Dental Treatment for Pregnant Patients: What’s Holding Us Back?

Reading time: 11 minutes

A new patient books an emergency appointment at your practice for severe toothache pain. Over the phone, she describes the pain as constant and throbbing to the point of disrupting normal eating and sleeping routines, and the difficulty eating has led to recent weight loss. Your staff works her into the day’s schedule, and she arrives at your office later that afternoon. When she arrives, it is quickly noted that she is 7 ½ months pregnant and in extreme pain and discomfort. How do you proceed?

The Fear Factor

“A few years ago, one of my best friends from childhood was pregnant,” Daniel Ninan, DDS, author of a new book titled Dentistry and the Pregnant Patient (Quintessence, 2018), recalls. “She had a severe toothache, and she could not find a dentist who would treat her. At the same time, the Federally Qualified Health Center I worked at started receiving additional funding to provide dental care to pregnant women who otherwise had no access to care. Because of this, I began seeing more pregnant patients. It quickly became apparent to me that the plight of my friend extended to other pregnant women who were also experiencing pain and suffering. Like my friend, these women also had difficulty finding dentists who would help them.”

A 2008 study found that 90% of dentists did not provide all necessary treatment to pregnant patients; the main reason for this is fear. The same study reported that the reasons dentists gave for withholding or delaying treatment until after pregnancy included fear of injuring the woman and fetus and fear of subsequent litigation.

“When I first started practicing dentistry, I noticed significant reluctance among my colleagues in providing dental care to pregnant patients,” Dr Ninan explains. “In the dental literature, there is at least one case of litigation regarding dental treatment and an adverse pregnancy outcome. During a patient’s third trimester, a dentist removed the patient’s wisdom teeth. The fetus later was stillborn, and both the obstetrician and the dentist were sued. The courts dismissed the case against the doctors, but the risk is real. Fortunately, my understanding is that there have been very few malpractice suits filed against dentists with regard to providing or withholding dental care for pregnant patients. Clinically, it is generally very difficult to link a pregnancy outcome with a specific dental procedure or treatment that occurred once during the pregnancy.

“One very important piece of this,” he continues, “is the patient’s perception of the safety of dental treatment during pregnancy. It’s important to ascertain the patient’s emotional bias toward the benefit or harm in providing dental treatment. This is because there is always a risk of adverse pregnancy outcomes. And even in the absence of supporting scientific data, the patient may come to the conclusion that the dental care provided—or withheld—is what caused her to have an adverse pregnancy outcome.”

While litigation may serve as a concrete assignment of blame on the dentist, most dentists are equally afraid of causing harm to the patient, her unborn child, or both. Only recently has scientific research begun on the safety and ramifications of dental treatment during the different stages of pregnancy, and that research is nowhere near comprehensive yet.

“I think perhaps one of the biggest fears is simply not knowing the safest way to proceed,” Dr Ninan emphasizes. “And intertwined with this is the fact that modern medicine allows women to be pregnant while having more complex medical conditions and while on more medications than in the past. Because of this, some of the women who are pregnant today are more medically compromised than in the past.

“Researchers are often observing the absence of adverse outcomes when providing dental treatment during research,” Dr Ninan continues, “but it is important to keep in mind that the absence of an observed adverse outcome doesn’t necessarily mean dental treatment is safe. However, it does suggest that necessary dental treatment might be okay to provide. It is also important to keep in mind that even though dental treatment is often safely provided, dental treatment itself is never completely safe, whether the patient is pregnant or not. There is always a myriad of very small risks that we are seeking to minimize. Some examples of these risks include allergic reactions, aspiration of dental material, and other procedural complications. So one question to consider is in the event there is a complication, when is the preferred time to manage the complication: during pregnancy or after pregnancy? This is why I generally suggest focusing on necessary treatment that improves the patient’s health during pregnancy and deferring any elective treatment until after pregnancy. In general, the safest option is to defer dental treatment until after pregnancy, when there is no fetal risk. However, emergency and urgent dental care should be provided at any time during pregnancy. Examples include providing care for acute infections and abscesses. If treatment is necessary, give consideration to both the type of treatment and the phase of pregnancy.”

