Home > Obstetrics, Rants and Raves > An open letter to the dentists of the world

An open letter to the dentists of the world

Dear Dentist-

Thank you for being there for patients around the world, fixing and cleaning their teeth and gums.  Thank you for your training and your wonderful set of skills which we all need.

But today I have a bone to pick with you.

For the one thousandth time today I was asked to write a note for a patient with an obviously infected tooth, giving my permission for you to treat her.  For the one thousandth time, I sat before my suffering patient, cursing your name, and wrote this ridiculous note.  And now my patient can go back to you, and now you can do the job you should have done when she first came to you with her painful tooth.

As an obstetrician, I am expected to be expert in all things pregnancy.  Not only that, but I am expected to understand how all things not pregnancy affect all things pregnancy.  It was for this that I went to medical school and trained long in my field.

You are much the same.

As a dentist, you are expected to know all things oral cavity, and furthermore how all things not oral cavity affect all things oral cavity.  It was for this that you went to dental school and trained long in your field.

And in this training, you no doubt learned something about the dental care of pregnant women.  You probably learned that local anesthetics are not harmful to a pregnancy, and that the narcotics you prescribe for pain and the penicillin based antibiotics you use for infection are also safe.  You probably learned that the millirads of radiation your oral films use are trivial compared the amount of radiation it would take to harm a fetus, and if you’re really on it you might even know that an obstetrician would do a 3 rad cat scan right through the fetus if he or she thought it was important enough.  At the least, you know that the big lead apron you use is going to block anything that might get to the fetus anyway.  You might have read that obstetricians are actually quite interested in oral health, and that we think that chronic oral disease may ironically be a contributing factor to the preterm labor you hope to avoid involvement with by refusing to treat oral disease in pregnancy women.

At the very least, you know that a fetus is kept in the uterine cavity, not in the oral cavity.

Since you already know these things, really what is going on is that you want your ass covered if under some strange coincidence something bad happens to a pregnancy after you treat a patient.

This is nonsense, and I am tired of it.

So forever more, here is a note for all the pregnant ladies of the world.

 

1. There is nothing you can do under local anesthesia that will hurt a fetus.

2. Penicillin antibiotics are safe in pregnancy

3. Local anesthetics are safe in pregnancy.

4. Narcotics are safe in pregnancy.

5. Oral xrays are safe in pregnancy.  Shield the baby like you would any patient.

 

If after reading this you ever again send away a pregnant patient in pain because they need a note from their obstetrician, I have only this to say:

Grow a pair.  You are doing your patient a disservice. Excercise the wonderful skills you spent years cultivating, and help your patient.

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  1. March 3, 2011 at 8:26 am

    Bravo, Bravo, Bravo!!! Very well put and long overdue. Let’s not forget that there also seems to be a link between proper oral health and improved pregnancy outcome. Regardless as to whether the link is causal or not; delayed dental care cannot be good for a pregnant woman or her fetus.

  2. March 3, 2011 at 8:38 am

    Maybe I’m going to start attaching this to any such note I write to a dentist. Dare I?

  3. March 3, 2011 at 11:14 am

    Spot on! Clap, clap, clap! Thank you!

  4. March 3, 2011 at 2:49 pm

    Ah, I feel your frustration! Reminds me of one time when a pregnant woman came into the pharmacy where I worked asking for something for a cold. Her regular doc wouldn’t recommend anything because she was pregnant, and told her to ask her OB; her OB wouldn’t recommend anything because he didn’t regularly prescribe cold meds, and didn’t know how these drugs might affect her/baby, and told her to call her regular doctor; and the pharmacist basically had to conference-call both docs at the same time, to figure out what she could take.

  5. Jespren
    March 3, 2011 at 3:20 pm

    Oh my, I love it. And it reminds me of my 2nd pregnancy and being told by multiple doctors they wouldn’t even SEE me because I was, get this, a ‘high risk patient’ because I was on pain meds AND pregnant! I had just moved and I had to go into the ER (hated having to do it but was what the 1 doctor who would actually SEE me told me to do after he said he wouldn’t write a refill for my script because I was pregnant and that made him uncomfortable) just to fill a script! I really disliked doctors for that 9 months! (Expect for you, you actually responded to an email with helpful intent, which, sorry to say, was more than any of the local docs would do. Unmitigated disaster!)

  6. March 3, 2011 at 4:15 pm

    Love it! Could you give your patients a blanket “dental care permission slip” when they first come see you, which (diplomatically) covers the above 5 points, and say “Bring this to your dentist if you need treatment”?

    • March 3, 2011 at 6:44 pm

      What a great suggestion, Rebecca! If every pregnant woman can be given these guidelines at her first prenatal visit, or a link to this post, it would save myriads of women and their dentists unnecessary pain, worry and suffering. Thanks for the info, Dr. Fogelson.

