Endodontic treatment in pregnant women

Radiographs in pregnant women

The primary biological risk associated with radiation exposure is the development of cancer.3 However, radiographs are deemed safe for both the mother and fetus when certain precautions are taken, such as properly directing the radiograph at the mouth while avoiding the abdominal area, using high-speed film, wearing a lead apron, and utilizing a thyroid-protective collar.3 Different interpretations surrounding the use of protective shielding can lead to confusion among practitioners striving to follow best practices. These practices are guided by radioprotection recommendations that adhere to the "as low as diagnostically acceptable, being indication-oriented and patient-specific" (ALADAIP) principle. When treating pregnant patients, dental practitioners often express concern regarding the potential harmful effects of ionizing radiation on the fetus. These professionals should understand the deleterious effects of cumulative radiation exposure and implement protective strategies for imaging procedures.5 Delaying dental X-rays until after delivery is an option; however, this approach is not advised when X-rays are essential for diagnosing dental problems that could worsen or become more difficult to manage if left undetected and untreated.

Antibiotics and pregnant women

In cases such as mild cellulitis, the use of drugs such as cephalexin, penicillin and amoxicillin are considered as the first line drug of choice. However when the patient is allergic to penicillin, Erythromycin or clindamycin may be used. In emergency cases where a pregnant patient is experiencing a toothache, the dentist can make an emergency root canal opening along with eliminating the inflamed pulp or drain the pus, and can release the pain.

Intracanal drugs such as chlorhexidine/metronidazole and calcium hydroxide can be used during certain conditions but however they may have teratogenic influences on the developing fetus during pregnancy. Also the drugs used during breastfeeding can have severe effects on the health of the growing baby. 6

The FDA has not reported any link between the use of amoxicillin during pregnancy and miscarriage, major birth defects, or adverse effects on the fetus or mother. However, certain studies have indicated that amoxicillin use during pregnancy may be associated with congenital abnormalities in the oral-maxillofacial region, such as cleft lip and palate, as well as enamel hypomineralization in teeth.

Amoxicillin combined with clavulanic acid is highly effective in treating severe odontogenic infections. Although the overall risk of infection is not substantial, it is advisable to avoid using this combination drug during the third trimester of pregnancy. 6

Certain studies have confirmed a link between the use of cephalosporins and the occurrence of anorectal atresia and atrial septal defects in infants. While clindamycin is not associated with adverse pregnancy outcomes or fetal loss, its use has been linked to congenital cardiovascular and musculoskeletal anomalies.

However the use of metronidazole is contraindicated in the first few months of pregnancy due to its teratogenic effects.

Local anesthetic in pregnant women

Local anesthesia is essential for most dental procedures, as it helps alleviate pain during treatments such as tooth extractions, cavity preparations, root canal treatments, abscess drainage, and minor oral surgeries.7 Local anesthetic injection in pregnancy is considered harmless because of the lack of evidence on teratogenic effects . Risk categories of drugs during pregnancy have been categorised as A, B, C, D and X. In Category B, no risk in animal studies is shown( no adequate studies in humans conducted and animal studies was found to be normal without any risk)Under Category C, it showed that risk cannot be ruled out as animal studies demonstrated a risk to the fetus. 8 But it is better to use anesthetic solutions categorized under Group B when compared to those under C. Anesthetic agents which lies under Group B include lidocaine and prilocaine while those under Group C include Mepivacaine, Bupivacaine and Articaine. Medications with teratogenic effects that cannot be avoided are classified under category C. Group D consists of drugs that have clear evidence of risk to human fetuses. Drugs in Group X are contraindicated for use during pregnancy. 4

According to FDA table of anesthetic solutions used in pregnancy, the drug of choice during this period is lidocaine and prilocaine. Local anesthetics (LA) cross the placenta to varying degrees. The concentrations found in the fetal circulation, in descending order, are prilocaine, lignocaine, and bupivacaine. Additionally, the amount of adrenaline used in lignocaine is so minimal that it is unlikely to have a significant impact on uterine blood flow. 9

When epinephrine is used as a vasoconstrictor, it decreases the uteroplacental blood flow when injected intravenously but when used in safe dose is not harm to the mother and child.

Analgesics and pain relief in pregnancy

Pain management during pregnancy and lactation is important, and women should be reassured that effective treatments are available. Unmanaged pain can lead to mental health issues like depression and anxiety.10 Paracetamol is the drug of choice for pain relief during pregnancy and is safe when used in therapeutic doses. Only plain paracetamol should be used—combination preparations should be avoided.11 It crosses the placenta but does not increase the risk of birth defects or adverse pregnancy outcomes.10 Acetaminophen can cause liver toxicity, and due to its many formulations, pregnant women should limit their intake to no more than 4g per day. But however Acetaminophen is often preferred over ibuprofen and Novofen for pain relief, as the latter two can increase the risk of bleeding and may be associated with complications in late-stage pregnancy.

While aspirin is used for mild pain and fever, low-dose aspirin may be prescribed in certain cases, such as for women with antiphospholipid syndrome or recurrent miscarriages.10 However, aspirin is generally contraindicated in pregnancy due to its potential to prolong pregnancy and cause fetal defects, such as oral clefts, at higher doses. Both aspirin and ibuprofen inhibit prostaglandin synthesis, which can lead to premature closure of the ductus arteriosus, resulting in pulmonary hypertension and increased fetal mortality. Ibuprofen, a non-steroidal anti-inflammatory drug (NSAID), should be used cautiously, especially in the third trimester.

Corticosteroids may be used in certain situations, such as in surgical procedures when the treatment cannot be delayed. 11

In summary, paracetamol is safe for pain relief during pregnancy, while aspirin and ibuprofen should be used with caution or avoided, especially in the third trimester, due to risks to the fetus. 10

Endodontic procedures

Root canal treatment is usually avoided during the first trimester as this is the phase of organogenesis and may harm the developing foetus. So if necessary, only draining of the root canal is done.

However during the second trimester, root canal procedures is found to be safe and no harm is caused to the developing baby.

Root canal treatment in the third trimester is possible but in most cases it is postponed or delayed until the baby is born as this is the most important phase of fetal development. Any mishap during this phase can cause harm to both the baby and the mother.

Apex locators, reciprocating files, and single standardized cone obturation techniques streamline endodontic treatment in pregnant patients, reducing clinical time and increasing comfort. 2