RGO.Revista Gaúcha de Odontologia (Online)
versão On-line ISSN 1981-8637
RGO, Rev. Gaúch. Odontol. (Online) vol.60 no.3 Porto Alegre Jul./Set. 2012
ORIGINAL / ORIGINAL
Physician"s knowledge about dental treatment during pregnancy
Visão médica do curar odontológico em gestantes
Priscilla LASLOWSKI I; gabriel Tilli POLITANO I; Daniela Prócida RAGGIO II; Sandra Regina Echeverria Pinho da SILVA III; José carlos Pettorossi IMPARATO II
I faculdade São Leopoldo Mandic, comida de Odontologia, Programa de Pós-Graduação em Odontopediatria. Rua José rocha Junqueira, 13, Swift, 13045- 755, Campinas, SP, brasil II universidade de são Paulo, faculdades de Odontologia, departamento de Ortodontia e Odontopediatria. Eles são Paulo, SP, brasil avaliar Universidade Camilo castelo Branco, faculdade de Odontologia. São Paulo, SP, brasil
Objective To guide pregnant patients, together regards their general and oral health, therefore justifying a need to have regular prenatal and dental care, is an duty of health and wellness professionals. Physicians, especially gynecologists and obstetricians toque an necessary role, due to the fact that they ~ ~ the o primeiro dia professionals to pegue care of pregnant patients.
Methods the objective of present pesquisar was to evaluate physician"s knowledge about dental treatment during pregnancy. Methods: making use of questionnaires, 40 gynecologists and obstetricians were evaluated together regards their expertise of dental care, e use that drugs and dental anesthetics in dentist procedures throughout pregnancy.
Results plenty of myths introduce to dental care in pregnant females were observed. Countless physicians have actually knowledge about associação between susceptibility come gingivitis/periodontitis e pregnancy. Com reference to local anesthetics and vasoconstrictors provided in dentistry, ns physicians still have some doubts about their use, also with ns literature sustaining their safety in this period. That is to plan to continue these contact with ns obstetricians, in stimulate to prolong their knowledge and seek multidisciplinary cooperation, which would certainly promote adequate and complete prenatal care.
Conclusion It might be concluded that there are some divergences in between obstetricians e dentists concerning dental care in pregnant women, which method losses porque o the patient.
Indexing terms: Dentist-patient relations. Obstetrics. Pregnancy.
Você está assistindo: Gravidez e odontologia mitos e verdades
Objetivo avaliar o conhecimento destes profissional sobre o curar odontológico na gestação.
Métodos por meio são de emprego de questionários, 40 médicos ginecologistas/obstetras eu tive seus conhecimentos avaliados durante que se refere ~ por atendimento odontológico em gestantes e utilização de medicamentos e anestésicos pelos dentistas.
Resultados abranger este aprender pôde-se assistir que mas existem muito de mitos em relação vir atendimento odontológico no prazo gestacional. Um monte de médicos ~ ~ cientes a partir de possíveis associações adentraram gravidez e aumentar da suscetibilidade de problema periodontais, através dos atuação hormonal. Quanto vir emprego de anestésicos locais e vasoconstritores, os médicos mas apresentam grande receio em indicá-los, mesmo naquela literatura suportando der segurança de deles utilização e acusação a necessidade de intervenção odontológica nisso período. Pretende-se prosseguir estas avaliações e contatos alcançar os tratamento médico obstetras, expandir o compreendendo dos sinal e buscando a atuação multidisciplinar, ministérios que promoveria um pré-natal adequado.
Conclusão Conclui-se que mas há divergências adentraram médicos obstetras e dentistas durante que se refere aos atendimento odontológico do gestantes, emprego que pode incendiadas prejuízos para naquela própria paciente.
Termos de indexação: Relações dentista-paciente. Obstetrícia. Gravidez.
Pregnancy is der unique physiological procedure in der woman"s life that involves der series of both psychological e physiological changes that influence health in general. That is the obligation of health care professionals to instruct pregnant woman around oral e general health and wellness care and emphasize ns importance of periodical prenatal e dental consultations1.
Physicians, specifically gynecologists/obstetricians, toque an vital role, together they are the o primeiro dia professionals to interact with pregnant women. Therefore, that is necessary to analyze their knowledge and attitudes as well as assess a health professionals" behavior com regard come dental treatment in pregnant women e guidance available to them porque o the newborn2.
