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.

  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.

    Like

  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?

    Like

    • Dave
      June 28, 2017 at 4:38 am

      Interesting topic Dr. Fogelson. Unfortunately, most dentists write these releases and send them to you because they do not have the same level of education and training as a physician. Hell, there are dental schools in the US like USC that do not require any of their dental students to take a single course in anything related to pharmacology.

      The problem here is that dental education and training falls grossly behind that of medical education and training. (Most dentists do not complete post-graduate, hospital-based residencies, unlike every board-certified physician in the US). When it comes to complex mechanisms and concepts like medchem, pharmacokinetics, toxicology, ect…, dentists are helpless. So of course I would expect a dentist who would not be capable of articulating why we have developed both amino-amide and amino-ester local anesthetics and why one may be used over the other, to understand if what they are doing in clinic, could hurt a pregnant patient or her fetus.

      Like

      • John
        July 19, 2017 at 11:53 am

        This is flat our wrong in so many ways and is a false perception of dental education. I’d be more than happy to educate you on the topic. Cheers

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      • Dave
        July 19, 2017 at 12:15 pm

        Please educate me.

        Here is the process for becoming a board certified physician (Primary Care or Specialty):
        1) Complete undergrad
        2) Take the MCAT (significantly more rigorous test than the DAT)
        3) Apply to medical school (<25% applicants accepted to allopathic programs each application cycle)
        4) Complete medical school (heavily weighted in academic, pharmacology education and training).
        5) Take relevant licensure examinations as deemed by your state for medical licensure.
        6) Complete a hospital-based residency (that can last anywhere from 2-6 years, where you are hazed by chief residents and attending physicians on a daily basis).
        7) Eligible for board certification in either family/internal medicine or some specialty and can practice a full-scope of medicine.

        Here is the process for becoming a licensed dentist (in 95% of states in the US):
        1) Complete undergrad
        2) Take the DAT (significantly less rigorous than the MCAT)
        3) Apply to dental school (about 50% of the applicants are accepted into either DMD/DDS programs each application cycle).
        4) Complete dental school (take didactic coursework somewhat similar to medical school students for the first two years, depending on the dental school you may or may not take any formal pharmacology coursework and then concentrate 100% of time the last two years learning technical skills associated with physically performing dental treatment).
        5) Take relevant licensure examinations as deemed by your state for dental licensure.
        6) Can practice a full-scope of dentistry.
        7) Hospital-based residencies in dentistry are optional and not required to practice the full scope of dentistry in any state except for New York. Dental residencies are Not as demanding as medical residencies and there exists No tradition of hazing among dental residencies (maybe in OMS, but those are overseen by physicians).

        Please tell me how a dentist's education and training allows them to make any medical decisions or give them any command of complex pharmacology mechanisms of MedChem, pharmacokinetics, toxicology, drug organic/inorganic chemical formulation ect… I am certain you will need to do a lot of googling terms like medchem and pharmacokinetics, because your dental school did Not teach you anything along those lines…

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      • DG
        July 20, 2017 at 3:54 pm

        I’ll try to educate you a bit then David. As you may know generalisations are usually used by folks that have both lack of knowledge of a spoken topic and are highly biased. Stereotyping is just wrong. In all medical fields there are good and bad professionals. Period. These type of comparisons in your post are just absurd, judgmental and most important of all misleading. Moreover if you are a health professional your comment is totally unethical. PS: The googling for pharmacokinetics made me laugh tho. I’ll admit it was pure genius.

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      • Dave
        July 20, 2017 at 4:42 pm

        DG,

        I didn’t stereotype, I listed facts.
        It is a fact that the MCAT is a more rigorous entry exam than the DAT.
        It is fact that allopathic medical schools are more difficult to gain acceptance to than dental schools.
        It is a fact that all four years of medical school and state-mandated hospital-based residencies place an extreme emphasis on things like medchem, pharmacokinetics, organic/inorganic drug chemical formulation ect…
        It is a fact that all dental schools do Not organize their curriculum to meet pharmacology educational standards expected of medical school students and residents.
        It is a fact that all physicians must complete a rigorous hospital-based residency where they will be regularly grilled by attendings and chief residents about things like how exactly various drugs work, their mechanisms, reasons why a drug has a specific interaction ect… This does Not predominate in dental school nor does it predominate in optional dental residencies.
        It is a fact that in the US, dentists are Not considered medical professionals, they are considered dental professionals.

        Nothing I said was misleading. It is incredibly insulting for a dentist that went to a dental school for four years, and straight into private practice, thinks that they have remotely the same level of education and training as a physician that went to a very selective medical school and nightmarish residency.

