No full-text available
To read the full-text of this research,
you can request a copy directly from the authors.
Drug therapy during pregnancy: Implications for dental practice
Abstract
Pregnancy is accompanied by various physiological and physical changes, including those found in the cardiovascular, respiratory, gastrointestinal, renal and haematological systems. These alterations in the pregnant patient may potentially affect drug pharmacokinetics. Also, pharmacotherapy presents a unique matter due to the potential teratogenic effects of certain drugs. Although medications prescribed by dentists are generally safe during pregnancy, some modifications may be needed. In this article we will discuss the changes in the physiology during pregnancy and its impact on drug therapy. Specific emphasis will be given to the drugs commonly given by dentists, namely, local anaesthetics, analgesics, antibiotics and sedatives.
... It is up to the dentist to present the correct pain management for these patients for analgesia [5]. Regarding non-steroidal anti-inflammatory drugs (NSAIDs), more caution is required when prescribing to pregnant women, as they pose a higher risk compared to analgesics, according to the Food and Drug Administration (FDA), especially in the third trimester due to greater risks to fetal health [6]. Concerning opioids, typically used for acute pain, their use must be cautious, in the correct and allowed doses, to avoid possible adverse effects. ...
... Concerning opioids, typically used for acute pain, their use must be cautious, in the correct and allowed doses, to avoid possible adverse effects. Opioids like Codeine and Oxycodone are commonly prescribed in combination with acetaminophen or acetylsalicylic acid [6,7]. ...
... Another point addressed in this study is the use of analgesics, considering they are the first line of choice for pain control. However, it is important to emphasize that, initially, the cause of the pain should be identified and then treated [6]. Dental care for pregnant patients is still considered complex. ...
Pregnant patients physiologically undergo various changes in their bodies due to hormonal actions. The oral cavity is not exempt from these alterations, and repercussions on oral health are also identified. It is essential to provide safe and appropriate dental care during pregnancy, taking into account the gestational trimester and the patient's overall health. Analgesia in pregnant patients remains a taboo for many professionals, especially for newly graduated dental surgeons. The use of local anesthetics in the office as a pain control method makes the procedure safer and more efficient. Regarding orally administered analgesics, acetaminophen is considered the first choice, with dipyrone as the second option. Aspirin, ibuprofen, and corticosteroids may be an option, but their use should be rationalized and when the benefits outweigh the risks to the maintenance of pregnancy and maternal health. The use of analgesia or reduction of the pain protocol in a pregnant patient in the office can be performed with 2% lidocaine with epinephrine, as it is considered safe. However, certain anesthetics, such as benzocaine and procaine, should be avoided due to risks of methemoglobinemia. Nonetheless, the professional must always weigh the risks and benefits of using analgesic medications for the pregnant patient and the fetus when choosing the medication.
... Assim como a terapia medicamentosa, a administração de anestésicos locais em tratamentos odontológicos causa insegurança nos profissionais. Os anestésicos locais são totalmente seguros durante a gravidez e não há contraindicações ao uso 15,24,25 . A maioria dos anestésicos são considerados como Classe B, de acordo com a classificação da FDA, com exceção da Mepivacaína e da Bupivacaína (Classe C). ...
... Não há contraindicações do uso de vasoconstritores na solução anestésica e suas vantagens se referem ao aumento da concentração local do anestésico (redução da toxicidade sistêmica), hemostasia e o prolongamento dos efeitos farmacológicos, proporcionando tempo adequado para as intervenções 15,24,25 . Ao realizar a anestesia local, a solução deve ser injetada lentamente e aspirada previamente como medida preventiva para evitar a injeção intravascular. ...
... É importante ressaltar que não se recomenda o uso de benzocaína e prilocaína como anestésicos locais, pois eles reduzem a circulação placentária e apresentam risco de metemoglobinemia e hipóxia fetal. E a solução contendo felipressina na composição deve ser evitada, uma vez que pode estimular a contração uterina devido a sua semelhança estrutural com a ocitocina em grandes doses 15,24,25 . ...
Ainda existem muitos tabus na sociedade sobre o acompanhamento odontológico durante a gestação e que, somado ao desconhecimento por parte dos profissionais, dificultam a difusão do conceito de pré-natal odontológico. O objetivo deste estudo foi sintetizar as principais evidências acerca do manejo da mulher durante a gestação, apontando as principais condutas que os profissionais devem adotar no estabelecimento de um protocolo holístico de pré-natal odontológico. No período de outubro/2020 a março/2021, as seguintes bases de dados foram acessadas: EMBASE, SCOPUS, MEDLINE (Entrez PubMed), Web of Science, BVS/LILACS, Cochrane Library e SCIELO. Foram incluídos estudos publicados entre janeiro/2000 a março/2021 em espanhol, inglês e português. O atendimento odontológico durante a gravidez é seguro e recomendado e os protocolos odontológicos preventivos devem ser adotados à todas as gestantes. Os procedimentos odontológicos clínicos podem ser realizados durante toda a gestação quando necessários, desde que existam justificativas plausíveis. Os profissionais devem realizar a anamnese e o exame clínico de maneira minuciosa a fim de evitar a exposição desnecessária das pacientes aos exames radiográficos e ao sobretratamento. É de suma importância que os cirurgiões-dentistas conheçam as indicações e contraindicações da radiografia odontológica, terapia medicamentosa e uso de anestésicos locais na gravidez, a fim de atuar com segurança, garantindo saúde para as mulheres e seus filhos.
... Acetaminophen is indicated for the management of mild to moderate pain and is the drug of choice in patients who cannot be prescribed NSAIDs, including children, elderly, and pregnant pa- Nephrotoxic agents • † including ulceration and perforation ∆ e.g., Crohn's disease, ulcerative colitis * Including ACE-inhibitors, beta-blockers, and diuretics (may be co-administered if the NSAID prescription is limited to 4 days or less) ø only a high dose is contraindicated, as in cancer therapy • adefovir, aminoglycosides, cisplatin, foscarnet Abbreviations: ADRs, adverse drug reactions; Dis, drug interactions; ASA, acetylsalicylic acid; NSAIDs, nonsteroidal anti-inflammatory drugs; SSRIs, selective serotonin reuptake inhibitors; ACE, angiotensin-converting enzyme tients. 7,17,18 Although it is a highly safe drug, acetaminophen overdose has been indicated as the leading cause of acute liver failure within the northern hemisphere. 19 The mechanism of action of acetaminophen is not entirely understood; however, several hypotheses have been proposed. ...
... These changes have implications on the pharmacokinetics of various drugs as well as the potential teratogenic effects of the drugs on the developing fetus. 18,59 Although clinicians should limit prescribing analgesics to pregnant patients, this cannot be avoided altogether as inadequately managed pain in pregnant patients carries its own risks. In general, medications should be prescribed to pregnant patients when the potential benefit to the mother is maximum and the potential risk to the fetus minimum. ...
... In general, medications should be prescribed to pregnant patients when the potential benefit to the mother is maximum and the potential risk to the fetus minimum. 18 Studies indicate that all drugs have the ability to cross the placenta and, therefore, affect the developing fetus. 60 Fetal organ development occurs primarily in the first trimester (first 90 days), and it is during this phase that the fetus is at the highest risk for teratogenesis. ...
... In the multiple-choice analysis, although the majority of respondents chose the second or third trimester of pregnancy as safe for antibiotic prescription, there was also a significant percentage of dentists (55.6%), which constituted 23.8% of the responses, who answered the first trimester as safe for antibiotic usage. The literature states that up to 43% of pregnant women may suffer from pathologies of odontogenic origin that can be dangerous for both the pregnant woman and the fetus because they can rapidly progress to systemic infections [39][40][41], and they should be treated aggressively to avoid further complications [41]. If drainage of the infection is not possible or there is severe inflammation or systemic involvement such as fever, antimicrobial treatment should be chosen [39], always weighing the risk and benefit to the mother and fetus [39,40,42,43], regardless of the trimester of gestation [44]. ...
... The literature states that up to 43% of pregnant women may suffer from pathologies of odontogenic origin that can be dangerous for both the pregnant woman and the fetus because they can rapidly progress to systemic infections [39][40][41], and they should be treated aggressively to avoid further complications [41]. If drainage of the infection is not possible or there is severe inflammation or systemic involvement such as fever, antimicrobial treatment should be chosen [39], always weighing the risk and benefit to the mother and fetus [39,40,42,43], regardless of the trimester of gestation [44]. However, there is a consensus that antibiotic prescription during the first trimester of pregnancy should be avoided where possible, as it is linked to iatrogenic teratogenicity [38]. ...
... The literature states that up to 43% of pregnant women may suffer from pathologies of odontogenic origin that can be dangerous for both the pregnant woman and the fetus because they can rapidly progress to systemic infections [39][40][41], and they should be treated aggressively to avoid further complications [41]. If drainage of the infection is not possible or there is severe inflammation or systemic involvement such as fever, antimicrobial treatment should be chosen [39], always weighing the risk and benefit to the mother and fetus [39,40,42,43], regardless of the trimester of gestation [44]. However, there is a consensus that antibiotic prescription during the first trimester of pregnancy should be avoided where possible, as it is linked to iatrogenic teratogenicity [38]. ...
In this study, we aimed to explore the trends among dentists in the Dominican Republic of providing antibiotic prescriptions to pregnant/breastfeeding dental patients. A survey was conducted among 98 dentists, using a self-administered questionnaire, about their knowledge and attitudes regarding antibiotic usage in pregnant/lactating women and the translation of these into practice. The majority of the survey population were female dentists (63.3%) aged 45–54 years. A chi-square test showed statistically significant differences in the knowledge sources between older and younger dentists, with a minority having chosen scientific literature as a source (p-value of 0.04). There were statistically significant associations between gender and certain attitudes and practice-based questions, with p-values of 0.04 and 0.01, respectively. The Spearman’s correlation test showed a statistically significant correlation between knowledge and attitude (p-value 0.001), whereas no correlation was found with practice (p-value 0.23). A multiple response analysis showed that the majority of the respondents chose the second and third trimester for antibiotic prescriptions for acute conditions such as cellulitis, periodontal abscess, and pericoronitis. Most dentists had sufficient knowledge about antibiotic usage in pregnant/lactating women, but it did not translate into practice, and a certain proportion of the participants followed incongruent drug prescription. These findings can be used to focus on judicious antibiotic usage by dentists in the Dominican Republic.
... A megnövekedett zsírszövet és plazmatérfogat miatt az alkalmazott gyógyszerek eloszlási térfogata jelentős mértékben megnő. Az alacsonyabb albuminszint következtében a szabad gyógyszer-koncentráció megemelkedik, valamint rövidebb felezési idővel kell számolnunk a megnövekedett RBF és GFR miatt [27]. A progeszteron-és az ösztrogénszint emelkedése az orális flóra befolyásolásán túl hatással van a máj micro so ma lis enzimrendszerére is. ...