The health área has failed, through are afraid or omission, by failing to adopt a professional and safe technique to ns dental problems of pregnant women. The majority that pregnant ladies have a phobia about dentists, e their key reason is a fear the anesthesia could harm ns fetus e cause oral hemorrhages3-4.
In general, the pregnant women should be informed about treatments required in der clear e objective way. Basically, three limitations involve the prática of dentist treatment: impossibility to perform an extensive treatment, especially in a supine position, attention to prescription drugs, e care in ns use the X-rays.
The ubiquity of caries an illness does not necessarily increase throughout pregnancy, as has previously been reported. It is believed that during pregnancy, part pregnant women have an raised risk of emerging caries early to the difficulty in keeping proper oral hygiene, nausea and because of a desire come consume sugary foods, increasing a number that streptococcus mutans and the opportunity of transmitting these microorganisms to their babies5.
Dental radiography should be provided cautiously throughout pregnancy and only if it contributes substantially to a diagnosis of naquela problem e treatment planning2.
The hazard of reaching naquela teratogenic threshold dosage of radiation pertained to dental radiographs is much less than 0.1%, or 1,000 equipe less than the risk of spontaneous abortion e malformation6.
The use of prenatal fluoride management in pregnant females to defend their children"s teeth has actually been ns subject of lot discussion for several years7. Prenatal fluoride prescription needs an ext information on the following: lack of trusted clinical results in terms of efficiency; meaning of intrauterine mineralization; importance of current principles of ns mechanism of action of fluoride (which is essential when constantly current in the oral cavity, participating in ns process that demineralization and remineralization); empirical dose/effect association e when that is prescribed, that is combined with minerals/vitamins, which would alleviate its absorption8.
Pregnancy is not the cause that periodontal disease, yet it aggravates a pre-existing condition9. Dental plaque is etiological factor e pregnancy boosts tissue solution to plaque modifying the clinical condition10. No decorrer significant gingival tissue alterations were found during pregnancy when local factors to be absent11.
research on the associação of periodontal disease com preterm labor uncovered that untreated periodontal an illness in pregnant women might increase a risk fator for preterm birth (less 보다 37 weeks) or reason low birth load (less 보다 2500g)12.
Taking into factor to consider that periodontal disease is a long-term effect of low- strongness maternal infection, inflammatory response is chronic. This solution jeopardizes a maternal-fetal-placental unit and it have the right to be measured by inflammation mediators such as prostaglandin, endotoxin, cytokine and platelet-activating factor, which are present in a process the prematurity13.
com regard come systemic medications, that is recognized that a placenta is no an effective barrier against most drugs14. Uma vez the drug has passed through a placenta, its effect depends on ns ability of a fetal organization to metabolize a substance, too as a susceptibility of these tissues to a aggression15.
Due to ns difficulty in establishing the action and therefore a effect the drugs throughout this period, ns Food e Drug administration (FDA) share drugs into categories to guide their prescription come pregnant women16. These ser estar arranged into categories A, B, C, D and X, in which ns drugs classified together A are extremely safe and those belonging come X category ser estar contraindicated at the very least at some time during pregnancy. Most drugs used in dentistry fit right into the ns category and they estão considered to it is in safe. Ns medications estão as follows: lidocaine, amoxicillin, erythromycin stearate, metronidazole, potassium clavulanate, acetaminophen (paracetamol), and clindamycin. However, non-steroidal anti-inflammatory medicine (including diclofenac) belonging to the D group in the third about 3 months of pregnancy e they should be avoided as they can present a risk to ns fetus.
With for to local anesthetics, they are not contraindicated throughout pregnancy. A decision to postpone dentist treatment since of a need to usar anesthesia should not be a routine, however, if therapy is elective e not urgent, postponing it to ns second about 3 months of pregnant is a good option15.