    • March 6, 2011 at 7:05 pm

      I was going to suggest just that…give the FULL post, signed, at the first prenatal visit. Instruct the woman that she should just keep it in her purse, and only bring it out if her dentist needs someone to tell him to “grow a pair.”

    • June 11, 2013 at 3:05 am

      Here is a list of the guidelines I have found for those interested.

      http://wheatondentist.blogspot.com/2012/08/safe-pregnant-breastfeeding-nursing.html

      I have also found that when a pregnant woman calls her OBGYN (I don’t call or write you guys) many don’t follow those guidelines and ask for exceptions (especially epi)

      Part of problem is these baby forums where moms are saying how they suffer through a root canal without being numb because they know it is “good for the baby” Yes mother the massive natural release of epi and coritsol from an hour and a half of a painful root canal is better than my controlled local delivery of LA??

      • Paula
        June 11, 2013 at 9:48 am

        It appears the table has some info omitted or is incorrect..? for example, Oxycodone is a class B pregnancy drug (this is missing) and Mepivicaine is Class C pregnancy drug-not Class B and Lidocaine is a Class B pregnancy drug-not Class C…? I woudn’t use this Table as-is….

  7. doctorjen
    March 4, 2011 at 1:41 am

    Amen to that note! I may need to make copies to attach to the dentist notes I write. I have started basically writing your 5 points on every note, although I usually specify what I mean by a narcotic after having more than one dentist apparently not know what the word means.

  8. mike xu
    March 4, 2011 at 4:39 am

    For sure. dentists are dumb and have no common sense. all they ever care about is to put the liability on doctors and making $$$. good job!

    • March 4, 2011 at 9:03 am

      Dentists only do work when they’re paid and set their own fees. Doctors take whatever the insurance company deigns to pay them and work for free on a frequent basis. We’re the dumb ones.

      They are smart people with important skills – but these notes are ridiculous.

      • March 6, 2011 at 7:07 pm

        In my area the dentists have to take the insurance pays too…not sure that it is much different anywhere else?

      • March 7, 2011 at 12:55 am

        Dentists bill insurance but they then charge the balance of their stated fee to the patient. They still collect every dollar of their fee.

        Physicians are not allowed to balance bill a patient if they are on an insurance company’s “panel”, which they are almost always on if they are seeing a patient. Physicians can only balance bill if they are out-of-network.

  9. RuralOB
    March 4, 2011 at 5:27 am

    I got so sick of writing these that I had one form made up and I signed. Now all my nurse has to do is put the patient’s name and the date so we can fax it to the dentist’s office. Just easier that way.

  10. Nancy Dyer
    March 4, 2011 at 9:24 am

    As a woman who had to do the dental dance while pregnant I concur. It was miserable just trying to get any dental help while pregnant. I had to wait for 2m postpartum for my root canal I was suffering with all pregnancy. Is it likely they are just fearful of being sued and want to ‘do the right thing’ which ends up being the WRONG thing?

  11. March 4, 2011 at 10:47 am

    I had a dentist refuse to do a regular six-month check-up because I was pregnant. Maybe he thought the mouthwash they use was toxic?

  12. Leah
    March 4, 2011 at 2:40 pm

    I love this post. It does, though, bring up some old resentment from when I had kidney stones during my first pregnancy. My OB group wouldn’t prescribe anything for pain. Kidney stones on nothing but tylenol sucks. I thought it was because of the baby but then the midwife group I saw with my next pregnancy said they’d have given me narcotics. I am still angry about that 5 years later, I’ve had two 10 lb baby med free deliveries and kidney stones were a million times worse, but no painkillers? I wish this post had around then!

  13. March 4, 2011 at 2:55 pm

    Nice rant Doc, I hope the dentist would listen. I hope all pregnant women who haveoral problems would be able to read this post.

  14. March 5, 2011 at 1:31 pm

    This may be my favorite post ever.

  15. Labor Nurse, CNM
    March 6, 2011 at 7:20 am

    LOVE IT!

  16. March 6, 2011 at 3:28 pm

    It would seem to me that the summation comments should also be released to the general public. I cannot tell you how many pregnant women come into my office fearful that my treatment will harm the fetus. Furthermore, many women will defer treatment until after delivery, further hampering my ability to adequately treat diseases that may be the cause of preterm problems. I believe the bigger picture is that thanks to our “sue happy” society and our legal colleagues, many dentists fear legal repercussions if we do not have consent for treatment from the obstetrician.

    • March 6, 2011 at 4:07 pm

      So if patients are worried that what you do will hurt their fetus, why would you then demand a permission slip to perform treatment? Its like saying that you think it is dangerous, but if the OB says its OK then I guess I’ll go ahead. If the patient is concerned, they by all means they should ask their OB for permission. But this is very different than the dentist demanding a release before proceeding with work.

      >> .. the bigger picture is that thanks to our “sue happy” society and our legal colleagues, many dentists fear legal repercussions if we do not have consent for treatment from the obstetrician.

