Can you have a tooth pulled when you are pregnant or breastfeeding?

How does having an extraction affect pregnancy and breastfeeding?

On the mind of every pregnant woman or breastfeeding mother is how their pending oral surgery might affect their child.

The good news is that it is possible to safely pull a tooth for a mother without undue concerns for either her or her child. The stipulation is, however, that basic guidelines (like those covered on this page) are adhered to.

• The first portion of this page discusses issues of concern with having a tooth removed when pregnant. – When can the extraction be performed? / Can x-rays be taken? / What medications can be used?
• The latter half of this page explains considerations with performing extractions for breastfeeding mothers. – What medications can be used? / Is breast milk affected?

A) Concerns with extraction procedures for pregnant women.

As an introduction to this subject, here’s a list of questions people frequently have. Our answers here are brief. We explain these issues in more detail in the text that follows this Q&A section.

Quick answers to 6 questions about extractions during pregnancy.

Important considerations when planning an extraction for a pregnant patient.

As a first consideration …

1) You and your dentist might decide to delay your procedure.

2) With the consent of the mother’s obstetrician, having an extraction is possible during any stage of pregnancy.

3) When possible, extractions are preferably targeted for the second trimester of pregnancy (week 14 to week 27).

… with emergency cases handled during the first trimester (weeks 1 to 13) and third trimester (week 28 to week 40) when required.

That’s for patients with problem-free medical histories.

If mother and child (fetus) are healthy and unencumbered with complications associated with medical conditions, both are generally considered low-risk patients during the second trimester (week 14 to week 27).

But if medical concerns exist, different guidelines are followed.

As an example, for women who have a history of previous spontaneous abortion, oral surgery procedures during both the first trimester (weeks 1 to 13) and second trimester (week 14 to week 27) should be avoided.

And because of the potential need for special guidelines like this one, the mother’s obstetrician should always be consulted and their recommendations sought prior to her having a tooth removed.

Miscellaneous concerns with pregnant extraction patients.

Here are some additional guidelines a dentist will need to keep in mind:

• During the first trimester (week 1 to week 13), the fetus is at greatest risk for developmental defects, therefore only urgent extractions should be considered.
• During the last several days of the third trimester, extraction procedures should be avoided because of the possibility of premature labor occurring during the appointment.

• Especially during the third trimester (week 28 to week 40), the need to keep near-term mothers in the fully supine position (lying back in the dental chair) can be a contraindication for extraction procedures because this positioning tends to restrict the mother’s blood flow to the fetus and/or result in a hypotensive episode for her. (Most cases can be accomplished in a more upright or lateral-left (turned to their left side) patient position.)
• Oral surgery performed late in pregnancy may need to include extra breaks or be scheduled as shorter appointments. The fetus tends to place pressure on the mother’s urinary bladder, therefore, causing her to need to urinate more frequently.

▲ Section references – Hupp, Koerner, Fragiskos

What medications are safe to use with pregnant extraction patients?

There’s nothing cut and dried about which drugs are considered safe for use during pregnancy. Opinion based on current research is always evolving.

The FDA (US Food and Drug Administration) recently phased out their previously used “letter grade” classification system that gauged pregnancy risk for prescription drugs. They replaced it with a narrative system where a medication’s packaging insert now includes a section of text describing its known risks and benefits.

This change seems to emphasize the fact that the use of any drug needs to be evaluated individually and on a case-by-case basis. When a question does exist, the patient’s obstetrician should be consulted and their recommendations followed.

Medications generally considered acceptable for use with pregnant extraction patients.

The following medications are typically found in lists considered least likely to harm a fetus when used in moderate amounts. (All held a Category B ranking in the FDA’s previous Pregnancy Risk system.)

• Pain relievers – acetaminophen (Tylenol).
• Antibiotics – penicillin, clindamycin, and cephalosporins (Keflex).
• Local anesthetics – lidocaine (Xylocaine, the most commonly used dental anesthetic for numbing teeth and gums), bupivacaine (Marcaine).

Our short list is of course an abbreviated one. But the drugs we’ve included are medications that collectively could be used to fully manage the preop, procedure, and postop needs of many routine extraction cases.

Can narcotic pain medications be used with pregnant extraction patients?

Notably missing from our list above are prescription narcotics (codeine, hydrocodone, oxycodone, etc…), which admittedly are routinely used with a large percentage of (non-pregnant) oral surgery patients.

Prescription pain relievers.

The patient’s need for controlling their discomfort vs. concerns for the drug’s potential effect on their fetus lies at the heart in making a decision about the use of these kinds of drugs. Usually, the patient’s obstetrician is consulted and their recommendations are followed.

Can sedative medications be used with pregnant extraction patients?

Also missing from our list above are sedative drugs (like those used to relax patients during their oral surgery, a technique termed conscious sedation). Once again, when the use of these types of medications is considered the patient’s obstetrician should be consulted.

• Generally, the use of sedative drugs (oral, I.V.) during pregnancy is best avoided.
• The historic exception has been nitrous oxide (laughing gas) whose use was typically limited to the second trimester (week 14 to week 27) and third trimester (week 28 to week 40), as a mixture with 50% oxygen or more, and just used for short durations (less than 30 minutes).