... Egyes gyógyszerek farmakokinetikája lehetővé teszi azok átjutását a placentán, ezzel befolyásolva a fejlődés egyes fázisait. Különösen igaz ez az első trimester idejére, amikor az organogenesis döntő hányada játszódik le [27]. A harmadik trimesterben történő helytelen gyógyszeres kezelés a koraszülés kockázatát fokozhatja [33]. ...
... Az NSAID fájdalomcsillapítókhoz képest terápiás dózisban ez a legbiztonságosabb, elsőként választandó gyógyszer minden fogászati jellegű fájdalomra az állapotosság összes időszakában [24]. A maximális dózisa 500-1000 mg 4 óránként, maximum napi 4 g [27]. ...
A várandós páciensek fogászati kezelése néhány pontban eltér a nem várandósokétól. A fogorvos feladata az erre vonatkozó naprakész információk ismerete, melyek betartásával az anya és a magzat egészsége is megóvható. A várandós nőknek gyakrabban kell látogatniuk a fogorvosi szakrendelést, hiszen a megváltozott hormonális hatások fokozott rizikót
jelentenek egyes fogászati kórképek kialakulására. Ezek felismerése és szakszerű ellátása kulcsfontosságú a terhesség során. Mind a kezelés menete, mind a szükséges gyógyszerelés nagyobb odafigyelést igényel a fogorvos részéről. A várandósok fogászati kezelését befolyásoló tényezőket és a magzati fejlődésre ható gyógyszereket számos tudományos kutatás célozza, ám a rendelkezésünkre álló információ még így is csekély. Cikkünkben a fogászati gyakorlatban használt gyógyszereket – antibiotikumok, fájdalomcsillapítók, helyi érzéstelenítők, gombaellenes készítmények, vírusellenes szerek, szorongáscsökkentők, szájfertőtlenítők és szájüregi ecsetelők – gyűjtöttük össze és összegeztük a várandósságban történő alkalmazhatóságukat az aktuális irányelvek alapján.
... Oft ist während der Behandlung eine medikamentöse Therapie bzw. eine Medikation erforderlich, wobei aber nicht selten große Unsicherheiten hinsichtlich der Wahl geeigneter Medikamente für eben diese Pa tientinnen bestehen 1,[4][5][6][7][8][9]14,[16][17][18][19][20][21][22][23][24] . Daher sollen im Folgenden hilfreiche Informationsquellen aufgelistet und häufig verwen dete Medikamente näher beleuchtet werden. ...
... Primäres Ziel bei der Präparateauswahl ist während der Schwangerschaft der Schutz des ungeborenen Kindes. Es geht um die Vermeidung toxischer und teratogener Schäden 1,[4][5][6][7][8][9]11,14,[16][17][18][19][20][21][22][23][24] . Die Auswirkung eines schädigenden Agens ist dabei im 1. Trimenon, der Phase der Or gananlage, am größten 11 . ...
... B. bei der Behandlung einer bakteriellen Vaginose in der Schwangerschaft eingesetzt wird 2 . In der Schwangerschaft sollten Medikamente prinzipiell so eingesetzt werden, dass der Nutzen für die Mutter möglichst groß und das Risiko für den heranwachsenden Fetus möglichst gering ist7,16 .Die Suchergebnisse aus der Embryotox-Recherche zu den Lokalanästhetika, Analgetika und Antibiotika (Tab. 1 bis 3) decken sich weitgehend mit den aktuellen Empfehlungen in der zahnmedizinischen Literatur[4][5][6][7][8][9]11,14,16,17,[20][21][22][23][24] . Als kleiner Unterschied ist zunächst festzustellen, dass die Empfehlungen im Schrifttum weniger klinischen Beobachtungen folgen, sondern eher an theoriegeleiteten medizinisch-pharmakologischen Überlegungen orientiert sind.Die Embryotox-Datenbank weist derzeit über 420 Arzneimittel aus. ...
Im Rahmen der zahnärztlichen Therapie herrscht im Praxisalltag häufig eine gewisse Unsicherheit bei der Auswahl geeigneter Medikamente während der Schwangerschaft und in der Stillzeit. Ziel des Beitrags ist es, aktuelle Hinweise zu hilfreichen Informationsquellen zu geben und einige zahnmedizinisch relevante Arzneimittel für die schwangere und stillende Patientin zu beleuchten.
... This misconception may be attributed to fear of adverse pregnancy outcomes like miscarriage or risk to fetal health. Local anesthetics are the most frequently used pharmaceutical agents in clinical dentistry [16], and they can be used safely in pregnant women. ...
... Of these two agents, lignocaine may be considered ideal because of its lower concentration (2%) compared to prilocaine (4%), with the result of less drug being administered per injection. Mepivacaine, articaine and bupivacaine are given an FDA category C, making them a less favorable choice during pregnancy [16]. Among topical preparations, lignocaine is the preferred choice since it has FDA category B as opposed to benzocaine, which has an FDA category C ranking [18]. ...
Objective: To investigate why women avoid dental visits during pregnancy and to explore the possible association between this attitude and relevant socio-demographic factors. Material and Methods: An online questionnaire was distributed to pregnant women during their routine visits to antenatal clinics in Al Madinah, Saudi Arabia. The questionnaire explored socio-demographic factors of age, education, employment status and nationality. It also explored misconceptions/ reasons for avoiding dental visits during pregnancy. Results: A total of 360 pregnant women participated, and their mean age was 30.08 years (range=18-52 years, SD=5.96). The most commonly cited misconception/reason for avoiding dental visits was “local anesthesia is not safe during pregnancy”, followed by “transportation is difficult” and lastly, “dental treatment is not safe during pregnancy”, (43.6%, 37.5%, 18.9%, respectively). Illiterate participants were statistically significantly associated with the misconception of “unsafe dental treatment during pregnancy” (p=0.002), whereas school-level and unemployed participants were statistically significantly associated with the misconception of “unsafe local anesthesia during pregnancy” (p=0.02, p=0.036 respectively). Conclusion: Pregnant women avoid dental visits mainly due to the misconception that local anesthesia is not safe during pregnancy. Difficult transportation seems to be another important deterrent in preventing pregnant women to visit dentists in this geographic area. Changing the misconceptions should be the starting point in addressing this public health problem and this should involve the three parties involved: pregnant women, oral healthcare providers and obstetric care providers.
... Die Suchergebnisse aus der EmbryotoxRecherche zu den Lokalanästhetika, Analgetika und Antibiotika (Tab. 1 bis 3) decken sich weitgehend mit den aktuel len Empfehlungen in der zahnmedizinischen Litera tur 49, 11,14,16,17,2024 . Als kleiner Unterschied ist zunächst festzustellen, dass die Empfehlungen im Schrifttum weniger klinischen Beobachtungen folgen, sondern eher an theoriegeleiteten medizinischpharmakologi schen Überlegungen orientiert sind. ...
... Prilo cain, das die FDA in der gleichen Gruppe wie Lidocain führt, wird indes von einigen Autoren wegen des Risikos einer Methämoglobinbildung als obsolet be trachtet 1,24 . Einigkeit herrscht hingegen in der Be wertung von Mepivacain, das in der Schwangerschaft nicht verwendet werden soll 1,16,24 . ...
Im Rahmen der zahnärztlichen Therapie herrscht im Praxisalltag häufig eine gewisse Unsicherheit bei der Auswahl geeigneter Medikamente während der Schwangerschaft und in der Stillzeit. Ziel des Beitrags ist es, aktuelle Hinweise zu hilfreichen Informationsquellen zu geben und einige zahnmedizinisch relevante Arzneimittel für die schwangere und stillende Patientin zu beleuchten.
... In order to manage pain, prescribing acetaminophen is preferable to ibuprofen and Novofen because the last two may increase the risk of bleeding and late delivery [29]. Administration of corticosteroids and tetracycline, NSAID, morphine, and aspirin are prohibited in pregnant women, and the antibiotics of choice for pregnant women are amoxicillin and clindamycin [30]. In case of any necessary X-ray irradiation, using an apron and a lead necklace is suggested to provide peace of mind. ...
Pregnant patients and how to manage their treatments is one of the most important challenges in endodontic practice. Endodontic treatment on pregnant women is sometimes an emergency condition to control toothache due to irreversible pulpitis and odontogenic infection. Tooth decay, oral health, local and general anesthesia, analgesics, antibiotic prescription, drug interactions, and X-ray radiation are the most important considerations that may impact treatment planning and endodontic practice in pregnancy. The aim of this article is to notify and explain the latest concepts in the endodontic management of pregnant patients.
... Também, o uso da anestesia local 2,24 e de medicações para o controle da dor e de infecções odontológicas 25 , um dos principais receios do profissional 11,12 , é seguro na gravidez 33 . Cabe aos profissionais avaliarem cuidadosamente os riscos versus os benefícios de prescrever medicamentos para uma gestante 34 . ...
Objetivo: avaliar gestantes internadas no setor de obstetrícia do Hospital Escola da UFPel quanto à necessidade de receber atendimento odontológico de urgência, ao conhecimento a respeito do atendimento durante a gravidez e de como prevenir a doença cárie dentária em seus filhos. Método: este estudo observacional, de base hospitalar e transversal, foi conduzido a partir de instrumento contendo uma entrevista e uma avaliação bucal de 83 gestantes. Os dados foram coletados junto ao leito por dois residentes treinados e avaliados pelo Teste Exato de Fisher e por análise multivariada, com Regressão de Poisson e variância robusta. Resultados: a média de idade das gestantes foi de 28,7 anos, sendo que 31,3% relataram dor dentária, estando relacionada à atividade de cárie e à busca de atendimento odontológico nos últimos 6 meses. Das gestantes avaliadas, 66,2% apresentaram, pelo menos, um tabu ou mito, sendo que realizar tratamento endodôntico foi o mais prevalente. Realizar pré-natal reduziu a presença de tabus ou mitos. Apenas 7,2% das mulheres demonstraram ter conhecimento de como prevenir a doença cárie dentária no filho, sendo significativamente maior nas donas de casa e nas que receberam orientação prévia. Conclusão: o pré-natal favoreceu a redução da presença de tabus e mitos da odontologia na gestação. O cirurgião-dentista tem um papel importante na condução do pré-natal odontológico, para evitar e tratar as odontalgias na gestação e orientar sobre a saúde bucal dos filhos, efetivando a atenção odontológica nos mil dias da criança.Palavras-chave: gestantes; saúde materno-infantil; assistência odontológica.
... In addition, it is important for the student to know that in order to perform dental procedures involving the use of an anesthetic, the first trimester of pregnancy represents a greater threat of teratogenicity, while in the second trimester the risk of fetal damage is minimal. Finally, if local anesthetics are to be administered in the third trimester, they should be administered in lower doses [32,33]. ...
Background:
Clinical management to maintain or restore oral health through the use of drugs during pregnancy is crucial, since at this stage physiological changes significantly influence the absorption, distribution and elimination of the drug, considering also that excessive administration of drugs during this period may have adverse effects on the mother and/or fetus. Therefore, the aim of the present study was to evaluate the factors associated with knowledge of pharmacological management of pregnant women in dental students of a Peruvian university located in the capital and province.
