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Wednesday, September 9, 2015

For all Dental Student and Dental Surgeons ....Must read ...

smile emoticoEndodontic treatments (RCT) During Pregnancy

Found this article written by DR.PANCHAL KUMARE SUMIT on Facebook. Very important and interesting for all Dental Student and Dental Surgeons. Good Luck!

Endodontic treatments (RCT) During Pregnancy
•Although pregnancy is not a contraindication to endodontic treatment, it does modify treatment planning.
•Protection of the fetus is a primary concern when administration of ionizing radiation or drugs is considered.
• Ideally, no drug should be given during pregnancy , especially in first trimesters

•It is a major event in any woman’s life and is associated with physiological changes affecting especially the endocrine, heart and blood systems and often attitude, mood or behavior.
•Therefore pregnant women should take extra care during this period to avoid any circumstances that could harm their fetuses, including certain dental treatments.
•The female body undergoes many changes during pregnancy due to hormonal imbalances. Some of the medical complications of pregnancy can include:
1-Hypertension (A common disorder in which blood pressure remains abnormally high which is a reading of 140/90 mm Hg or greater) is a dangerous complication leading to greater threat to both fetus and mother. Hypertensive pregnant women must therefore rest as much as possible and have anti-hypertensive treatment.
2-Blood hypercoagulability (excessive thickening of blood), which can lead to venous thrombosis (occlusion of blood vessels), particularly postoperatively or occasionally to disseminated intravascular coagulopathy (A rare, life-threatening condition that prevents a person’s blood from clotting normally).
3-Anemia (A deficiency of red blood cells). Expansion of the blood volume may cause an apparent anemia but in about 20%, true anemia develops, mainly because of fetal demands for iron and folate. Pregnancy may worsen pre-existing anemias, especially sickle cell anemia.
4- Supine hypotension syndrome. In later pregnancy up to 10% of patients may become hypotensive (low blood pressure) if laid flat( 3 to 7 min ), when the gravid uterus compresses the inferior vena cava and impedes blood return to the heart and may get syncope ..

Pregnancy and Dental Work
•Preventive dental cleanings and annual exams during pregnancy are not only safe, but are recommended.
•The rise in hormone levels during pregnancy causes the gums to swell, bleed, and trap food causing increased irritation to gums.
•Preventive dental work while pregnant is essential to avoid oral infections such as gum disease, which has been linked to preterm birth.
•If dental work is done during pregnancy, the second trimester is ideal and safe. Once patient reach the third trimester, it may be very difficult to lie on dental chair for an extended period of time and may get syncope.
•The safest course of action is to postpone all unnecessary dental work until after the birth. However, sometimes emergency dental work such as a root canal or tooth extraction may be necessary.
•Elective treatments, such as teeth whitening and other cosmetic procedures, should be postponed until after the birth. It is best to avoid this dental work while pregnant and avoid exposing the developing baby to any risks, even if they are minimal.
•Lidocaine is the most commonly used drug for dental work. Lidocaine (Category B) does cross the placenta after administration.
•If dental work is needed, the amount of anesthesia administered should be as little as possible, but still enough to make your patient comfortable.
•Dental work often requires antibiotics to prevent or treat infections. Antibiotics such as penicillin, amoxicillin, and clindamycin, which are labeledcategory B for safety in pregnancy.
• According to the American College of Radiology, no single diagnostic x-ray has a radiation dose significant enough to cause adverse effects in a developing embryo or fetus.
•Fetal organ development occurs during the first trimester; it is best to avoid all potential risks at this time if possible.
• If non-emergency dental work is needed during the third trimester, it is usually postponed until after the birth.
•During pregnancy, surgical endodontic is normally only considered in the mid- trimester and ideally should be avoided

Dental treatment in Pregnancy
•Dental treatment is best carried out during the second trimester, but advanced restorative procedures are probably best postponed until the state of the gums improves after giving birth and prolonged sessions of treatment are better tolerated.
•In the second and third trimesters the fetus is growing and maturing but can still be affected by infections, drugs and possibly other factors.
• In the third trimester the supine hypotension syndrome may result if the pregnant woman is laid flat.
The person should therefore be put on one side to allow blood return to recover. Some pregnant women also have a hypersensitive gag reflex. Elective dental care should be avoided in the last month of pregnancy, as it is uncomfortable for the patient.

•Routine dental treatment of pregnant women under local anesthesia, for example extraction of teeth, is safe from the second trimester on wards but unnecessary drugs should be avoided.
•Some specific anesthetics have been recommended and approved by the FDA in case the patient undergoing the root canal treatment is pregnant women.
•Nonetheless, the anesthetics that endodontist administer are safe for conceived women, still the quantity of anesthesia applied to the pregnant women can be a cause of concern.
•In case the administered initial dose is insufficient, you may inject additional anesthesia enabling the patient feel relaxed.
• Incurred pain during treatment stirs the stress, and it could be much more damaging to the fetus than some more quantity of anesthetic dose

Associated Chemicals:
•It has been established that neither the cleaning liquid administered during the treatment i.e. sodium hydrochloride or bleach nor the filing component is detrimental to the fetus.
•Formocresol should not be used with individuals who are pregnant or suspected to be pregnant.