        The difference between me and a dentist is that I can actually articulate why exactly morphine is the prototypical opioid (even though codeine is far more structurally analogous to the other opioids). I understand how a drug like Narcan works and what would happen if it were mistakenly admin to a pt w/out any opioid overdose (fyi, it wouldn’t be a big deal). I can explain to you why it would be useless to advise a patient who has been on Plavix >7days, to stop the medication a day or two before a procedure (not really required for dental procedures anymore though). I can pick-up an article in the Journal of Medicinal Chemistry and freely discuss it’s topics with other physicians.
        In medical school, residencies and for the purposes of things like step I and step II, you are required to know and understand things like this.

        It is Ok if you do not agree with me, but if you don’t, place some facts to support your claim that I am biased.

        Like

      • AE
        August 2, 2017 at 3:05 am

        What? What are you talking about? Dental education is on par with, if not superior to, medical education. Please, please stop espousing these dangerous stereotypes of what Dentistry is and how dentists operate. Your ignorance is dangerous.

        Like

      • Dave
        August 2, 2017 at 6:16 am

        AE,

        Medical education and training aims to produce physicians that know:

        1) HOW to do XYZ
        2) WHY they do XYZ
        3) WHAT exactly are they doing.

        This predominates in medical education and training.

        For example:
        pt presents to the ER with serotonin syndrome sxs x6hrs.
        current med list is as follows: Ultram 50mg, tpo 1TAB prn, qh4. oxymorphone HCl ER 20mg, tpo 1TAB, BiD. Zestril 5mg, tpo 1TAB, QD.
        Pertinent bloodwork is ordered and no illicit drug use is found in results.
        Pt is provided O2 and IV fluid push while temp is monitored and repeat labs are drawn prior to pt discharge.
        ER physician recommends pt cease taking Ultram immediately and f/u w/pain mgmt.
        pt is discharged.

        Anyone can google or read a book the size of a Charlie Sheen prenup as to HOW you can Dx and Tx a patient with serotonin syndrome.
        In medical education, you will be asked:
        WHY did the ER physician recommend the patient cease the Ultram immediately.
        If you actually know WHAT you are doing, you will know that:
        1) Ultram delivers a racemic mixture of tramadol, each isomer has serotonin and nor-epinephrine re-uptake inhibition properties and that
        2) the parent isomers must undergo first-pass, CYP2D6-mediated metabolism to produce an active metabolite (M1) that has mu-opioid receptor agonizing properties.
        3) oxymorphone is a potent mu-opioid agonist and is an active metabolite of oxycodone.
        4) oxycodone is partially metabolized into oxymorphone via CYP2D6-mediated metabolism.
        5) 10% of humans have profound CYP2D6 metabolic impairment.
        6) most pts on oxymorphone fall into this 10% of the population that can not properly mediate CYP2D6 metabolism of drugs.
        7) pt is taking an abnormally high dose of Ultram for breakthrough pain because his/her body is not effectively inducing CYP2D6-metabolism to produce the active metabolite (M1) that actually agonizes the mu-opioid receptor and provides analgesia.
        8) pt is therefore exposing him/herself to abnormally high doses of SSRI and SNRI-acting compounds from the racemic mixture found in Ultram, since analgesia is not produced (as stated above).
        9) the concomitant use of Ultram with the potent mu-opioid receptor agonist oxymorphone, will definitely precipitate serotonin syndrome sxs and the patient should use a different drug for breakthrough pain.

        Dentists are trained How to do XYZ, they are Not trained why they do XYZ or what exactly it is they are doing.

        For example:
        pt presents to a dental office for wisdom tooth extraction.
        current med list is as follows: Plavix 75mg, tpo 1TAB, QD
        pt has Hx of previous bruising of the jaw and face from previous dental Tx and prolonged wound closures in the past.
        DDS/DMD recommends pt stop taking the drug 2-3days prior to treatment.
        pt is seen for Tx
        DDS/DMD goes through the physical motions of extracting the tooth.
        pt returns to clinic the next day with severe bruising on the face and jaw, as well as a lot of bleeding that is not going away.
        DDS/DMD is clueless as to WHY this happened.
        DDS.DMD does Not know WHAT they are actually doing.

        This is WHY your pt is still bruising and bleeding from your incision sites:
        1) Plavix is an IRREVERSIBLE, ADP-platelet receptor inhibitor.
        2) the lifespan of a platelet in human blood is about 8 days.
        3) if a patient has been on Plavix for >7days, it will take at least 7days of d/c’ing Plavix for the anti-platelet aggregation actions of the medication to stop working.
        4) advising the pt to stop the medication <7days prior to Tx will do nothing…

        I am sorry if I sound like a rude MD, but the problem is that the dental profession does fall far-behind the medical profession with regards to teaching students and the few dentists that pursue a residency, WHY they must do certain things and WHAT exactly it is they are doing.