Methods:
This analytical, cross-sectional, prospective and observational study assessed 312 Peruvian dental students from third to fifth year of study between February and April 2022. A validated questionnaire of 10 closed questions was used to measure knowledge about pharmacological management in pregnant women. A logit model was used to assess the influence of the variables: gender, age, year of study, marital status, place of origin and area of residence. A significance of p < 0.05 was considered.
Results:
The 25.96, 55.13 and 18.91% of the dental students showed poor, fair and good knowledge about pharmacological management in pregnant women; respectively. In addition, it was observed that students under 24 years of age and those from the capital were significantly (p < 0.05) 44% less likely to have poor knowledge of pharmacological management in pregnant women compared to those aged 24 years or older (OR = 0.56; CI: 0.34-0.92) and those from the province (OR = 0.56; CI: 0.32-0.98); respectively. Finally, those in their third and fourth year of study were significantly three times more likely to have poor knowledge (OR = 3.17; CI: 1.68-5.97 and OR = 3.88; CI: 2.07-7.31; respectively) compared to fifth year dental students.
Conclusion:
The knowledge of dental students about pharmacological management in pregnant women was predominantly of fair level. In addition, it was observed that being under 24 years of age and being from the capital city were protective factors against poor knowledge, while being a third- and fourth-year student was a risk factor. Finally, gender, marital status and area of residence were not influential factors in the level of knowledge.
... 20,23,32,40 However, evidence demonstrates that the use of local anesthesia with vasoconstrictor is safe during pregnancy. 48 In fact, a prospective observational study that followed 210 pregnancies exposed to dental local anesthetics versus 794 pregnancies not exposed to them reported no differences between groups in the rate of miscarriages, gestational age at delivery, or birth weight. 49 Given that the small concentration of the vasoconstrictors in the anesthetic solution, they do not represent a risk to the fetus or the pregnancy. ...
Background
Hormonal and behavioral changes during pregnancy may impact the oral health of women, which can influence the pregnancy course. Prenatal care practitioners (PCP) must be aware of this bidirectional relation in order to include an oral assessment in routine prenatal care.
Objectives
To characterize the knowledge and attitudes of PCP regarding oral health in pregnant women.
Search Strategy
The search was carried out in PubMed, Web of Science, Lilacs, Scopus, and Embase on May 2022.
Selection Criteria
Peer‐reviewed cross‐sectional studies published in English within the last 5 years that assessed the knowledge, attitudes, and practices of PCP towards oral health in pregnancy were selected.
Data Collection and Analysis
Data were standardly extracted by the three reviewers from the selected articles and their bias was assessed.
Main Results
From a total of 996 articles, 24 were selected. Overall, most PCP have an adequate level of knowledge regarding the importance of oral health during pregnancy. Although several professionals reported referring their patients to a dentist, the attitudes and practices of the majority of PCP were still inadequate.
Conclusions
PCP are aware of the importance of oral health during pregnancy but still lack translating this knowledge into clinical practice.
... As recommended for local anesthetics during pregnancy in dental medicine, we recommend the application of lidocaine topically and articaine submucosally to anesthetize the nasal mucosa prior to treatment [18]. ...
Appropriate management of hereditary hemorrhagic telangiectasia (HHT) is of particular importance in females, as HHT-mediated modifications of the vascular bed and circulation are known to increase the risk of complications during pregnancy and delivery. This study was undertaken to evaluate female HHT patients’ awareness of and experience with HHT during pregnancy and delivery, with a focus on epistaxis. In this retrospective study, 46 females (median age: 60 years) with confirmed HHT completed a 17-item questionnaire assessing knowledge of HHT and its pregnancy-associated complications, the severity of epistaxis during past pregnancies and deliveries, and the desire for better education and counselling regarding HHT and pregnancy. Results revealed that 85% of participants were unaware of their disease status prior to the completion of all pregnancies. Further, 91% reported no knowledge of increased pregnancy-related risk due to HHT. In regard to epistaxis, 61% of respondents reported experiencing nosebleeds during pregnancy. Finally, approximately a third of respondents suggested that receiving counseling on the risks of HHT in pregnancy could have been helpful. Findings suggest that awareness of HHT and its potential for increasing pregnancy-related risk is poor. Best practices in HHT management should be followed to minimize negative effects of the disorder.
... Surprisingly, the safest drug on the list was amoxicillin and it was identified as safe by relatively fewer respondents (Naseem et al., 2016). This can be alarming, as Amoxicillin is the first choice of antibiotics for the management of pregnant patients reporting facial swelling (Ouanounou & Haas, 2016). ...
Background
The objectives of the study were to assess the knowledge, attitude, and practice of dentists towards providing oral health care to pregnant women and to identify barriers and predictors of periodontal and caries related perinatal oral healthcare practices.
Methods
A cross-sectional analytical survey was conducted on dentists by using a random sampling technique, and a pre-validated questionnaire was delivered to 350 dentists from May 2018 to October 2018. Data were analyzed by utilizing SPSS software. Frequencies and percentages were recorded for descriptive variables. Binary logistic regression was used to analyze the probability of predicting group membership to the dependent variable using different independent variables determined from contingency tables.
Results
Overall response rate was 41%. The mean knowledge score of respondents was 15.86 ± 3.34. The lowest correct responses were noted in the questions related to periodontal health. It was found that the advice to delay dental visits until after pregnancy was eight times more likely to be observed among dentists who lacked the knowledge of importance of oral health during pregnancy ( P = 0.04, OR = 8.75). Dentists were more likely to consult obstetricians regarding dental procedures when they fear a risk of labor in the dental practice ( P < 0.05, OR = 3.72). Dentists who had the knowledge of periodontal disease association with preterm delivery were about four times more likely to treat periodontal disease during pregnancy ( P = 0.01, OR = 3.95). Dentists knowing the association between maternal oral health and childhood decay were more likely to counsel pregnant patients regarding caries prevention ( P > 0.05, OR = 3.75).
Conclusions
Collectively the results indicated few gaps in knowledge among some dentists and a need to improve existing attitudes towards perinatal oral health. Dentists failing to recognize the importance of perinatal oral health are more likely to be hesitant in treating pregnant patients. Failing to recognize the link between periodontal disease and obstetric complications increases the possibility of hesitance to counsel pregnant patients regarding the same. The appreciation of the evidence for poor perinatal oral health and risk of early childhood caries increases the likelihood of counseling by dentists on caries prevention.
... Die Auswirkung einer schädigenden Substanz ist im 1. Trimenon, der Phase der Organanlage, am größten[1]. In der Stillzeit steht der Schutz des Neugeborenen an erster Stelle.Generell gilt: In der Schwangerschaft sollten Medikamente so eingesetzt werden, dass der Nutzen für die Schwangere möglichst groß und das Risiko für den heranwachsenden Fetus möglichst gering ist[1,2,3].Eine nützliche Informationsquelle zur Arzneimittelsicherheit in der Schwangerschaft und Stillzeit ist die Homepage www.embryotox.de (▶ Abb. ...
Die Behandlung schwangerer und stillender Patientinnen ist herausfordernd. Ein Grund mehr für ein Basic, um hier ein Plus an Sicherheit bei der Wahl geeigneter Arzneimittel zu schaffen, wenn während der Schwangerschaft und Stillzeit eine Medikamentengabe erforderlich sein sollte.
... Local anesthetic like 2% Lignocaine with 1:100,000 Adrenaline is also safe during pregnancy if needed. 14 Due to the physiological and anatomical changes, oral health of the pregnant patient can worsen which is usually neglected by the patient. Studies also provide evidence that dentists tend to defer urgent dental care of pregnant patients. ...
OBJECTIVE: The purpose of this study is to reinforce the safety of non-surgical endodontic treatment in the management of acute dental pain of pulpal origin in pregnant patients in all trimesters. METHODOLOGY: The study was conducted amongst pregnant females with acute dental pain. Pain of endodontic origin in 273 pregnant patients was managed by performing non-surgical root canal treatment. Percentages were calculated as descriptive statistics to have a comparison of preferred treatment by dentists for acute pain management during pregnancy. One Way ANOVA was used to explore the difference between treatment selection plans. RESULTS: From the total sample of 273 participants, there was no significant difference found between the selection of endodontic treatment and Trimesters (F (2,270) = .79, p=.45) same results were obtained for the analgesics prescription during pregnancy and the trimesters during pregnancy (F (2,270) = 1.41, p=.24). On the other hand, the difference between the prescription of antibiotics during 1st, 2nd and 3rd trimesters was found which was statistically significant (F (2,270) = 12.38, p> .001). Endodontic treatment was completed on 251 (91.6%) pregnant patients to relieve the acute dental pain whereas only 22 (8.4%) patients did not undergo endodontic treatment in pregnancy. Among the cases who had endodontic treatment, 75.4% of cases were dealt with in the second trimester of pregnancy. The recommendation of antibiotics was less. In the entire data, antibiotic prescription was seen in the second trimester of pregnancy, whereas, overall, antibiotic prescription was at minimal level. Analgesic prescription was found to be (44.1%) in practice among pregnant participants during the treatment. CONCLUSION: Non-Surgical Endodontic Treatment is a safe and reliable treatment option for the management of restorable teeth with acute pain of pulpal origin in pregnant patients. Dentists should not be reluctant in prompt invasive dental management in these patients if indicated. KEYWORDS: pregnancy, pain, dental treatment, endodontic treatment HOW TO CITE: Khan SA, Hassan AU, Iqbal Z, Hassan M. Endodontic management of acute dental pain among pregnant patients. J Pak Dent Assoc 2021;30(1):7-11.
... Various experimental studies demonstrated that the OTM is reduced by the effects of nonsteroidal anti-inflammatory drugs (NSAIDs) due to a reduction in the number of osteoclasts, as prostaglandins are involved in differentiation or stimulation of osteoclasts. 13,14 The effects of various groups of NSAIDs and their effects on OTM are described below: ...
Pregnancy is associated with the various physiological and hormonal changes in females. Orthodontic as well as any dental treatment should not be denied during pregnancy, perhaps some necessary precautions should be taken while treating a pregnant patient. This review article focuses on the hormonal changes and the prescribed drugs taken during pregnancy that affects the orthodontic treatment, the importance of communication and motivation, the precautions to be taken and the orthodontic considerations and management for the pregnant patients. This electronic search was undertaken through Google scholar and PubMed databases by utilizing the appropriate keywords. Literature was extensively reviewed to get information regarding dental and orthodontic treatment during pregnancy. Finally, the overall findings were summarized and presented in the following article. Based on the researched reviews, the orthodontists as well as other health care professionals need to realize that the orthodontic treatment is not a contraindication during pregnancy and can be performed successfully during this period by tak-ing certain precautions. A good communication between the patient and the orthodontist must be established for the successful completion of the orthodontic treatment.
... It is currently believed that the second trimester poses the lowest risk of foetal harm and local anaesthesia use should in theory be safe. 43 While it is possible to complete elective dental treatment during the third trimester of pregnancy, there is a higher risk of aortocaval compression and increased conduction blockade. If local anaesthesia is to be administered in the third trimester, lower doses should be used. ...
