Journal of Dental Hygiene Supplement of Dental Hygiene · Journal of Dental Hygiene T HE A MERICAN...

Journalof Dental Hygiene

T H E A M E R I C A N D E N T A L H Y G I E N I S T S ’ A S S O C I A T I O N

2008Journal of

Dental Hygiene

Supplement to ADHA Access

Periodontal Diseases and Adverse PregnancyOutcomes: A Review of the Evidence andImplications for Clinical Practice

• Initiative on Oral Health Care• Periodontal Disease and Other Systemic

Conditions• Pregnancy Complications• Periodontal Disease and Its Impact

on Pregnancy • Implications for Dental Hygiene

Assessment, Diagnosis, and Treatment• Oral Health Knowledge in the

Medical Community• Future Projections in Care of Pregnant

Patients• Future Directions for Research and

EducationThis supplement is sponsored by Philips Sonicare.CEUs available online—see page 1.

ow many of you have receivedquestions from your patientsand other health care providers

about the importance and safety oftreating pregnant patients? We are so

pleased to be able to bring you thistimely CE supplement on a topic thatis of interest to every practicing den-tal hygienist. Estimates are that over50% of pregnant women have someform of gingival disease either fromgingivitis or periodontitis. Infectionsin the mother have been identified asincreasing the risk for pregnancycomplications such as preterm birthand preeclampsia. In addition, preg-nancy complications substantiallyincrease the burden to the public byescalating health care costs (estimatedat billions of dollars per year), not tomention the emotional trauma to fam-ilies who experience an adverse preg-nancy outcome.

This supplement will update everydental hygienist on the latest evidenceabout the impact of periodontal dis-ease on pregnancy and includes themost recent treatment recommenda-tions for pregnant patients. The paper

thoroughly reviews the literature onthe topic as well as explains the studydesigns of the many investigationsconducted over the years. A quick ref-erence guide to relevant studies isincluded as well as information aboutwhich dental procedures are deemedsafe during pregnancy. The authorshave also provided you with pub-lished practice guidelines for care andweb sites for easy reference.

Another important feature of thissupplement is the collaborationbetween dental hygiene and medicinein the writing of this piece. HeatherJared, BSDH, MS, is a graduate ofthe University of North Carolina,where she received both her BSdegree and MS degree in DentalHygiene. While in graduate school,Heather conducted her thesis projecton the topic of adverse pregnancy out-comes and it grew into a full-time jobas a research associate professor atUNC. Heather is now part of the Cen-ter of Oral and Systemic Diseases,with the primary responsibility ofplanning and conducting clinical tri-als. Kim Boggess, MD, an obstetri-cian, is an associate professor in theSchool of Medicine at the Universityof North Carolina and part of an inter-disciplinary research team investigat-ing the effect of periodontal diseaseon adverse pregnancy outcomes. Col-laboration with other health care pro-fessionals is vital to the improvementof health for our patients and for mov-ing our profession forward in thefuture.

Finally, I want to extend sincereappreciation to Philips Sonicare fortheir support of this supplement andtheir dedication to the improvementof oral health throughout the world.

Rebecca S. Wilder, RDH, BS, MSEditor-in-Chief, Journal of Dental [email protected]

■ Heather Jared, BSDH, MS, is a researchassociate professor in the Department ofDental Ecology and conducts research inthe Center for Oral Systemic Disease at theUniversity of North Carolina School ofDentistry, Chapel Hill, NC.

■ Kim A. Boggess, MD, is an associateprofessor of Obstetrics & Gynecology in theDivision of Maternal-Fetal Medicine at theUniversity of North Carolina in Chapel Hill,NC.

about the authors

From the Editor-in-Chief of the Journal of Dental Hygiene

H

Special supplement The Journal of Dental Hygiene 1

Journal of Dental Hygiene

IFC From the Editor-in-Chief of the Journal of Dental Hygiene

Rebecca S. Wilder, RDH, BS, MS

Periodontal Diseases and Adverse Pregnancy Outcomes: AReview of the Evidence and Implications for Clinical PracticeHeather Jared, BSDH, MS and Kim A. Boggess, MD

3 Introduction

4 Initiative on Oral Health Care

4 Periodontal Disease and Other Systemic Conditions

4 Pregnancy Complications

5 Periodontal Disease and Its Impact on Pregnancy8 Inconsistencies with Previous Studies

12 Implications for Dental Hygiene Assessment, Diagnosis, and Treatment13 First State Practice Guidelines for Treatment of Pregnant Patients

14 Oral Health Knowledge in the Medical Community

17 Future Projections in Care of Pregnant Patients

17 Future Directions for Research and Education

18 Conclusion

Inside

Message

Supplement

This special issue of the Journal of Dental Hygiene was fundedby an educational grant from Philips Sonicare.

This supplement can also be accessed online atwww.adha.org/CE_courses/

To obtain one hour of continuing education credit, complete thetest at www.adha.org/CE_courses/course19

■■ STATEMENT OF PURPOSE

The Journal of Dental Hygiene is the refereed, scientific publication of the American Dental Hygienists’ Association. It promotes the publication of original research related to the profession, the education, and the practice of dental hygiene. The journal supports the development and dissemination of a dental hygiene body of knowledge through scientific inquiry in basic, applied, and clinical research.