        Dentists are taught How to practice dentistry, they do Not understand What exactly it is they are doing. In medicine you are required to know What exactly it is you are doing. Not just How to do it.

        Like

  3. March 3, 2011 at 11:14 am

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

    Like

  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.

    Like

  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!)

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  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”?

    Like

    • 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.

      Like

    • 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.”

      Like

    • 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??

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      • 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….

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  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.

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  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!

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    • 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.

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      • 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?

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      • 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.

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  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.

    Like

  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?

    Like

  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?

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  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!

    Like

  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.

    Like

  14. March 5, 2011 at 1:31 pm

    This may be my favorite post ever.

    Like

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

    LOVE IT!

    Like

  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.

    Like

    • 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.

      Like

    • 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.

      Like

  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”

    Like

  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!

    Like

  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.

    Like

    • 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

      Like

  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

    Like

  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!!

    Like

    • 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.

      Like

    • May 31, 2011 at 1:55 pm

      Wow! That’s a really neat awsner!

      Like

  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).

    Like

    • 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.

      Like

  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.

    Like

    • 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.

      Like

  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?

    Like

  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?

    Like

    • 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.

      Like

      • 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.

        Like

      • 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.

        Like

  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?

    Like

    • 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.

      Like

    • 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!

      Like

  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.

    Like

  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

    Like

    • 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.

      Like

      • 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.”

        Like

  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.

    Like

  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?

    Like

    • 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”

      Like

  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

    Like

  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.

    Like

  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.

    Like

  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.

    Like

  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……….

    Like

  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)!

    Like

  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 🙂

    Like

    • 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.

      Like

      • 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.

        Like

  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!

    Like

    • March 17, 2017 at 1:20 am

      ESto tiene una pinta estupenda, y a estas horas se me hace la boca agua.Ahora entro a mirar las medidas del pan de lentejas que en casa ha sido un exzauio.Sterte!

      Like

  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.

    Like

  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..?

    Like

    • 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.

      Like

  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.

    Like

    • 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.

      Like

  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!

    Like

  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

    Like

    • 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”

      Like

      • Dr Willie Endo
        January 4, 2016 at 9:59 am

        Awesome! And I only ask if the patient requests it. I will and have done rot canals on pregnant women, sometimes in an an emergency, right up to having the baby. Everyone should brush their teeth, floss and maybe decrease soda drinking. Outside of trauma related issues, almost all dental work is preventable.

        Like

    • Dr Willie Endo
      January 4, 2016 at 10:00 am

      I meant root canals, pun was not intended

      Like

    • July 19, 2017 at 12:03 pm

      Love it

      Like

  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.

    Like

  45. August 24, 2014 at 4:22 am

    Amazing! Its in fact remarkable piece of writing, I have got much clear idea concerning from this post.

    Like

  46. ab
    December 10, 2014 at 7:46 am

    An easier way to do this would be once your patient finds out their pregnant, at their first OBGYN appt give them dental clearance. EASY AND EFFICIENT and everyone is covered from a LEGAL standpoint.

    Like

  47. Steve
    January 6, 2015 at 5:16 am

    Great note….practicing DDS here who was taught that pregnancy is a normal physiological condition as long as proper precautions are takes (no NSAIDS, etc) . I would also ask that you speak to your OB/GYN colleagues who baselessly request no epinephrine during pregnancy. This is nonsense and in fact Lidocaine with Epi is the only category B local available in dentistry.This silliness cuts both ways , unfortunately.

    Like

  48. March 30, 2016 at 6:17 am

    Thanks so much for sharing this! Where can I find a good training dentist ? I think it’s important to know of one just in case

    Like

  49. June 10, 2016 at 12:26 pm

    6. You seem like an arrogant jerk. We typically defer some questions to physicians out of respect for a fellow practitioner. You, however, are an exception and don’t seem to deserve that respect.