Over the past century, there is perhaps no greater contribution to the practice of clinical dentistry than the development and application of local anaesthesia. What were once considered painful procedures have now been made routine by the deposition and action of local anaesthetics. This article will serve as a review of basic pharmacological principles of local anaesthesia, subsequent sequelae that can arise from their use, considerations when using local anaesthetics, and recent advances in the delivery of local anaesthetics.
... Traditionally paracetamol is considered to be the safest of all the analgesics due to its least side effects. NSAIDs are avoided as they are inhibitors of cyclooxygenase and cause premature closure of ductusarteriosus and pulmonary resistance vessels [17]. Opioids such as Codeine are commonly found in over the counter drugs. ...
... Traditionally, paracetamol is considered the safest of all the analgesics due to the lowest side effects. Non-steroidal anti-inflammatory drugs (NSAIDs) are avoided, as they are inhibitors of cyclooxygenase and cause the premature closure of the ductus arteriosus and pulmonary resistance vessel [17]. Opioids such as codeine are commonly found in over-the-counter drugs. ...
... Lidocaine with or without epinephrine in judicious doses has been shown to be the safest local anesthetic during both pregnancy and lactation. [20][21][22] If the practitioner decides to avoid epinephrine, then the safest choices would be plain lidocaine (which has not been available in dental cartridges since 2011) or prilocaine. 23 All other local anesthetic solutions carry a lesser US Food and Drug Administration Pregnancy Category safety rating than lidocaine and prilocaine. ...
... In addition to selected reports, a sizable number of excellent reviews, systematic reviews, and clinical descriptive materials were also published on topics of prosthodontic interest. Although commenting in detail on this additional material is impossible, it is listed here for those interested in practice guidelines, [1][2][3][4] anatomy and physiology, [5][6][7] bruxism, 8,9 conventional removable complete prosthodontics, [10][11][12][13] conventional fixed prosthodontics, [14][15][16][17][18][19][20][21][22][23][24][25][26][27][28][29][30][31] conventional removable partial prosthodontics, 32 diagnostics, 33,34 digital dentistry, [35][36][37] esthetics, [38][39][40][41][42][43][44][45] evidence-based dentistry, [46][47][48] general topics in implant dentistry, [49][50][51][52][53][54][55][56][57][58][59][60][61][62][63][64][65][66] general topics in prosthodontics, [67][68][69][70] geriatric dentistry, [71][72][73][74][75][76][77][78] implant-fixed prosthodontics, [79][80][81][82][83][84][85][86] implant-removable prosthodontics, [87][88][89][90] implant site development, [91][92][93][94][95] implant surgery, [96][97][98][99][100][101][102][103][104] implant treatment planning considerations, [105][106][107][108][109][110][111][112][113][114][115][116] maintenance, [117][118][119][120][121] material science, [122][123][124][125][126][127] maxillofacial prosthetics, [128][129][130] occlusion, [131][132][133][134][135][136] pathology and disease, [137][138][139][140][141][142][143][144][145] pharmacology, [146][147][148][149][150][151][152][153][154][155][156][157][158][159][160][161] radiology, [162][163][164] restorative successsurvival, [165][166][167][168][169][170][171] tooth structure loss and restoration, [172][173][174][175][176][177][178][179][180][181][182] and xerostomia. 183 General prosthodontic considerations Accurate transfer of condylar guidance controls from the patient to an articulator is important prior to laboratory fabrication of indirect occlusal restorations. ...
This review was conducted to assist the busy dentist in keeping abreast of the latest scientific information regarding the clinical practice of dentistry. Each of the authors, who are considered experts in their disciplines, was asked to peruse the scientific literature in their discipline published in 2016 and review the articles for important information that may affect treatment decisions. Comments on experimental methodology, statistical evaluation, and the overall validity of conclusions are included with many of the reviews. The reviews are not meant to stand alone but are intended to inform the interested reader about what has been discovered in the past year. The readers are then invited to go to the source, if they want more detail.
The treatment of dermatological diseases during pregnancy and breastfeeding poses particular challenges for the therapist for medical and legal reasons. Maternal and fetal influencing factors must be taken into account and the special need for protection of the fetus, infant, and mother must be considered in the treatment decision, usually outside of the approval process. Due to the lack of or insufficient evidence for most therapies during pregnancy and breastfeeding, an individual risk–benefit assessment should always be carried out, which also takes into account the risk of nontreatment. In the case of difficult or potentially momentous decisions, information from relevant databases, intercollegiate consultation and, if possible, advice from a clinical ethics committee should be obtained. In any case, the parents, and in particular the mother, should be carefully informed and their consent should be obtained and documented. Recommendations can be made for common chronic inflammatory and infectious dermatoses, but these should be reviewed on a case-by-case basis. For other therapy situations, an individual analysis and decision-making process is necessary. Overall, however, it can be stated that digital data processing and availability, combined with careful analysis, empathetic consideration and information for those affected, enables a successful treatment decision to be made in the vast majority of cases.
Background
Safe and effective local anesthesia is a prerequisite for emergency oral surgeries and most dental treatments. Pregnancy is characterized by complex physiological changes, and increased sensitivity to pain. Pregnant women are particularly vulnerable to oral diseases, such as caries, gingivitis, pyogenic granuloma and third molar pericoronitis. Maternally administered drugs can affect the fetus through the placenta. Therefore, many physicians and patients are reluctant to provide or accept necessary local anesthesia, which leads to delays in the condition and adverse consequences. This review is intended to comprehensively discuss the instructions for local anesthesia in the oral treatment of pregnant patients.
Methodology
An in-depth search on Medline, Embase, and the Cochrane Library was performed to review articles concerned with maternal and fetal physiology, local anesthetic pharmacology, and their applications for oral treatment.
Results
Standard oral local anesthesia is safe throughout the pregnancy. At present, 2% lidocaine with 1:200,000 epinephrine is considered to be the anesthetic agent that best balances safety and efficacy for pregnant women. Maternal and fetal considerations must be taken into account to accommodate the physiological and pharmacological changes in the gestation period. Semi-supine position, blood pressure monitoring, and reassurance are suggested for high-risk mothers to reduce the risk of transient changes in blood pressure, hypoxemia, and hypoglycemia. For patients with underlying diseases, such as eclampsia, hypertension, hypotension, and gestational diabetes, the physicians should use epinephrine cautiously and control the dose of anesthetic. New local anesthesia formulations and equipment, which contribute to minimizing injection pain and relieving the anxiety, have and are being developed but remain understudied.
Conclusions
Understanding the physiological and pharmacological changes during pregnancy is essential to ensure the safety and efficiency of local anesthesia. Optimal outcomes for the mother and fetus hinge on a robust understanding of the physiologic alterations and the appropriate selection of anesthetic drugs and approaches.
Articaine is an intermediate-potency and short-acting amide local anesthetic with a fast metabolism due to an ester group in its structure. Articaine was widely used in dental practice, but now has an effective form for surgical and anesthetic use. Articaine is effective with local infiltration or peripheral nerve block in dentistry, when administered as a spinal, epidural, ocular, or regional nerve block, or when intravenously injected for regional anesthesia. Comparative trials have not revealed a generally significant difference in its clinical effects from those of other short-acting local anesthetics, such as lidocaine, prilocaine, and chloroprocaine, and no conclusive evidence has demonstrated above-average neurotoxicity. Thus, this review discusses the pharmacokinetics and pharmacodynamics, clinical efficacy, and possible side effects of articaine.
Pregnancy is a unique time in a woman's life with many physiological, physical, emotional and hormonal changes occurring. It can also be quite an anxious time for women particularly in the first trimester when the risk of miscarriage is at its highest. Uncertainty still exists around the topic of dental treatment and care during pregnancy, which may create challenges for both the patient and the dental team.
CPD/Clinical Relevance: The treatment options available when managing pregnant patients and for safe prescribing for this population are described.
Die Behandlung schwangerer und stillender Patientinnen ist herausfordernd. Ein Grund mehr für eine SOP, um hier ein Plus an Sicherheit bei der Wahl geeigneter Arzneimittel zu schaffen, wenn während der Schwangerschaft und Stillzeit eine Medikamentengabe erforderlich sein sollte (aktualisierter Nachdruck aus ZWR – Das Deutsche Zahnärzteblatt 2021; 130(6): 295–297).
El objetivo de este artículo es revisar información enfocada en mitos sobre la gestación y la salud oral. Las gestantes son consideradas un grupo prioritario de atención en salud, pero una de las barreras más importantes para que esta atención sea realizada son las creencias populares que trascienden de generación en generación. Entre estas, podemos encontrar algunos mitos como el que las mujeres embarazadas desarrollan un mayor número de lesiones cariosas, debido a que el ser en formación requiere mayor requerimiento de calcio. De igual forma, se acepta como un proceso normal durante la gestación que por cada hijo se pierde un diente. Así mismo, existe también la creencia que la atención odontológica causa daño al feto por el uso de anestésicos locales o medicamentos. Otro de los mitos más temidos es la toma de imágenes radiográficas durante la gestación y si el uso de amalgama en las restauraciones dentales es tóxica para el bebé.
Physiologic changes in pregnancy induce profound alterations to the pharmacokinetic properties of many medications. These changes affect distribution, absorption, metabolism, and excretion of drugs, and thus may impact their pharmacodynamic properties during pregnancy. Pregnant women undergo several adaptations in many organ systems. Some adaptations are secondary to hormonal changes in pregnancy, while others occur to support the gravid woman and her developing fetus. Some of the changes in maternal physiology during pregnancy include, for example, increased maternal fat and total body water, decreased plasma protein concentrations, especially albumin, increased maternal blood volume, cardiac output, and blood flow to the kidneys and uteroplacental unit, and decreased blood pressure. The maternal blood volume expansion occurs at a larger proportion than the increase in red blood cell mass, which results in physiologic anemia and hemodilution. Other physiologic changes include increased tidal volume, partially compensated respiratory alkalosis, delayed gastric emptying and gastrointestinal motility, and altered activity of hepatic drug metabolizing enzymes. Understating these changes and their profound impact on the pharmacokinetic properties of drugs in pregnancy is essential to optimize maternal and fetal health.
Importance:
Acetaminophen (paracetamol) is the most commonly used medication for pain and fever during pregnancy in many countries. Research data suggest that acetaminophen is a hormone disruptor, and abnormal hormonal exposures in pregnancy may influence fetal brain development.
Objective:
To evaluate whether prenatal exposure to acetaminophen increases the risk for developing attention-deficit/hyperactivity disorder (ADHD)-like behavioral problems or hyperkinetic disorders (HKDs) in children.
Design, setting, and participants:
We studied 64,322 live-born children and mothers enrolled in the Danish National Birth Cohort during 1996-2002.
Exposures:
Acetaminophen use during pregnancy was assessed prospectively via 3 computer-assisted telephone interviews during pregnancy and 6 months after child birth.
