The relationship between maternal periodontitis, adverse pregnancy outcome and miscarriage in never smokers

Preconception Periodontitis and Risk of Spontaneous Abortion in a Prospective Cohort Study

Few studies have evaluated the association between periodontitis and spontaneous abortion (SAB), and all had limitations. We used data from the Pregnancy Study Online (PRESTO), a prospective preconception cohort study of 3,444 pregnancy planners in the United States and Canada (2019-2022), to address this question. Participants provided self-reported data on periodontitis diagnosis, treatment, and symptoms of severity (i.e., loose teeth) via the enrollment questionnaire. SAB (pregnancy loss at <20 weeks' gestation) was assessed via bimonthly follow-up questionnaires. Participants contributed person-time from the date of a positive pregnancy test to the gestational week of SAB, loss to follow-up, or 20 weeks' gestation, whichever came first. We fitted Cox regression models with weeks of gestation as the time scale to estimate adjusted hazard ratios (HRs) and 95% confidence intervals (CIs), and we used inverse probability of treatment weighting to account for differential loss to follow-up. We used probabilistic quantitative bias analysis to estimate the magnitude and direction of the effect of exposure misclassification bias on results. In weighted multivariable models, we saw no appreciable association between preconception periodontitis diagnosis (HR = 0.97, 95% CI: 0.76, 1.23) or treatment (HR = 1.01, 95% CI: 0.79, 1.27) and SAB. A history of loose teeth was positively associated with SAB (HR = 1.38, 95% CI: 0.88, 2.14). Quantitative bias analysis indicated that our findings were biased towards the null but with considerable uncertainty in the bias-adjusted results.

Microbiome Changes in Pregnancy Disorders

The human microbiota comprises all microorganisms, such as bacteria, fungi, and viruses, found within a specific environment that live on our bodies and inside us. The last few years have witnessed an explosion of information related to the role of microbiota changes in health and disease. Even though the gut microbiota is considered the most important in maintaining our health, other regions of the human body, such as the oral cavity, lungs, vagina, and skin, possess their own microbiota. Recent work suggests a correlation between the microbiota present during pregnancy and pregnancy complications. The aim of our literature review was to provide a broad overview of this growing and important topic. We focused on the most significant changes in the microbiota in the four more common obstetric diseases affecting women's health. Thus, our attention will be focused on hypertensive disorders, gestational diabetes mellitus, preterm birth, and recurrent miscarriage. Pregnancy is a unique period in a woman's life since the body undergoes different adaptations to provide an optimal environment for fetal growth. Such changes also involve all the microorganisms, which vary in composition and quantity during the three trimesters of gestation. In addition, special attention will be devoted to the potential and fundamental advances in developing clinical applications to prevent and treat those disorders by modulating the microbiota to develop personalized therapies for disease prevention and tailored treatments.

The Potential Association Between Periodontal Diseases and Adverse Pregnancy Outcomes in Pregnant Women: A Systematic Review of Randomized Clinical Trials

Preceding studies have demonstrated that periodontitis might increase the liability of adverse pregnancy outcomes such as preterm birth, preeclampsia, low birth weight, and perinatal fatality in pregnant women. Nonetheless, there is no convincing testimony that periodontitis is related directly to adverse pregnancy outcomes in pregnant women. This systematic review intended to assess and review all the available randomized clinical trials that concentrated on the association between periodontal diseases and adverse pregnancy outcomes, and the impact of periodontal disease therapy on adverse pregnancy outcomes. The databases like Scopus, PubMed, Google Scholar, and Web of Science were consumed to explore relevant and suitable studies after adopting the inclusion and exclusion criteria. The search included articles with no time restrictions and certain keywords were utilized in the databases. The investigation was done through four independent reviewers employing the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Twenty-three studies fulfilled the exclusion and inclusion criteria and were used and included in this systematic review. The above-mentioned studies assessed the association between periodontal diseases and adverse pregnancy outcomes and the effect of periodontal disease treatment in reducing the influence of adverse pregnancy outcomes. This systematic review revealed that there is a relationship between periodontitis and adverse pregnancy outcomes, and periodontal treatment has a reducing impact on adverse pregnancy outcomes in pregnant women with periodontitis. Prospect studies are warranted to investigate the relationship between periodontitis and different adverse pregnancy outcomes and to decide the best type and the most effective therapy to treat periodontitis in pregnant women.

Power Play of Commensal Bacteria in the Buccal Cavity of Female Nile Tilapia

Fish are widely exposed to higher microbial loads compared to land and air animals. It is known that the microbiome plays an essential role in the health and development of the host. The oral microbiome is vital in females of different organisms, including the maternal mouthbrooding species such as Nile tilapia (Oreochromis niloticus). The present study reports for the first time the microbial composition in the buccal cavity of female and male Nile tilapia reared in a recirculating aquaculture system. Mucus samples were collected from the buccal cavity of 58 adult fish (∼1 kg), and 16S rRNA gene amplicon sequencing was used to profile the microbial communities in females and males. The analysis revealed that opportunistic pathogens such as Streptococcus sp. were less abundant in the female buccal cavity. The power play of certain bacteria such as Acinetobacter, Acidobacteria (GP4 and GP6), and Saccharibacteria that have known metabolic advantages was evident in females compared to males. Association networks inferred from relative abundances showed few microbe–microbe interactions of opportunistic pathogens in female fish. The findings of opportunistic bacteria and their interactions with other microbes will be valuable for improving Nile tilapia rearing practices. The presence of bacteria with specific functions in the buccal cavity of female fish points to their ability to create a protective microbial ecosystem for the offspring.