    Like

  50. Semi professional joe
    September 22, 2016 at 7:13 am

    I am a dentist and I can tell you that there are many lower IQ dentists out there that have no reasoning ability. There are also some med docs that have slipped through the system but not as many. There are many dentists that are just not that bright which would make sense just due to the fact that it is much easier to become a dentist. Just as the average intelligence of ancillaries would naturally be lower. Average not all. There are some brilliant dentists to be sure as in any profession. But dentistry does not attract or demand the highest of intellect. Many dentists will react the the general public that has no exposure to medicine. When it was first found that use of bisphosphonates could contribute to osteonecrosis of the jaw afyer tooth extraction many dentists just refused to extract a tooth even if they were the only one available in a rural community to remove their tooth. They did not get that the tooth had to be removed and as gentle to the surrounding bone as possible and deal with any problems in future that may arise. Now if an oral surgeon they felt was more skillful at extraction could be utilized then fine but tooth still needed to be removed. Many without the ability to reason waited until someone of authority in the profession would explain this reasoning that the situation was not that common and had to be dealt with. Also once these fears transfer to the other workers in the dental office it is believed forever and very difficult to change beliefs. Now, in defence of dentists, things are totally different with dental profession than in medicine. The patients, staff and everyone else do not understand that( as is stated so correctly by the Obgyn ) that the dentist is responsible for understanding the oral cavity and everything that could affect or be affected by it. Because people pay for care they are much more critical of decisions. And complain much more if things are not absolutely perfect. People complain more if an 800 dollar root canal fails than if their loved one dies on the operating table. So dentists are constantly worried about reputation being slandered. It has been well known that taking an x-ray on a pregnant patient is 100 Not contraindicated. But if at all possible I don’t do it. You cannot reason with a community college educated assistant that it is OK. If they have seen other dentists freak out over doing it they will be shocked at the thought of it forever. The staff at the desk , the hygienist , everyone. And the patient many times . So I could go ahead after my assistant refuses to take it rolls her eyes and looks horrified and have the whole staff going around thinking that I don’t care and telling other people behind by back OR delay the x-ray , get approval from a real doctor and be thought the sweet caring dentist going the extra mile for their patient . So while I get the frustration of the stupid unprofessional poor excuses for health care professionals that many dentists are( believe that I share in the frustration), many of us have no choice. If that baby even has jaundice it will be blamed on the dentist if he does not have some perceived higher authority approve the procedure. Si , yes I have sent the moron requests to appease my dental hygienist and they are very happy and respectful when I Do. Not to mention once the asst, hygienist, etc had worried the patient by mentioning that we should get approval I have no choice. In summary. 10 to 15 % of med docs are morons, they have said some very stupid things to my patients preventing their proper care. 40 % of dentists either morons or lower intelligence than needed to be in charge of a specialty area in healthcare. Good idea to give a letter at the beginning to the patient. I would appreciate that. I had a hygienist that didn’t understand that I was the authority to decide on pre medication( which is another issue that both dentist and Medical doctors should be ashamed of) so she would consult with physician on many of her patients about this and other reasons she could not perform her open heart procedures, lol and they would get extremely upset at our office.i tried to explain things many times but I was no match for her gruelling science program from her hygiene program. When you hear of a dentists acting ridiculously, many times it is just because dental offices are ridiculous places and there is nothing they can do about it. I don’t do this and I pay the price for being ethical, but many will not shock a new patient by telling them what they really need. The patient will present with obvious carious lesions and infection but the dentist will not inform them and tell them things are fine and wait for a year or longer till they have a more trusting relaxed relationship. This happens all the time. Promoted actually by many in the profession as the smart thing to do. Can you imagine as a medical doctor that you would not inform the patient of your clinical findings? Dentistry is a needed and proper scientific profession, but there is a joke proportion to it for sure. 60% serious part of it that deserves respect and 40% pure joke . That is my estimate

    Like

  51. December 12, 2016 at 9:45 am

    Here is an idea. Rather than attacking the dentists it would behoove you to start good working relationships with your area dentists. Medical providers need to understand the deantists are taught to collaborate. With each other and yes with you!

    Collaboration with an OBGYN is paramount. Call the dentists rather than just a letter, have a conversation and let them know what your preferences are as far as your patients are concerned.

    I have had OBGYNs scream at me for treating a pregnant patient late in the pregnancy or earlyin pregnancy. Saying I should have waited. I don’t agree. But rather than thinking all OBGYNs are NUTS, I request a letter.

    Patients many times do not inform us of their high risk pregnancy and the medications that they are on that could affect the bleeding during an emergency procedure. So take a deep breath!

    My recommendations are these:
    1. Stop attacking your dentists. Collaborate with US!
    2. Have lunch with us and complain, we do care and will listen
    3. Once those relationships have been made, if you run into the ones who dont seem to care, refer your patients to the ones who do
    4. Dentists see pregnant patients for emergencies, usually due to their neglect. They see OBGYNs as soon as they find out they are pregnant. They dont see us as soon as they get a cavity. Usually they don’t want to admit to their negligence and rather throw another dentist under the bus! “The last dentist told me I had cavities. But he was just trying to take my money!” Then attempt to dictate their own treatment. And they use OBGYNs as the back up. “Are you sure this is safe for the baby? I dont want to take the xray until I ask my OBGYN. I know you say it is safe but for my baby, Just to make sure…” talk to your patients.
    5. Don’t assume you know anything about our insurance reimbursements. It’s not like medical, similar but not the same and it is difficult. And we have to fight for reimbursement just as you do. Cannot always bill the difference, get frequently disrespected by our patients for recommendations since even the medical profession sees dentists as just out for money.
    6. Assume we care. We break our backs for patients. Of course we expect an income BUT we are passionate about helping too.

