Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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Dr Bhanu K Bhakhri

"The Journal of Clinical and Diagnostic Research (JCDR) has been in operation since almost a decade. It has contributed a huge number of peer reviewed articles, across a spectrum of medical disciplines, to the medical literature.
Its wide based indexing and open access publications attracts many authors as well as readers
For authors, the manuscripts can be uploaded online through an easily navigable portal, on other hand, reviewers appreciate the systematic handling of all manuscripts. The way JCDR has emerged as an effective medium for publishing wide array of observations in Indian context, I wish the editorial team success in their endeavour"



Dr Bhanu K Bhakhri
Faculty, Pediatric Medicine
Super Speciality Paediatric Hospital and Post Graduate Teaching Institute, Noida
On Sep 2018




Dr Mohan Z Mani

"Thank you very much for having published my article in record time.I would like to compliment you and your entire staff for your promptness, courtesy, and willingness to be customer friendly, which is quite unusual.I was given your reference by a colleague in pathology,and was able to directly phone your editorial office for clarifications.I would particularly like to thank the publication managers and the Assistant Editor who were following up my article. I would also like to thank you for adjusting the money I paid initially into payment for my modified article,and refunding the balance.
I wish all success to your journal and look forward to sending you any suitable similar article in future"



Dr Mohan Z Mani,
Professor & Head,
Department of Dematolgy,
Believers Church Medical College,
Thiruvalla, Kerala
On Sep 2018




Prof. Somashekhar Nimbalkar

"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."



Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018




Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



Dr Kalyani R
Professor and Head
Department of Pathology
Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
On Sep 2018




Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
‘Knowledge is treasure of a wise man.’ The free access of this journal provides an immense scope of learning for the both the old and the young in field of medicine and dentistry as well. The multidisciplinary nature of the journal makes it a better platform to absorb all that is being researched and developed. The publication process is systematic and professional. Online submission, publication and peer reviewing makes it a user-friendly journal.
As an experienced dentist and an academician, I proudly recommend this journal to the dental fraternity as a good quality open access platform for rapid communication of their cutting-edge research progress and discovery.
I wish JCDR a great success and I hope that journal will soar higher with the passing time."



Dr Saumya Navit
Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
Lucknow
On Sep 2018




Dr. Arunava Biswas

"My sincere attachment with JCDR as an author as well as reviewer is a learning experience . Their systematic approach in publication of article in various categories is really praiseworthy.
Their prompt and timely response to review's query and the manner in which they have set the reviewing process helps in extracting the best possible scientific writings for publication.
It's a honour and pride to be a part of the JCDR team. My very best wishes to JCDR and hope it will sparkle up above the sky as a high indexed journal in near future."



Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata




Dr. C.S. Ramesh Babu
" Journal of Clinical and Diagnostic Research (JCDR) is a multi-specialty medical and dental journal publishing high quality research articles in almost all branches of medicine. The quality of printing of figures and tables is excellent and comparable to any International journal. An added advantage is nominal publication charges and monthly issue of the journal and more chances of an article being accepted for publication. Moreover being a multi-specialty journal an article concerning a particular specialty has a wider reach of readers of other related specialties also. As an author and reviewer for several years I find this Journal most suitable and highly recommend this Journal."
Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
Muzaffarnagar.
On Aug 2018




Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011

Important Notice

Dentistry
Year : 2010 | Month : August | Volume : 4 | Issue : 4 | Page : 2974 - 2978

Endodontic Consideration For The Usage Of Drugs In Pregnant And Lactating Mothers

AGGARWAL R*,SINGLA M**, MITTAL N***

*(MDS)Senior Lecturer, **(MDS)Professor, ***(MDS)Senior Lecturer,Dept of conservative dentistry and Endodontics Surendera dental college & research institute Sri Ganganagar (Rajasthan).

Correspondence Address :
Dr Munish Singla
(MDS),Professor,Dept of conservative dentistry and Endodontics
Surendera dental college & research institute
Sri Ganganagar Rajasthan,(India)
Phone no 9198141-45816,
email munishsinglaendo@yahoo.com

Abstract

The pregnant or lactating patient presents with a number of unique management problems for oral health care providers. Practitioners with minimal training in gestational medicine may be hesitant to treat their pregnant patients. Because of a fear of injuring either the mother or unborn child, some practitioners may withhold care or medications from their patients, inadvertently causing harm. An understanding of the patient’s physiological changes, the effects of chronic infection or illicit drugs and the risks or benefits of medications are necessary to adequately advise a patient on her options regarding medical/dental care.