Main outcomes and measures:
To ascertain outcome information we used (1) parental reports of behavioral problems in children 7 years of age using the Strengths and Difficulties Questionnaire; (2) retrieved HKD diagnoses from the Danish National Hospital Registry or the Danish Psychiatric Central Registry prior to 2011; and (3) identified ADHD prescriptions (mainly Ritalin) for children from the Danish Prescription Registry. We estimated hazard ratios for receiving an HKD diagnosis or using ADHD medications and risk ratios for behavioral problems in children after prenatal exposure to acetaminophen.
Results:
More than half of all mothers reported acetaminophen use while pregnant. Children whose mothers used acetaminophen during pregnancy were at higher risk for receiving a hospital diagnosis of HKD (hazard ratio = 1.37; 95% CI, 1.19-1.59), use of ADHD medications (hazard ratio = 1.29; 95% CI, 1.15-1.44), or having ADHD-like behaviors at age 7 years (risk ratio = 1.13; 95% CI, 1.01-1.27). Stronger associations were observed with use in more than 1 trimester during pregnancy, and exposure response trends were found with increasing frequency of acetaminophen use during gestation for all outcomes (ie, HKD diagnosis, ADHD medication use, and ADHD-like behaviors; P trend < .001). Results did not appear to be confounded by maternal inflammation, infection during pregnancy, the mother's mental health problems, or other potential confounders we evaluated.
Conclusions and relevance:
Maternal acetaminophen use during pregnancy is associated with a higher risk for HKDs and ADHD-like behaviors in children. Because the exposure and outcome are frequent, these results are of public health relevance but further investigations are needed.
Paracetamol is used extensively during pregnancy, but studies regarding the potential neurodevelopmental sequelae of foetal paracetamol exposure are lacking.Method Between 1999 and 2008 all pregnant Norwegian women were eligible for recruitment into the prospective Norwegian Mother and Child Cohort Study. The mothers were asked to report on their use of paracetamol at gestational weeks 17 and 30 and at 6 months postpartum. We used data on 48 631 children whose mothers returned the 3-year follow-up questionnaire by May 2011. Within this sample were 2919 same-sex sibling pairs who were used to adjust for familial and genetic factors. We modelled psychomotor development (communication, fine and gross motor development), externalizing and internalizing behaviour problems, and temperament (emotionality, activity, sociability and shyness) based on prenatal paracetamol exposure using generalized linear regression, adjusting for a number of factors, including febrile illness, infections and co-medication use during pregnancy.
The sibling-control analysis revealed that children exposed to prenatal paracetamol for more than 28 days had poorer gross motor development [β 0.24, 95% confidence interval (CI) 0.12-0.51], communication (β 0.20, 95% CI 0.01-0.39), externalizing behaviour (β 0.28, 95% CI 0.15-0.42), internalizing behaviour (β 0.14, 95% CI 0.01-0.28), and higher activity levels (β 0.24, 95% CI 0.11-0.38). Children exposed prenatally to short-term use of paracetamol (1-27 days) also had poorer gross motor outcomes (β 0.10, 95% CI 0.02-0.19), but the effects were smaller than with long-term use. Ibuprofen exposure was not associated with neurodevelopmental outcomes.
Children exposed to long-term use of paracetamol during pregnancy had substantially adverse developmental outcomes at 3 years of age.
Opioids remain the cornerstone of modern-day pain treatment, also in the paediatric population. Opioid treatment is potentially life-threatening, although there are no numbers available on the incidence of opioid-induced respiratory depression (OIRD) in paediatrics. To get an indication of specific patterns in the development/causes of OIRD, we searched PubMed (May 2012) for all available case reports on OIRD in paediatrics, including patients 12 yr of age or younger who developed OIRD from an opioid given to them for a medical indication or due to transfer of an opioid from their mother in the perinatal setting, requiring naloxone, tracheal intubation, and/or resuscitation. Twenty-seven cases are described in 24 reports; of which, seven cases were fatal. In eight cases, OIRD was due to an iatrogenic overdose. Three distinct patterns in the remaining data set specifically related to OIRD include: (i) morphine administration in patients with renal impairment, causing accumulation of the active metabolite of morphine; (ii) codeine use in patients with CYP2D6 gene polymorphism associated with the ultra-rapid metabolizer phenotype, causing enhanced production of the morphine; and (iii) opioid use in patients after adenotonsillectomy for recurrent tonsillitis and/or obstructive sleep apnoea, where OIRD may be related to hypoxia-induced enhancement of OIRD. Despite the restrictions of this approach, our analysis does yield an important insight in the development of OIRD, with specific risk factors clearly present in the data.
Objective:
Benzodiazepines (BDZs) safety profiles in pregnancy suggest that the risk of major malformations (MMs) cannot be considered simply as a "class effect". The aim of this paper was to review and update the available literature on the risks of MMs in women exposed to BDZs in the first trimester of pregnancy.
Methods:
PubMed was searched for English-language articles, from January 2001 to November 2011, introducing as keywords "teratogens", " major malformation", "foetus", "infant", "newborn", "pregnancy", in conjunction with "benzodiazepines" as a keyword or BDZ generic name as text words.
Results:
Twelve studies were selected for the review. BDZ exposure during the first trimester of pregnancy seems not to be associated with an increasing risk of congenital MMs. Diazepam and chlordiazepoxide should be considered drugs of first choice.
Conclusions:
Data published in the last 10 years did not indicate an absolute contraindication in prescribing BDZs during the first gestational trimester. In any case, studies analyzed suffer from a number of methodological limitations such as lack of careful report of BDZ patterns of use in pregnancy, possible influences of recall bias, lack of controlling for confounding factors and lack of data concerning possible MMs in aborted fetuses.
Despite advances in the study of birth defects related to drug exposures during pregnancy, medication use during pregnancy still causes anxiety and misunderstanding among both members of the public and health care professionals. This may result in a woman's unknowingly taking a medication that may harm the fetus or cause a birth defect or discontinuing medications necessary for treating chronic conditions. Using medications while breast-feeding also represents a challenge for patients and prescribers. Many mothers are told they must stop breast-feeding or "pump and discard" their breast milk if they are taking certain medications; however, in many cases, this advice-based on what may be limited education on the part of the health care provider about breast-feeding and medication use-may be incorrect. The authors review the current evidence regarding drugs that may be safe for pregnant or breast-feeding patients and medications that such patients should avoid.
When considering prescribing in pregnancy, the dentist must weigh the risk to the fetus versus the benefit to the mother, and the appropriate conclusion should reflect current evidence. In some cases medication dosing should be avoided or altered; however, there are times when it is unnecessary to stop the use of medications. Breast-feeding also represents a clinical challenge, the risks and benefits of which need to be understood by both the patient and practitioner before any medication is administered.
Dentists should be familiar with the risks and benefits for pregnant or breast-feeding patients posed by five types of medications: analgesics and anti-inflammatories, antibiotics, local anesthetics, sedatives and emergency medications.
To assess whether treatment with metronidazole during pregnancy is associated with preterm birth, low birth weight, or major
congenital anomalies, we conducted chart reviews and an analysis of electronic data from a cohort of women delivering at an
urban New York State hospital. Of 2,829 singleton/mother pairs, 922 (32.6%) mothers were treated with metronidazole for clinical
indications, 348 (12.3%) during the first trimester of pregnancy and 553 (19.5%) in the second or third trimester. There were
333 (11.8%) preterm births, 262 (9.3%) infants of low birth weight, and 52 infants (1.8%) with congenital anomalies. In multivariable
analysis, no association was found between metronidazole treatment and preterm birth (odds ratio [OR], 1.02 [95% confidence
interval [CI], 0.80 to 1.32]), low birth weight (OR, 1.05 [95% CI, 0.77 to 1.43]), or treatment in the first trimester and
congenital anomalies (OR, 0.86 [0.30 to 2.45]). We found no association between metronidazole treatment during the first or
later trimesters of pregnancy and preterm birth, low birth weight, or congenital anomalies.
Pregnancy is a unique time in a woman's life, accompanied by a variety of physiologic, anatomic, and hormonal changes that can affect how oral health care is provided. However, these patients are not medically compromised and should not be denied dental treatment simply because they are pregnant. This article discusses the normal changes associated with pregnancy, general considerations in the care of pregnant patients, and possible dental complications of pregnancy and their management.
Diazepam transfer by the first trimester human placenta was investigated at pregnancy termination between 6 and 12 weeks of gestation. Fetal fluid samples were obtained from the exocoelomic and amniotic cavities of 65 pregnancies between 8 and 25 min following the i.v. administration of 0.1 mg/kg diazepam to the mother. Diazepam was detected in one-third of coelomic fluid samples and two-thirds of amniotic fluid samples. Maternal serum and urine diazepam concentrations correlated negatively and positively respectively, with time from drug injection to sampling. Individual diazepam concentrations were low on the fetal side, and the corresponding concentrations were independent of maternal serum concentrations and the time from drug injection to sampling. Amniotic fluid diazepam content increased significantly with advancing gestational age. A multiple regression analysis showed that the diazepam content of the coelomic fluid was not influenced by maternal serum diazepam concentration, the time from drug injection to sampling or gestational age, whereas only gestational age contributed to the diazepam content of amniotic fluid. These data demonstrate that the placental transfer of diazepam occurs from week 6 of gestation, indicate a preferential transfer of this drug to the amniotic cavity and suggest that diazepam may accumulate in fetal circulation and tissues during organogenesis.
To determine if exposure to benzodiazepines during the first trimester of pregnancy increases risk of major malformations or cleft lip or palate.
Meta-analysis.
Studies from 1966 to present.
Studies were located with Medline, Embase, Reprotox, and from references of textbooks, reviews, and included articles. Included studies were original, concurrently controlled studies in any language.
Data extraction and quality assessment were done independently and in duplicate.
Maternal exposure to benzodiazepines in at least the first trimester; incidence of major malformations or oral cleft alone, measured as odds ratios and 95% confidence intervals with a random effects model.
Of over 1400 studies reviewed, 74 were retrieved and 23 included. In the analysis of cohort studies fetal exposure to benzodiazepine was not associated with major malformations (odds ratio 0.90; 95% confidence interval 0.61 to 1. 35) or oral cleft (1.19; 0.34 to 4.15). Analysis of case-control studies showed an association between exposure to benzodiazepines and development of major malformations (3.01; 1.32 to 6.84) or oral cleft alone (1.79; 1.13 to 2.82).
Pooled data from cohort studies showed no association between fetal exposure to benzodiazepines and the risk of major malformations or oral cleft. On the basis of pooled data from case-control studies, however, there was a significant increased risk for major malformations or oral cleft alone. Until more research is reported, level 2 ultrasonography should be used to rule out visible forms of cleft lip.
Bacterial vaginosis has been associated with preterm birth. In clinical trials, the treatment of bacterial vaginosis in pregnant women who previously had a preterm delivery reduced the risk of recurrence.
To determine whether treating women in a general obstetrical population who have asymptomatic bacterial vaginosis (as diagnosed on the basis of vaginal Gram's staining and pH) prevents preterm delivery, we randomly assigned 1953 women who were 16 to less than 24 weeks pregnant to receive two 2-g doses of metronidazole or placebo. The diagnostic studies were repeated and a second treatment was administered to all the women at 24 to less than 30 weeks' gestation. The primary outcome was the rate of delivery before 37 weeks' gestation.