    Like

    • December 12, 2016 at 10:09 am

      Dr. Barker this is an old post and somewhat tongue in cheek. The reality is that I don’t refer patients to dentists, they already have one generally.

      I will reiterate my original comment, which is that the idea that you need to defer to the obstetrician about anything dental is wrong. They have no experience in dentistry, and actually most have very little hard knowledge about the use of anesthetics in pregnancy, other than maybe 1 paragraph of information from an obstetrics textbook which says that if surgery is necessary its best in the second trimester.

      General anesthetics are generally not used in dentistry, so there really isn’t an issue to be dealt with.

      I think that dentists really should look at this differently. They should read and read and read about what is safe in pregnant women in their field, and then just do what is safe. Any pregnancy can potentially miscarry, and if a miscarriage happens after dental work its just coincidence. I take issue at all with the idea that a dentist needs to get permission from an obstetrician. Such things delay dental care, and as you note in many cases prevent it entirely.

      Like

  52. Dan Whittaker
    July 19, 2017 at 11:34 am

    You think that lawsuits are nonsense? How long have you been in practice? I don’t think it’s a lot of fun paying a lawyer to prove you’re right about a case. That said, I’ve never been sued for malpractice so I can’t attest to those costs personally. I know most malpractice cases are settled by insurance companies, but I would not put it past some mother who miscarries shortly after an extraction to go after anybody who treated her. Let’s also not forget that pain is not a life threatening condition. I have never had to turn away a pregnant woman in pain but I don’t see many cases like that. In short, your missive to dentists is insulting. Speak to the providers in question rather than besmirching an entire profession. Real quick, are malpractice insurance rates so damned high for ob/gyns because pregnant mothers DON’T sue? Yeah I didn’t think so

    Like

    • July 19, 2017 at 12:07 pm

      No they’re not. They are a tremendous hassle for all parties, and part of a fairly broken system for seeking justice from medical mishap or maloccurence. But I reiterate my original point – seeking permission from another doctor to do something that you know is safe is to involve them in a web of risk unncecessarily. If a patient miscarries after dental treatment, a zillion experts will be happy to defend that case as not related to the dental work. If it were really dangerous, the dentist should be aware of that and act accordingly. If it isn’t, why do you want to obstetrician to get sued along with you?

      I fully admit there was a lot of snark in this post, posted many years ago. It must have gotten reposted to Facebook today because its blowing up again.

      Like

  53. July 19, 2017 at 2:14 pm

    Well said! Thank you Dr Fogelson for such a well-written and informative post. My brother (an endodontist) shared it with me (a general dentist) today. For years, I have been trying to teach dentists (and sometimes patients) that dentistry is very safe, in spite of what some dental school professors say. Also, we should focus on treating our patients safely and not choosing whatever may prevent a lawsuit. Besides, there are lots of reasons that dentists can be sued, including for denying a pregnant patient needed dental treatment based only on her pregnancy. I can think of many situations that could lead to an unfavorable outcome. Perhaps an untreated abscessed tooth could turn into a cellulitis and instruct her airway.

    Like

  54. July 19, 2017 at 3:41 pm

    I love it. So true!!

    Like

  55. CristinaMaura Del Picchia Maluf
    July 19, 2017 at 7:17 pm

    Bonsoir! I have been working as a Dentist since 1988 and In the recent years I have noticed how our work has not been recognized as it should, especially when the relevant subject are special patients … In these cases, we dedicate ourselves with love and redoubled attention, but recognition is often insignificant. They created many “paradigms” in relation to pregnant patients when in an emergency, everything is worth saving the mother and Baby too … Let’s continue believing in our principles !!! C’est lá vie !!!

    Like

  56. Caloy hunter
    July 19, 2017 at 11:36 pm

    This is actually great for the dentists out there. If anything wrong happens to the pregnancy, the mother and the fetus, and then patients start blaming the dentists, they can always point to this article and this author/doctor for giving this blanket clearance. Great! Thanks and good luck.

    Like

  57. Dr.Pradip R Deore
    July 20, 2017 at 3:55 am

    Wondrrful letter.
    I am a retired dentist but still take interest in dental fraternity.
    I practised in a subarb of Mumbai India.over no.of years i gave been saying samething during association meetings.
    I put medical ins. as the main thing behind the fear of any medical professional taking decisions.
    Once again bravo.
    Atleast somebody showed guts to say this.