Association between maternal periodontal disease and adverse pregnancy outcomes: an analysis of claims data

BACKGROUND

While a number of studies have explored the link between periodontal disease and adverse pregnancy outcomes, both epidemiological studies and intervention trials have reached contradictory results with relatively small sample sizes. Utilizing large-scale claims data, we aim to investigate the association between maternal periodontal disease and adverse pregnancy outcomes.

OBJECTIVE

Utilizing large-scale claims data, we aim to investigate the association between maternal periodontal disease and adverse pregnancy outcomes.

METHODS

Using de-identified claims data from a national commercial insurer in the USA, records of all observed pregnancies from 2015 to 2019 were included in this retrospective cohort study. Adverse pregnancy outcomes, including low birthweight (LBW) of the newborn, preterm birth (PTB) and spontaneous abortion, were primary outcomes. To evaluate the association between periodontal disease and pregnancy outcomes, logistic mixed-effect model was estimated with periodontal disease status, age, existing clinical conditions of mothers and geographic location as covariates.

RESULTS

Out of 748 792 observed pregnancy records, 18.66% resulted in adverse pregnancy outcomes; 5.92% in LBW, 14.46% in PTB and 2.22 % in spontaneous abortion. Adjusting for individual-level risk factors, periodontal disease was significantly associated with maternal complications with odds ratios of 1.19 (95% CI:1.15, 1.24) for any adverse pregnancy outcomes, 1.10 (95% CI:1.03, 1.17) for LBW, 1.15 (95% CI:1.10, 1.19) for PTB and 1.34 (95% CI:1.23, 1.46) for spontaneous abortions.

CONCLUSIONS

Maternal periodontal disease may be associated with an increased risk of maternal complications and neonatal morbidity. A timely diagnosis and treatment of periodontal disease during pregnancy should be encouraged by considering oral health as part of routine prenatal care.

Periodontology and pregnancy: An overview of biomedical and epidemiological evidence

Women are particularly susceptible to developing gingival problems during pregnancy. In addition, periodontal disease in pregnant women may lead to adverse outcomes for both mother and infant, which have serious clinical and public health implications. Both scenarios have been extensively researched, helping to bring attention to pregnant women as an important and vulnerable population as it concerns periodontal health. The increase in gingival inflammation caused by hormonal changes in pregnant women is undisputed and has been studied and documented since the 1960s, although the exact etiology is not fully understood. The relationship between periodontal disease during pregnancy and adverse pregnancy outcomes is less substantiated, because of conflicting evidence. This review of the biomedical and epidemiologic literature provides an overview of both sides of this relationship and examines the potential mechanisms for developing periodontal disease during pregnancy and the proposed mechanisms by which periodontal disease leads to adverse pregnancy outcomes.

Oral microbiome and pregnancy: A bidirectional relationship

The oral cavity contains the second most complex microbial population within the human body, with more than 700 bacterial organisms. Recent advances in Next Generation Sequencing technology have unraveled the complexities of the oral microbiome and provided valuable insights into its role in health and disease. The human oral microbiome varies dramatically during the different stages of life, including pregnancy. The total viable microbial counts in pregnant women are known to be higher compared to non-pregnant women, especially in the first trimester of pregnancy. A balanced oral microbiome is vital for a healthy pregnancy, as perturbations in the oral microbiome composition can contribute to pregnancy complications. On the other hand, physiological changes and differences in hormonal levels during pregnancy, increase susceptibility to various oral diseases such as gingivitis and periodontitis. A growing body of evidence supports the link between the composition of the oral microbiome and adverse pregnancy outcomes such as preterm birth, preeclampsia, low birth weight among others. This review aims to summarize the dynamics of oral microbiome during pregnancy and to discuss the relationship between a dysbiotic oral microbiome and pregnancy complications.

Quantitative analysis of key periodontopathic bacteria in gestational diabetic and non-diabetic women

Purpose

The aim of this study is to compare the periodontal status and quantify Porphyromonas gingivalis (Pg) and Prevotella intermedia (Pi) from plaque samples of both gestational diabetic mellitus (GDM) and non diabetic pregnant women.

Materials and methods

Sixty first time pregnant women were selected after adjusting for age, duration of pregnancy and educational status. They were then categorized into gestational diabetic women (GDM) (Group A) and healthy pregnant women (non GDM) (Group B). Periodontal examination was done by assessing gingival index, periodontal disease index and probing depth. Microbial analysis on sub-gingival plaque was performed using polymerase chain reaction (PCR). Statistical analysis was done by student t test, chi square test and Fischer exact test.

Results

Group A showed higher gingival index, probing depth and periodontal disease index scores than group B at p < 0.001. Pg was detected in 80% of group A and 40% of group B. Amongst these; it was measured over 2.0 × 10⁴ in 33% of group A, while in the group B it never scored more than 1.0 × 10⁴. While Pi were also detected in 73% of group A women and 40% Group B women but quantification showed Pi > 2.0 × 10⁴ in more number of group A women.

Conclusion

This study showed that there is significant association between the severity of periodontal disease and increased levels of Pg and Pi in gestational diabetic women.

Association between periodontitis and spontaneous abortion: A case-control study

BACKGROUND

Spontaneous abortion, or miscarriage, is a complication of pregnancy which can severely affect women both physically and psychologically. We investigated the associations of periodontitis and periodontopathic bacteria with spontaneous abortion.