Introduction
Many dental professionals may be apprehensive about providing dental care to their gestational patients due to fears of inadvertently harming the foetus. The need to minimize systemic infection and the disease is of utmost importance during this period (1),(6) and so, all dental procedures are not contraindicated during pregnancy. They should be performed with added precautions and drug modifications. With respect to the field of endodontics, if dental caries is a source of pain or acute infection in an otherwise healthy gestational woman, a dentist should provide invasive care, no matter what the patient’s phase of pregnancy is (1),(13). Dental decay also presents an additional source of bacterial load on the patients. The endodontic treatments performed to alleviate the pain and infection, along with proper drug selection to reduce the side effects of drugs on pregnant females and their unborn foetuses.

Additionally, there is no contraindication in using radiographs during diagnostic procedures which are deemed necessary, such as radiographs with normal safety precautions. These precautions include beam collimation, high speed films, limited exposure and lead apron for the patients (6). It is estimated that an average full mouth dental film series may expose the foetus to 1x10-5 rads of radiation, far below the teratogenic risk to an unborn child (11),(14),(16).

Drugs And Pregnancy
Medications may be either a boon or liability during a woman’s pregnancy. This determination can only be made if the weight of her medical/dental condition, the foetus’s risk of exposure and the need for dental treatment are evaluated and balanced (3). Physicians, dental professionals, or patients may have an irrational belief that all medications may be harmful to the unborn child. However, some medical or dental conditions, if left untreated, may be more detrimental to the foetus. This may lead to progressive maternal disease status, teratogenesis, impaired foetal growth or development, premature birth, spontaneous miscarriage, or abortion (9). While some medications may be harmful to a foetus, safe alternatives are often available to treat many of these dental conditions. Both the patients and the dentalprofessionals need to make an informed choice in this matter.
In the United States, the FDA has developed a five-category system to determine foetal risks of medications (12). The categories range from A, the safest listing, to the final category, X, which is completely contraindicated during pregnancy (18) (Table/Fig 1) .

The dental professionals must use scientific literature and study reviews; confer with the patient’s obstetrician, physicians, or pharmacists who are familiar with pregnancy interactions; or make use of reliable published reference sources.

Many factors play roles in determining the foetal risk of medications. First, it should be determined if a drug is tetragenic in nature. Most foetal organogenesis occurs during the first trimester, which is the period of most concern for many medication effects on the foetus. The next matter of concern would be the degree of foetal exposure to a medication. Not all drugs readily pass through the placental barrier. For example, drugs with little or no foetal contact are those that bind to proteins or that which are made up of large molecules that cannot transfer through the barrier (9).

The drugs that would readily go across the placental barrier include lipid-binding drugs, acidic medications, or those that depend on renal clearance (17). Though tetracycline and minocycline are both effective antibiotics, both known to be associated with abnormalities in both bone and dentaldevelopment. These drugs are thus not advised for pregnant patients (18). Alcohol is also contraindicated during gestation, as it has been proven to cause neurodevelopmental defects after repeated or high-dose exposure (2).

The pharmacokinetics of a drug may be altered by pregnancy. For example, vasodilation leads to increased hepatic metabolisms and renal clearance rates. The increase in blood volume causes a larger volume of distribution of a given medication (14). Pregnancy is also associated with slower peristalsis and gastric emptying, as well as increased cardiac output, blood volume, body fat, and glomerular filtration (9),(10). Thus, unbound free drugs may be transferred across the placenta and drugs that are usually cleared by the kidney do so at a faster rate. This leads to lower serum drug concentrations and thus lower effectiveness, unless the dosage is adjusted (9).

Drugs Used In Endodontics
Fortunately, many drugs in a dental office’s armamentarium are considered to be generally safe for both pregnant patients and their unborn children. Most dental professionals should have access to a medication reference if questions arise regarding a proposed drug’s efficacy or safety. However, if a dental professional has any doubts about either dental medication choices or the risk factors for pregnant patients, he or she should refer to the patient’s obstetrician.

1. Local Anaesthesia
Local anaesthetics are among the most commonly used medications by dentists. Lidocaine and prilocaine have been given an FDA category B rating when given in a therapeutic range and should be the first-line choices for local anaesthesia for pregnant women who do not have any contraindications, such as allergy (4),(18). Bupivicaine, mepivicaine, and articaine have each been given FDA category C ratings. Bupivicaine’s rating stems from animal studies demonstrating embryo death with higher-than-therapeutic dosages.