    Like

  58. Dr Reddy
    July 20, 2017 at 4:25 am

    Hi whosoever it is
    You have expressed a lot of anguish in your letter but what you failed to understand is that it is not dentist who do not know dental procedures are safe in pregnant women it’s the patients who do not trust our recommendation especially pregnant women they in general feel what we know about the safety of foetus .. God forbid if any untoward incident had to happen they would immediately attribute it to dental negligence .. hence your consent is required .

    Like

  59. Cheryl Leatherwood
    July 20, 2017 at 7:17 am

    Dear Mr/Ms Obstetrician,
    I have been a Hygienist for 23 years. I do know that all dental professionals are extremely aware of your statements. I have seen many faxes from high risk pregnant patients doctors that DO NOT allow or recommend radiographs, local anesthesia or EVEN a prophylaxis during the entire or certain trimesters of their pregnancy. Also, as you well know, we live in a “LAWSUIT HAPPY ” world!! My Dental office will ALWAYS require an OB release for ALL pregnant women, high risk or not. It is ALWAYS better to be safe than sorry.

    Like

  60. Dario
    July 20, 2017 at 8:07 am

    It’s all about getting our ass covered, fine… the thing is that if the dentist says it, they look funny at us as if saying ‘what in the world do you know about my baby?’….
    when they go to the obstetrician and he/she heavily says, yes.. amoxicillin will be safe and Lidocaine, 2 to 4 intraoral X-rays are allowed and whatever else they come back jumping to us with the prescription, saying ‘look what the Doctor said, we can go for it!!’
    You don’t fool me, I’ve been a dentist for a while and it works like this in every country. So please charge your bills and get ahead.

    Like

  61. Jesse Welsh
    July 20, 2017 at 9:43 am

    Spot on. However you should have also written this letter to your colleagues. I’m a dentist and I frequently have pregnant women tell me they can’t have any radiographs because that’s what their ob/gyn said. Or they can only have 1 carpule of lidocaine or no narcotics, etc etc.

    And they’re the “real” doctors 😀

    Like

  62. Mike hegamin
    July 20, 2017 at 9:59 am

    If you promise to cover all legal fees and expenses involved if I ever get sued I will never consult you before doing dental work on a pregnant person

    Like

  63. Eli
    July 20, 2017 at 10:23 am

    A few points.

    1. As far as I know pharmacology is taught at dental schools. As with other coursework, much of it will never be relevant to a dentist. Pharmacology is tested on the national dental licensure exam.
    2. The overall tone of the letter is extremely disappointing. Have respect for a profession where surgical procedures are performed routinely on patients under highly anxiety conditions. This is as opposed to most physicians who perform no surgery whatsoever.
    3. A majority of ob consults I get prohibit use of lidocaine with epi. This is the most commonly used local anesthetic. They would rather I use mepivicaine which is not as safe and not as effective. Many obs prohibit radiographs or at the least ask for double shielding.
    4. Most of the time consults are needed at the urging of th dentists employer who want to cover themselves.
    5. We live in a litigious society.
    6. Med consults are sometimes waived when patients are in pain. Discretion is of course a part of being a doctor.
    7. We don’t know which patients are high risk and you don’t know which dental procedures are high risk.

    Like

    • Dave
      July 22, 2017 at 5:23 am

      Eli,

      The “pharmacology” coursework that dental students receive is similar to that of undergraduate nursing students. You are taught the nomenclature of some drugs and respective class(s), adverse reactions, indications of use, dose and admin ect… Dental school students are not provided extensive education and training in complex mechanisms of medchem, pharmk, fetal tox ect… Further, all of the dental schools have embraced the “problem-based learning” and have not formally organized any pharmacology into their curricula. You can discuss this with current students at schools like USC’s dental school.

      I can tell that the dentists on this board are not very well versed in more complex pharmacology topics because they would know that the FDA has stated that caution must be given when admin almost any drug to a pt who is in their early stages of pregnancy. They would know this because there exists little to no accepted research into these drugs and pregnant populations, as such their respective risk to the fetus and mother, is unknown. If you also have an understanding of how the fetus develops and the complex physiology of pregnancy, you would understand why it is difficult to properly commission and interpret results from a clinical study of a drug in a pregnant patient population.

      We know things like prolonged use of opioids during pregnancy can precipitate withdrawal sxs in newborns. But it is not completely understood as to whether or not amoxicillin or amino-amide/ester local anesthetics can harm a human fetus. Route of admin is also important, but that would be beyond the scope of practice for dentistry.