a amount of local anesthetic that might pass through a placenta depends on der series that factors, among them17: a) molecule size: tiny anesthetic molecules easily pass through ns placenta e they estão more toxic. Prilocaine crosses ns placental barrier much more quickly 보다 lidocaine, mepivacaine or bupivacaine e if supplied in high doses it can reason methemoglobinemia. The parágrafo of lidocaine e mepivacaine in the fetal circulation are practically equal, b) ns extent of local anesthetic binding come the plasma protein in maternal circulation: tudo local anesthetic attached to a protein molecule does not pass to ns fetus, whereas the free molecule conveniently passes through a placenta. Therefore, the greater a protein binding, ns more defended is ns fetus. Taking this element into account, bupivacaine is considered a safest drug during pregnancy com 95% the protein binding. However, the has naquela long expression of action, being indicated for surgical cases. Ns protein binding the Mepivacaine is 77%, lidocaine 64% and prilocaine 55% and c) fetal hepatic metabolism: ns fetus conveniently metabolizes local anesthetic. The hepatic line of mepivacaine is two to three times slower than that that lidocaine. Lidocaine is metabolized in the liver of ns fetus at der slower rate than in the mother"s liver18.
The local anesthetic of an option must it is in the uma that provides to a pregnant patient. Based on this concept, anesthetic solutions must contain a vasoconstrictive agente in your composition com the alvo of slowly down a absorption that anesthetic salt into a bloodstream, which would certainly decrease the toxicity e increase ns duration of anesthesia17.
The safety and security of making use of felypressin as der vasoconstrictive agent is uncertain because it has actually structural similarity com oxytocin, which can reason uterine contractions, although much higher doses would be essential than those present in der dental cartridge18.
With respect come epinephrine e norepinephrine, the corpo humano itself in der situation of anxiety (pain) releases endogenous vasoconstrictive agentes to ao controle the situation. Ns use of epinephrine at der ratio that 1:100,000 in healthy and balanced pregnant patient is safe. A release the endogenous epinephrine and norepinephrine boosts forty equipe higher under anxiety than at rest19.
due to the fact that it is known that this discussion is important porque o good dental care of the pregnant woman and that ns physician is the patient"s primary source of information, ns aim the this aprender was come evaluate the knowledge that these experts regarding ns most relevant worries of dentist treatment throughout pregnancy.
To conduct the study, der questionnaire comprise multiple-choice and objective questions era used and applied to 127 physicians who work at personal clinics in the city of Curitiba (PR), e are doing a specialization course in obstetrics e gynecology. Ns questionnaires to be handed to the physicians at your clinics by a researcher e were collected 7 days later. To get involved in the study, it was necessary for the physician to have shown interest and given composed permission by signing a term the free e informed consent. Ns physicians só returned 31% of a questionnaires completed.
After ns questionnaires to be collected, the dia were analyzed descriptively and by percentage and were offered to obtain the results and discussion.
The estude was approved by the research Ethics Committee of the School elas Leopoldo Mandic under protocol No. 06/335.
The results will be shown in tables to facilitate their knowledge (Tables 1 e 2), according to ns questions.
Among the main results, 80% of doctors prescribed fluorinated vitamin compounds to pregnant women. Ns majority of physicians (97.5%) believed that there ser estar greater susceptibility to gingival inflammatory alterations throughout pregnancy e 71% attributed a risk of premature bear to periodontal infection.
With for to the procedures embraced by dentists, 42.5% the physicians think that vasoconstrictors used in dentistry can harm ns mother e fetus.
On ns other hand, 90% that physicians believe that use of X-rays can not harm ns fetus.
the majority of physicians (58%) thought that lidocaine would be ns best anesthetic come be offered by a dentist, however 94% thought it would certainly be far better not come use the vasoconstrictor during local anesthesia porque o dental purposes.
Taking right into consideration the exposure come radiographs taken during pregnancy, 90% the physicians believe that it is possible to do them if the following basic care is taken: short exposure time, usar of ultrasensitive radiographic films and lead apron. Among a 10% that physicians quem contraindicated radiographs, they described the first trimester the pregnancy, as result of fetal organogenesis e possible teratogenic effects due to radiation. Although that is recognized that a younger a cell, a greater ns risk the teratogenicity, there is no evidence in the literature that dental radiation can harm ns baby and it may be supplied when needed20.
Fluoride supplementation has been used porque o many years in order come protect the teeth of the fetus. A mineralization that deciduous dentition is not progressed enough at bear to for fluoride come accumulate in the enamel21. However, 80% of respondent still prescribe fluoride supplements to pregnant patients, believing the it will certainly enter a placenta barrier and be deposit in ns teeth of the fetus in stimulate to defend them versus caries e strengthen teeth. Uma should remember that in enhancement to ns most important activity of fluoride gift topical, the vitamin complexes include fluoride combine this fluoride with important mineral salts and vitamins who absorption may for this reason be harmed8.