METHODS

We conducted a matched case-control study in two tertiary hospitals in Khon Kaen, Thailand. Cases were 85 women with spontaneous abortion at <20 weeks of gestation matched to 85 controls on age, gestational age, and hospital. Full-mouth periodontal examinations were performed. Periodontitis was defined as at least one site with probing depth ≥5 mm and clinical attachment level ≥2 mm at the same site. Subgingival plaque samples were collected to determine the levels of Porphyromonas gingivalis, Tannerella forsythia, and Fusobacterium nucleatum using real time polymerase chain reaction.

RESULTS

The cases were significantly more likely to have periodontitis (50.6%) than the controls (21.2%; P = 0.007). Conditional logistic regression revealed a crude odds ratio (OR) of 4.1 for the association between periodontitis and spontaneous abortion (95% confidence interval [CI] = 1.9-8.9, P = 0.001). The OR decreased, but was still significant, after controlling for previous miscarriage (OR = 3.3, 95% CI = 1.4-7.8, P = 0.006). There was no significant association between the levels of periodontopathic bacteria and spontaneous abortion. Increased levels of P. gingivalis and F. nucleatum were associated with periodontitis in both case and control groups. Association between increased T. forsythia levels and periodontitis was observed only in the case women.

CONCLUSIONS

Periodontitis was more common in women with spontaneous abortions as compared with matched controls. Levels of periodontopathic bacteria was not associated with spontaneous abortion in this population.

Periodontitis, cardiovascular disease and pregnancy outcome--focal infection revisited?

Over the last two decades there has been a renewed interest around the possible effects of periodontal disease on both cardiovascular health and pregnancy outcome (among other diseases), a topic which has interested science for hundreds of years. These have led to a range of studies, workshops and consensus documents being published, with corresponding coverage in general and professional media. In this article the authors summarise the history and supporting theories behind such associations, whether clinical studies have been able to confirm these and what this might mean for general practitioners who are questioned on this topic by patients.

Epidemiology of association between maternal periodontal disease and adverse pregnancy outcomes--systematic review

BACKGROUND AND OBJECTIVES

There is still debate regarding potential relationships between maternal periodontitis during pregnancy and adverse pregnancy outcomes. The aim of this systematic review was to synthesize the available epidemiological evidence on this association.

DATA SOURCES

Combined electronic and hand search of MEDLINE, EMBASE, WEB OF SCIENCE and Cochrane Central Register databases.

STUDY ELIGIBILITY CRITERIA

Original publications reporting data from cross-sectional, case-control or prospective cohort epidemiological studies on the association between periodontal status and preterm birth, low birthweight (LBW) or preeclampsia. The search was not limited to publications in English. All selected studies provided data based on professional assessments of periodontal status, and outcome variables, including preterm birth (<37 weeks gestation), LBW (<2500 g), gestational age, small for gestational age, birthweight, pregnancy loss or miscarriage, or pre-eclampsia.

PARTICIPANTS

Pregnant women with or without periodontal disease, and with or without adverse pregnancy outcomes, assessed either during pregnancy or postpartum. No intervention studies were included. Study appraisal and synthesis methods - Publications were assessed based on predefined screening criteria including type of periodontal assessment, consistency in the timing of the periodontal assessment with respect to gestational age, examiner masking and consideration of additional exposures and confounders.

RESULTS

Maternal periodontitis is modestly but significantly associated with LBW and preterm birth, but the use of a categorical or a continuous exposure definition of periodontitis appears to impact the findings: Although significant associations emerge from case-control and cross-sectional studies using periodontitis "case definitions," these were substantially attenuated in studies assessing periodontitis as a continuous variable. Data from prospective studies followed a similar pattern, but associations were generally weaker. Maternal periodontitis was significantly associated with pre-eclampsia.

LIMITATIONS

There is a high degree of variability in study populations, recruitment and assessment, as well as differences in how data are recorded and handled. As a result, studies included in meta-analyses show a high degree of heterogeneity.

CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS

Maternal periodontitis is modestly but independently associated with adverse pregnancy outcomes, but the findings are impacted by periodontitis case definitions. It is suggested that future studies employ both continuous and categorical assessments of periodontal status. Further use of the composite outcome preterm LBW is not encouraged.

Bi-directional relationship between pregnancy and periodontal disease

During pregnancy profound perturbations in innate and adaptive immunity impact the clinical course of a number of infectious diseases, including those affecting periodontal tissues. Conversely, it has been suggested that periodontal infections may increase the risk of adverse pregnancy outcomes. In this review, a summary of the literature associated with the bidirectional relationship between pregnancy and periodontal disease as well as the possible mechanisms behind this interaction were examined.

Periodontitis in pregnant baboons: systemic inflammation and adaptive immune responses and pregnancy outcomes in a baboon model

BACKGROUND/OBJECTIVES

Chronic periodontal infections have been suggested to contribute to the risk of adverse pregnancy outcomes.

MATERIAL AND METHODS

This study describes the relationship of patterns of systemic inflammatory mediators and IgG antibody to 20 oral bacteria in pregnant female baboons (Papio anubis) coupled with clinical features of ligature-induced periodontitis, as risk indicators for adverse pregnancy outcomes. Animals showing a preterm delivery and/or low birth weight newborns, as well as those pregnancies resulting in spontaneous abortion, stillbirth, or fetal demise were tabulated as adverse pregnancy outcomes.