      I would suggest that you dentists pick-up an FDA drug label every once in a while and try to interpret the information in it. A good website where you can find a good library of FDA drug labels can be found here: https://dailymed.nlm.nih.gov/

      Like

  64. July 20, 2017 at 11:18 am

    I love it! However, no matter how many times I tell the patient the treatment is safe they always want to talk to their OB. And do you know how many OBs have put restrictions on me or have told the patient to tell me I am wrong? Almost every single one of them! Then they leave the practice and do not trust me! I now have them ask the OB the one overseeing them and their unborn fetus. It’s not that easy….I wish it was.

    In dental school I was in Springfield, MO shucking teeth and placing dentures on pregnant teenagers. I had a patient in yesterday 5 months pregnant pharmacist in yesterday and she kept asking me if the root canal treatment was safe for her infected tooth. I told her the same I explain here but her OB said not to unless it was absolutely necessary. What do I do with that?! LOL

    Like

  65. David cassity, DMD, MAGD
    July 20, 2017 at 11:22 am

    You are exactly correct, however if I did not consult with you and get your approval my backside would be in a sling. For the same reasons that I do not remove patients from blood thinners prior to dental treatment. I am not a physician, I am a dentist. In the eyes of the legal profession I am not you. So, to save time may I suggest you develop a check sheet for dental care that your staff can check and you can initial. That will save you time, minimize our harassment and cover legal concerns

    Like

  66. Berous Parish
    July 20, 2017 at 1:16 pm

    Please get the any national obstetrics organization to agree totally with your letter and promise to appear as an expert witness to the fact and promise to publicly censure any obgyn that testifies otherwise. It is insane to treat a pregnant woman without the ok of her ob. A DDS will be hung out to dry by the very same ob if an untoward event happens. Not to mention expert guns for hire. Sorry for the inconvenience of writing a letter. Fix it if you have the power. We can’t.

    Like

  67. Steven Rosenblat
    July 20, 2017 at 1:33 pm

    And patients don’t believe us because we aren’t REAL doctors….

    Like

  68. Jarod
    July 20, 2017 at 1:40 pm

    I’m a pediatric dentist and I have performed surgical extractions, root canals, and many other procedures under local anesthesia because other dentists won’t. Thank you for being an advocate for the patients you treat. An infection in a pregnant woman would be way more harmful than anything I could do!

    Like

  69. Robby
    July 20, 2017 at 3:46 pm

    Grow a pair and do your job You are paid for this Would you say same for complicated procedures like an impaction

    Like

  70. Georgia
    July 20, 2017 at 7:26 pm

    Very well said!!! But when the patient in pain already spoke to the OBGYN and he already said all the no’s to Xray and adrenaline and etc who do you think the patient will listen to???
    Taking in mind the patient does not want to sit on our dental chair and wants the pain magically to go away!!
    Wish it was all that easy….
    Still love the letter!!!

    Like

    • Cristina Del Picchia Naluf
      July 20, 2017 at 8:24 pm

      Bonsoir! In my opinion we( Dentists) must have a strong and firm posture in front these stress patients ( emotional). We must do our work with eficience, dedication and racionallity, if not – nothing will be made!!!! Any patient , whom enters in my Clinic replies the Anamnese and our dialogue(talking) always must be sincere and clear about the treatment and possible intercorrencies- then, my patients normally sign the term about the treatment details. They must feel safe in relation the treatment!!! I know perfectly of my responsibility as a Dentist and I always will do the best for these patients!!! The health will come at the first place!!!

      Like

  71. July 20, 2017 at 8:32 pm

    Interesting…! It was fear that stopped treating these patients at all. Thanks a bundle!

    Like

  72. Jaswanth
    July 20, 2017 at 10:50 pm

    before you question on our knowledge and on ethical statements that we ask from you on a concern note or a moral support and to make sure the patient is comfortable to get a dental treatment we ask our patients to just take an opinion from you mind it pls it’s an opinion not a permission. It’s solely because at that point of their period they trust you a lot since you have been taking care of her pregnancy the future kid of theirs …so we ask them to be on safer grounds and ask an opinion from you whether it would be safe to give certain medicines to the patient.Not that we don’t know the pencillins are safe and painkillers especially NSAIDS are unsafe. A paracetamol would be safe ….pls you have mastered in it and we deal the situation as multidisciplinary and ask you an opinion or clearance certificate like how a surgeon asks for a clearance certificate from a cardiac patient from his cardiologist or if you can say even we the dentists ask for a clearance from cardiologist ….though we studied and know that blood thinners need to be stopped for 2to3 days.
    And madam gynaec….we don’t have time to irritate you either …..pls nowadays Dr Google is irritating like hell.
    And one more doubt why the so called gynaec whom are so interested in oral cavity couldn’t suggest or counsel their own patients to get an oral check up done before pregnancy and get it cleared or filled way before conceiving so that the patient need not suffer during pregnancy and you can avoid the irritation and that would help your mental health and status can be sound .
    Respect any one who performs any procedure with complete knowledge and the same way respect those who ask or try to improve themselves by taking an opinion from the specialist before starting a procedure. They are not trying to blame or safe .They are concerned about the patient .
    Thank you .

