since this tooth had already been retreated previously.

Now we see here on her preoperative x-ray, the root canal is well done. It goes right to the apical area.

However, there’s a fairly large radial lucency at the apex of this tooth, and so what we’ve done is we went in surgically. We removed approximately three millimeters of the apical area, and we replaced that gutta percha towards the end with bc.

Sealer and here you can see on the x-ray on the far right – the area’s totally been removed, and you can see a nice seal placed at the apical area in terms of a followup virtually immediately after the incision and drainage.

The patient’s pain disappeared. There was no further requirement for antibiotics, which is always a good thing, because the fewer drugs that you give these patients, the better off you are the surgery, went ahead without incident the patient healed well and to add to the beneficial result.

The patient delivered a healthy girl. Four months later. That’s terrific, so, in this case kind of becomes a great diving board to get into this whole area of how do we manage patients that are pregnant, that come in for anatomic therapy or have acute pain or our emergency patients, but they are pregnant.

Various stages of pregnancy and they’re you know we have to consider them. What are some of the broad considerations for patients that are pregnant, that we have to do to kind of manage.

That’s that that’s a great question, because that’s probably the single most important factor that you consider is: how do you handle these patients and there’s basically four categories of information that you have to know or be able to practice when you’re dealing with this? The first is the timing of the treatment. When is the best time to perform the treatment that you need.

The second type is: what kind of procedures can you perform the? Thirdly, what kind of pharmacology can you utilize and then there’s the overall physiological considerations that you have to deal with because of that state, and so some of these overall considerations that you need to keep in mind?

What would what are they? The overall considerations are, the first thing is cardiovascular. The second thing is the respiratory changes that take place, gastrointestinal changes as well and then there’s oral changes which are mainly brought on by high levels of estrogen and when you look individually at each Gouri, the first and foremost one is cardiovascular changes.

Cardiovascular, take places take place in most women and, generally speaking, there’s a 30 to 50 percent increase in cardiac output during the second and third trimester. There’s a decrease in blood pressure when the patient is supine and, generally speaking, this can manifest itself in fainting, nausea and dizziness.

When the patient is being treated to prevent this, we can elevate the right hip and the reason for doing that would be to facilitate the venous return by reducing pressure on the inferior vena cava.

The next thing we can look at our respiratory changes as the fetus develops and enlarges. The diaphragm is pushed up into the thoracic cavity when that happens, there’s an increase in intro thoracic pressure, and this can result in difficulty, breathing, inhaling and exhaling when the patient is in the chair, and this also must be taken into account. The third. The third change is gastrointestinal changes.

What happens is there’s an increase in gastric pressure because of the decreased volume within the abdomen, and this can result in reflux. As a matter of fact, it affects as many as thirty to fifty percent of the women, so in this particular case, in order to deal with certainly chair position is important.

We want to treat these patients in a semi supine position, not laying flat in order to make them comfortable, and the last thing we deal with are the oral changes, the oral changes which are brought about by estrogen levels. One of the most important things we see is we see inflammation of the gingival tissues, and we can see reactive lesions and the most common reactive lesion. That we see is a pyogenic granuloma.

This is often called a pregnancy tumor because it takes place during pregnancy. We also note salivary changes when we see salivary changes. We note a decrease in the amount of saliva produced in these people.

High estrogen levels will also predispose the area to gingival inflammation, and they can make pre-existing periodontal conditions far worse. They can also initiate periodontal conditions.

If they’re not properly managed initially, however, dental caries is also increase, and this is generally due to a drop in oral pH and an increase in the amount of bacteria that can grow within that environment.

So, in order to combat this scenario, what we always encourage patients is very, very good oral hygiene, that’s meticulous, brushing flossing and the use of various mouth rinses that can keep the area very, very clean and sanitary, terrific.

So, in terms of the pharmacology of medications that are indicated, contraindicated in terms of the management of the patient is going to have ended on Keira P. Well, what are some of the considerations? Well, generally speaking, almost all drugs would be contraindicated.

However, some are more contraindicated than others. Now certain drugs can have profound influences on the fetus because they readily cross the placental membrane and, as a matter of fact, even postpartum.

We see that many of these drugs are in fact excreted in breast milk and that will compound the effects of them.

So, drugs are generally categorized a through D as the risk increases and then there’s another group, which is a group X which is totally contraindicated because severe to rato genic effects.

Now, antibiotics with in terms of them most of them, will cross the placental membrane and will have an effect on the fetus.

So, there are certain antibiotics for to be exact that can be used during pregnancy with relatively few side effects. That would be penicillin, amoxicillin, clindamycin and metronidazole.