RESULTS

A significantly greater frequency of the periodontitis group neonates had a low birth weight (18.1%; p = 0.008) and decreased gestational age (9.8%). Spontaneous abortion/stillbirth/fetal demise were increased in the periodontitis (8.7%) versus the control group (3.8%) (p = 0.054). The baseline oral clinical presentation of the experimental animals did not relate to the adverse pregnancy outcomes. Animals with the greatest extent/severity of periodontitis progression during the initial ½ of gestation (ie. to mid-pregnancy) had the greatest risk for adverse pregnancy outcomes. Baseline biological parameters indicating historical responses of the animals to periodontal challenge demonstrated individual variation in selected mediators, some of which became more differential during ligature-induced periodontitis. The relationship of clinical parameters to systemic inflammatory responses was consistent with a temporal contribution to adverse pregnancy outcomes in a subset of the animals.

CONCLUSIONS

These results support a link between periodontitis and adverse pregnancy outcomes in the baboons and provide a prospective experimental model for delineating the biologic parameters that contribute to a causal relationship between chronic oral infections and birth events.

Very low and low birth weight associated with maternal periodontitis

AIM

The aim of this study was to evaluate the association of very low and low birth weight (VLBW and LBW) with maternal periodontitis.

MATERIAL AND METHODS

Overall, 1206 women were examined at post-partum and two alternative criteria for periodontitis definition were used: (1) four or more teeth with at least one site with probing depth (PD) ≥ 4 mm and clinical attachment loss (CAL) ≥ 3 mm; and (2) at least one site with PD and CAL ≥ 4 mm. For each definition, two multivariate analyses were performed: (1) linear regression for birth weight; (2) ordinal logistic regression for birth weight, categorized as adequate (n = 1046), LBW (n = 145) and VLBW (n = 15).

RESULTS

Linear regression showed that maternal periodontitis was associated with a decrease in mean birth weight (periodontitis definition 1: p = 0.027; periodontitis definition 2: p = 0.003). Ordinal logistic regression showed that maternal periodontitis was associated with LBW and VLBW [odds ratio (OR) = 2.0; 95% confidence interval (CI) 1.39-2.90, when considering periodontitis definition 2]; and with LBW (OR = 1.65; 95% CI 1.15-2.36, when considering periodontitis definition 1).

CONCLUSION

Maternal periodontitis was associated with a decrease in mean birth weight, as well as with LBW and VLBW.

Maternal periodontitis as a risk factor for prematurity

BACKGROUND

The aim of this study was to investigate maternal periodontitis associated with prematurity.

METHODS

We carried out a case-control study including 718 puerperae who experienced a spontaneous delivery: 360 cases (premature) and 358 controls (full-term). Sociodemographic, obstetric, prenatal, perinatal and periodontal data were obtained within 48 h after delivery. Periodontitis was defined as probing depth ≥ 4 mm and attachment loss ≥ 3 mm at same site, for ≥ 4 teeth.

RESULTS

Periodontitis was associated with prematurity (odds ratio 6.95; confidence interval 3.69-13.09). Prematurity was associated with maternal age < 20 years, family income < one minimum salary, maternal schooling < 8 years, premature birth history, premature membrane rupture, ruptured membranes > 24 h, smoking, urinary tract infection, leukorrhea, pre-eclampsia, prenatal consultations < 3 and precarious housing. After multivariate confounder adjustments, periodontitis remained independently associated with prematurity (odds ratio 6.05; confidence interval 3.01-12.16).

CONCLUSIONS

Periodontitis is strongly associated with prematurity, indicating necessity for regular periodontal investigation and treatment during pregnancy.

The relationship between maternal periodontitis and preterm low birth weight: A case-control study

Background:

The relationship between periodontal diseases in pregnancy and children born prematurely or with low birth weight has been increasingly investigated, showing positive and negative results, respectively. Objective: To evaluate the association between Maternal Periodontitis and Preterm delivery or Low Birth Weight.

Materials and Methods:

In this case-control study, 104 pregnant women without systemic disease or other risk factors for preterm labor were chosen. The control group (n = 52) had term labor (infants ≥37 weeks) and the case group (n = 52) had preterm labor (infants <37 weeks). Plaque index, bleeding index, and birth weight were measured.

Results:

The data of plaque index (cases 1.21±0.56; controls 0.63±0.31), bleeding index (cases, 2.08±0.62; controls, 1.52±0.61), birth weight (cases, 2.01±0.36; controls 2.87±0.32), and Probing Pocket Depth (PPD) ≥4mm and Clinical Attachment Level (CAL) ≥3mm in at least 4 teeth (odds ratio 137.50, P value < 0.0001) revealed a statistically significant difference between the two groups P< 0.05).

Conclusions:

A noticeable relationship between periodontal health and duration of pregnancy; periodontal disease could be a risk factor for preterm labor. Oral hygiene maintenance should be a part of prenatal care protocol.

Periodontal treatment during pregnancy decreases the rate of adverse pregnancy outcome: a controlled clinical trial

Objectives

The aim of this study was to evaluate the effects of non-surgical treatment of periodontal disease during the second trimester of gestation on adverse pregnancy outcomes.

Material and Methods

Pregnant patients during the 1^st and 2^nd trimesters at antenatal care in a Public Health Center were divided into 2 groups: NIG – "no intervention" (n=17) or IG- "intervention" (n=16). IG patients were submitted to a non-surgical periodontal treatment performed by a single periodontist consisting of scaling and root planning (SRP), professional prophylaxis (PROPH) and oral hygiene instruction (OHI). NIG received PROPH and OHI during pregnancy and were referred for treatment after delivery. Periodontal evaluation was performed by a single trained examiner, blinded to periodontal treatment, according to probing depth (PD), clinical attachment level (CAL), plaque index (PI) and sulcular bleeding index (SBI) at baseline and 35 gestational weeks-28 days post-partum. Primary adverse pregnancy outcomes were preterm birth (<37 weeks), low birth weight (<2.5 kg), late abortion (14-24 weeks) or abortion (<14 weeks). The results obtained were statistically evaluated according to OR, unpaired t test and paired t test at 5% significance level.