      Exactly. Don’t give in to the madness.

    • March 6, 2011 at 4:14 pm

      To elaborate on this -

      So there is a completely irrational idea that any event that is correlated with another event is ergo causative of the second event. While this is completely wrong, this logical fallacy is too often plied by plaintiff’s attorneys.

      I do not deny this.

      However, given that dental work is most certainly not related to adverse obstetrical outcomes, and in fact may even improve outcomes in some cases, the idea that you want an OB to give you permission to do dental work is frankly insulting.

      You admit that this is just about legal liability, but then you defend the idea that you are righteous in attempting to dump that legal liability onto another party rather than accepting it yourself. If the OB had the same attitude, they would never sign the letter of permission. Why would they want to accept the liability?

      They sign the note irrespective of this issue because their patients needs care.

  17. Ed Howard
    March 6, 2011 at 3:38 pm

    I am a dental student with a limited # of patients-Yet, those patients are constantly threaten legal action against me or my classmates. If an adverse medical event occurs down the road would the OB who was not consulted take the stand in a court of law to defend my actions? Lets say I take a few xrays, would you the OB completely ignore that fact if a congenital defect is present?
    By the way, I’m so proud of you for being “interested in oral health.” I can assure you dentists are at least “interested in healthy fetuses”

  18. March 6, 2011 at 4:05 pm

    So glad a few dentists have weighed in!

    >> If an adverse medical event occurs down the road would the OB who was not consulted take the stand in a court of law to defend my actions?

    If they were interested in being an expert witness they would, which most are not. You would certainly find someone that would attest to that though. Its not hard to find folks to testify to hard facts.

    >> Lets say I take a few xrays, would you the OB completely ignore that fact if a congenital defect is present?

    Of course I would.

    >> I’m so proud of you for being “interested in oral health.” I can assure you dentists are at least “interested in healthy fetuses”

    Great!

  19. Baynon
    March 8, 2011 at 6:57 am

    Although this is common knowledge for us dentists already, there are liability reasons why we defer to the OBGYN in these cases. It would be nice if this was posted somewhere officially, and with a signature on it, and not as an anonymous Rant & Rave blog.

    • March 8, 2011 at 7:02 am

      The appropriate place for such a post would be as a policy statement of the American Dental Association.

      Nothing anonymous about Academic OB/GYN

  20. levon
    March 8, 2011 at 1:25 pm

    I just received this link from my chief, great post and discussion. We are a hospital program, oral maxillofacial surgery. I can tell you that i have never asked for a consult from OBGYN in a form of “permission” to treat. This applied to any medical consult for all our dental colleagues (there are more appropriate formats: i.e. asking for medical risk assessment, cardiac optimization prior to surgery) Furthermore, i still think it’s quite silly to ask OBGYN for permission to treat and hope this will help in court it will simply not stand. The dentist is the one rendering the treatment, he/she also has a doctorate and therefore is completely responsible.
    In regards of treating a pregnant patient there is a great body of literature that addresses these patients in dental community, and an official stand from ADA is hardly required.

    Thanks

  21. James Campbell
    March 8, 2011 at 2:55 pm

    Some good points made. BUT, as a practicing (29Yrs) general dentist, I have never denied treatment to anybody in pain. HOWEVER, my experience is the moms-to -be often have more confidence in the opinion of their ob-gyn MD regarding any potential harm to the baby. If the patient needs non-emergency care am I lacking a “pair” if I allow the mom to confirm this with the MD? What best serves the needs of the patient? I’m ultimately responsible for whatever care I provide. Oh yeah- don’t be too jealous- I belong to some PPO panels so the insurance companies regulate my fees too!!

    • March 8, 2011 at 3:10 pm

      If a patient wants the reasurrance of her OB/GYN, then by all means they should make a phone call or a visit. But if this is all it were about, why would I be asked to write a note before the dentist will do the work? It is clearly not about the patient’s concern when a note is required.

    • May 31, 2011 at 1:55 pm

      Wow! That’s a really neat awsner!

  22. erica
    March 8, 2011 at 5:38 pm

    I had tooth pain in my last pregnancy, and once I got past the receptionist, the dentist was fine with doing the few x-rays necessary to take a look at it. But the receptionist tried to refuse to make an appointment! I had to threaten the receptionist with being responsible for my (potential, hypothetical) preterm labor just to get her to book me!

    Oddly, though it really hurt – so bad I couldn’t chew on that side at times – the dentist couldn’t find anything wrong with the tooth or gum. When I asked him why it hurt so much, if there wasn’t anything wrong, he blamed pregnancy hormones. Kind of frustrating, but it eventually went away (while I was still pregnant).

    • March 9, 2011 at 11:40 am

      Strangely, I have had patient with similar complaints a few times, and these symptoms also went away postpartum. I don’t know what this was from either.