Mepivicaine and articaine have been rated as category C drugs because of insufficient animal studies (5). None of the above listed local anaesthetic agents have been associated with poor foetal outcomes when given in dental therapeutic dose ranges [4,5]. Additionally, the use of vasoconstrictors such as epinephrine or levonorderfrin, is not contraindicated when they are a part of the commercially available local anaesthetics. Though given a C rating, these vasoconstrictors, when used in low concentrations in pre-packaged local anaesthetic cartridges, cause no foetal harm as long as normal precautions are taken. These precautions include avoiding injection within the blood vessels and maintaining total dosages at or below therapeutic ranges such as 0.04 mg for epinephrine and 0.2 mg for levonorderfrin (4),(5).

2. Antibiotics
Frequently, the best treatment option for a patient is to immediately address pain or infections at the source (1),(5),(11). However, there are occasions when infections cannot be treated immediately with invasive dental care and antibiotics may be a necessary course of action. Many of a dentist’s first line antibiotics are rated by the FDA as category B for pregnancy risk. These include the penicillin family, the erythromycins (except for the estolate form), azithromycin, clindamycin, metronidazole, and the cephalosporins (18). However, tetracycline, minocycline, and doxycycline are given D ratings due to their likelihood of chelating in bones and teeth. Thus, tetracycline, minocycline, and doxycycline should be normally avoided (18).

3. Analgesics
When discussing pain, the dental professional should be aware of many potential pitfalls. Not all nonsteroidal anti-inflammatory drugs are safe for the foetus. Neither aspirin nor diflusinal are recommended for a pregnant woman. Aspirin and diflusinal have both been associated with prolonged gestation and labour, anaemia, increased bleeding potential and premature closure of the ductus arteriosus of the heart (5). Even ibuprofen, ketoprofen, and naproxen are contraindicated in the third trimester of pregnancy, where they are considered as FDA category D choices, due to their risks of prolonged labour, haemorrhage risk during delivery and premature closure of the ductus arteriosus. However, these three analgesics are given a category B rating for the first two trimesters of pregnancy (5). The first-line nonsteroidal anti-inflammatory drug of choice should be acetaminophen. Acetaminophen has earned an FDA B rating for all three trimesters of pregnancy (18). If stronger pain medication is necessary, most narcotic combinations are relatively safe for short durations, despite their risks for foetal growth retardation or foetal dependency if prescribed for long periods. Oxycodone has received a B rating for short-term usage, while meperidine, hydrocodone, propoxyphene and codeine are FDA category C narcotic medications, though they are still considered to be reasonably safe for short-duration pain control (18). However, long-term narcotic usage is ill-advised, as the foetus may develop either neonatal depression or withdrawal symptoms (12).

4. Anxiolytics
When treating anxiety in the dental setting, nonpharmaceutical methods are preferred because they reduce the foetus’s exposure to medication. Most benzodiazepines for anxiolytic relief must be administered with extreme caution and consultations with the patient’s physician because most drugs in this class are classified in categories C or D for pregnancy risk [1,5]. Triazolam which is listed by the FDA in category X is absolutely contraindicated in gestational patients (5). Intranasal nitrous oxide use is very controversial because there is risk of reduced uterine blood flow or tetratogenic effects when it is used in high concentrations (1). Short-term (ie, %30 minutes) use of nitrous oxide, when used in combination with O50% oxygen for nonelective dental procedures, may be warranted if patient management is not possible without anxiolytic management. However, anecdotal reports have indicated risks of cleft palate development which are associated with the short-tern use of nitrous oxide in combination with oxygen (1),(13).

Herbal Medication
Herbal medications have been used throughout human history and are once again gaining popularity in Western cultures. While physicians commonly prescribe vitamin supplements for their pregnant patients, they may be unaware or may be uncomfortable in discussing other natural products with patients. Americans are more frequently adding dietary supplements to their daily routine and may be using these agents during their pregnancies. Because herbs are considered to be natural products, patients may not perceive them as risky (9). The FDA, in conjunction with the Dietary Supplement Health and Education Act of 1994, has recently begun reviewing the efficacy and safety of herbs. Controlled scientific studies which are related to herbs are needed. The effects and risks associated with most natural substances are dose related. For example, garlic and ginger have been used as spices for generations without any reported effects on pregnancy. Yet, high doses of garlic may increase the risk of heavy bleeding by its antiplatelet aggregation properties (3). Other herbs such as blue cohosh and passionflower may alter uterine contraction patterns, which may then affect labour (3).