Bacterial vaginosis resolved in 657 of 845 women who had follow-up Gram's staining in the metronidazole group (77.8 percent) and 321 of 859 women in the placebo group (37.4 percent). Data on the time and characteristics of delivery were available for 953 women in the metronidazole group and 966 in the placebo group. Preterm delivery occurred in 116 women in the metronidazole group (12.2 percent) and 121 women in the placebo group (12.5 percent) (relative risk, 1.0; 95 percent confidence interval, 0.8 to 1.2). Treatment did not prevent preterm deliveries that resulted from spontaneous labor (5.1 percent in the metronidazole group vs. 5.7 percent in the placebo group) or spontaneous rupture of the membranes (4.2 percent vs. 3.7 percent), nor did it prevent delivery before 32 weeks (2.3 percent vs. 2.7 percent). Treatment with metronidazole did not reduce the occurrence of preterm labor, intraamniotic or postpartum infections, neonatal sepsis, or admission of the infant to the neonatal intensive care unit.
The treatment of asymptomatic bacterial vaginosis in pregnant women does not reduce the occurrence of preterm delivery or other adverse perinatal outcomes.
To estimate the risk of adverse birth outcome in women who take non-steroidal anti-inflammatory drugs during pregnancy.
Population based cohort study and a case-control study, both based on data from a prescription registry, the Danish birth registry, and one county's hospital discharge registry.
COHORT STUDY: 1462 pregnant women who had taken up prescriptions for non-steroidal anti-inflammatory drugs in the period from 30 days before conception to birth and 17 259 pregnant women who were not prescribed any drugs during pregnancy. CASE-CONTROL STUDY: 4268 women who had miscarriages, of whom 63 had taken non-steroidal anti-inflammatory drugs, and 29 750 primiparous controls who had live births.
Incidences of congenital abnormality, low birth weight, preterm birth, and miscarriage.
Odds ratios for congenital abnormality, low birth weight, and preterm birth among women who took up prescriptions for non-steroidal anti-inflammatory drugs were 1.27 (95% confidence interval 0.93 to 1.75), 0.79 (0.45 to 1.38), and 1.05 (0.80 to 1.39) respectively. Odds ratios for the taking up of prescriptions in the weeks before miscarriage ranged from 6.99 (2.75 to 17.74) when prescriptions were taken up during the last week before the miscarriage to 2.69 (1.81 to 4.00) when taken up between 7 and 9 weeks before. The risk estimates were no different when the analysis was restricted to missed abortions.
Use of non-steroidal anti-inflammatory drugs during pregnancy does not seem to increase the risk of adverse birth outcome but is associated with increased risk of miscarriage.
Infection with Trichomonas vaginalis during pregnancy has been associated with preterm delivery. It is uncertain whether treatment of asymptomatic trichomoniasis in pregnant women reduces the occurrence of preterm delivery.
We screened pregnant women for trichomoniasis by culture of vaginal secretions. We randomly assigned 617 women with asymptomatic trichomoniasis who were 16 to 23 weeks pregnant to receive two 2-g doses of metronidazole (320 women) or placebo (297 women) 48 hours apart. We treated women again with the same two-dose regimen at 24 to 29 weeks of gestation. The primary outcome was delivery before 37 weeks of gestation.
Between randomization and follow-up, trichomoniasis resolved in 249 of 269 women for whom follow-up cultures were available in the metronidazole group (92.6 percent) and 92 of 260 women with follow-up cultures in the placebo group (35.4 percent). Data on the time and characteristics of delivery were available for 315 women in the metronidazole group and 289 women in the placebo group. Delivery occurred before 37 weeks of gestation in 60 women in the metronidazole group (19.0 percent) and 31 women in the placebo group (10.7 percent) (relative risk, 1.8; 95 percent confidence interval, 1.2 to 2.7; P=0.004). The difference was attributable primarily to an increase in preterm delivery resulting from spontaneous preterm labor (10.2 percent vs. 3.5 percent; relative risk, 3.0; 95 percent confidence interval, 1.5 to 5.9).
Treatment of pregnant women with asymptomatic trichomoniasis does not prevent preterm delivery. Routine screening and treatment of asymptomatic pregnant women for this condition cannot be recommended.
To evaluate whether prenatal use of non-steroidal anti-inflammatory drugs (NSAIDs) is associated with increased risk of miscarriage.
Population based cohort study. Prenatal use of NSAIDs, aspirin, and paracetamol (acetaminophen) ascertained by in-person interview.
Kaiser Permanente Medical Care Program, a healthcare delivery system, in the San Francisco area of the United States.
1055 pregnant women recruited and interviewed immediately after their positive pregnancy test. Median gestational age at entry to the study was 40 days.
Pregnancy outcomes up to 20 weeks of gestation.
53 women (5%) reported prenatal NSAID use around conception or during pregnancy. After adjustment for potential confounders, prenatal NSAID use was associated with an 80% increased risk of miscarriage (adjusted hazard ratio 1.8 (95% confidence interval 1.0 to 3.2)). The association was stronger if the initial NSAID use was around the time of conception or if NSAID use lasted more than a week. Prenatal aspirin use was similarly associated with an increased risk of miscarriage. However, prenatal use of paracetamol, pharmacologically different from NSAIDs and aspirin, was not associated with increased risk of miscarriage regardless of timing and duration of use.
Prenatal use of NSAIDs and aspirin increased the risk of miscarriage. These findings need confirmation in studies designed specifically to examine the apparent association.
Pregnancy is associated with profound anatomical, physiological, biochemical and endocrine changes that affect multiple organs and systems. These changes are essential to help the woman to adapt to the pregnant state and to aid fetal growth and survival. However, such anatomical and physiological changes may cause confusion during clinical examination of a pregnant woman. Similarly, changes in blood biochemistry during pregnancy may create difficulties in interpretation of results. Conversely, clinicians also need to recognise pathological deviations in these normal anatomical and physiological changes during pregnancy to institute appropriate action to improve maternal and fetal outcome
Background. Fertility is reduced in female rats exposed to levels of nitrous oxide similar to those found in some dental offices. Epidemiologic studies have suggested an association between exposure to mixed anesthetic gases and impaired fertility. We investigated the effects of occupational exposure to nitrous oxide on the fertility of female dental assistants. Methods. Screening questionnaires were mailed to 7000 female dental assistants, ages 18 to 39, registered by the California Department of Consumer Affairs. Sixty-nine percent responded. Four hundred fifty-nine women were determined to be eligible, having become pregnant during the previous four years for reasons unrelated to the failure of birth control, and 91 percent of these women completed telephone interviews. Detailed information was collected on exposure to nitrous oxide and fertility (measured by the number of menstrual cycles without contraception that the women required to become pregnant). Results. After controlling for covariates, we found that women exposed to high levels of nitrous oxide were significantly less fertile than women who were unexposed or exposed to lower levels of nitrous oxide. The effect was evident only in the 19 women with five or more hours of exposure per week. These women were only 41 percent (95 percent confidence interval, 23 to 74 percent; P<0.003) as likely as unexposed women to conceive during each menstrual cycle. Conclusions. Occupational exposure to high levels of nitrous oxide may adversely affect a woman's ability to become pregnant.
Pregnancy involves remarkable orchestration of physiologic changes. The kidneys are central players in the evolving hormonal milieu of pregnancy, responding and contributing to the changes in the environment for the pregnant woman and fetus. The functional impact of pregnancy on kidney physiology is widespread, involving practically all aspects of kidney function. The glomerular filtration rate increases 50% with subsequent decrease in serum creatinine, urea, and uric acid values. The threshold for thirst and antidiuretic hormone secretion are depressed, resulting in lower osmolality and serum sodium levels. Blood pressure drops approximately 10 mmHg by the second trimester despite a gain in intravascular volume of 30% to 50%. The drop in systemic vascular resistance is multifactorial, attributed in part to insensitivity to vasoactive hormones, and leads to activation of the renin-aldosterone-angiostensin system. A rise in serum aldosterone results in a net gain of approximately 1000 mg of sodium. A parallel rise in progesterone protects the pregnant woman from hypokalemia. The kidneys increase in length and volume, and physiologic hydronephrosis occurs in up to 80% of women. This review will provide an understanding of these important changes in kidney physiology during pregnancy, which is fundamental in caring for the pregnant patient.
The disposition of many medications is altered during pregnancy. Due to changes in many physiological parameters as well as variability in the activity of maternal drug-metabolizing enzymes, the efficacy and toxicity of drugs used by pregnant women can be difficult to predict. Enzymatic activity exhibited by the placenta and fetus may affect maternal drug distribution and clearance also. In addition, efflux transporters have been detected in high amounts within placental tissue, potentially limiting fetal exposure to xenobiotics. Dosage adjustments of antiepileptic drugs, antidepressants and anti-infectives administered during pregnancy have been required due to these changes in drug metabolism and disposition. As such, pregnant women may require different dosing regimens than both men and non-pregnant women.
This review of the safety and risks of nitrous oxide (N(2) O) labor analgesia presents results of a search for evidence of its effects on labor, the mother, the fetus, the neonate, breastfeeding, and maternal-infant bonding. Concerns about apoptotic damage to the brains of immature mammals exposed to high doses of N(2) O during late gestation, possible cardiovascular risks from hyperhomocysteinemia caused by N(2) O, a hypothesis that children exposed to N(2) O during birth are more likely to become addicted to amphetamine drugs as adults, and possible occupational risks for those who provide care to women using N(2) O/O(2) labor analgesia are discussed in detail.
Research relevant to the 4 special concerns and to the effects of N(2) O analgesia on labor and the mother-child dyad were examined in depth. Three recent reviews of the biologic, toxicologic, anesthetic, analgesic, and anxiolytic effects of N(2) O; 3 reviews of the safety of 50% N(2) O/oxygen (O(2) ) in providing analgesia in a variety of health care settings; and a 2002 systematic review of N(2) O/O(2) labor analgesia were used.
Nitrous oxide analgesia is safe for mothers, neonates, and those who care for women during childbirth if the N(2) O is delivered as a 50% blend with O(2) , is self-administered, and good occupational hygiene is practiced. Because of the strong correlation between dose and harm from exposure to N(2) O, concerns based on effects of long exposure to high anesthetic-level doses of N(2) O have only tenuous, hypothetical pertinence to the safety of N(2) O/O(2) labor analgesia.
Nitrous oxide labor analgesia is safe for the mother, fetus, and neonate and can be made safe for caregivers. It is simple to administer, does not interfere with the release and function of endogenous oxytocin, and has no adverse effects on the normal physiology and progress of labor.
Before marketing a new drug, the manufacturer almost never tests the product in pregnant women to determine its effects on the fetus. Consequently, most drugs are not labeled for use during pregnancy. Typically, descriptions of drugs that appear in the Physicians' Desk Reference and similar sources contain statements such as, “Use in pregnancy is not recommended unless the potential benefits justify the potential risks to the fetus.” Since the risk has been adequately established for only a few drugs, physicians caring for pregnant women have very little information to help them decide whether the potential benefits to the mother outweigh . . .