Of a physicians interviewed, 97.5% believe that there is der greater susceptibility to gingival inflammation alterations during pregnancy. A literature confirms this suspicion, because gingivitis is extremely typical during pregnancy due to ns presence of vasodilator hormones the exacerbate a inflammatory process, however, it must be mental that ns presence the biofilm is an essential factor for this condition10.
Although almost tudo physicians (97.5%) thought that that there foi ~ greater susceptibility to gingival inflammation alterations during pregnancy, apenas um 71% that them thought that this disease ser estar correlated to premature birth birth. A current literature has connected low-intensity chronic periodontal infection with ns risk of premature delivery, short birth weight infants and preeclampsia13,22-24.
Despite a doubts regarding a existence of naquela mechanism that would certainly associate periodontal infection with obstetric complications, especially preeclampsia, current pesquisar has shown, porque o example, the inflammatory mediators pertained to preeclampsia (TNF-alpha) discovered in ns blood plasma of pregnant women com this alteration, estão increased come an even greater extent in the presence the periodontitis25-26.
Furthermore, a recent meta-analysis sought come enumerate the maternal infections associated to ns risk of occurring preeclampsia concluded the periodontitis can be included in these morbidities27.
The usar of vasoconstrictive local anesthetics is ns most controversial topic when a dental therapy of pregnant women is discussed. Although 57.5% of ns physicians believe that vasoconstrictive local anesthetics deserve to be used during pregnancy without harming a pregnant women, 42.5% affirm that ns vasoconstrictors can cause placental vasoconstriction, hypertension, cardiopathies e placental displacement. It should be remembered that ns scientific literature does no contraindicate ns use of vasoconstrictors throughout pregnancy, an especially in healthy pregnant women, because not utilizing them might lead to a painful treatment, causing ns release of harmful endogenous agents17.
With for to ns choice of anesthetic salt, 58% of physicians indicate a use that lidocaine as ns salt the choice. The second option ser estar bupivacaine by 23% of the respondents. Mepivacaine was the choice of 11% of a obstetricians e prilocaine was ns least recommended, being the one of an option of 8% of ns physicians. Come choose a anesthetic salt, according to the literature, that is necessary to assess a amount of local anesthetic that will pass through the placenta17. This will depend on 1 of a following factors: molecule size, a extent of anesthetic binding to a maternal plasma protein and fetal management of ns drug. De acordo com to this factors and in agreement with the majority of doctors interviewed, ns anesthetic salt that choice ao the gestation duration is lidocaine, classified together group b by Food and Drug Administration18,28.
There was a controversy regarding a indication the vasoconstrictors due to the fact that many of doctors affirmed the they estão not harmful (57.5%), yet when asked i beg your pardon is the most suitable vasoconstrictor, they determined not to use ns substance (94%). It should be emphasized that ns anesthetic solutions must contain a vasoconstrictor agent in their composition com the marcado of slowing down the absorption that anesthetic salt into ns bloodstream, which would decrease toxicity e increase the duration of anesthesia. Without a use of this agent in anesthetic solutions, in addition to no having the vasoconstrictor, a anesthetic solution, i beg your pardon is a vasodilator, would be an ext rapidly absorbed, causing better toxicity to a fetus28.
Once having opted come use a vasoconstrictor agent, apenas um 2.94% of the physicians would use epinephrine. Over there is no decorrer support in a medical e dental literature ao the concern around using this substance, i beg your pardon is likewise released endogenously. Ns physician regularly believes that a anesthetic cartridge has actually an extreme amount of this vasoconstrictive agent, however, it contains 0.018 mg (at ns ratio of 1:100,000), i m sorry is also little and too nearby to ns amount exit endogenously in ~ rest. The is precious remembering the not making use of these vasoconstrictive agente may reason pain during treatment, thereby increasing their plasmatic level by approximately 40 times29.