  23. Erika Smit, D.D.S.
    March 9, 2011 at 11:25 am

    Dear Doctor:

    I take umbrage with the recent defamation of my dental profession and its adherence to the standards of ethics and jurisprudence with regard to gravid patients. Dentists receive intensive instruction about human physiology and pathology, and we take serious consideration in our treatment planning of all of our patients. Doctors and dentists should all agree that there are special precautions that must be taken when treating patients with tiny humans developing inside of them.

    I personally have been on both sides of the explorer- as a dentist who treats pregnant patients, and as a pregnant patient. I have never refused to see a patient for an emergency exam, and have followed all protocols in the treatment of emergent patients. Many high risk patients require hospital settings for extractions so that immediate measures may be taken for unforseen medical complications.

    As a patient, I was rigorously counselled by my OBGYN on the dangers of hot dogs, lunch meat, drying paint and the lifting of heavy objects. It stands to reason, from the patient’s perspective, that a medical professional who specializes in obstetrics should be consulted with regard to medicaments injected into the blood stream and for health risks associated with intensive procedures. That said…

    If real doctors are so smart, and we dentists are so dumb, why has it taken all of these years to finally complain? These letters have been requested and written for decades. How about spending the whining time instead on finding a solution to YOUR problem? It sounds like the MD’s should have “grown a pair” years ago and relinquished their egos and their control. These patients haven’t always had the internet for immediate access to medical protocols- the fear of dental procedures and xrays didn’t arise from thin air. The fear came from the good old boys from the medical society years ago. We’ve just been good little kids playing by their rules. Now they cry foul because its too difficult to create a form letter and sign their names? Shame on them.

    • March 9, 2011 at 11:38 am

      Two sides to every coin.

      I think if a patient has a high enough risk procedure to need anesthesia in a hospital, we have a horse of a different color. This is a lot different that refusing to give antibiotics or do a cleaning without a permission slip.

      I think you have accepted some idea that OBs want to have dominion over whether you can treat an pregnant patient. We don’t, because there is no scientific reason to fear minor oral procedures done under local anesthesia. I don’t know an OB in the world that wants to spend their time giving permission for another person to practice what they are expert in, even though that person knows full well that what they are doing is not harmful to a pregnancy. If they don’t know that, there is knowledge deficit. If they know that and just want to transfer liability to someone else, there is a deficit of another kind.

      Clearly some of your colleagues agree. See comment #28.

      And as I said in my post and my comments, I have great respect for dentists and their skills, but just not this particular behavior. The issue is the requirement of a note. If any dentist honestly needs information from an OB about the appropriate way to deal with a pregnant patient, then it is entirely professional and appropriate to seek that information. Seeking a note before proceeding, on the other hand, is completely inappropriate and unprofessional, particularly when it delays treatment of patients in pain.

  24. Adrian Acosta DDS
    March 9, 2011 at 2:13 pm

    I think we all know why we do this little dance. That being said, I have never turned away a pregnant woman for emergency dental treatment…ever. I do try to get something from her MD, a letter is nice but a telephone consult is just as good, but even if “Our Hero” can’t tear himself away from his golf game long enough to give his input, I’ll still solve her problem. I just think it’s funny when the letter comes back and it says “no epinephrine”… No epi? Really? That’s what you’re goin with?

  25. March 9, 2011 at 3:52 pm

    I’m sorry the tone of my note turned you off. It was more fun to write that way. That’s why its under rants.

    I’m glad you don’t turn people away, but am sorry you feel the need to get a letter.

    I agree with that last bit, nothing wrong with using epi. So do you actually not use the epi then even though you know better? Was the note actually for advice or to cover your liability? Think about that. Are you actually going to do the wrong medical thing with full knowledge that it is wrong, because someone with basically no training in your field says you should do it their way?

    • Adrian Acosta DDS
      March 17, 2011 at 6:44 am

      No your tone didn’t turm me off. I’m sure it was more fun to write that way and it was more fun to read that way too. In fact that’s why I wrote mine in like fashion. (albeit less eloquently)
      As far as the MD consult,(I just do a phone call, no “permission slip” required) it’s just what they taught us in school when we were young and impressionalbe. It’s hard to change a habit when someone has taken it upon themselves to scare the living $#!? outta you. I DO listen for nuggets of advice that seem to make sense but in the end I’ll do what I feel is right. At the very least I’ve taken the time to do my due diligence and given the MD the chance to yell “DON’T TOUCH HER!!!” in which case a more meaningfull conversation is in order.

      • Adrian Acosta DDS
        March 17, 2011 at 6:57 am

        My last response raises a question in my own mind. I have never had an OBGYN tell me not to treat a patient but I wonder, in all your years of practice have you ever had ocasion to advise a dentist not to treat a patient? Or have you ever suggested any treatment modifications like say for example, “patient has extremely high BP, monitor carefully” or “premedicate with something for BP”? Just curious.

