Assessment of Dentists’ Knowledge Concerning the Management of Breastfeeding Patients in Dental Office

Methodology: In this study were included active dentists. An online questionnaire was applied. The questionnaire was anonymous and the responses were collected online. The questions assessed the therapeutic approach of the patients during the breastfeeding period, what kind of treatments they perform in this category of patients and the time chosen for the dental treatments. The last category of questions collected data about the medication used or prescribed in breastfeeding patients. The data was analyzed using the descriptive statistics and the results were presented as means.


Introduction
Breastfeeding, also known as nursing, is the feeding of babies and young children with milk from a woman's breast [1]. Health professionals recommend that breastfeeding begin within the first hour of a baby's life and continue as often and as much as the baby wants [2,3]. During the first few weeks of life babies can be nursed roughly every two to three hours and the duration of a feeding is usually ten to fifteen minutes on each breast [4]. Older children can be breastfed less often [5]. Mothers may express their milk using breast pumps, so that it can be used later when breastfeeding is not possible [1]. Breastfeeding has a number of benefits to both mother and baby, that infant formula lacks [3,6].
Deaths of an estimated 820,000 children under the age of five could be prevented globally every year by increasing breastfeeding [7].
Breastfeeding decreases the risk of respiratory tract infections and diarrhoea, both in developing and developed countries [2,3]. Other benefits include lower risks of asthma, food allergies, type 1 diabetes, and leukemia [3]. Breastfeeding may also improve cognitive development and prevent obesity in adulthood [2]. Mothers may feel pressured to breastfeed, but in the developed world, children generally can grow up normally when are bottle fed [8].
Benefits for the mother include: less blood loss following delivery, better uterus shrinkage, and decreased postpartum depression [3]. Breastfeeding delays the return of menstruation and fertility, a phenomenon known as lactational amenorrhea [3]. Long term benefits for the mother include decreased risk of breast cancer, cardiovascular disease, and rheumatoid arthritis [3,7]. Moreover, breastfeeding is less expensive than infant formula [9,10]. Health organizations, including the World Health Organization (WHO), recommend breastfeeding exclusively in the first six months [2,3,11]. This means that no other foods or drinks other than possibly vitamin D are typically given [11]. After the introduction of solid foods at six months of age, recommendations include continued breastfeeding until one to two years of age or more [2,3]. Globally about 38% of infants are only breastfed during their first six months of life [2]. In the United States in 2015, 83% of women begin breastfeeding and 58% were still breastfeeding at 6 months, although only 25% exclusively [12]. Medical conditions that contraindicate breastfeeding are rare [3]. Mothers who take certain recreational drugs and medications should not breastfeed (e.g. -antiretroviral medications, chemotherapy agents, sleep-aid medicine, lithium and lamotrigine) [13]. Smoking, limited amounts of alcohol, or coffee are not reasons to avoid breastfeeding [14][15][16].

Aim
To assess the dentists' knowledge regarding the dental treatments that can be performed in breastfeeding women and how to prescribe drugs for these patients in the dental office.

Materials and Methods
An online questionnaire regarding the management of breastfeeding patients in the dental office was administered through the www.isondaje.ro platform such as was described by Ilea et. al [17]. The study was attended by 128 dentists, of various specialties, aged between 25 and 55 years. The questionnaire was anonymous and the responses were collected online. The

The Attitude of Dentists Regarding Treatments that Can Be Performed in a Breastfeeding Patient
The question referring to the attitude adopted at the time of the anamnesis when they are informed that the patient in the dental chair is breastfeeding, had four variants of response: h) It can be seen that the last answer was chosen by more than half of the subjects ( Figure 1).

Figure 1:
The graphical representation of dentists' attitude towards a breastfeeding patient.

The Reasons Why a Dentist Would Not Treat a Patient Who is Breastfeeding
The next question in the questionnaire was addressed only to subjects who chose not to treat a breast-fed patient or had reserved attitude, which was one of the first three variants of the previous

Dental Treatments in a Breastfeeding Patient
When asking about the dental treatments performed in a

Specific Treatment for Gingivitis in a Breastfeeding Patient
The question about the specific treatment for gingivitis in a breastfeeding patient had a total of 128 responses, out of which six answers

Dental Extractions in Breastfeeding Patients
When asking about the dental extraction performed in a

Performing Dental X-Rays in a Breastfeeding Patient
When asked about recommending dental x-rays in a breastfeeding patient, there were four variants of answer:  Figure   5). The answer to this question showed that regarding to dental radiographs in a nursing patient, about ¾ of the doctors were well informed.