A Circular Problem

But dentists aren’t the only ones responsible for a woman’s oral health during pregnancy. Even as more research surfaces to support both the negative effects oral pathologies can have on a pregnancy and the benefits of a healthy mouth during pregnancy, studies have found that most women are not advised by their prenatal care provider to see a dentist.

“Most women don’t see a dentist at all during their pregnancy, but the consequences of not receiving urgent and emergency dental care can be devastating,” Dr Ninan states. “In a 2012 study, it was reported that obstetricians were well informed on the relationship between periodontal disease and pregnancy outcomes. However, at the same time, many prenatal general practitioners and midwives may not understand the link between oral health and overall health. The authors of the study also found that most of the time, prenatal care providers did not discuss oral health with their patients and dental referrals were often only made when the patient self-identified an oral health problem. Another study found that only 26% of women were advised by their prenatal care provider to see a dentist. While there has been an improvement in recent years on awareness of how oral health may affect pregnancy, this has not translated to a greater number of dental referrals from prenatal providers.”

This awareness also hasn’t translated to greater awareness among pregnant patients of the need for dental care. “In the United States,” Dr Ninan explains, “only 25% to 50% of women will receive any dental care while pregnant, including prophylaxis. This is true even though 50% of pregnant women have dental problems. Pregnant women do not seek dental care during pregnancy for several reasons: They may not realize they have an oral disease, they may believe poor oral health is normal during pregnancy or that dental treatment may harm the fetus, or they are just not informed that they should seek care. Patients often look to their health care providers to know what is or isn’t safe, and I predict that patients will naturally seek care that is necessary to improve their health if it’s recommended by health care professionals. I think this can be simplified down to the idea that perhaps one of the best things we can do for the fetus is to help the woman be in a state of optimal health.”

The Silent Barrier

Another far more complicated issue is that of patient access to dental care. A 2008 study found that while 84% of patients believed dental treatment during pregnancy was safe, only 44% of those patients received dental care. The main limitation reported was financial access.

Unlike dental benefits for children, which are mandated by the Affordable Care Act, adult dental benefits remain optional even under Medicaid. According to the Medicaid website, states have the ability to choose whether to provide dental benefits for adult Medicaid enrollees. Most states provide at least emergency dental services for adults, but less than half of the states currently provide comprehensive dental care. Some states, including California where Dr Ninan practices, also offer dental services for pregnant woman in addition to the federally mandated coverage for children.

“Pregnancy may be the only time women in the lower socioeconomic strata are eligible for dental benefits,” Dr Ninan states. “But because adult dental benefits are optional under the Affordable Care Act, whenever states who provide them run low on money, those benefits could be eliminated. One example is when California cut adult dental benefits for nearly a decade.”

In 2009, California slashed its adult dental program, Denti-Cal, in response to the state’s budget deficit. An analysis by the California Health Care Foundation of the program’s performance in 2007, completed in 2010 after the program was largely defunded, provides important data. According to the study, only one in seven pregnant women covered by the program in 2007 actually visited a dentist. The study also identified dental provider reimbursement rates as a major problem affecting the program: Reimbursement rates through Denti-Cal program were much lower than both the national Medicaid averages and the fees dentists receive from commercial insurance, and in 2007 only 24% of California’s private dentists accepted Denti-Cal.

“As of 2018, Denti-Cal has been fully restored or funded,” Dr Ninan says. “However, because of the low reimbursement, it is still difficult to find general dentists and specialists who will accept it. Only time will tell whether the program can overcome these hurdles—and how long California will continue to fund it.”

While care providers may have little control over the reimbursement rates and budget constraints that affect this and similar government programs, they can be the voice to advocate for this patient need to be met.

The Role of Information

But what is the driving factor toward this recent interest in better oral care for pregnant patients? The answer is the desire for evidence-based care. As more evidence is found that shows the connection between periodontal disease and pregnancy outcomes, more dentists and prenatal care providers are beginning to acknowledge the need for oral care for pregnant patients.

