A review on safety Endodontic Management in Pregnancy

Chanchal Rathi*1, Manoj Chandak1, Madhulika Chandak1, Pavan Bajaj2, Pooja Chandak1 1Department of Conservative Dentistry and Endodontics, Sharad Pawar Dental College and hospital, Datta meghe institute of medical sciences ,deemed to be university(DU) Sawangi, Maharashtra , India 2Department of Periodontics and implantology , Sharad Pawar Dental College and hospital, Datta meghe institute of medical sciences , deemed to be university(DU) sawangi, Maharashtra , India


INTRODUCTION
From the last ten years, dentistry has undergone many changes, especially related to preventive prac-tice. Dental practitioners provide dental treatment to pregnant women to maintain their oral health. This is known as Intrauterine Dentistry. This term involved a multidisciplinary team of dentists, obstetricians and paediatricians (Fagoni et al., 2014). Dental treatment neither is cancelled nor be obstructed after con irming the pregnancy. Precautions should be taken while performing dental treatment (Zanata et al., 2004) During pregnancy, complete maintenance of oral hygiene should be done Kloetzel et al. (2011) . During pregnancy number of physiologic and hormonal changes are taking place. Due to this, the oral cavity is more prone to infection. Also, increased consumption of carbohydrates leads to more acid formation. Also, vomiting and saliva are reduced (Enabulele and Ibhawoh, 2015). Also, pregnant women are always at high risk for caries than non-pregnant women. So proper dental health care of a pregnant patient is utmost necessary. Endodontic management in pregnancy is related to the control of oral diseases. It also helps to maintain a healthy oral cavity. Endodontic treatment comprises the use of radiographs, local anaesthetic agents, intracanal irrigants, intra-canal medicaments, and drugs (analgesics and antibiotics). This review discusses endodontic consideration and possible risk while performing dental treatment.

Dental treatment
It is a big question about performing the dental treatment in pregnant patient or not. The answer is that it should be performed at any phase of pregnancy. Second and third trimesters are a safe period to perform the dental treatment. Because it minimizes the chances of stillbirth or early delivery (Hemalatha et al., 2013). Most of the gynaecologist (95%) recommend that dental treatment can be performed at any phase. From16th to 32nd weeks of pregnancy is the most safer period. Morning appointments should not be given to the pregnant patient due to higher chance of nausea. During pregnancy, dental treatment is avoided due to a lack of knowledge about the importance of oral health care of a pregnant patient. Proper dental health care is necessary for both patient and baby. Also, the mother is not aware that her ignorance about periodontal and restorative therapy may put the baby at a more signi icant risk.

First trimester (up to 14th week)
It is the most crucial phase in which rapid mitosis occurs. Also, quicker development of organs occurs between the 15 days to 2 months of post-conception. So in this period, there is a high-stress level present. More teratogens produce during this period. 45% to 74% of abortions occurred in this stage (Kurien et al., 2013).
Steps to be followed 1. Knowledge to the pregnant patient about maternal stomatic changes during pregnancy.
2. Strictly oral hygiene maintenance to control the plaque growth.
4. Avoid radiographs. Take only when necessary.

Second trimester (up 28th week)
Development of organ is inished during this period. So the risk to the fetus is minimal. Some elective and emergent dentoalveolar procedures are safer in this phase (Kurien et al., 2013).
Steps to be followed 1. Strictly oral hygiene maintenance to control the plaque growth.
2. Scaling and root planing can be performed if it is needed.
3. Almost dental procedures are safe.
4. Avoid radiographs.take only when necessary.

Third trimester (from 29th week till childbirth)
In this phase, there is no danger to the fetus. Pregnant women suffer from discomfort in this phase. Shorter dental appointments should be scheduled. Also, the supine position is avoided to avoid supine hypotension. It is safer to carry regular dental procedures in the starting phase. From the middle of the third trimester, usual dental treatment should be restricted (Kurien et al., 2013).

The recommendations are,
1. Strictly oral hygiene maintenance to control the plaque growth.
2. Scaling and root planing can be performed if it is needed (Ranka et al., 2018).

Endodontic Considerations
It includesa) Use Of Radiographs b) Use of local anaesthesia c) Use Of intracanal irrigants and root illing material : d) Use of antibiotics and analgesic drugs

Use of Radiographs
"According to (Lee et al., 1999) " radio graphs should be taken only when it is necessary. It helps in diagnosis and emergency dental treatment. The radio graphs should be taken with minimal exposure (Lee et al., 1999). However, chances of damage to the baby and mother are lesser. Because the radiation dose and exposure time are less, in the irst three months, radio graphs should be avoided.
The teratogenic exposure to radiation of radio graphic ilms is 1,000 times lesser than spontaneous miscarriage or malformation. The exposure to less than 5 rad minimizes the fetal malformation. 'According to (Timins, 2001), the mother exposure to x-ray should be less so that it does not cause any fetal malformation. High radiation exposure cause damage to the central nervous system of newborn/fetus (Timins, 2001).