We try to stay away from the broad-spectrum tetracycline. It is not to be used because it causes staining in the teeth and in the bone yeah coming. If you think about it.

Clearly, them for a patient that is for all patients, if you will that they already have a bio flora or a biome, basically in their GI, taking the antibiotic will change that biome.

However, of course, for the pee fetus itself, because the fetus is sterile, doesn’t have any bacterial kind of there’s no floor associated with the fetus, so the antibiotic will not have effect on the biome itself.

However, it will basically you know things such as recycling. Zat stain the skeleton and the two teeth, it will have an issue with that: the other group of medications, obviously that are highly used during the anatomic management of a patient’s analgesics.

So, what about those analgesics are used, obviously, for pain control and the most common analgesic that you can use with very little in the way of consequence is acetaminophen, however, morphine can be used, and one must be careful in terms of using morphine because of respiratory depression, Where, as we mentioned previously, there’s already difficulty breathing, so you should use it with caution and meperidine or Demerol can also be used.

It has less respiratory depression, a vicodin and oxycodone can be used, but certainly with caution. Now contraindicated are a si and non-steroidal anti-inflammatories. They should definitely not be used, especially in the third trimester because of the bleeding associated with them, and they have also been associated with cardiac septal defects in the fetus, so they’re definitely contraindicated for any kind of pain management on the pregnant patient.

Of course, what about local anesthetics, because that’s obviously another area, yeah local anesthetics – are our bread and butter in dentistry and essentially, there are two that are certainly okay to use?

That would be lidocaine and prior cane, but if you can perform a procedure without anesthetic, and you’re dealing with a non vital tooth, obviously that’s preferable.

But if you have to lidocaine and prior cane are good choices, one should shy away from a pivot cane and bupivacaine. They should be used with caution because they’re known to cause fetal bradycardia, which is the slowing of the heart yeah.

Of course, although I must say that, given the safety level of lidocaine with there’s a constrictor, I think I will probably go on the side of making sure that patients are completely comfortable because taking a chance at skipping, an anesthetic in order to reduce any potential.

Not really harmful what kind of sex to be given to a patient during pregnancy can increase on the other side, a patient, anxiety level.

You know all kinds of endogenous reason are that, because it’s gonna be released, so I think it’s critical that the patient’s completely numb uncomfortable during a procedure, especially if they’re pregnant, because all kinds of things can’t go wrong if they’re not comfortable and given the As we talked about it, a given, I mean local, I’m citizen, with a cane and even as I looking with epinephrine or category a drug, so they’re fairly safe to use.

Yes, they are by the way. You know the other article and things like that or category C. Yes, so that’s one of the ones that we don’t want to use if we can help it on a pregnant patient. So, what about sedatives? Because that’s also some people give sedatives to patients that are not pregnant.

What about for the pregnant patient for the pregnant patient, the most common sedative that we use is nitrous oxide and nitrous oxide is definitely contraindicated in the first trimester because it’s been associated with spontaneous abortion.

Certainly, when you look at barbiturates and benzodiazepines they’re also contraindicated, because they’ve been associated with cleft lip and palate, probably better off, not to give those drugs during pregnancy right.

So, the other thing that everybody all pregnant patients are worried about is radiographs. Obviously, you know x-rays have a pretty bad reputation. Luckily, x-rays have improved with digital technology in terms of the dosage and the rats that a patient gets.

But x-rays are critical, for you know for our Diagnostics, because if you don’t have proper information, you can screw up a case and the question is you know? What is that happy balance? We just had a conversation with the head of radiology at Harvard, and he said to his much expertise is needed. Basically, what is what do you? What do you think III agree somewhat with that?

Certainly, you don’t want to take unnecessary x-rays when you look at the actual dose that the fetus gets. The fetus gets 150 thousand, the dose that the mother gets in the oral cavity.

So, we’re not talking about large amounts of radiation. I think – and I totally agree with you – that x-rays are mandatory to make a proper diagnosis when you weigh the risk-benefit reward, it’s definitely better to take an x-ray and understand exactly the type of pathology that you’re dealing with now the greatest risk of x-rays and If you want to try to avoid x-rays, would come during the first trimester, that’s the most rapidly growing area for that fetus.

So at that point in time, if you can avoid it, but most of the other areas during the pregnancy, you can go ahead and provide the patient with quality diagnosis by using an x-ray.

You know there is no question about that. I think skipping really important. Radiographic information, just for the fear of X radiation, is really not warrant, especially in today’s world, because you now have collimated x-ray sources where the x-ray is almost like a laser beam.

It goes right through. There is no scatter right previously.