2 The Journal of Dental Hygiene Special supplement

Journal of DentalHygiene

special supplement

■■ EDITORIAL REVIEW BOARD

Celeste M. Abraham, DDS, MSCynthia C. Amyot, BSDH, EdDJoanna Asadoorian, AAS, BScD, MScCaren M. Barnes, RDH, BS, MSPhyllis L. Beemsterboer, RDH, MS, EdDStephanie Bossenberger, RDH, MSKimberly S. Bray, RDH, MSLorraine Brockmann, RDH, MSPatricia Regener Campbell, RDH, MSDan Caplan, DDS, PhDBarbara H. Connolly, PT, EdD, FAPTAValerie J. Cooke, RDH, MS, EdDMaryAnn Cugini, RDH, MHPSusan J. Daniel, AAS, BS, MSMichele Darby, BSDH, MSCatherine Davis, RDH, PhD. FIDSASusan Duley, BS, MS, EdS, EdD, LPC, CEDSJacquelyn M. Dylla, DPT, PTKathy Eklund, RDH, BS, MHPDeborah E. Fleming, RDH, MSJane L. Forrest, BSDH, MS, EdDJacquelyn L. Fried, RDH, BA, MSKathy Geurink, RDH, BS, MAMary George, RDH, BSDH, MEdEllen Grimes, RDH, MA, MPA, EdDJoAnn R. Gurenlian, RDH, PhDLinda L. Hanlon, RDH, BS, MEd, PhDKitty Harkleroad, RDH, MSLisa F. Harper Mallonee,BSDH,MPH,RD/LDHarold A. Henson, RDH, MEdLaura Jansen Howerton, RDH, MS

Heather L. Jared, RDH, BS, MSWendy Kerschbaum, RDH, MA, MPHSalme Lavigne, RDH, BA, MSDHJessica Y. Lee, DDS, MPH, PhDDeborah S. Manne,RDH,RN,MSN,OCNAnn L. McCann, RDH, BS, MS, PhDStacy McCauley, RDH, MSGayle McCombs, RDH, MSTricia Moore, RDH, BSDH, MA, EdDChristine Nathe, RDH, MSKathleen J. Newell, RDH, MA, PhDJohanna Odrich, RDH, MS, DrPhPamela Overman, BSDH, MS, EdDVickie Overman, RDH, BS, MEdFotinos S. Panagakos, DMD, PhD, MEdM. Elaine Parker, RDH, MS, PhDCeib Phillips, MPH, PhDMarjorie Reveal, RDH, MS, MBAPamela D. Ritzline, PT, EdDJudith Skeleton, RDH, BS, MEd, PhDAnn Eshenaur Spolarich, RDH, PhDSheryl L. Ernest Syme, RDH, MSTerri Tilliss, RDH, BS, MS, MA, PhDLynn Tolle, BSDH, MSNita Wallace, RDH, PhDMargaret Walsh, RDH, MS, MA, EdDDonna Warren-Morris, RDH, MS, MEdCheryl Westphal, RDH, MSKaren B. Williams, RDH, PhDCharlotte J. Wyche, RDH, MSPamela Zarkowski, BSDH, MPH, JD

EXECUTIVE DIRECTORAnn Battrell, RDH, BS, [email protected]

DIRECTOR OF COMMUNICATIONSJeff [email protected]

EDITOR EMERITUSMary Alice Gaston, RDH, MS

EDITOR-IN-CHIEFRebecca S. Wilder, RDH, BS, [email protected]

STAFF EDITORKatie [email protected]

LAYOUT/DESIGNJean MajeskiPaul R. Palmer

■■ BOOK REVIEW BOARD

Sandra Boucher-Bessent, RDH, BSJacqueline R. Carpenter, RDHMary Cooper, RDH, MSEdHeidi Emmerling, RDH, PhDMargaret J. Fehrenbach, RDH, MSCathryn L. Frere, BSDH, MSEdPatricia A. Frese, RDH, BS, MEdJoan Gibson-Howell, RDH, MSEd, EdDAnne Gwozdek,RDH, BA, MA

Cassandra Holder-Ballard, RDH, MPALynne Carol Hunt, RDH, MSShannon Mitchell, RDH, MSKip Rowland, RDH, MSLisa K. Shaw, RDH, MSMargaret Six, RDH, BS, MSDHRuth Fearing Tornwall, RDH, BS, MSSandra Tuttle, RDH, BSDHJean Tyner, RDH, BS

■■ SUBSCRIPTIONS

The Journal of Dental Hygiene is published quarterly, online-only, by the AmericanDental Hygienists’ Association, 444 N. Michigan Avenue, Chicago, IL 60611. Copy-right 2008 by the American Dental Hygienists’ Association. Reproduction in whole orpart without written permission is prohibited. Subscription rates for nonmembers areone year, $45; two years, $65; three years, $90; prepaid.

■■ SUBMISSIONS

Please submit manuscripts for possible publication in the Journal of Dental Hygieneto Katie Barge at [email protected].