•Sedation with diazepam or midazolam are particular hazards and must be avoided in the first trimester and in the last month of the third trimester of pregnancy.
•Nitrous oxide, though able to interfere with vitamin B12 and folate metabolism, does not appear to be teratogenic(Of or relating to substances or agents that can interfere with normal embryonic development) though it is advisable to:
restrict use to the second or third trimester,
limit the duration of exposure to less than 30 minutes,
use 50% oxygen,
avoid repeated exposure,
Use scavenging in the dental surgery to minimize staff exposure.

•Drugs may be teratogenic and should therefore be avoided where possible, especially in the first trimester.
•Many women are unaware of being pregnant in the early part of the first trimester and therefore it is preferable for women of childbearing age to avoid taking any drugs, unless absolutely essential.
•Aspirin and other NSAIDs may cause closure of the ductus arteriosus in the uterus, and fetal pulmonary hypertension as well as delaying or prolonging labor and therefore are contraindicated in the third trimester.
• Aspirin, in addition, causes a platelet defect and may induce abortion and is best avoided throughout pregnancy.
•Corticosteroids can suppress fetal adrenals and if taken, a steroid cover is needed for labor.

•Radiography should be avoided, especially in the first trimester, even though dental radiography is unlikely to be a significant risk unless the beam is directed to the fetus.
•When an apron is used in dental radiography, gonadal and fetal exposure is negligible.
• It has been estimated that two periapical dental X-rays give an exposure less than that due to natural radiation for 1 day. Nevertheless, of radiography is essential, patients must wear a lead apron and exposure must be minimal.
•MRI (magnetic resonance imaging) is best avoided during the first trimester.
•To perform a successful root canal, we must have a good understanding of the severity of the infection and the internal layout and shape of the associated tooth and the related canals.
•As per statement of the American College of Radiology, no x-ray used for diagnostic purpose has such radiation dose prominent enough to impact the growing fetus or embryo adversely.
•In addition, the x-rays are directed to the mouth not the abdomen. Still to be in the safe side, even we generally provide the patient with a lead cover to avoid x-rays approaching the abdomen.
•ADC and FDA, states that dental radiograph procedures” do not need to be altered because of pregnancy “when a lead apron( apron with thyroid color) is use during dental radiographic procedures, the amount of radiation received in the pelvic region is nearly zero . the embryo or fetus receives no detectable exposure with the use of a lead apron
•Although scientific evidence indicates that dental x –ray procedures can be performed during pregnancy, many dentists and pregnant patients prefer to post pond such x-ray procedures because of patient’s concern.

LACTATION and Dental drugs
•Since drugs may pass in the breast milk from mother to fetus, care should be taken in their use.
•Drugs should preferably be taken by the mother immediately after breast feeding, so that milk levels of the drug is low as possible at the next feed.
•Cephalexin is a useful antimicrobial as it is not secreted in the milk.
•Fluoride passes into breast milk and of the local water supply contains more than 1 mg/l fluoride, supplements are not indicated for the breast-fed infant.
Analgesics – aspirin (high dose), dextropropoxyphene, diflunisal, indometacin
Antimicrobials – tetracyclines, aminoglycosides, co-trimoxazole, fluconazole, ganciclovir, metronidazole, sulfonamides
Premedication – atropine, choral hydrate, beta-blockers
Others – antidepressants, barbiturates, etretinate, carbamazepine, corticosteroids (high dose), povidone-iodine

Risks if Root Canal is Avoided During Pregnancy
•In case the endodontist recommends the root canal even after being aware of the pregnancy status of the patient it means the risks associated with postponing the root canal are greater than the performing the root canal treatment in pregnancy.
Risks if Case Root Canal is Postponed Due To Pregnancy
•Severe Pain: Tooth abscess condition requires immediate root canal treatment and is generally followed by extreme toothache. Unrelenting pain throughout the phase of pregnancy can be much more stressful situation that may potentially impact the mother and child adversely in this critical juncture.
•Infection: Tooth infection is the cause that leads to root canal during pregnancy! It is advisable to treat the infection as early as possible to ward off further complications even in pregnancy. If it is not treated it can pose threat to the pregnancy too.
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Masih di Malaysia. Berbaki lagi 3 minggu sebelum pulang ke Jordan. Cuti kali ni agak sibuk dgn persiapan perkahwinan kak long dan kak ieda lagi 10 lagi, ni belum majlis sendiri lagi,huhu. Seperti biasa bnyk spend masa dengan family dan yang paling menarik cuti ni dapat buat attachment kat klinik swasta before masuk clinical year, membuatkan hati ini bertambah chenta dgn dentistry.hehe. tak sabar nak masuk 4th year, moga ALLAH mudahkan! Ameen ^^