Results

No significant differences were observed between groups at baseline examination. Periodontal treatment resulted in stabilization of CAL and PI (p>0.05) at IG and worsening of all periodontal parameters at NIG (p<0.0001), except for PI. Significant differences in periodontal conditions of IG and NIG were observed at 2nd examination (p<0.001). The rate of adverse pregnancy outcomes was 47.05% in NIG and 6.25% in IG. Periodontal treatment during pregnancy was associated to a decreased risk of developing adverse pregnancy outcomes [OR=13.50; CI: 1.47-123.45; p=0.02].

Conclusions

Periodontal treatment during the second trimester of gestation contributes to decrease adverse pregnancy outcomes.

Effectiveness of interventions to screen and manage infections during pregnancy on reducing stillbirths: a review

BACKGROUND

Infection is a well acknowledged cause of stillbirths and may account for about half of all perinatal deaths today, especially in developing countries. This review presents the impact of interventions targeting various important infections during pregnancy on stillbirth or perinatal mortality.

METHODS

We undertook a systematic review including all relevant literature on interventions dealing with infections during pregnancy for assessment of effects on stillbirths or perinatal mortality. The quality of the evidence was assessed using the adapted Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach by Child Health Epidemiology Reference Group (CHERG). For the outcome of interest, namely stillbirth, we applied the rules developed by CHERG to recommend a final estimate for reduction in stillbirth for input to the Lives Saved Tool (LiST) model.

RESULTS

A total of 25 studies were included in the review. A random-effects meta-analysis of observational studies of detection and treatment of syphilis during pregnancy showed a significant 80% reduction in stillbirths [Relative risk (RR) = 0.20; 95% confidence interval (CI): 0.12 - 0.34) that is recommended for inclusion in the LiST model. Our meta-analysis showed the malaria prevention interventions i.e. intermittent preventive treatment (IPTp) and insecticide-treated mosquito nets (ITNs) can reduce stillbirths by 22%, however results were not statistically significant (RR = 0.78; 95% CI: 0.59 - 1.03). For human immunodeficiency virus infection, a pooled analysis of 6 randomized controlled trials (RCTs) failed to show a statistically significant reduction in stillbirth with the use of antiretroviral in pregnancy compared to placebo (RR = 0.93; 95% CI: 0.45 - 1.92). Similarly, pooled analysis combining four studies for the treatment of bacterial vaginosis (3 for oral and 1 for vaginal antibiotic) failed to yield a significant impact on perinatal mortality (OR = 0.88; 95% CI: 0.50 - 1.55).

CONCLUSIONS

The clearest evidence of impact in stillbirth reduction was found for adequate prevention and treatment of syphilis infection and possibly malaria. At present, large gaps exist in the growing list of stillbirth risk factors, especially those that are infection related. Potential causes of stillbirths including HIV and TORCH infections need to be investigated further to help establish the role of prevention/treatment and its subsequent impact on stillbirth reduction.

Reducing stillbirths: prevention and management of medical disorders and infections during pregnancy

BACKGROUND

An estimated two-thirds of the world's 3.2 million stillbirths occur antenatally, prior to labour, and are often overlooked in policy and programs. Poorly recognised, untreated or inadequately treated maternal infections such as syphilis and malaria, and maternal conditions including hypertensive disorders, are known risk factors for stillbirth.

METHODS

We undertook a systematic review of the evidence for 16 antenatal interventions with the potential to prevent stillbirths. We searched a range of sources including PubMed and the Cochrane Library. For interventions with prior Cochrane reviews, we conducted additional meta-analyses including eligible newer randomised controlled trials following the Cochrane protocol. We focused on interventions deliverable at the community level in low-/middle-income countries, where the burden of stillbirths is greatest.

RESULTS

Few of the studies we included reported stillbirth as an outcome; most that did were underpowered to assess this outcome. While Cochrane reviews or meta-analyses were available for many interventions, few focused on stillbirth or perinatal mortality as outcomes, and evidence was frequently conflicting. Several interventions showed clear evidence of impact on stillbirths, including heparin therapy for certain maternal indications; syphilis screening and treatment; and insecticide-treated bed nets for prevention of malaria. Other interventions, such as management of obstetric intrahepatic cholestasis, maternal anti-helminthic treatment, and intermittent preventive treatment of malaria, showed promising impact on stillbirth rates but require confirmatory studies. Several interventions reduced known risk factors for stillbirth (e.g., anti-hypertensive drugs for chronic hypertension), yet failed to show statistically significant impact on stillbirth or perinatal mortality rates. Periodontal disease emerged as a clear risk factor for stillbirth but no interventions have reduced stillbirth rates.

CONCLUSION

Evidence for some newly recognised risk factors for stillbirth, including periodontal disease, suggests the need for large, appropriately designed randomised trials to test whether intervention can minimise these risks and prevent stillbirths. Existing evidence strongly supports infection control measures, including syphilis screening and treatment and malaria prophylaxis in endemic areas, for preventing antepartum stillbirths. These interventions should be incorporated into antenatal care programs based on attributable risks and burden of disease.

Oral health care patterns and the history of miscarriage

OBJECTIVE

Oral infections can trigger the production of pro-inflammatory mediators that may be risk factors for miscarriage. We investigated whether oral health care patterns that may promote or alleviate oral inflammation were associated with the history of miscarriage in 328 all-Caucasian women.

