The American Academy of Pediatric Dentistry (AAPD) recommends that all pregnant adolescents seek professional oral health care during the first trimester. After obtaining a thorough medical history, the dental professional should perform a comprehensive evaluation which includes a thorough dental history, dietary history, clinical examination, and caries risk assessment. The dental history includes, but is not limited to, discussion of preexisting oral conditions, signs/symptoms of such, current oral hygiene practices and preventive home care, previous radiographic exposures, and tobacco use. The adolescent's dietary history should focus on exposures to carbohydrates, especially due to increased snacking, and acidic beverages/foods. During the clinical examination, the practitioner should pay particular attention to health status of the periodontal tissues. The AAPD's caries-risk assessment tool (AAPD, "Policy on the use", 2006), utilizing historical and clinical findings, will aid the practitioner in identifying risk factors in order to develop an individualized preventive program.
Based upon the historical indicators, clinical findings, and previous radiographic surveys, radiographs may be indicated. Because risk of carcinogenesis or fetal effects is very small but significant, radiographs should be obtained only when there is expectation that diagnostic yield (including the absence of pathology) will influence patient care. If dental treatment must be deferred until after delivery, radiographic assessment also should be deferred. All radiographic procedures should be conducted in accordance with radiation safety practices. These include optimizing the radiographic techniques, shielding the pelvic region and thyroid gland, and using the fastest imaging system consistent with the imaging task. Image receptors of speeds slower than American National Standards Institute (ANSI) speed group E shall not be used.
Counseling for all pregnant patients should address:
- Relationship of maternal oral health with fetal health (e.g., association of periodontal disease with preterm birth and pre-eclampsia)
- An individualized preventive plan including oral hygiene instructions, rinses, and/or xylitol gum to decrease the likelihood of Streptococcus mutans (SM) transmission postpartum
- Dietary considerations (e.g., maintaining a healthy diet, avoiding frequent exposures to cariogenic foods and beverages, overall nutrient and energy needs)
- Anticipatory guidance for the infant's oral health including the benefits of early establishment of a dental home
- Anticipatory guidance for the adolescent's oral health to include injury prevention, oral piercings, tobacco and substance abuse, sealants, and third molars
- Oral changes that may occur secondary to pregnancy (e.g., xerostomia, shifts in oral flora)
- Individualized treatment recommendations based upon the specific oral findings for each patient
Preventive services must be a high priority for the adolescent pregnant patient. Ideally, a dental prophylaxis should be performed during the first trimester and again during the third trimester if oral home care is inadequate or periodontal conditions warrant professional care. Referral to a periodontist should be considered in the presence of progressive periodontal disease. While fluoridated dentifrice and professionally-applied topical fluoride treatments can be effective caries preventive measures for the expectant adolescent, the AAPD does not support the use of prenatal fluoride supplements to benefit the fetus (AAPD, 2007).
A pregnant adolescent experiencing morning sickness should be instructed to rinse with a cup of water containing a teaspoon of sodium bicarbonate and to avoid tooth brushing for about 1 hour after vomiting to minimize dental erosion caused by stomach acid exposure (New York State Dept of Health, 2006). Where there is established erosion, fluoride may be used to minimize hard tissue loss and control sensitivity. A daily neutral sodium fluoride mouth rinse or gel to combat enamel softening by acids and control pulpal sensitivity may be prescribed (Linnett & Seow, 2001). A palliative approach to alleviate dry mouth may include increased water consumption or chewing sugarless gum to increase salivation.
Customary practice regarding invasive dental procedures requires certain precautions during pregnancy, particularly during the first trimester. Elective restorative and periodontal therapies should be performed during the second trimester. Dental treatment for a pregnant patient who is experiencing pain or infection should not be delayed until after delivery. When selecting therapeutic agents for local anesthesia, infection, postoperative pain, or sedation, the dentist must evaluate the potential benefits of the dental therapy versus the risk to the pregnant patient and the fetus. The practitioner should select the safest medication, limit the duration of the drug regimen, and minimize dosage. Health care providers should avoid the use of aspirin, aspirin-containing products, erythromycin estolate, and tetracycline in the pregnant patient (New York State Dept of Health, 2006).
Patients requiring restorative care should be counseled regarding the risk and benefits and alternatives to amalgam fillings. The dental practitioner should use rubber dam and high speed suction during the placement or removal of amalgam to reduce the risk of vapor inhalation (Whittle, Whittle, & Sarll, 1998). Consultation with the prenatal medical provider should precede use of nitrous oxide/oxygen analgesia/anxiolysis during pregnancy. Nitrous oxide inhalation should be limited to cases where topical and local anesthetics alone are inadequate. Precautions must be taken to prevent hypoxia, hypotension, and aspiration (Rosen, 1999).
The pediatric dentist should incorporate positive youth development (PYD) (AAPD, "Guideline on adolescent", 2006) into care for the adolescent patient. This approach goes beyond traditional prevention, intervention, and treatment of risky behaviors and problems and suggests that a strong interpersonal relationship between the adolescent and the pediatric dentist can be influential in improving adolescent oral health and transitioning to adult care. Through positive youth development, the dentist can promote healthy lifestyles, teach positive patterns of social interaction, and provide a safety net in times of need. At a time agreed upon by the patient, parent, and pediatric dentist, the patient should be transitioned to a practitioner knowledgeable and comfortable with managing that patient's specific oral care needs.
Dental practitioners must be familiar with state statutes that govern consent for care for a pregnant patient less than the age of majority. If a pregnant adolescent's parents are unaware of the pregnancy, and state laws require parental consent for dental treatment, the practitioner should encourage the adolescent to inform them so appropriate informed consent for dental treatment can occur.