Drugs And Lactation
With the increasing recognition of the benefits of breast-feeding, clinicians must often weigh the benefits versus risks of drug therapy in lactating women. Mechanisms of the excretion of drugs in breast milk include both passive diffusion and carrier-mediated transport. The amount of a drug excreted in breast milk depends on the characteristics of the drug, such as the drug’s molecular weight, lipid solubility, pKa, and plasma protein bonding (7),(8). Small, water-soluble non-electrolytes pass into milk by simple diffusion through aqueous channels in the mammary epithelial membrane that separates plasma from milk. With larger molecules, only the lipid soluble, non-ionized form passes through the membrane. The pH of milk is generally lower (more acidic) than that of plasma and milk can act as an “ion trap” for weak bases. At equilibrium, basic drugs may be more in concentration in milk as compared to plasma. Conversely, acidic drugs are limited in their ability to enter milk, because the concentration of the nonionized free form in the milk is higher than that in plasma and a net transfer of the drug from milk to plasma occurs.

The factors that determine the advisability of using a particular drug in a nursing mother includes the potential for acute or long-term, dose-related and non-dose-related toxicity; dosage and duration of therapy; age of the infant; quantity of milk consumed by the infant ; and the drug’s effect on lactation. To minimize the infant’s exposure to medication in milk, clinicians should consider the following strategies: withhold drug therapy, delay drug therapy temporarily, advise the mother to avoid nursing at peak plasma concentrations of the drug, administer the drug to the mother before the infant’s longest sleep period and/or withhold breast-feeding temporarily. Drugs that are prescribed for women who are lactating are listed in (Table/Fig 2).

Conclusion

Every gestational woman should be encouraged to seek medical and dental care during her pregnancy, as failure to treat developmental problems affects the health of both the mother and the unborn child. Dental care professionals should educate themselves by gaining a basic understanding of the underlying physiological changes of pregnancy, the influences related to the use of medications or illicit drugs or substances during gestation and how these may interact with the delivery of dental care. This understanding aids the development of a treatment plan and the delivery of the necessary medical, nutritional and dental care, as well as it prepares the professionals for counseling their pregnant patients on relevant issues such as nutritional supplement usage or the need to avoid chemicals or substances that may be harmful to either the mother or the child.

References

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Alexander RE. Eleven myths of dentoalveolar surgery. J Am Dent Assoc 1998; 129(9):1271–9.
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Andres RL. Effects of therapeutic, diagnostic, and environmental agents and exposure to social and illicit drugs. In: Creasy RK, Resnik R, Iams JD, editors. Maternal–fetal medicine: principles and practice. Philadelphia: W.B. Saunders; 2004. p. 281–314.
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Briggs GG, Freeman RK, Yaffe SJ. Drugs in pregnancy and lactation. 7th edition. Philadelphia: Lippincott, Williams, &Wilkins; 2005. p. xiiii–xix,168–71,362–77,714–7, 1249–51.
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Haas DA. An update on local anesthetics in dentistry. J Can Dent Assoc 2002; 68(9):546–51.
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Hilgers KK, Douglass J, Mathieu GP. Adolescent pregnancy: a review of dental treatment guidelines. Pediatr Dent 2003;25(5):459–67.
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Kacew S. Adverse effect of drugs and chemicals in breast milk on the nursing infant. J. Clin Pharmacol 1993;33:213-221.
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Kweder SL, Lee RV. Prescribing for the pregnant patient. In: Lee RV, Rosene-Montella K, Barbour LA, et al, editors. Medical care of the pregnant patient. Philadelphia: ACP-ASIM; 2000. p. 69–85.
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Lindheimer MD, Katz AI. Pregnancy, the kidney, and hypertension. In: Humes HD, DuPont HL, Gardner LB, et al, editors. Kelley’s textbook of internal medicine. Philadelphia: Lippincott, Williams, & Wilkins; 2000. p. 1260–5.
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Livingston HM, Dellinger TM, Holder R. Considerations in the management of the pregnant patient. Spec Care Dentist 1998;18(5):183–8.
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Moore PA. Selecting drugs for the pregnant dental patient. J Am Dent Assoc 1998;129(9): 1281–6.
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