MATERIALS AND METHODS

Of 328 women in this cross-sectional cohort, 74 had history of miscarriage (HMC). Medical, dental and sociodemographic data were collected through clinical examinations, medical record searches and structured questionnaires.

RESULTS

The multivariate regression analyses indicated that urgency-based dental treatment demonstrated a significant association [odds ratio (OR) = 2.54; 95% confidence interval (CI): 1.21-5.37; P = 0.01] and preventive dental treatment demonstrated a marginally significant inverse association (OR = 0.53; CI: 0.26-1.06; P = 0.07) with HMC. Self-rated poor oral health had a non-significant positive association with HMC (OR 1.60; CI: 0.88-2.90).

CONCLUSION

Our results provide sufficient evidence for hypothesis generation to test whether other precise measures of oral inflammation are associated with adverse birth outcomes.

Benefits of Periodontal Therapy When Preterm Birth Threatens

There is growing evidence that chronic periodontitis may be a risk factor for pre-term birth. The goal of this intervention study was to determine the effect of periodontal treatment on the pregnancy outcome in women with threatening pre-term birth and initial localized chronic periodontitis. Forty-one women with a singleton pregnancy were enrolled in the study. For this treatment group, oral hygiene instruction and periodontal therapy were provided in the third trimester, while those in the control group (42 persons) did not receive any periodontal treatment. In the treatment group, the mean weight of newborns was 3079.0 g, compared with the control group mean of 2602.4 g. The incidence of pre-term birth and low birthweight in the treatment group was significantly less than in the control group ( p = 0.015). Periodontal treatment completed before the 35th week appeared to have a beneficial effect on birth weight and time of delivery.

A critical assessment of adverse pregnancy outcome and periodontal disease

BACKGROUND

Pre-term birth is a major cause of infant mortality and morbidity that has considerable societal, medical, and economic costs. The rate of pre-term birth appears to be increasing world-wide and efforts to prevent or reduce its prevalence have been largely unsuccessful.

AIM

To review the literature for studies investigating periodontal disease as a possible risk factor for pre-term birth and adverse pregnancy outcomes.

MAIN FINDINGS AND CONCLUSION

Variability among studies in definitions of periodontal disease and adverse pregnancy outcomes as well as widespread inadequate control for confounding factors and possible effect modification make it difficult to base meaningful conclusions on published data. However, while there are indications of an association between periodontal disease and increased risk of adverse pregnancy outcome in some populations, there is no conclusive evidence that treating periodontal disease improves birth outcome. Based on a critical qualitative review, available evidence from clinical trials indicates that, although non-surgical mechanical periodontal treatment in the second trimester of pregnancy is safe and effective in reducing signs of maternal periodontal disease, it does not reduce the rate of pre-term birth. Clinical trials currently underway will further clarify the potential role of periodontal therapy in preventing adverse birth outcomes. Regardless of the outcomes of these trials, it is recommended that large, prospective cohort studies be conducted to assess risk for adverse pregnancy outcome in populations with periodontal disease. It is critical that periodontal exposure and adverse birth outcomes be clearly defined and the many potential confounding factors and possible effect modifiers for adverse pregnancy outcome be controlled in these studies. If periodontal disease is associated with higher risk of adverse pregnancy outcome in these specific populations, large multicenter randomized-controlled trials will be needed to determine if prevention or treatment of periodontal disease, perhaps combined with other interventions, has an effect on adverse pregnancy outcome in these women.

Maternal periodontal disease, pregnancy, and neonatal outcomes

The purpose of this article is to review the current literature on the association between maternal periodontal disease and poor pregnancy and neonatal outcomes and outline the role nurses can play in improving the oral health of pregnant women. Maternal periodontal disease is linked to preterm birth, low birthweight, and preterm low birthweight, but treatment of periodontal disease during pregnancy has been shown to be safe and effective. Nurses, nurse practitioners, and nurse-midwives are in a position to educate pregnant women on the benefits of good oral health and identify and refer women who are in need of dental care for treatment.

Periodontal disease and pregnancy outcomes: state-of-the-science

To examine the existing evidence on the relationship between periodontal disease and adverse pregnancy outcomes, we conducted a systematic review of studies published up to December 2006. Studies published in full text were identified by searching computerized databases (e.g., MEDLINE, EMBASE). A meta-analysis was performed to pool the effect size of the clinical trials. Forty-four studies were identified (26 case-control studies, 13 cohort studies, and 5 controlled trials). The studies focused on preterm low birth weight, low birth weight, preterm birth, birth weight by gestational age, miscarriage or pregnancy loss, preeclampsia, and gestational diabetes mellitus. Of the chosen studies, 29 suggested an association between periodontal disease and increased risk of adverse pregnancy outcome (odds ratios [ORs] ranging from 1.10 to 20.0) and 15 found no evidence of an association (ORs ranging from 0.78 to 2.54). A meta-analysis of the clinical trials suggested that oral prophylaxis and periodontal treatment may reduce the rate of preterm low birth weight (pooled risk ratio (RR): 0.53, 95% confidence interval [CI]: 0.30-0.95, P < 0.05), but did not significantly reduce the rates of preterm birth (pooled RR: 0.79, 95% CI: 0.55-1.11, P > 0.05) or low birth weight (pooled RR: 0.86, 95% CI: 0.58%1.29, P > 0.05). The authors conclude that periodontal disease may be associated with increased risk of adverse pregnancy outcomes. More methodologically rigorous studies are needed in this field. Currently, there is insufficient evidence to support the provision of periodontal treatment during pregnancy for the purpose of reducing adverse pregnancy outcomes.