      • March 17, 2011 at 7:17 am

        I’ve never advised a dentist to not treat a problem. The only exception I might think of is if a periodontist wanted to remove a pyogenic granuloma – which wouldn’t be necessary as they all regress after delivery.

        If a pregnant woman was so sick that I worried about the short term variations in her blood pressure, she’d be an inpatient.

  26. March 11, 2011 at 11:33 am

    Thanks for the great info. You have a brilliant idea here, lets make some guidelines together that can be certified by OB’s. I always find it funny when we have to waste time writing notes that we already know the answer to. Unfortunately your professional association has not sat down for 10 minutes to write guidelines that we can adhere to when dealing with pregnancy, so we have to resort to asking on every single case even though we know the answer. You know the cardiologists came up with these great guidelines for premedication and I rarely send to them for authorization. Would you like to petition your board to write some simple guidelines for the dental office?

    • March 11, 2011 at 6:29 pm

      I think that’s a great idea – for the dental association. ACOG might put out a committee opinion about dental procedures in pregnancy, but ultimately ACOG is the governing body for OBGYNs, not dentists. Still would probably be useful, though.

    • March 16, 2011 at 3:10 pm

      On further thought, it would be great if ACOG and the ADA made a joint Practice Bulletin.

      PS your website is great!

  27. EDMD
    March 14, 2011 at 5:00 pm

    Dear OB-

    Why do I have to get consent for a chest x-ray in a pregnant woman and a shielded belly?

    Why do you want an ABG to rule-out pulmonary embolsim?

    Why do you and the ACOG guidelines say Rhogam must be given for first trimester vaginal bleeding, when it’s incredibly expensive and the only “evidence” suggesting it prevents maternal sensitization is cited as “Conversation with doctor?” European guidelines don’t even recommend it.

  28. DDS
    March 16, 2011 at 2:58 pm

    Here is an article that may be useful from the American Pregnancy Association regarding pregnancy and dental treatment, compiled from the ADA, American College of OBGYN, and American College of Radiologists from 2007:

    http://www.americanpregnancy.org/pregnancyhealth/dentalwork.html

    • March 16, 2011 at 3:06 pm

      Thanks for that resource.

      I find the part about local anesthetics a little strange. As they say, lidocaine is category B which is quite safe really. I’d hate to be the patient who is having some work done with a marginal anesthetic under the idea that some incremental additional amount of lidocaine is going to be harmful. Given with epinepherine, the amount of lidocaine that is going to enter the blood stream is pretty small, especially as we are only talking about a few CC of 1 or 2% solution.

      • DDS
        March 16, 2011 at 7:49 pm

        Yes, the local anesthetic part is a little strange. The risk is definitely small for absorption since we inject into soft tissue and are supposed to aspirate to make sure we’re not going directly into the bloodstream. I think it’s just the fear of one bad incident with any patient with a medical issue. That fear is what should drive us to make sure we’re up to date with changes in dentistry AND medicine.

        I totally understand the issue with written letters from medical physicians. My sister’s a cardiologist and hates when dentists ask for “clearance.”

  29. Kristy
    March 18, 2011 at 4:47 am

    Rant away. Love it.

    And while we’re at it, can we please start putting the “risk” of consuming soft cheeses, lunch meat, et al into perspective as well?!? Rant #1 – the issue isn’t “soft cheeses”, but unpasteurized cheeses, which are damn hard to find Stateside (not impossible, mind you, but you have to go looking for them). Rant #2 – choosing not to eat lunch meat during pregnancy is almost akin to choosing not to drive during pregnancy. The risks are on par with each other. Yes, I realize folks can’t avoid driving and they can avoid lunch meat. But, sheesh, already, ALL these precautions and warnings do nothing but serve to propagate the perception that the state of pregnancy is nothing but a disaster waiting to happen. (And that medicine is there to “rescue” them. And that if medicine fails, someone’s at fault.) Little things like this can mean a lot.

  30. Doc99
    March 19, 2011 at 9:50 am

    “There is nothing you can do under local anesthesia that can hurt a fetus.”

    Ever hear of abortion? Amniocentesis? PUBS?
    Care to rephrase?

    • March 19, 2011 at 10:57 am

      OK hater maybe you should read the post. The context is pretty clear.

      “There is nothing you dentists can do under local anesthesia that can hurt a fetus”

  31. Katherine
    March 30, 2011 at 5:54 am

    Trust me, we’re sick of writing them. How can a change be made when dentists are still being taught to write these letters (despite the fact that everything you said is true, and we know the letters are ridiculous?) Believe me, I cringe every time I write one. Sometimes I wonder if they’re just written to convince the patient that everything is going to be fine as the pregnant ladies of the world don’t know:
    1. There is nothing you can do under local anesthesia that will hurt a fetus.
    2. Penicillin antibiotics are safe in pregnancy
    3. Local anesthetics are safe in pregnancy.
    4. Narcotics are safe in pregnancy.
    5. Oral xrays are safe in pregnancy. Shield the baby like you would any patient.