Use of Anesthetics in a Breastfeeding Patient
The woman, but about just 1/3 will use mepivacaine and less than 3% will use lidocaine, anesthetic substances admitted in a breastfeeding woman.

Prescription of Antibiotics in a Breastfeeding Patient
The question about prescribing antibiotics to a breastfeeding patient had two variants of response:

Discussions
The hormonal changes associated with breastfeeding were discussed with reference to the findings from animal studies. Both once the fetus and the placenta are delivered, helps to stimulate lactation [18]. An indirect effect of the high levels of prolactin, which supports breastfeeding, is the increased need for calcium in the nursing woman. Some authors stated that during breastfeeding, 300-400 mg of calcium are transferred to breast milk, while other authors have stated that during lactation, calcium is preserved by the kidney to maintain the bone metabolism. Bone calcium loss is counterbalanced by higher levels of vitamin D, growth hormone changes, prolactin, and also by nutritional habits and lifestyle [19,20]. After birth, the patient is in a recovery period, called period of lice. This physiological period lasts about six to eight weeks and is necessary for the body to be restored after birth.
In our study, referring to the dental treatments, most dentists would perform it at any time, but would recommend to the patient not to breastfeed and express and discard the next milk after the anesthesia. The main and most important issue raised in the dental office is the administration of drugs. In our study, almost half of the doctors would prescribe the same type of medicine which they usually prescribe in the dental office, probably based on their knowledge regarding the properties of the drug. The prescription of medication during breastfeeding is a challenge for both the patient and the physician. Therefore, many mothers are advised to express and discard the breast milk if they take certain medication.
However, this advice is often based on limited medical information.
Some studies reviewed the evidence on certain medicines that are safe or others that should be avoided during breastfeeding. Dentists should be familiarized with the risks and benefits of prescribing for a nursing patient certain classes of drugs: antibiotics, local anesthetics, and emergency medications [21].
The milk secretion occurs 24-48 hours after birth. Most substances or drugs ingested by the mother are secreted into the breast milk.
Antibiotics can be ingested by the baby through breast milk if the mother is under antibiotic treatment for a variable period of 5 -7 -10 days required as adjuvant treatment of oral cavity pathology.
This results in early exposure of the infant to antibiotics, which will reduce the long-term breastfeeding beneficial effects (such as reducing the frequency of infections and the risk of overweight) and also, the infant's microbiota can be modified [22]. Some authors recommend that after dental treatments that require the loco-regional anesthesia, the baby's first suckling should be suppressed, and milk be expressed and discarded [24].
In our study, most dentists would perform a dental treatment at any time but would recommend to the patient not to breastfeed after the anesthesia. It is important to know how the drugs are secreted into the breast milk and what factors are involved, in order to know what drugs can be safely administered. According to the literature, the use of lidocaine, mepivacaine, and bupivacaine for local anesthesia is considered compatible with breastfeeding because of low levels in breast milk. Thus, the relative infant dose (RID), which is calculated by dividing the infant's dose via milk by the mother's dose, is 0.5-3.1 for lidocaine and 0.9 for bupivacaine.
In our study, approximately two-thirds of physicians indicated local anesthesia with articaine and only about 1/3 with mepivacaine, which showed insufficient knowledge among respondents [25].
Multiple situations requiring pharmacological treatment may occur in breastfeeding women. Due to the many health benefits of breast milk in infants, breastfeeding should only be discontinued when the drug necessary for the mother could be harmful to the child.
There is no reliable evidence that most drugs cause adverse effects to the breastfed child. Moreover, interruption of breastfeeding, even temporary, may be difficult. Therefore, decisions on the use of medication should be based on correct information. Most antibiotics are considered compatible with breastfeeding [26].

Conclusion
There is insufficient knowledge of an appreciable number of dentists in related to the treatments that can be performed in breastfeeding women. Therefore, postgraduate courses and continuous medical education would be required in order to update the knowledge of dental practitioners.