Tooth Extraction During Pregnancy

Hormonal changes occur during pregnancy due to which the gums become sensitive in case of pregnant females. Gums swell up and will become inflamed in case of pregnancy and will bleed. Periodontal problems occur in this period due to plaque which is present around the teeth. Gum problems very often occur around the wisdom tooth and gums become more aggravated in case of pregnant females. Neglecting ordinary oral care because of press of other duties may increase the incidence of dental caries in pregnant females.

Pregnancy is not a disease but special considerations should be made when tooth extraction is required during pregnancy. The most important thing is to avoid any damage to the baby. Elective procedures should be deferred in the first and the third trimester. If the tooth is infected and is non-restorable, then it should be removed. Infection may cause harm to the baby. Baby should not be exposed to any harmful factors.  

Dentists or oral surgeons usually avoid tooth extraction during pregnancy. If a mother is in constant pain during pregnancy, then she would be stressing her body which would be not good for the child. So tooth extraction should be done in case of pregnancy.

Tooth extraction is no longer painful these days. The procedure is done under anesthesia. Lesser amount of anesthesia should be given to the patient.  Obstetricians and gynecologists also allow tooth extraction during pregnancy if the patient has pain.

If tooth extraction has to be done in pregnancy, then it has to be done in the middle trimester period. Patients in first or the last trimester should have their tooth extraction postponed if possible. Tooth extraction can also be done in latter part of first trimester and first month of last trimester. Extensive surgical procedures should be avoided in the first and the last trimester. They should be deferred until after the child has been delivered.

Trimesters of pregnancy

There are 3 trimesters of pregnancy- first trimester, second trimester and third trimester.

1. In the first trimester, organogenesis of foetus takes place that is the formation of organs of the baby takes place. Liver, kidneys, heart etc. are formed in first trimester of pregnancy. Foetus is highly susceptible to developmental malformations if the mother passes through stress and strain in first trimester. If tooth extraction has to be done in the first trimester, then it should be done in the latter part of first trimester.
2. During the second trimester of pregnancy, the baby is just growing. It is considered as safe period in pregnancy and all the dental procedures can be performed in second trimester. Second trimester is the best time of tooth extraction in pregnancy. While doing the tooth extraction, if the patient falls into syncope, then patient is turned on to the left side to relieve the pressure. Patient should not be kept in supine or reclined position. This is to avoid pressure on inferior vena cava by the foetus which can even lead to hypotension (Decrease in blood pressure).
3. In the third trimester, it is problem for the lady to sit in the dental chair in the same position for hours. Large quantities of steroids are released into the blood. Uterine contraction is stimulated by oxytocin hormone which causes change of premature labour. Blood volume increases and patient can’t be comfortable on the chair. If patient is in severe pain and tooth extraction has to be done in third trimester, then it should be done in the first month of last trimester.

Obstetricians and gynecologists allow for full dental care during the last trimester of pregnancy and the most elective dental care during the second trimester.

Wisdom Tooth Extraction during pregnancy

Wisdom teeth might need extraction when the lady is pregnant. Most of the obstetricians and gynecologists believe that wisdom tooth extraction can be done during pregnancy. Wisdom tooth should be removed with minimum of trauma during pregnancy. Antibiotics and pain pills may be prescribed by the dentist to reduce the infection and pain which can further stress both mother and baby. Wisdom tooth Extraction should be done in the second trimester which is the safe period of pregnancy.

Medications during pregnancy

Pain killers used during pregnancy

• Acetaminophen can be prescribed to the patient for pain relief. It is considered safe throughout pregnancy.
• Ibuprofen is considered safe till 32 weeks of pregnancy. If pain is very severe, then narcotics can be given like codeine for short duration of time after consulting patient’s obstetrician.

Antibiotics are required to treat or prevent infection. Antibiotics used during pregnancy

• Penicillin (Category B for safety in pregnancy) and cephalosporin’s can be given to the patient unless the patient is allergic to it.
• Erythromycin is also safe during pregnancy provided patient’s stomach can tolerate it.
• Tetracycline should not be given to the patient. Tetracycline given during pregnancy in second or third trimester or in neonates may lead to tetracycline pigmentation in teeth of baby.

Time of tetracycline treatment                                                                                       Teeth affected

4 months intrauterine life (foetus) to 3 months post-partum                                                 Deciduous incisors

(period after the birth of baby)

5 months intrauterine life to 9 months post-partum                                                             Deciduous canines

Tetracycline causes internal pigmentation due to chelate formation of tetracycline with calcium.

Use of anesthesia during pregnancy

Lidocaine is commonly used local anesthetic agent used during tooth extraction. (Category B for safety in pregnancy). It does cross placenta after it is given. Anesthesia which is administered should be as less in amount as possible but it should be enough to make patient comfortable. If pain is experienced by the patient, then she will be administered more local anesthesia. Local anesthesia is usually used without epinephrine. Epinephrine is a vasoconstrictor and it increases the duration of anesthesia. If the dentist feels that the patient requires anesthesia with epinephrine, then patient’s obstetrician can be consulted. If a patient is comfortable, then the stress on the patient and baby is also reduced. Anesthesia will also be more effective if the patient is more comfortable.  

Inhalation or intravenous anesthesia is avoided during pregnancy as it increases the risk of miscarriage in the first trimester.  