TARGET AUDIENCE

Obstetricians & Gynecologists, Family Physicians.

LEARNING OBJECTIVES

After completion of this article, the reader should be able to state that the published literature is not vigorous to clinically link periodontal disease and/or its treatment to specific adverse pregnancy outcomes, and explain that more rigorous studies with world-wide agreed-upon definitions are particularly needed before periodontal disease treatment can be recommended.

Periodontal disease as a risk factor for adverse pregnancy outcomes: a prospective cohort study

AIM

The aim of this study was to determine the association between periodontitis and the incidence of preterm birth (PB), low birth weight (LBW) and preterm low birth weight (PLBW) MATERIAL AND METHODS: One thousand and ninety-six women were enrolled. Periodontal data, pregnancy outcome variables and information on other factors that may influence adverse pregnancy outcomes were collected. Data were analysed using a logistic regression model.

RESULTS

The incidence of PB and LBW was 6.6% and 6.0%, respectively. The incidence of PLBW was 3.3%. PB was related to mother's age, systemic diseases, onset of prenatal care, previous PBs, complications of pregnancy, type of delivery, the presence of untreated caries and the presence of periodontitis (odds ratio 1.77, 95% confidence interval: 1.08-2.88). LBW was related to mother's smoking habits, ethnicity, systemic diseases, previous LBW babies, complications of pregnancy and type of delivery. PLBW was related to mother's age, onset of prenatal care, systemic diseases, previous LBW babies, complications of pregnancy and type of delivery.

CONCLUSIONS

The factors involved in many cases of adverse pregnancy outcomes have still not being identified, although systemic infections may play a role. This study found a modest association between periodontitis and PB. Further research is required to establish whether periodontitis is a risk factor for PB and/or LBW.

Stimulatory response of neutrophils from periodontitis patients with periodontal pathogens

OBJECTIVE

Neutrophils play a crucial role in the defense of invading bacteria by releasing biologically active molecules. The response of peripheral blood neutrophils was studied in periodontitis-affected patients and in healthy controls towards stimulation to Porphyromonas gingivalis (Pg) and Actinobacillus actinomycetemcomitans (Aa) extracts.

MATERIALS AND METHODS

Peripheral venous blood was drawn from 23 adult patients with moderate to advanced chronic periodontitis (probing depth >or=5 mm, attachment loss >or=3 mm), and 30 healthy volunteers. Neutrophil response followed by metalloproteinase-9 (MMP-9) and interleukin-8 (IL-8) secretion was assayed by zymography and enzyme-linked immunosorbent assay, respectively, on both whole blood and purified neutrophils. In addition to periodontal pathogen extracts, known stimulating agents were tested, such as Escherichia coli-lipopolysaccharide (LPS), phytohemagglutinin, and zymosan A.

RESULTS

Neutrophil response, expressed as a secretion ratio under stimulated and non-stimulated conditions, measured in whole blood, showed no differences between periodontitis and healthy controls. Instead, in purified neutrophils from patients, MMP-9 exhibited a significantly higher secretion ratio with LPS and Pg (1.5- to 2-fold), whereas IL-8 showed a larger increase in secretion ratio (3- to 7-fold) in the presence of Pg, Aa, LPS, and zymosan A.

CONCLUSION

Peripheral neutrophils of periodontitis-affected patients are more reactive as suggested by their significantly higher response toward periodontal pathogen extracts and other stimulating agents.

Maternal oral health status and preterm low birth weight at Muhimbili National Hospital, Tanzania: a case-control study

Background

The study examined the relationship between oral health status (periodontal disease and carious pulpal exposure (CPE)) and preterm low-birth-weight (PTLBW) infant deliveries among Tanzanian-African mothers at Muhimbili National Hospital (MNH), Tanzania.

Methods

A retrospective case-control study was conducted, involving 373 postpartum mothers aged 14–44 years (PTLBW – 150 cases) and at term normal-birth-weight (TNBW) – 223 controls), using structured questionnaire and full-mouth examination for periodontal and dentition status.

Results

The mean number of sites with gingival bleeding was higher in PTLBW than in TNBW (P = 0.026). No significant differences were observed for sites with plaque, calculus, teeth with decay, missing, filling (DMFT) between PTLBW and TNBW. Controlling for known risk factors in all post-partum (n = 373), and primiparaous (n = 206) mothers, no significant differences were found regarding periodontal disease diagnosis threshold (PDT) (four sites or more that had probing periodontal pocket depth 4+mm and gingival bleeding ≥ 30% sites), and CPE between cases and controls. Significant risk factors for PTLBW among primi- and multiparous mothers together were age ≤ 19 years (adjusted Odds Ratio (^aOR) = 2.09, 95% Confidence interval (95% CI): 1.18 – 3.67, P = 0.011), hypertension (^aOR = 2.44, (95% CI): 1.20 – 4.93, P = 0.013) and being un-married (^aOR = 1.59, (95% CI): 1.00 – 2.53, P = 0.049). For primiparous mothers significant risk factors for PTLBW were age ≤ 19 years (^aOR = 2.07, 95% CI: 1.13 – 3.81, P = 0.019), and being un-married (^aOR = 2.58, 95% CI: 1.42 – 4.67, P = 0.002).

Conclusions

These clinical findings show no evidence for periodontal disease or carious pulpal exposure being significant risk factors in PTLBW infant delivery among Tanzanian-Africans mothers at MNH, except for young age, hypertension, and being unmarried. Further research incorporating periodontal pathogens is recommended.