  Nowadays, the use of nitrous oxide is viewed more controversially. It’s considered best practice to consult with the patient’s obstetrician when making a decision about the suitability of its use.

▲ Section references – Hupp, Koerner, Ouanounou, Patton

Considerations with taking x-rays for pregnant tooth extraction patients.

Here are some brief answers to frequently asked questions. Read our text below for more details.

Answers to questions about dental x-rays during pregnancy.

X-ray of a severely decayed molar slated for removal.

Knowing the root structure of a tooth is a valuable aid in removing it.

Is it safe for pregnant dental patients to have x-rays taken?

• The x-ray beam used to take dental radiographs is highly directed (collimated) and therefore creates a negligible exposure to other parts of the patient’s body (including where the fetus lies).
• By design, the level of radiation exposure needed to take dental x-rays is small, thus keeping the radiation dose received by the mother, and even more so by the fetus, low.

Other guidelines.

In all cases, only essential x-rays should be taken. And always just the minimal number required.

It’s preferable to avoid taking x-rays during the first trimester (week 1 to week 13) of the pregnancy since this is a period of active fetal organ development.

We will point out that it may not be possible for a dentist to provide proper extraction care without having radiographs of the tooth’s root(s) and surrounding bone tissue.

B) Concerns with extraction procedures for women who are breastfeeding.

To start this section, here are some brief answers to frequently asked questions. Read our text below for more details.

Answers to questions about tooth extractions and nursing.

Issues a dentist must consider when planning an extraction for a nursing mother.

The primary concern with nursing mothers having a tooth pulled is that medication(s) used during her procedure are secreted by her body into her breast milk and therefore could adversely affect her infant.

• When evaluating what risk exists, it’s not just the type of medication and its dosing (amount and duration) that’s of concern. The infant’s age and weight will need to be considered too.
• Anytime a question exists, it’s the mother’s obstetrician/infant’s pediatrician who should have the final say in what medications are allowed.

Drugs generally considered acceptable for use with breastfeeding extraction patients.

One would expect that most dentists would consider the following list of medications safe to use with lactating mothers when used in moderate amounts.

The amount of these drugs that passes into breast milk is low and not considered a level where the infant should be adversely impacted. Their use is not considered a contraindication for breastfeeding.

• Pain relievers – acetaminophen (Tylenol).
• Antibiotics – penicillin, erythromycin, and cephalexin (Keflex).
• Local anesthetics – lidocaine (Xylocaine, the most commonly used dental anesthetic for numbing teeth and gums), bupivacaine (Marcaine).

While short and abbreviated, our list does contain medications that collectively could be used to fully manage the preop, procedure, and postop needs of many routine extraction cases. (Like with pregnancy, notably left off our list are narcotic pain relievers and sedative drugs. See below.)

A source for information – The Drugs and Lactation Database.

The LactMed database is a compilation of known drug considerations with breastfeeding. The database is maintained by the U.S. National Library of Medicine and can be accessed via the National Institutes of Health’s (nih.gov) website where individual medications can be looked up. Here’s the link:
Drugs and Lactation Database LactMed.

Is the use of local anesthesia during extractions a contraindication for breastfeeding?

No, the local anesthetics in our list above (lidocaine, bupivacaine), when used in conjunction with performing dental procedures like having a tooth pulled, have not been found to significantly impact a mother’s milk or adversely affect her nursing infant.

No special precautions are required following the mother’s oral surgery. She may breastfeed her child immediately. There’s no requirement to discard (pump and dump) breast milk due to the use of these local anesthetics.

Can breastfeeding mothers use narcotic pain relievers after having a tooth pulled?

Narcotics (like codeine, hydrocodone, oxycodone, etc…) taken by the mother are excreted by her body into her breast milk and therefore have the potential to produce a detrimental effect on her feeding child (infant drowsiness, central nervous system depression, with possible serious consequences). Although, the actual level of the medication that enters the mother’s milk varies according to the specific compound and dosing regimen.

A decision about using narcotics needs to weigh the lactating patient’s need in controlling their discomfort vs. concerns for potential effects on her infant. Or, a substitute for active nursing might be utilized during the period when the breast milk is affected (such as planning to pump and store breast milk in advance or feed the child a substitute formula). The dentist should consult with the patient’s obstetrician or infant’s pediatrician when making their decision.

Can breastfeeding mothers be given sedative medication for extraction appointments?

Many of the Sedatives used in dentistry are excreted into a lactating mother’s milk and therefore have the potential to produce a detrimental effect on her feeding child (infant drowsiness, central nervous system depression, with possible serious consequences). The level of the drug that enters the mother’s milk varies according to the specific compound and dosing regimen.

A decision about the use of sedation with a nursing mother’s oral surgery needs to weigh her needs vs. concerns for the infant. Or, a substitute for active nursing might be utilized during the drug’s period of effect (such as planning to pump and store breast milk in advance or feed the child a substitute formula). The dentist should consult with the patient’s obstetrician or infant’s pediatrician when making their decision.

Laughing Gas

▲ Section references – Hupp, Koerner, Ouanounou, Patton