We had these cone-shaped x-ray house, but it was just spraying x-ray, all over the room. Now, if you’re just a tiny bit off, there is no extra on your sensor.

You know you have a big cone cut, so your x-rays are very collimated, and they don’t end up going towards the abdominal area with it where the baby is where the fetuses and I do agree on the first trimester.

You would like to minimize those, but I think even then the main reason we’re doing that.

To be honest, is because of medical legal reasons B, and the reason for that is because there’s the highest rate of spontaneous abortions they’re in the first trimester, and he don’t nobody wants to get blamed for it.

So, you’re not you’re basically trying to avoid x-rays. But I think the overall lesson here is that I think if you need radiographs diagnostically, you should take them because it’s far more important to manage the case to get enough information.

So, you can prevent the progression of the disease rather than bury your head in the sand. Over this unrealistic and irrational fear of radiographs, which could then later on cost the mother and the fetus a lot more in terms of your inability to manage a situation that could have been, you know that could have been prevented from being elevated to a level of Facial space infection – that’s traveling all over the place by just taking the proper x-ray as a right time, but if you think about it, if you thought to that extent, you wouldn’t go out in the Sun, you wouldn’t travel on an airplane. You wouldn’t expose yourself to all differ types.

You wouldn’t be in a kitchen next to a microwave oven. So, when you think about it, these are all greater sources of radiation than in fact, the radiation that we’re using to make a diagnosis.

So, as you say, it is irrational to know that way, no doubt about it, yeah absolutely, so I guess it’s all about finding a right balance, but the ultimate thing is that diagnosing the disease and treating it properly is the pipe the primary priority of all practitioners.

So, let’s talk about the timing, we all know that pregnancy is divided into three trimesters right, what about in terms of the indications of treatment at various stages of the pregnancy? Well, generally speaking, in terms of timing, you want to try to avoid any kind of elective procedure in the first trimester and the second half of the third trimester all the other times.

If you have to, you can provide treatment for the patient now. The second trimester, as I mentioned, is the slot that you have the little window you have in pregnancy, or you can provide relatively safe treatment in the third trimester.

You want to try to avoid lengthy procedures, because the patient gets a lot more uncomfortable because of the position that you have to keep the patient in for a long period of time.

So, that should be provided in a semi, supine position and certainly very, very short, and one should definitely try to avoid the second half of the third trimester, because that’s the most uncomfortable time for the mother.

Absolutely, of course, the Adamic infections do not really come with a weather warning, no, which is probably why it’s a good idea to have a sense of you know a kind of a tune-up if you will prior somebody’s planning on having a nice.

But you know having a pregnancy, it’s a good idea to go in for an appointment, exactly to make sure that everything is in order so that there are no problems that could creep up all of a sudden in the middle of the pregnancy.

That could cause a lot of problems for both the mother and the baby, so that you know if there was any large decay or carrier series, it could be taken care of in advance, so it doesn’t become a big problem during the problem.

So, what is your conclusion over the whole, really in conclusion other than routine examination scaling and prophylaxis? You should try to if you can avoid dental treatment unless, of course, there’s an emergency problem there, where you can at certain points, definitely treat the patient.

The emergency treatment can be read can be rendered, but one has to weigh out the risk benefit ratio, and before you offer the treatment, and certainly, if there’s a question about this kind of thing, the obstetrician can be consulted and certainly together with the medical Team we can make an informed decision.

I think that you should not avoid treatment just because the patient is pregnant. However, being careful and prudent about weighing the risks for each procedure is definitely paramount.

No, absolutely I think it’s, and it’s very well put. I think understanding the overall requirements – it’s always best to kind of have that information in advance prior to pregnancy.

You can avoid problems, but sometimes you don’t and things can go wrong at that point, I think it’s important to kind of put the risk-benefit into the equation.

Understand that any kind of untreated disease could be a problem not just for the mother, but also for the fetus, but keep the treatment to that which is actually required, and emergency treatment.

Elective treatment should be done prior or after the pregnancy. I think what we talked here today is that there are, obviously there’s some metabolic and physiological changes that occur in the mother during the pregnancy, not only in terms of the hormonal changes, but also through the physical pressure of a growing fetus inside the abdominal cavity.

That that changes the management style of these patients, even from postural too, to also pharmaceutical logical, as well as treatment modalities, that we need to keep in mind and, at the end of the day, it’s you know, making sure that you’re not overly afraid of getting proper Treatment just because of the fact that you have these considerations but limited to that which is necessary.

Well, thank you and for reward and oh I’m a leanness, and I will join by Dr Ian Grayson, the postdoctoral fellow at Harvard minna-san post-election Adamic program, and we hope you found this information helpful.

 

 

 

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