Periodontal disease and pregnancy outcomes: exposure, risk and intervention

Despite the many advances in medicine, the rate of preterm birth has not significantly decreased in the United States over the past several decades. In fact, the rate rose in 2003 to more than 12% of all births in the United States. This equates to over half a million premature births in the United States alone. Consequently, the identification of risk factors for preterm birth which are amenable to intervention would have far-reaching and long-lasting effects. There is emerging evidence of a relationship between periodontal health and adverse pregnancy outcomes, particularly preterm birth/preterm low-birth-weight infants. Therefore this chapter explores the putative association between periodontal disease and infant prematurity, as well as the results of intervention studies which treated periodontal disease in order to reduce the incidence of prematurity. Of 31 published studies, 22 show a positive association between premature birth and periodontal disease. Ongoing studies are addressing the efficacy of periodontal treatment for decreasing the incidence of infant prematurity.

Periodontal treatment in pregnant women improves periodontal disease but does not alter rates of preterm birth

DESIGN

This was a multicentre randomised controlled trial (RCT).

INTERVENTION

Pregnant women were divided into two groups. Those to whom dental treatment was given had up to four visits of periodontal scaling and root planing using ultrasonic and hand instruments, with local anaesthesia as needed. Treatment recipients were also given instruction in oral hygiene and monthly tooth polishing and re-instruction in oral hygiene, with scaling and planing as needed. Control patients received only a brief oral examination at monthly follow-ups but attended the same number of visits as the treatment group. Patients in the control group were offered the same periodontal therapy after delivery.

OUTCOME MEASURE

The primary outcome was gestational age at delivery. Secondary outcomes included birth weight, the proportion of infants who were small for gestational age, Apgar scores, and admissions to a neonatal intensive care unit.

RESULTS

Preterm birth (before 37 weeks of gestation) occurred in 49 out of 407 women (12.0%) in the treatment group (resulting in 44 live births) and in 52 out of 405 women (12.8%) in the control group (resulting in 38 live births). Although periodontal treatment improved periodontitis measures (P<0.001), it did not significantly alter the risk of preterm delivery [P 0.70; hazard ratio for treatment group versus control group, 0.93; 95% confidence interval (CI), 0.63-1.37]. There were no significant differences between the treatment and control groups in mean babies' birth weights (3239 g versus 3258 g; P 0.64) or in the rate of delivery of infants who were small for gestational age (12.7% versus 12.3%; odds ratio, 1.04; 95% CI, 0.68-1.58). There were five spontaneous abortions or stillbirths in the treatment group, compared with 14 in the control group (P 0.08).

CONCLUSIONS

Treatment of periodontitis in pregnant women improves periodontal disease and is safe but does not significantly alter rates of preterm birth, low birth weight or foetal growth restriction.

Treatment of periodontal disease and the risk of preterm birth

BACKGROUND

Maternal periodontal disease has been associated with an increased risk of preterm birth and low birth weight. We studied the effect of nonsurgical periodontal treatment on preterm birth.

METHODS

We randomly assigned women between 13 and 17 weeks of gestation to undergo scaling and root planing either before 21 weeks (413 patients in the treatment group) or after delivery (410 patients in the control group). Patients in the treatment group also underwent monthly tooth polishing and received instruction in oral hygiene. The gestational age at the end of pregnancy was the prespecified primary outcome. Secondary outcomes were birth weight and the proportion of infants who were small for gestational age.

RESULTS

In the follow-up analysis, preterm birth (before 37 weeks of gestation) occurred in 49 of 407 women (12.0%) in the treatment group (resulting in 44 live births) and in 52 of 405 women (12.8%) in the control group (resulting in 38 live births). Although periodontal treatment improved periodontitis measures (P<0.001), it did not significantly alter the risk of preterm delivery (P=0.70; hazard ratio for treatment group vs. control group, 0.93; 95% confidence interval [CI], 0.63 to 1.37). There were no significant differences between the treatment and control groups in birth weight (3239 g vs. 3258 g, P=0.64) or in the rate of delivery of infants that were small for gestational age (12.7% vs. 12.3%; odds ratio, 1.04; 95% CI, 0.68 to 1.58). There were 5 spontaneous abortions or stillbirths in the treatment group, as compared with 14 in the control group (P=0.08).

CONCLUSIONS

Treatment of periodontitis in pregnant women improves periodontal disease and is safe but does not significantly alter rates of preterm birth, low birth weight, or fetal growth restriction. (ClinicalTrials.gov number, NCT00066131 [ClinicalTrials.gov].).

Possible association between mother's periodontal status and preterm delivery

BACKGROUND

A case-control study was undertaken to detect whether initial chronic localized periodontitis could be a risk factor for preterm birth (PB) and foetal growth restriction.

METHODS

A PB case was defined if a patient had a threatening premature event during pregnancy pre-term premature rupture of membranes, or spontaneous pre-term delivery, before the 37th week of pregnancy, and/or the weight of the newborn was <2500 g. Into the PB (case) group, 77 women were allocated, while 84 were included in the control group, all of whom had delivery after the 37th gestational week and with a newborn weighing >or=2500 g.

RESULTS

A significant association was found between PB and initial chronic localized periodontitis, the criteria being bleeding at >or=50% of the examined teeth and having at least at one site at >or=4 mm probing depth (p=0.0001). The adjusted odds ratio for initial chronic localized periodontitis was 3.32, 95% CI: 1.64-6.69. The average weight of newborns of mothers with periodontitis was significantly less than that of the women without periodontitis (p=0.002).

CONCLUSIONS

The results support the hypothesis that initial chronic localized periodontitis of pregnant women could lead to PB, and birth-weight reduction.