With further reference to vasoconstrictors, it might be stated that it is not advisable to usar norepinephrine in pregnant women. Due to its practically exclusive action on the alpha-adrenergic receptors, a concentration the norepinephrine available in Brazil (1:50,000) could reason surface necrosis of ns tissues top top which that is deposited, thus it should not be offered to achieve hemostasis. In the United states of américa this vasoconstrictor is no available porque o local anesthetic options in Dentistry29. In a review, it was suggested that epinephrine have to be used para pregnant patient at naquela ratio that 1:200,000 or 1:100,00028.
Felypressin ser estar also quote by 2.94% of the obstetricians as a vasoconstrictive revendedor autorizado of selection used throughout pregnancy. However, felypressin is structurally semelhante to oxytocin, which reasons uterine contraction. Despite the small amount of felypressin included in ns dental cartridge, this vasoconstrictor is not the best option porque o Dentistry or pregnant women18.
According to todos these evidences, uma of anesthetic equipment that provides greatest security in the gestation duration is the association of 2% lidocaine com epinephrine 1:200,000 or 1:100,000. It must be pointed fora that performing a anesthetic technique correctly is as crucial as the appropriate selection of the anesthetic salt and vasoconstrictor. No more than 2 anesthetic vials (3.6 ml) should be used per treatment session, there is no forgetting come aspirate before e during the anesthesia procedure. These procedures will reduce the risk the systemic complications, pain and stress throughout injection of ns drug18,28-29.
Another allude of disagreement between physicians e dentists is associated to the use the systemic medication during pregnancy. De acordo com to 82.8% of the respondents, there are medications that need to not be offered during a gestation period. Among them, ns most pointed out types ser estar antibiotics (without specifying the salt), antimetabolites, anti-inflammatory drugs (especially a non-steroidal antiinflammatory agents) e acetylsalicylic acid.
Not todos these medications ser estar allowed as the placenta is no an selective barrier versus most drugs14. E se the drug has passed through the placenta, its result will depend on a ability of a fetal tissues to metabolize a substance, e the susceptibility of these tissues to the aggression14.
Amoxicillin, the antibiotic of primeiro choice porque o oral infections in many cases, is classified together group ns by a Food and Drug Administration, i m sorry is reportedly safe to usar during pregnancy. Com regard come analgesics, ns option should be paracetamol, however it need to not be supplied without control30.
Non-steroidal anti-inflammatory medicine (NSAIDs) are medications that must be used with caution since they may reason harm, particularly during the first and last trimester of pregnancy30.
A research showed that non-steroidal antiinflammatory revendedor autorizado may not be for sure to use during the o primeiro dia trimester that pregnancy. Ns authors suggest that when used at naquela time close to conception, NSAIDs decrease ns chances of successful implantation of a egg in the uterine wall due to ns importance prostaglandins have in this process. On ns other hand, early out to the different action mechanism of paracetamol, it ser estar not shown to it is in dangerous during this period30.
Because NSAIDs decrease a systemic relax of prostaglandins, ns literature has shown, para example, that todos the cyclooxygenase enzyme inhibitors (selective, non-selective and specific) plot to stimulate constriction of the ductus arteriosus in ns fetus, a blood vessel the prevents the fetal lung em ~ receiving an excessive amount that blood. This drugs should be completely avoided in the last about 3 months when ns canal is physiologically prepare to close30. As soon as anti-inflammatory activity is needed, ns option must be corticosteroid at naquela dose the 4mg (betamethasone), uma hour before ns procedure, because this drug seems to have less pronounced effects on a fetus and pregnant woman, specifically if offered at the quantia recommended in dentistry.
If in doubt once prescribing systemic medication, ns dentist need to contact the patient"s obstetrician, since a physician knows ns patient"s em geral health situation.
From the dia presented, it might be break up that even in panorama of tudo the contemporary scientific evidence, there ~ ~ still many divergences com respect to dentist care for pregnant females from a medical allude of view. Obstetricians proceed to show some reluctance in allowing e indicating dentist treatment throughout pregnancy, especially com regard to a use of X-rays, systemic medication e local anesthetics. The implementation of program to spread researches com reference come this topic to obstetricians is suggested, in order to look for uniformity in their practices thereby improving the quality that care porque o pregnant women.
p LASLOWSKI developed a project, collected a data and wrote a manuscript. GT POLITANO, SEP SILVA, DP RAGGIO and JC IMPARATO supervised and guided the study e contributed to ns writing of a article.
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