    And they probably aren’t reading this thread.
    - Dentist T minus 2 months

  32. sandi
    May 10, 2011 at 2:41 pm

    Thanks you, Thank you, THANK YOU!!!
    My dentist cannot understand why more in her profession do not work on pregnant women. She actually rec’s that you get your teeth cleaned and checked every trimester and FYI many of the dental insurance companies will cover these cleaning/check ups in pregnancy if you ask or the dentist requests it.

  33. Karen
    May 10, 2011 at 5:52 pm

    How about notes to GPs, gastroenterologists, rheumatologists and every other sub-specialty out there? Gravid women get sick, we break bones….shit freakin’ happens folks you need to learn to deal with us! Sorry….got a little out of hand there but it is an issue I’ve dealt with too frequently.
    Having been pregnant….a lot I have had cause to seek treatment for non-pregnancy related issues. You’d think I was asking a physician to handle a rattlesnake when asking for treatment of a non-pregnancy related condition during pregnancy.
    I had on GP tell me after handing me a scrip for amox for a raging bilateral OM “If this doesn’t work, don’t come back, there is nothing else I can give you beacuse you are pregnant.” I was about 28 weeks and otherwise healthy.
    I ended up in the ER on New Years Day, two days later with two perf’d TM’s and a lot of pain. God Bless the NP who used her head, called the OB resident got a quick approval for a cephalosporin and some codeine.
    Then there is the broken foot at 36 weeks and the radiology tech who layered so much lead on me that I had trouble breathing. Oy.

  34. DentistNurse
    May 23, 2011 at 4:49 am

    As a dentist and former RN who is training young dentists, I love this rant. My quote to my residents is,”It’s not the patients responsibility to NOT be pregnant, it’s your responsibility to know how to treat them safely!” Hope this makes the rounds, dentists are could do better.

  35. sandytrini
    June 14, 2011 at 1:17 pm

    I work as a Dental Assistant first of all asking for a letter from your obgyn nothing is wrong with that they can fax same day and being see. It is for the patient own safety if something going wrong guess what the paients always saying I am going to sued your ass, talk to my lawyer. nothing wrong with protecting yourself and the patients.In the world everything is sue sue sue……….

  36. guest dentist
    June 23, 2011 at 7:00 pm

    As a new dentist, I love this post. Unfortunately, I work with some of these “dentists” that require an OB note in spite of the fact that we have all attended CE classes together that state this is an outdated practice. Perhaps a phone call to these specific providers would be helpful. I can’t seem to convince my senior colleagues that turning away a patient that the hospital referred to us for treatment is inappropriate just to wait for the OB letter that says the same four things every time (for needed dental treatment: lidocaine=okay, penicillin=okay, narcotics=okay, x-rays with apron=okay)!

  37. Amy
    March 5, 2012 at 5:01 pm

    Good article. But, I would like to point out that not of all dentists follow this mantra. If a pregnant comes to my office with bombed out teeth, pain, swelling. Guess what? She’s getting an xray that day and she’s getting treated. In school, I was taught to do this!!! Now, if a patient needs comprehensive care, i.e., fillings. Yes, I’ll be writing you a note to make sure my patient is clear (i.e., no complications) to have routine dental care..Appts are usually longer and patients have multiple visits versus a faster, one appointment emergency visit. Hey, this article is awesome…maybe I’m being naiive, but I think health care professionals should work together for our patients. I hope you know… I’m on your side here :-)

    • March 22, 2012 at 1:46 am

      But why would you need such a note? Is the problem that you don’t understand the impact of dental work on a pregnancy (which is none?) or that you just want some sort of legal protection if there is a complication? It must be one or other other, yet neither reason seems acceptable to me. Pregnant women are common, so a dentist should probably understand enough about the condition to know whether what they do is safe in pregnancy (which it is). If its the latter reason, then its just a distasteful practice of trying to transfer liability to another party for a procedure in which the other party has no involvement.

      • Baynon
        March 22, 2012 at 4:25 am

        It is not so much about TRANSFERRING liability, but rather DUE DILIGENCE. Let’s paint the worst case scenario that there is a coincident miscarriage or serious pregnancy complication shortly after dental treatment. When faced with a potential malpractice suit or accusation, a question that will arise is did the dentist take every possible precaution prior to treating that “high risk” patient??? Would having prior collaborations with that patients OBGYN help the defense cause ? I think the answer would be YES.

  38. Sukanya
    March 20, 2012 at 5:52 am

    As a young dentist, I take umbrage in Ed Howard’s comments.dear OBGYN, If you are sick of writing them, then don’t. Just give a phone call. If you’re sick of that too,then may be you’re totally completely forgetting the point that we are dealing with 2 live patients here, and many a time, treatments involve more than a mere 2 cc innocuous lidocaine injection! Its just to bulwark ourselves from a blemished reputation (just in case!)… Pls do remember that our jobs aren’t as easy either… It’s a “pick and showel” too… So you COULD do with a scruple of RESPECT here!