Benzodiazepines are commonly used by women of reproductive age, and hence many pregnant women are exposed to them. An updated meta-analysis of their fetal safety synthesized nine studies with over one million pregnancies, yielding an odds ratio of 1.07 (95% CI 0.91 to 1.25). While benzodiazepines do not appear to increase teratogenic risk in general, case-controls suggest a twofold increased risk of oral cleft.
Acetaminophen is commonly used during pregnancy. Experimental animal studies do not suggest increased malformations after therapeutic use of single-ingredient acetaminophen during pregnancy. Cohort studies in humans in which exposure is prospectively ascertained show no detectable increase in congenital malformation risk associated with single-ingredient acetaminophen use during pregnancy. A case-control study identified an association between acetaminophen use during pregnancy and risk of gastroschisis in the offspring, but the study was limited by recall bias, unblinded interviewers, possible misclassification of gastroschisis, confounding by indication, difficulty in separating out the effects of combination products, and possible selection bias. Two case-control studies failed to identify a statistically significant association between acetaminophen use during pregnancy and gastroschisis. No other malformation has been shown to be causally associated with single-ingredient acetaminophen. A reported association between pre-eclampsia, preterm birth, and acetaminophen may be explained by reverse causation. Concerns expressed about childhood asthma and prenatal acetaminophen use has been addressed in a separate review. The use of single-ingredient acetaminophen during pregnancy can be justified based on outcome data. Data on the effects of acetaminophen cannot necessarily be extended to acetaminophen combination products.
Medication use during pregnancy is prevalent, but pharmacokinetic information of most drugs used during pregnancy is lacking in spite of known effects of pregnancy on drug disposition. Accurate pharmacokinetic information is essential for optimal drug therapy in mother and fetus. Thus, understanding how pregnancy influences drug disposition is important for better prediction of pharmacokinetic changes of drugs in pregnant women.
Pregnancy is known to affect hepatic drug metabolism, but the underlying mechanisms remain unknown. Physiological changes accompanying pregnancy are probably responsible for the reported alteration in drug metabolism during pregnancy. These include elevated concentrations of various hormones such as estrogen, progesterone, placental growth hormones and prolactin. This review covers how these hormones influence expression of drug-metabolizing enzymes (DMEs), thus potentially responsible for altered drug metabolism during pregnancy.
The reader will gain a greater understanding of the altered drug metabolism in pregnant women and the regulatory effects of pregnancy hormones on expression of DMEs.
In-depth studies in hormonal regulatory mechanisms as well as confirmatory studies in pregnant women are warranted for systematic understanding and prediction of the changes in hepatic drug metabolism during pregnancy.
Local anesthetics are believed to be the most frequently used drugs in clinical dentistry, and although they are generally regarded as safe, some adverse reactions can be expected and do occur. The purpose of this study was to obtain, by means of a mail survey, information on the types and amounts of local anesthetics used by Ontario dentists during 2007.
A survey requesting data on the annual use of injectable local anesthetics was mailed to all 8,058 dentists licensed by the Royal College of Dental Surgeons of Ontario in 2007.
The effective response rate to the single mailing was 17.3% (1,395 respondents). By extrapolation, the estimated use of local anesthetics by all Ontario dentists during 2007 was determined to be about 13 million cartridges, which represents an average of 1,613 cartridges per dentist per year. Lidocaine with epinephrine 1:100,000 was the most commonly used formulation with 37.31% of total anesthetic use, followed by articaine with 1:200,000 epinephrine (27.04%) and articaine with 1:100,000 epinephrine (17.16%). Overall, local anesthetics combined with a vasoconstrictor accounted for more than 90% of total anesthetic use. A minority of survey respondents (15.68%) indicated that their pattern of anesthetic use had changed significantly in the past few years. Patterns of use were similar for early and late survey respondents. These data provide a current account of the use of local anesthetics by Ontario dentists.
Women in the second half of pregnancy, who were infected with genital mycoplasmas and who gave written informed consent, were randomly assigned to receive capsules of identical appearance containing erythromycin estolate, clindamycin hydrochloride, or a placebo for 6 weeks. Levels of serum glutamic oxalacetic transaminase (SGOT) were determined before and during treatment by a fluorometric method. All pretreatment levels of SGOT were normal (<41 units). Participants who received erythromycin estolate had significantly more abnormally elevated levels of SGOT (16/161, 9.9%) than did those who received clindamycin (4/168, 2.4%, P < 0.01) or those who received placebo (3/165, 1.8%, P < 0.01). Elevated levels of SGOT ranged from 44 to 130 U. Serum bilirubin levels were normal. Gamma-glutamyl transpeptidase activity was abnormal in six of six participants who had abnormal levels of SGOT while receiving erythromycin estolate. There were few associated symptoms, and all levels of SGOT returned to normal after cessation of treatment. The treatment of pregnant women with erythromycin estolate may be inadvisable.
6.6% of all Australian patients attending an antenatal clinic were found to be taking salicylate preparations regularly, most commonly in powder form and almost always as self-medication. In this group of salicylate takers there was an increased incidence of anaemia, anti-partum and post-partum haemorrhage, prolonged gestation, complicated deliveries, and perinatal mortality compared with non-takers. These findings suggest that regular salicylate consumption has detrimental effects in pregnancy. Routine antenatal urinary screening for salicylate in pregnancy is recommended.
Fertility is reduced in female rats exposed to levels of nitrous oxide similar to those found in some dental offices. Epidemiologic studies have suggested an association between exposure to mixed anesthetic gases and impaired fertility. We investigated the effects of occupational exposure to nitrous oxide on the fertility of female dental assistants.
Screening questionnaires were mailed to 7000 female dental assistants, ages 18 to 39, registered by the California Department of Consumer Affairs. Sixty-nine percent responded. Four hundred fifty-nine women were determined to be eligible, having become pregnant during the previous four years for reasons unrelated to the failure of birth control, and 91 percent of these women completed telephone interviews. Detailed information was collected on exposure to nitrous oxide and fertility (measured by the number of menstrual cycles without contraception that the women required to become pregnant).
After controlling for covariates, we found that women exposed to high levels of nitrous oxide were significantly less fertile than women who were unexposed or exposed to lower levels of nitrous oxide. The effect was evident only in the 19 women with five or more hours of exposure per week. These women were only 41 percent (95 percent confidence interval, 23 to 74 percent; P less than 0.003) as likely as unexposed women to conceive during each menstrual cycle.
Occupational exposure to high levels of nitrous oxide may adversely affect women's ability to become pregnant.
Acute or chronic exposure to nitrous oxide or chronic exposure to ethanol decreases the activity of the vitamin B12-dependent enzyme methionine synthase. To assess the combined effect of acute exposure to nitrous oxide and ethanol, mice were given an intraperitoneal injection of ethanol (3 g/kg) and exposed to an inspired mixture of 66% nitrous oxide and 34% oxygen for 4 hr. Methionine synthase activities in liver, kidney, and brain were measured immediately after exposure to nitrous oxide and at various times over a 4-day recovery period. Methionine synthase activities in liver and kidney returned to control levels 2-4 days following inactivation. In brain, a significant 16% decrease in methionine synthase activity remained after a 4-day recovery period. The acute administration of ethanol did not alter the magnitude of the inactivation induced by nitrous oxide nor the time course of recovery of methionine synthase activity following inactivation. Moreover, in mice that were not exposed to nitrous oxide, methionine synthase activity was not altered by the acute administration of ethanol alone or in combination with 0.4% atm isoflurane. Thus, in this animal model, an acute dose of ethanol does not alter methionine synthase activity nor does it enhance the inactivation produced by nitrous oxide.
A mail survey of 30,650 dentists and 30,547 chairside assistants grouped according to occupational exposure to inhalation anesthetic and sedatives in the dental operatory indicated increased general health problems and reproductive difficulties among respondents exposed to anesthetics. For male dentists who were heavily exposed to anesthetics, the increase in liver disease was 1.7-fold, kidney disease was 1.2-fold, and neurological disease was 1.9-fold. For wives of male dentists who were heavily exposed to anesthetics, the increase in spontaneous abortion rate was 1.5-fold. Among female chairside assistants who were heavily exposed to anesthetics, the increase in liver disease was 1.6-fold, kidney disease was 1.7-fold, and neurological disease was 2.8-fold. The increase in spontaneous abortion rate among assistants who were heavily exposed was 2.3-fold. Cancer rates in women heavily exposed to inhalation anesthetics were increased 1.5-fold but this finding was not statistically significant (P = .06). Separate analysis of the data for disease rates and birth difficulties by type of inhalation anesthetic indicates that in both dentists and chairside assistants chronic exposure to nitrous oxide alone is associated with an increase rate of adverse response.
Studies in pregnant women treated in different stages of pregnancy with metronidazole do not yield evidence of teratogenic effects. However, premature births, stillbirths and birth defects have been reported in mice, rats and guinea pigs. The characteristics of metronidazole suggest a potential teratogenicity. Evidence for this could be 2 unrelated patients with midline facial defects, one with holotelencephaly and the other with unilateral cleft lip and palate.
A mail survey to obtain data on the annual use of local anesthetics in dentistry was sent to each of the 6,271 certified dentists in Ontario in 1993. The survey asked dentists to identify the different types and total amounts of local anesthetics used in their practice yearly. A total of 2,426 dentists responded to the survey. Based on extrapolation of the data collected, it is estimated that more than 11,000,000 cartridges of local anesthetic are administered annually by dentists in Ontario. The distribution of use of specific types of local anesthetics and vasoconstrictors was also determined. Lidocaine with 1:100,000 epinephrine accounted for 23.4 per cent of all cartridges used, followed by articaine with 1:200,000 epinephrine (19.9 per cent), articaine with 1:100,000 epinephrine (17.9 per cent), prilocaine with 1:200,000 epinephrine (16.4 per cent), mepivacaine with 1:20,000 levonordefrin (6.4 per cent), and mepivacaine plain (6.3 per cent). Other anesthetics were used to a lesser degree. Further analysis revealed no statistically-significant differences in the use of local anesthetics among dentists who responded to the survey and non-responders. The results of this survey document the current use of local anesthetics in dentistry.
Our purpose was to determine from published experience in humans whether metronidazole exposure during the first trimester of pregnancy is associated with an increased teratogenic risk.
All published articles reporting on metronidazole use during pregnancy were screened by two independent reviewers to select those including pregnant patients exposed during the first trimester and comparing the outcomes of their pregnancies with that of patients either not exposed to metronidazole or exposed only during the third trimester. The outcome under consideration was the occurrence of birth defects in live-born infants. The overall odds ratios of first-trimester exposure versus no first-trimester exposure was calculated by combining the selected studies in a meta-analysis according to the procedure of Mantel and Haenszel.