X-rays during pregnancy

During tooth extraction procedure, it may be necessary to take a radiograph. While taking x-ray in pregnant woman, to cover the upper part of body, lead apron shield can be used. Diagnostic x-rays don’t have radiation dose too much which can cause any side effect to the developing foetus or embryo.

Pregnant women should-

1. Tell the dentist that she is pregnant. The treatment plan and the medications which are to be given to the patient may be altered in case of pregnancy.
2. To avoid dental problems, she should maintain a good oral hygiene and should get dental cleaning done during the course of pregnancy to avoid deposits in the teeth.
3. She should not miss her dental appointments. Pregnant woman needs to get dental cleaning done regularly because of sensitivity and bleeding of gums.

It is always better to visit the dentist or the oral surgeon to know whether tooth extraction should be performed or not. Dentist can take care of pregnant woman and the baby.

courtesy: SSDC

DENTAL ANESTHESIA (LOCAL ANESTHESIA)

Dental anesthesia (or dental anaesthesia) is a field of anesthesia that includes not only local anesthetic but sedation and general anesthesia.

Local anesthetic agents in dentistry

The most commonly used local anesthetic is lidocaine (also called xylocaine or lignocaine), a modern replacement for novocaine and procaine. Its half-life in the body is about 1.5–2 hours. Other local anesthetic agents in current use include articaine (also called septocaine or ubistesin), marcaine (a long-acting anesthetic), and mepivacaine. A combination of these may be used depending on the situation. Also, most agents come in two forms: with and without epinephrine or other vasoconstrictor that allow the agent to last longer and also controls bleeding in the tissue during procedures. Usually the case is classified using the ASA Physical Status Classification System before any anesthesia is given.

Types of local anesthesia in dentistry

• Nerve Block— a common form of local dental anesthesia; blocks the reception of pain in one region of the mouth at a time.
• Infiltration given inferior to the root the tooth involved in the dental work; used usually for minor procedures such as restorations.
• Palatal block given into the hard palate using pressure anesthesia; useful in anesthetizing the palate side of the maxillary teeth.
• Intraosseous an injection of local anesthetic given directly into the osseous (bone) structure of the tooth for more involved dental procedures such as surgery or endodontic therapy (root canals).
• Intrapulpal an injection of local anesthetic given directly into the pulp of the tooth to completely desensitize the tooth.
• Pressure anesthesia---- pressure with a cotton swab in the area to distract the nerve sensation of pain when the needle enters certain areas such as palatal tissue.
• Electrical Nerve Block--- a technology that involves using electrical current to block the reception or generation of pain signals; the pain control can be transient.
• Acupuncture ---An alternative to chemical or electrical blocks, but is rarely used.

Most common local anesthetic procedure

The Inferior alveolar nerve anaesthesia or block or IANB (sometimes termed "inferior dental block", or wrongly referred to as the "mandibular block") probably is anesthetized more often than any other nerve in the body. An injection blocks sensation in the inferior alveolar nerve, which runs from the angle of the mandible down the medial aspect of the mandible, innervating the mandibular teeth, lower lip, chin, and parts of the tongue, which is effective for dental work in the mandibular arch. To anesthetize this nerve, the needle is inserted somewhat posterior to the most distal mandibular molar on one side of the mouth. The lingual nerve is also anesthetized through diffusion of the agent to produce a numb tongue as well as anesthetizing the floor of the mouth tissue, including that around the tongue side or lingual of the teeth.

Several nondental nerves are usually anesthetized during an inferior alveolar block. The mental nerve, which supplies cutaneous innervation to the anterior lip and chin, is a distal branch of the inferior alveolar nerve. When the inferior alveolar nerve is blocked, the mental nerve is blocked also, resulting in a numb lip and chin. Nerves lying near the point where the inferior alveolar nerve enters the mandible often are also anesthetized during inferior alveolar anesthesia, such as affecting hearing (auriculotemporal nerve).

The facial nerve lies some distance from the inferior alveolar nerve within the parotid salivary gland, but in rare cases anesthetic can be injected far enough posteriorly to anesthetize that nerve. The result is a transient facial paralysis, with the injected side of the face having temporary loss of the use of the muscles of facial expression that include the inability to close the eyelid and the drooping of the labial commissure on the affected side for a few hours, which disappears when the anesthesia wears off.

In contrast, the superior alveolar nerves are not usually anesthetized directly because they are difficult to approach with a needle. For this reason, the maxillary arch is usually anesthetized locally for dental work by inserting the needle beneath the oral mucosa surrounding the teeth so as to anesthetize the smaller branches.

Dental syringe

A dental syringe is a syringe used by licensed dental professionals for the injection of a local anesthetic. It consists of a breech-loading syringe fitted with a sealed cartridge containing anesthetic solution.

Other drugs used in combination with general anesthesia in dentistry

• Decadron a steroid is often administered through IV to suppress inflammation and swelling resulting during the surgery while under general anesthesia.

Ondansetron brand named Zofran is often administered to prevent nausea during the surgery which may result from the blood draining into the stomach while under general anesthesia, or it is given after the procedure for postoperative nausea which may result from the anesthesia itself which was administered.    

The use of inhalation sedation and local anaesthesia can be an alternative to general anaesthesia for dental extractions in children

SIDE EFFECTS

Source

wikipedia