  39. Aditi Noir
    April 22, 2012 at 12:14 am

    The note may be for the mum to be reassured. You are her primary health care giver with her primary health condition (the pregnancy). It is to reassure their fears that the dental treatment is safe, a second like of confirmation.

  40. paula
    October 22, 2012 at 6:18 am

    I as a dentist completely agree, however you need to address your frustration to your colleagues-as THEY are the OBs that very often tell us “the dentists” that “cleaning is fine but NO XRAYS are allowed (I can’t properly determine a cleaning, and can’t properly diagnose without Xrays!) or ONLY LIDO 2% NO EPI can be used, which we do not have, we are then left to consider using Mepivicaine which has no epi BUT is a Pregnancy Class C drug-not favorable. So until the OBs have a universal position as to how the pregnant patient should be treated, how can dentists be held to an imaginary guideline for treating pregnant women..?

    • November 23, 2012 at 11:38 am

      So my question would be – why are you asking an obstetrician about how to do dentistry? And question #2 – when you get an answer that doesn’t make sense, why are you listening to that answer?

      You can go read on the effect of the millirads of radiation on a fetus, and find that it will have no effect.

      You can also go read about the effect of subcutaneous epi on a pregnancy, and also find that it has no ill effect.

  41. Dawn
    February 2, 2013 at 4:44 pm

    I am having severe tooth pain on an already cracked tooth. I made an appiontment with a dentist on a friday night. I waited over an hour for him to tell me he didn’t know if any dental work would harm my baby. He actually said I don’t know if what I will do could abort your baby. I found his behavior unprofesional and was shocked. Thank you for sticking up for us pregnant women.

    • paula
      February 2, 2013 at 8:17 pm

      Now that is simply ridiculous; in-pain the pregnant pt must be seen. And treated. Period. The risks of not treating vs. treating are higher so I am sorry for you that that dentist didn’t know any better.

  42. barefootbetsy
    March 27, 2013 at 12:54 pm

    Thank you, thank you, thank you!

    I spent an hour earlier today trying to explain to a dental specialist about why it was not reasonable for me to wait until I have a newborn to get two very necessary root canals on painful teeth. I’ve had tooth pain throughout my entire first trimester and am now in my second trimester (21 weeks) because no dentist would touch me in my first trimester. My weight gain is minuscule so far because eating hurts and my stress levels have been through the roof.

    I think the specialist today finally “got it” but it really should not have taken an hour and me bursting into tears for him to listen and stop telling me that I really should wait for the “good of my baby.” I’ve been a wreck for the rest of the day, but reading this post has put me in much better humor! So, thank you again! I will be providing this post to any doula clients I have who try to see a dentist in this town.

    I have seen several dentists during this pregnancy and have had to educate every single one of them to some degree or other about what is and isn’t okay during pregnancy (thankfully I did some research before going to see them). Some were very nice (I continue to see the nice ones), but it was still stressful to explain repeatedly why I don’t leave my newborn babies and why it’s unacceptable for me to remain in pain for 20+ more weeks.

    Thank you again!

  43. August 9, 2013 at 7:00 am

    I trained for my dental career in a hospital setting so I honestly can’t stand having to call you as much as you don’t like getting the call. I am comfortable treating pregnant patients – maybe I am in the minority? I honestly don’t know any dentists in my area who turn away patients in pain but I guess they must be out there. Since there are no joint standards with ACOG and the ADA, maybe it’s just a case of lawyer-it is or a lack of info?

    Quite frankly in my experience, most of your OB colleagues unintentionally scare your patients about all of the things they cannot eat or do lest they kill their unborn child. One of my wife’s friends recently broke down in tears at lunch because she found out that there was blue cheese in her dressing after she ate it…

    They have also provided little to no information to their patients regarding their oral health during pregnancy. Do you screen your patients for oral infections, broken teeth and rampant decay? Do you ask them if they see a dentist on a regular basis? If so, great, you are the exception and not the rule. It amazes me how terrible some patients teeth are when they show up for an emergency and yet they have just had joint replacement, heart bypass or are 8 months pregnant. These are all conditions where the patient has had an extensive relationship with their doctors yet nobody has ever looked in their mouths?!?

    With the lack of good info, it is no wonder that the first thing out of most of these women’s mouths in an emergency is that we need to clear everything with their OB before we can even touch them. This creates a lose-lose situation for me every time. If I don’t get and document “permission” and the patient has ordered me to, how can I possibly proceed in an ethical fashion? By the same token, when my office calls and receives such typical misinformation as “no x-rays” or “no epi”, now I am in the position of having to document and ignore your stupid advice and do what needs to be done. Believe it or not but there are as many ignorant physicians out there as there are dentists.