Use of Local anaesthesia
In Dentistry, local anaesthesia has been chosen depending upon its effects on the baby and pregnant women. Anaesthesia should include vasoconstrictors. It slows the absorption from the bloodstream and prolongs its action. Ultimately it reduces the toxicity of anaesthesia in pregnant women. "The obstetrician's evaluation on the health state of pregnant women with problems may help the dentist to select the best drug (Figures 1 and 2)".
The use of local anaesthetics like lidocaine is safer. Also, prilocaine and etidocaine are safer to use in pregnancy. But prilocaine crosses the placenta quicker than lidocaine and bupivacaine. It is because of its smaller molecular size. Excessive doses of prilocaine can cause methemoglobinemia. A large dose of prilocaine and articaine causes respiratory damages. It will ultimately lead to death. Lidocaine with adrenaline is the safer combination to use in pregnant women.
1.8 ml of 2% lidocaine with adrenaline was safer to use. It is useful for an operative procedure in pregnancy with rheumatic valvular heart disease (Miller, 1995) . Bupivacaine and tetracaine are contraindicated. It will increase fetal bradycardia. Nitrous oxide is not safe to use in the irst three months. Felypressin and bupivacaine should be avoided because it causes uterine contraction due to its long period of action. Fetes liver is not capable of metabolizing the mepivacaine. In pregnancy, LA with vasoconstrictor is not contraindicated. But it should not be used in special conditions like untreated hypertension, diabetes. It also avoids severe heart disease, hyperthyroidism.

Use of intracanal irrigants and root illing material
It is stated that neither the irrigating solution like sodium hypochlorite nor the obturating materials used in root canal treatment are harmful to the developing embryo (Chandak et al., 2017). The early three months of pregnancy is important for the growth of the fetus. The second trimester is a perfect phase to undertake endodontic treatment. However, extensive elective root canal procedures should be postponed until delivery (Giglio et al., 2009).

Antibiotics
In any dental treatment, the irst procedure is to eliminate the cause of infection In fever or any in lammatory situation penicillin is the irst choice of antibiotic. Among the penicillin group, amoxicillin is the most widely used. Amoxicillin and cephalosporin are considered to be safe in pregnancy (Miller, 1995;Little et al., 2008). If a patient is allergic to penicillin, erythromycin is the antibiotic of choice. Chloramphenicol and Streptomycin cause injury to the acoustic nerve of the fetus. Ultimately it inhibits various enzymatic systems and proven metabolism. This antibiotic alters and darkens the enamel. Tetracyclines also interfere in the development of the enamel. It also interferes in dentine formation. It changes the colour of enamel and detention from yellowish to greyish. Tetracycline form chelates when reacting with calcium ion present in teeth. It will lead to hypoplasia of teeth. Due to these mechanisms, it should be avoided during pregnancy and childhood (Miller, 1995). "According to (Gordon, 2002) in cases of severe infections, amoxicillin with clavulanate potassium should be given".
If patients are allergic to penicillin, clindamycin should be advised.

Analgesics and Anti-in lammatory drugs
Analgesics are used when a patient is in pain condition. Whenever analgesia is required paracetamol is always used safely in pregnancy. It is the drug of choice for pain relief. Only plain paracetamol is indicated. Paracetamol Combination with other analgesics should be avoided in pregnancy (Yagiela et al., 2011). Centrally acting analgesics should be cautiously given only in an emergency. Non-steroidal anti-in lammatory drugs (NSAIDs) should be carefully used in pregnancy. Many studies stated that aspirin should be contraindicated in pregnancy. It is because it interferes in releasing adenosine phosphate (ADP). So energy de iciency occurs. It will ultimately prolong the pregnancy. Also, its higher dose may cause oral clefts and other fetal defects.
"These drugs are classi ied as class D at the third trimester. It is because they have been associated with childbirth complications and constriction of the fetal ductus arteriosus" (Fagoni et al., 2014).
Acetaminophen is not associated with any complica-tions during pregnancy. So it belongs to class B.And it always considered the irst choice of analgesic in pregnancy. (Fagoni et al., 2014). Ibuprofen is both an analgesic and non-steroidal anti-in lammatory drug. But it should be cautiously used during pregnancy because it may cause alterations in fetal and neonatal blood circulation. Aspirin and Ibuprofen obstructed the prostaglandin synthesis. It will lead to the earlier closure of the fetal ductus arteriosus resulting in pulmonary hypertension, due to this reason, fetal mortality rate increases. Corticosteroids can be recommended in surgical or endodontic procedures only in the situation when the treatment cannot be postponed until delivery.

Anxiolytics
The use of benzodiazepines and other central nervous system depressants is questionable.
"Many studies stated that more chances of cleft lip and palate in children are occurred after using diazepam by pregnant women up to 6 months. So it should be contraindicated in pregnancy". Thalidomide is the sedative, sleep-inducing drug responsible for limb malformation. Aminopterin, used in the treatment of leukaemia, possesses higher toxicity causing thrombocytopenia and leukopenia. Barbiturates should not be indicated as they cause placenta rupture and fetal damages. If anxiolytics are required, consent from obstetrician is needed (Yagiela et al., 2011).

CONCLUSIONS
Use of radiographs, local anaesthesia, analgesics and antibiotics should be used cautiously in pregnant women with gynaecologist consent. Also, dental treatment should be done in the second trimester as it is the safest period. Avoid dental treatment when it is not necessary. So Proper assessment, intervention and patient education about the dental problem in pregnancy provide active dental treatment enhancing the maternal health with minimizing the fetal risk.