    Like

  73. July 21, 2017 at 4:01 am

    Thank you doctor for your letter. You are preaching to the choir. I don’t know how many reads this got but it serves all dentists well to take your advice and treat the patient. You have at your access another tool that will help with premature pregnancies and gingival inflammation being pandemic amongst pregnant and wanting to be pregnant women. Periodontal pathogens set up an immune response side effects of high CRP levels il-1 il-6 and other inflammatory markers that affect term of pregnancy and also as you’ll see in my LinkedIn postings pregnancy itself. The medical device Dental Air Force is the only FDA-approved home care product in the history of Dentistry to be an adjunct to periodontal therapy. It provides 5 times The Beneficial predictable outcome of periodontal therapy alone in mitigating this inflammatory response. It is a device that all dentists and Physicians and patients themselves have at there access. See http://www.DentalAirForce.com
    P. piero dds

    Like

  74. Scott Manhart
    July 21, 2017 at 12:21 pm

    Instead of complaining to us, tell the lawyers that! If anything happens with the pregnancy, regardless of how remote and unrelated to the dental problem and we do not have a case specific clearance from an MD we are toast: medico-legally speaking. Furthermore we are mostly solo or small group entities lacking the multimillion dollar institutional legal support to handle malpractice claims. I understand your frustration but until you change the system form your end your had better get used to writing those notes.

    Like

  75. July 21, 2017 at 6:21 pm

    Hello, very interesting and passionate speech.
    Can you share some scientific publications for us the Dentist to use not only to calm pregnant patients uncertainty, but possible legal facings.
    Thank you.

    Like

  76. Dr. Roomani Srivastava
    July 21, 2017 at 8:06 pm

    Dear obstetrician,
    Dentists write such notes to you not because they lack the knowledge but because the law in some places mandates them to…
    Sadly by the ignorant high headed… People of the entire medical community think dentists are second class citizens in the world of health care and have the audacity to think we lack decision making capabilities. We write such notes so that some ungrateful jerk of a patient doesn’t come back and file a suit that my baby has xyz condition coz you treated me during my pregnancy. So this note to you which we hate writing equally is more of paper work… Deal with it! While you are at it deal with your inflated ego too!

    Like

  77. Andy
    July 22, 2017 at 8:04 am

    Wow, what a pissing contest we have going on here. Until every OB/GYN promises to never be an “expert” witness in a malpractice suit against a dentist who did not consult prior to treatment then sorry. Also “Dave” listed wrong facts. He said “Hospital-based residencies in dentistry are optional and not required to practice the full scope of dentistry in any state except for New York.” Don’t say you are listing facts if your facts are wrong. Delaware also requires one and has even before New York did. #fakenews

    Like

  78. wygdds
    July 22, 2017 at 2:33 pm

    I couldn’t more. I am a dentist. My father was an OB/Gyn and agrees with you. But one only has to be called and chewed out a few times by a disagreeable OB to offer the pregnant patient the service of double checking instead of having a less knowledgeable OB criticize you the next time the patient sees them.

    Like

  79. Amez
    July 23, 2017 at 12:13 pm

    X

    Like

  80. July 30, 2017 at 1:51 am

    Well said. It even applies Downunder. Read the Policies and Guidelines of your own professional association, ADA Inc.

    Like

  81. Dr Aijaz
    September 24, 2017 at 5:54 pm

    Very true

    Like

  82. GD Singhal
    September 26, 2017 at 4:40 am

    Very well description n education on pregnancy n oral disease management. Thanks a lot doctor for being open n fair.
    For the first time, I’ve come across such advice from a gynecologist. Otherwise, I always in my practice of 39 yrs after postgraduation, found at receiving end, gynecologist advising no or minimum TT in pregnancy inspite of my advice for safe outcome in 2nd n 3rd trimester s at least.
    Thanks once again in interest of patient care.

    Like

  83. Dr GK Thapliyal
    September 27, 2017 at 6:04 pm

    Need of the a hour advise to dentist friends.
    I am sure many dentist will not refuse their patients seeking dental care during any trimester of pregnancy . I suggest dental examination of pregnant women should be the part of pre- natal examination.
    Thanks
    Dr GK Thapliyal
    Oral and Maxillofacial Surgeon

    Like

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