Guideline on Oral Health Care for the Pregnant Adolescent.

Resident’s Name: Jessica Wilson

Program: Lutheran Medical Center - Providence

Article title: Guideline on Oral Health Care for the Pregnant Adolescent.

Author(s): Council on Clinical Affairs, Committee on the Adolescent.

Journal: AAPD Reference Manual.

Year. Volume (number). Page #’s: 2007. 32(6). 127-131.

Major topic: Pregnant Adolescent

Overview of method of research: Clinical Guidelines.

Purpose:
To address the management of oral health care particular to that of the pregnant adolescent.

Methods:
Guideline is based on a review of current literature as well as best clinical practice and expert opinion.

Background:

Although the birth rate for US females decreased 1% from 2003 to 2004, about 900,000 teenagers still become pregnant each year. Additionally 50% of teen pregnancies occur within the first 6 months of initial sexual intercourse and 83% of pregnant teenagers are from low income families. Once an adolescent has given birth to one infant, she is at an increased risk of giving birth to another. Pregnant females between the ages of 11 and 15 are at a higher risk for medical complications.

During pregnancy, nutrients such as folate, vitamin B 6 & 12, calcium and zinc are particularly important. Nausea and vomiting are associated with 50-90% of all pregnancies in the first trimester and are associated with young age and low SES.

The FDA has defined 5 categories of drugs in regard to their safety for use in pregnant women. Category A includes drugs studied on humans and have been shown to be safe for use, category B drugs have shown no evidence of risk, category C drugs may be used with caution (aspirin and aspirin-containing drugs), and categories D and X and not intended for use during pregnancy.

Women who smoke during pregnancy have an increased risk for ectopic pregnancy, spontaneous abortion and preterm delivery. Infants born to mothers that smoke are also likely to be of low birth weight, increased risk of stillbirths, and SIDS as well as possible mental retardation and birth defects such as clefting. The exposure of second hand smoke has been shown to be associated with lower respiratory infections, middle ear infections, asthma, and caries in the primary dentition. Women are more likely to stop smoking during pregnancy during pregnancy than any other time in their lives.

There are several oral conditions associated with pregnancy such as, xerostomia, gingivitis and periodontitis.

One study concluded that most pregnant women do not seek dental care during their pregnancy even though 50% had a problem. The consequences of not treating an active infection during pregnancy outweigh the risks posed by most of the medications required for dental care.

When taking radiographs on a pregnant individual, shielding the thyroid gland as well as the abdomen are of utmost importance as are using high-speed film or digital radiography and avoiding retakes. The juvenile thyroid is one of the most sensitive organs to radiation-induced tumors. This sensitivity decreases with age and almost disappears after the age of 20. The typical dental radiograph rarely if ever uses a measurable absorbed dose to the embryo or fetus.

The safest and most comfortable time to treat a pregnant female is during weeks 14-20. During the last trimester pregnant women have delayed gastric emptying and are therefore at a higher risk for aspiration. Elective dental treatment should be performed during the second trimester and may prevent problems from occurring the third trimester.

Currently there is no evidence supporting adverse effects of existing amalgams on the fetus, but the mercury vapor from placement or removal of amalgam may be inhaled and can cross the placenta. A rubber dam and high speed suction can decrease the exposure to mercury.

Improving oral health during pregnancy which leads to a reduction of SM can reduce the SM in offspring as transmission can occur as early as the first year of life. “Beginning in the sixth month of pregnancy, a daily rinse of 0.05 percent sodium fluoride and 0.12 percent chlorhexadine has resulted in significant reduction in levels of caries-causing bacteria…” Xylitol gum has also been shown to decrease levels of SM; however the frequency, amount and duration are still unclear.

Laws regarding informed consent for underage pregnant females vary from state to state. Some require parental consent, some entitle adolescents to confidentiality regarding their health and pregnancy, and others consider the adolescent to be a “mature minor” and some states emancipate minors who are pregnant. The practitioner should be aware and abide by the laws set by their state.

Recommendations:

AAPD recommends all pregnant adolescents seek professional oral health care during the first trimester. A thorough evaluation including a caries risk assessment tool should be conducted. Radiographs may be indicated. If dental treatment must be deferred until after delivery, so should radiographic evaluation.

Counseling should address:
1. The relationship between maternal health with fetal health (perio disease and preterm birth or preeclampsia)
2. OHI including rinses and xylitol gum to decrease postpartum SM transmission
3. Diet counseling, avoiding frequent exposure to cariogenic foods and beverages
4. Anticipatory guidance for the infant’s oral health including the early establishment of a dental home
5. Anticipatory guidance for the adolescent including injury prevention, oral piercings, tobacco and substance abuse, sealants and third molars
6. Changes in the oral environment secondary to pregnancy (xerostomia and shifts in oral flora)
7. Individualized treatment recommendations for each patient

Preventative services should be of high priority, with a prophy being completed during the first trimester and again during the third trimester. A periodontal referral may be necessary if progressive perio disease exists. The AAPD does not support the use of fluoride supplements to benefit the fetus.

The pregnant adolescent experiencing morning sickness should be advised to rinse with water and sodium bicarbonate and to avoid tooth brushing for approximately 1 hour after vomiting in order to decrease erosion. Fluoride can used to decrease sensitivity and hard tissue loss.
In order to treat xerostomia, patients should increase their water intake and try chewing sugarless gum to stimulate salivation.

Elective restorative and periodontal procedures should be completed during the second trimester. The patient should be aware of benefits, risks and alternatives to amalgam restorations and a rubber dam should be used for the application or removal of amalgam. N2O should be limited and may be contraindicated in the first trimester

Local anesthesia and other medications should be evaluated for benefits versus risks. The provider should use the safest medication, the minimum dosage and limited duration. Aspirin or aspirin-containing products, erythromycin estolate and tetracycline should be avoided.

The provider should be familiar with state statutes that determine consent required for an underage adolescent. When parental consent is required and the parents are unaware of the pregnancy, the adolescent should be encouraged to inform them in order to understand the benefits and risks involved in a procedure.

The pediatric dentist should also use positive youth development (PYD) in interacting with the adolescent as a strong relationship can be influential in improving adolescent oral health and aiding in the transition to adult health care. This can provide a safety net for the adolescent in times of need.

Assessment of Article:
Although a lot of this is common sense and same protocols for any pregnant woman, it was a great review.