    In my practice, when we have a patient who is pregnant or planning on it, we give them a letter with information so they can make good choices. Since I may only see about 40% of the population and you see almost all of the pregnant women first, maybe you can use it instead of the snarky one above. I have changed it a little so that it comes from you. Feel free to copy, paraphrase or whatever and include with your NP information. If you clarify it up front with your patients, maybe I won’t have to call you so much… best regards, Dr W.

    =========

    Pregnancy and Your Teeth

    Dear Patient:

    It is always important to take good care of your teeth but even more so during your pregnancy. As you know, your body will be going through significant changes. This includes changes in hormone levels that affect the way your gums react to bacteria and how they heal and protect you from disease.

    Make sure that you are brushing and flossing thoroughly. Small amounts of plaque and tartar that don’t normally cause problems can cause severe gingivitis or even “gum boils” during pregnancy. The term for this is actually called Pregnancy Gingivitis and the abscesses are called Pyogenic Granulomas. They will normally resolve on their own with increased hygiene as well as after pregnancy when hormone levels settle back to a more normal state but they can be quite painful.

    If you are planning to get pregnant, see your dentist and make sure that your mouth is healthy. All needed work preferably should be completed before you get pregnant. There are significant restrictions on many types of anti-inflammatory pain medicine and the stress on your baby from dental pain and infection is simply easier to prevent with good planning than it is to treat as an emergency.

    If you are already pregnant, the safest time for elective care is during your second trimester. We recommend that you keep to your regular schedule of cleanings and checkups to make sure that small problems stay small and are discovered before they become an emergency.

    Should you have a dental emergency while you are pregnant, it is safe to have most dental procedures completed. Again, the stress to your baby from pain and infection in your mouth far outweighs the risk of dental treatment using local anesthetic.
    1. Your condition likely cannot be diagnosed without an x-ray. With the dosages given from modern equipment, the use of a collimation device and the use of a lead apron, there is no significant risk to your baby.
    2. Local anesthetics, especially in the small doses used in dentistry, are safe for you and your baby.
    3. Antibiotics like Penicillin are safe during pregnancy.
    4. Pain medications with narcotics are safe for you to take though they can make you drowsy.

    In general, unless you have a very high-risk pregnancy, have multiple drug allergies which preclude the use of safer drugs or have other diseases and conditions that increase your risk for complications, most all of your routine or emergency dental conditions can be treated while you are pregnant.

    Yours in health,

    Dr. OBGYN

    • pdarne@gmail.com
      August 9, 2013 at 8:33 am

      THAT is a beautiful piece of writing Sent from my BlackBerry 10 smartphone on the Verizon Wireless 4G LTE network. From: Academic OB/GYNSent: Friday, August 9, 2013 1:00 PMTo: pdarne@gmail.comReply To: Academic OB/GYNSubject: [New comment] An open letter to the dentists of the world

      a:hover { color: red; } a { text-decoration: none; color: #0088cc; }

      a.primaryactionlink:link, a.primaryactionlink:visited { background-color: #2585B2; color: #fff; } a.primaryactionlink:hover, a.primaryactionlink:active { background-color: #11729E !important; color: #fff !important; }

      /* @media only screen and (max-device-width: 480px) { .post { min-width: 700px !important; } } */ WordPress.com

      Dr Woodman commented: “I trained for my dental career in a hospital setting so I honestly can’t stand having to call you as much as you don’t like getting the call. I am comfortable treating pregnant patients – maybe I am in the minority? I honestly don’t know any dentists in m”

  44. September 4, 2013 at 5:10 am

    As a dentist, I find this piece hilarious! I apologize for the relatively few members of our dental profession who go overboard by taking unnecessary precautions when treating pregnant women. Unfortunately, there will always be those uniformed dentists who aren’t up to date on recommended protocol. Similarly, there are uninformed physicians who do not follow recommended guidelines and still tell their patients they need to take antibiotics before dental treatment if they have Mitral Valve Prolapse or a total joint replacement. And I wouldn’t be surprised if there are OB-GYNs who still tell their patients to avoid non-emergency dental treatment, especially during the first trimester (which is what I was taught in dental school in 1985).

    Fortunately, we all now have clear guidelines put out by ACOG and endorsed by ADA:

    http://www.acog.org/About_ACOG/News_Room/News_Releases/2013/Dental_X-Rays_Teeth_Cleanings_Safe_During_Pregnancy

    http://www.ada.org/news/8898.aspx

    ACOG released their recommendations in July of this year. “We can all reassure our patients that routine teeth cleanings, dental X-rays, and local anesthesia are safe during pregnancy,” said Dr. Cheng. “Pregnancy is not a reason to delay root canals or filling cavities if they are needed because putting off treatment may lead to further complications.”

    Maybe this will help some of the behind-the-times dentists “grow a pair”. I wouldn’t bet on it. But at least you have an official recommendation, endorsed by the ADA, that you can politely refer them to.

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