From 32 identified studies, 7 met the inclusion criteria for meta-analysis. Six were prospective and included 253 women exposed to the drug in the first trimester of pregnancy; one was retrospective and reported on 1083 exposed women. The overall weighted odds ratio of exposure versus no exposure during the first trimester calculated by meta-analysis of the 7 studies was 0.93 (95% confidence interval 0.73 to 1.18). The odds ratio calculated from the 6 prospective studies was 1.02 (95% confidence interval 0.48 to 2.18).
Metronidazole does not appear to be associated with an increased teratogenic risk.
To determine whether the use of metronidazole by pregnant women increases the risk of birth defects in the offspring.
Two cohorts of pregnant women who delivered live-born or stillborn infants between January 1, 1983 and December 31, 1988 were identified from the Tennessee Medicaid enrollment files. The exposed cohort consisted of 1387 women who filled a prescription for metronidazole between 30 days before and 120 days after the onset of their last normal menstrual period. The unexposed cohort consisted of 1387 comparable women who did not fill a prescription for metronidazole during the same time. Medical records for 94% of the offspring of both study cohorts were then reviewed to ascertain the occurrence of birth defects.
Pregnancy outcomes were similar for the exposed and unexposed cohort members. There was no excess of overall birth defect occurrence in the offspring of exposed women (risk ratio 1.2, 95% confidence interval 0.9-1.6), nor could an excess risk be detected for any category of birth defects.
This study provides no evidence that prenatal use of metronidazole increases the risk of overall birth defect occurrence.
In order to assess whether the use of metronidazole during pregnancy is associated with a higher risk of congenital malformations, a meta-analysis was conducted.
All epidemiological studies (cohort and case-control) which estimate risk of congenital malformations after exposure to metronidazole during early pregnancy were included in the meta-analysis. To obtain a summary odds ratio, the Mantel-Haenszel method was used. A test to verify absence of heterogeneity was also performed.
One unpublished case-control and four published cohort studies fulfilled the inclusion criteria and were not statistically heterogeneous. A summary odds ratio was calculated for metronidazole exposure during the first trimester: OR = 1.08, 95% CI: 0.90-1.29, heterogeneity test chi2 = 4.72, P = 0.32.
This meta-analysis did not find any relationship between metronidazole exposure during the first trimester of pregnancy and birth defects.
The dental patient who is pregnant or lactating may require management involving the administration or prescription of drugs. The approach of completely avoiding all drugs may not permit appropriate treatment of the patient and most often is not warranted. This article reviews the current considerations in the use of drugs in the dental patient who is either pregnant or lactating. The safety of the local anesthetics, vasoconstrictors, analgesics, antimicrobials, and sedatives used in dentistry is discussed.
Despite the widespread use of benzodiazepines during pregnancy and lactation, little information is available about their effect on the developing fetus and on nursing infants. The authors review what is currently known about the effects of benzodiazepine therapy on the fetus and on nursing infants.
A MEDLINE search of the literature between 1966 and 2000 was conducted with the terms "benzodiazepines," "diazepam," "chlordiazepoxide," "clonazepam," "lorazepam," "alprazolam," "pregnancy," "lactation," "fetus," and "neonates."
Currently available information is insufficient to determine whether the potential benefits of benzodiazepines to the mother outweigh the risks to the fetus. The therapeutic value of a given drug must be weighed against theoretical adverse effects on the fetus before and after birth. The available literature suggests that it is safe to take diazepam during pregnancy but not during lactation because it can cause lethargy, sedation, and weight loss in infants. The use of chlordiazepoxide during pregnancy and lactation seems to be safe. Avoidance of alprazolam during pregnancy and lactation would be prudent. To avoid the potential risk of congenital defects, physicians should use the benzodiazepines that have long safety records and should prescribe a benzodiazepine as monotherapy at the lowest effective dosage for the shortest possible duration. High peak concentrations should be avoided by dividing the daily dosage into two or three doses.
Minimizing the risks of benzodiazepine therapy among pregnant or lactating women involves using drugs that have established safety records at the lowest dosage for the shortest possible duration, avoiding use during the first trimester, and avoiding multidrug regimens.
Acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs) and opioids are available as analgesics in dentistry. They each have specific advantages, disadvantages, indications and contraindications. This article provides a brief review of their role in the management of acute postoperative pain.
Local anesthetics are the most commonly used drugs in dentistry. This article provides a brief update on the pharmacology, adverse effects and clinical applications of these drugs, as well as the role of vasoconstrictors.
To estimate whether antibiotic treatment of asymptomatic women with a positive cervical or vaginal fetal fibronectin test in the second trimester would reduce the risk of spontaneous preterm delivery.
Women were screened between 21 weeks 0 days and 25 weeks 6 days of gestation with cervical or vaginal swabs for fetal fibronectin. Women with a positive test (50 ng/mL or more) were randomized to receive metronidazole (250 mg orally three times per day) and erythromycin (250 mg orally four times per day) or identical placebo pills for 10 days. The primary outcome was spontaneous delivery before 37 weeks' gestation after preterm labor or premature membrane rupture.
A total of 16,317 women were screened for fetal fibronectin, and 6.6% had a positive test; 715 fetal fibronectin test-positive women consented to randomization. Outcome data were available for 703 women: 347 in the antibiotic group and 356 in the placebo group. The antibiotic and placebo groups were not significantly different for maternal age (P =.051), ethnicity (P =.849), marital status (P =.127), education (P =.244), and bacterial vaginosis (P =.236). No difference was observed in spontaneous preterm birth before 37 weeks' (odds ratio [OR] 1.17, 95% confidence interval [CI] 0.80, 1.70), less than 35 weeks' (OR 0.92, 95% CI 0.54, 1.56), or less than 32 weeks' (OR 1.94, 95% CI 0.83, 4.52) gestation in antibiotic- compared with placebo-treated women. Among women with a prior spontaneous preterm delivery, the rate of repeat spontaneous preterm delivery at less than 37 weeks' gestation was significantly higher in the active drug compared with the placebo group (46.7% versus 23.9%, P =.039).
Treatment with metronidazole plus erythromycin of asymptomatic women with a positive cervical or vaginal fetal fibronectin test in the late second trimester does not decrease the incidence of spontaneous preterm delivery.
The purpose of this study was to provide information on the prevalence of the use of prescription drugs among pregnant women in the United States.
A retrospective study was conducted with the use of the automated databases of 8 health maintenance organizations that are involved in the Health Maintenance Research Network Center for Education and Research on Therapeutics. Women who delivered of an infant in a hospital from January 1, 1996, through December 31, 2000, were identified. Prescription drug use according to therapeutic class and the United States Food and Drug Administration risk classification system was evaluated, with the assumption of a gestational duration of 270 days, with three 90-day trimesters of pregnancy, and with a 90-day period before pregnancy. Nonprescription drug use was not assessed.
During the period 1996 through 2000, 152,531 deliveries were identified that met the criteria for study. For 98,182 deliveries (64%), a drug other than a vitamin or mineral supplement was prescribed in the 270 days before delivery: 3595 women (2.4%) received a drug from category A; 76,292 women (50.0%) received a drug from category B; 57,604 women (37.8%) received a drug from category C; 7333 women (4.8%) received a drug from category D, and 6976 women (4.6%) received a drug from category X of the United States Food and Drug Administration risk classification system. Overall, 5157 women (3.4%) received a category D drug, and 1653 women (1.1%) received a category X drug after the initial prenatal care visit.
Our finding that almost one half of all pregnant women received prescription drugs from categories C, D, or X of the United States Food and Drug Administration risk classification system highlights the importance of the need to understand the effects of these medications on the developing fetus and on the pregnant woman.
The purpose was to investigate the dose-response relationship for intrathecally administered epinephrine added to a local anesthetic-opioid combination in combined spinal-epidural analgesia for labor, in order to evaluate analgesia and side-effects.
The subjects were 100 consecutive ASA I or II parturients at 37 weeks' gestation, who received combined spinal-epidural analgesia during labor. Each woman was randomly assigned to one of five groups that received 2-mL volumes of different spinal solutions. The control group received an intrathecal injection of bupivacaine 2.5 mg and fentanyl 25 microg only. The others received epinephrine 12.5, 25, 50 or 100 microg added to this intrathecal regimen. Maternal arterial pressure, heart rate and pain scores were recorded before and 5, 10, 15 and 30 min after intrathecal injection. Level of sensory blockade, motor blockade score, duration of intrathecal analgesia, side effects, fetal heart rate, and 1- and 5-min Apgar scores were also assessed.
Compared to the control group, all four epinephrine groups had significantly longer duration of intrathecal analgesia, but the durations were similar. The frequencies of side effects were similar in all five groups.
The results suggest that adding epinephrine to a combination of standard intrathecal doses of bupivacaine and fentanyl in combined spinal-epidural analgesia for labor significantly prolongs spinal analgesia. Of the four epinephrine doses tested, the lowest one (12.5 microg) was optimal for this clinical setting.
Observational studies have documented that women take a variety of medications during pregnancy. It is well known that pregnancy can induce changes in the plasma concentrations of some drugs. The use of mechanistic-based approaches to drug interactions has significantly increased our ability to predict clinically significant drug interactions and improve clinical care. This same method can also be used to improve our understanding regarding the effect of pregnancy on pharmacokinetics of drugs.
Limited studies suggest bioavailability of drugs is not altered during pregnancy. Increased plasma volume and protein binding changes can alter the apparent volume of distribution (Vd) of drugs. Through changes in Vd and clearance, pregnancy can cause increases or decreases in the terminal elimination half-life of drugs. Depending on whether a drug is excreted unchanged by the kidneys or which metabolic isoenzyme is involved in the metabolism of a drug can determine whether or not a change in dosage is needed during pregnancy. The renal excretion of unchanged drugs is increased during pregnancy. The metabolism of drugs catalysed by select cytochrome P450 (CYP) isoenzymes (i.e. CYP3A4, CYP2D6 and CYP2C9) and uridine diphosphate glucuronosyltransferase (UGT) isoenzymes (i.e. UGT1A4 and UGT2B7) are increased during pregnancy. Dosages of drugs predominantly metabolised by these isoenzymes or excreted by the kidneys unchanged may need to be increased during pregnancy in order to avoid loss of efficacy. In contrast, CYP1A2 and CYP2C19 activity is decreased during pregnancy, suggesting that dosage reductions may be needed to minimise potential toxicity of their substrates.
There are limitations to the available data. This analysis is based primarily on observational studies, many including small numbers of women. For some isoenzymes, the effect of pregnancy on only one drug has been evaluated. The full-time course of pharmacokinetic changes during pregnancy is often not studied. The effect of pregnancy on transport proteins is unknown. Drugs eliminated by non-CYP or non-UGT pathways or multiple pathways will need to be evaluated individually. In conclusion, by evaluating the pharmacokinetic data of a variety of drugs during pregnancy and using a mechanistic-based approach, we can start to predict the effect of pregnancy for a large number of clinically used drugs. However, because of the limitations, more clinical, evidence-based studies are needed to fully elucidate the effects of pregnancy on the pharmacokinetics of drugs.