“Perceptions of the safety of dental treatment during pregnancy by patients, dental providers, and prenatal providers all contribute to the lack of oral health care during pregnancy,” Dr Ninan explains. “Over time, I’ve noticed a shift in perspective on the part of health care providers. As researchers uncover more evidence linking oral and systemic health and also evidence of the potential impact oral health has on pregnancy, I have seen health care provider professional organizations start advocating for evidence-based care. For example, the American College of Obstetricians and Gynecologists has released a committee opinion in support of the benefits that oral health care can have for the pregnant patient. Organizations such as the American Academy of Periodontology, the New York State Department of Health, and the California Dental Association Foundation have also released practical guidelines for care providers.

“I suspect,” Dr Ninan continues, “that all health care providers have had some education about providing treatment during pregnancy. What I think is lacking are the details of where to get up-to-date information. I also suspect there is gap in time between when they learned how to treat a pregnant patient and when they are first confronted with the need to treat a pregnant patient. They know the general concepts, but they don’t know the details. I still remember seeing my first pregnant patient. I was still in dental school and had just had a lecture that included the topic. I was still nervous, so I actually went to the instructor who taught the local anesthesia course and double-checked that my lecture notes were indeed accurate. I suspect that it’s a similar lack of knowledge that creates the fear of causing harm, even among more experienced care providers. I believe that more information is a critical piece to solving this problem and that increasing the information available will help to facilitate better treatment.”

It’s this lack of organized information that inspired Dr Ninan to write his book Dentistry and the Pregnant Patient. “When we started seeing more pregnant patients where I was practicing,” he recalls, “I went back and looked at my textbooks from school. They did not have enough information, so I read everything I could find on the subject and quickly became aware of the lack of easily accessible knowledge on how to safely provide dental care to pregnant women. I also couldn’t find a collection of all of the information in one place, so I began collaborating with physicians, nurses, pharmacists, general dentists, periodontists, other authors, independent editors, and others. I synthesized all of the information that I had found on the topic with the goal of creating a single resource that would aid in safer and more effective care. My book is a tool that clinicians can use to quickly refresh their memory on the various details of treating the pregnant dental patient.”

Several example chapters from Dr Ninan’s book showing its value as a clinical reference. Click images to view larger.

Dr Ninan’s book provides detailed information on when and how to provide dental treatment for pregnant patients, including management of complications and administration of drugs and anesthetics, and will no doubt serve as an important knowledge base for clinicians. It also advances the topic of dental treatment during pregnancy by representing another source of information on the safety and efficacy of such treatment. By providing this information in an accessible format, his book may even inspire the next step: a wave of clinicians who are no longer afraid to provide necessary treatment for their patients during pregnancy.

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Daniel Ninan, DDS, currently works as a general dentist in San Bernardino, California. He is an assistant professor of dental education services at Loma Linda University School of Dentistry in Loma Linda, California, where he was awarded his Doctor of Dental Surgery degree in 2009. He has coauthored a study in the Journal of Obstetrics, Gynecology, and Neonatal Nursing based on neonatal research conducted at Loma Linda University Medical Center. Dr Ninan was also awarded the SAC Health System’s Provider of the Quarter Award in 2012, and he has served on the Quality Council, Mission Possible Committee, Privacy Board, and FQHC Quality Measures Committee for the SAC Health System. Dr Ninan is active in organized dentistry and has served on the Tri-County Dental Society’s New Dentist Committee and Communication Committee. Before earning his doctoral degree, Dr Ninan completed a Bachelor of Science degree in computer science in 1999 and a Bachelor of Arts degree in biology with honors in 2004, both from California State University, San Bernardino, California.

 

Dentistry and the Pregnant Patient

Daniel Ninan

To err on the side of caution, some dentists may hesitate to perform necessary procedures on pregnant patients. However, good oral health is essential to a healthy pregnancy and can help reduce prenatal complications, including preterm delivery and fetal loss. This book serves as an easy-to-use guide to help dentists of all specialties provide safe, effective care for their patients during pregnancy. The book is broken down into chapters on general treatment guidelines, pregnancy-related conditions in each organ system that may impact care, and the safety of the use of common dental drugs, including anesthetics, during pregnancy. With over 50 quick-reference charts and tables and a breakdown of treatment recommendations by trimester, this book is a must-have for any dental office.

160 pp (softcover); ©2018; ISBN 978-0-86715-779-6 (B7796); US $48 Special preorder price! $40