Introduction

Periodontal diseases are a group ofconditions that cause inflammationand destruction to the supportingstructures of the teeth. These chronicoral infections are characterized bythe presence of a biofilm matrix thatadheres to the periodontal structuresand serves as a reservoir for bacteria.Dental plaque biofilm is a complexstructure of bacteria that is marked bythe excretion of a protective and adhe-sive matrix.1 Within this matrix aregram-negative anaerobic and micro-aerophilic bacteria that colonize onthe tooth structures, initiate theinflammatory process, and can lead tobone loss and the migration of thejunctional epithelium, resulting inperiodontal pocketing and periodontaldisease. This bacterial insult can resultin destruction of the periodontal tis-sues which precipitates a systemicinflammatory and immune response.2

For many years, it was believedthat specific pathogenic bacteriafound within dental plaque biofilmwere solely responsible for peri-odontal diseases. While it is knownthat pathogenic bacteria are one facetof the disease process and are con-sistently present, it is not the onlycause of periodontitis. The hostresponse to the bacterial insult mod-ulates the severity of the disease byactivating the immune system tomediate the disease process. Howwell the host responds to the patho-

genic bacteria modulates how thedisease is initiated and progresses.This is evidenced by the fact that gin-givitis does not always progress intoperiodontitis.

Over the years, several risk factorsfor periodontitis have been identified.For example, stress, poor dietaryhabits with high sugar intake, smok-ing and tobacco use, obesity, age, andpoor dental hygiene all contribute tothe development of periodontal dis-ease. Other major risk factors includeclinching or grinding teeth, geneticfactors, other family factors, othermedical diseases such as diabetes,cancer, or AIDS, defective dentalrestorations medication use, and con-ditions that change estrogen levels(puberty, pregnancy, menopause).3-4

Eighty percent of individuals with

periodontal disease have at least onerisk factor that increases their sus-ceptibility to the infectious processand subsequent tissue damage. Oftenmultiple factors are present.3-4

Initiative on Oral HealthCare

The first-ever Surgeon General’sReport on Oral Health in 2000 out-lined the prevalence of oral diseasessuch as dental caries and periodontalinfection. It also identified vulnera-ble populations that have a higherprevalence of oral disease, and thatsignificant racial/ethnic and socioe-conomic disparities exist in theUnited States. Subsequently, the sur-geon general put forth a call for action

Periodontal Diseases and Adverse PregnancyOutcomes: A Review of the Evidence and Implications for Clinical PracticeHeather Jared, BSDH, MS, and Kim A. Boggess, MD

SupplementSupplement

AbstractPeriodontal diseases affect the majority of the population either as gingivitisor periodontitis. Recently there have been many studies that link or seekto find a relationship between periodontal disease and other systemic dis-eases including, cardiovascular disease, diabetes, stroke, and adversepregnancy outcomes. For adverse pregnancy outcomes, the literature isinconclusive and the magnitude of the relationship between these 2 has notbeen fully decided. The goal of this paper is to review the literature regard-ing periodontal diseases and adverse pregnancy outcomes, and provideoral health care providers with resources to educate their patients. Alter-natively, this paper will also discuss what is occurring to help increase theavailability of care for pregnant women and what oral health care providerscan do to help improve these issues.

Keywords: gingivitis, periodontitis, preterm labor, preterm birth, low birthweight

to promote access to oral health carefor all, reduce the morbidity of oraldiseases, and eliminate oral healthdisparities. The report concluded thatoral diseases can be associated withsystemic conditions, including dia-betes, heart disease, and adverse preg-nancy outcomes. Specifically, thereport stressed that periodontal treat-ment during pregnancy is an impor-tant strategy to potentially improvematernal and infant health.5

Oral health and its relationship tosystemic health is important to societybecause up to 90% of the worldwidepopulation is affected by periodontaldisease—either gingivitis or periodon-titis.6 Reports indicate that up to 30% ofthe general population has a geneticpredisposition to periodontitis and aconservative estimate is that over 35million people in the United Stateshave periodontitis.7

Periodontal Diseaseand Other SystemicConditions

There is considerable interest in thelink between oral and systemic healthamong dental and medical providers.Current evidence suggests that peri-odontal disease is associated with anincreased risk for cardiovascular dis-ease,8,9 diabetes,10,11 community andhospital acquired respiratory infec-tions,12 and adverse pregnancy out-comes.13-15 Individuals with periodontaldisease have approximately a 1.5 – 1.9increased odds for developing cardio-vascular disease.8,16 There appears to bea bidirectional relationship betweenperiodontal disease and diabetes with a2- to 3-fold increased risk for diabetesamong individuals with tooth loss.Teeth and periodontium may serve as areservoir and may contribute to respi-ratory infections. Individuals with poororal hygiene such as dental decay havea 2- to 9-fold increase odds for pneu-monia.12 Many recent studies havereported that maternal periodontal dis-ease may be an independent contribu-tor to abnormal pregnancy outcomesincluding preterm birth, low birth

weight, risk for preeclampsia, mortal-ity, and growth restriction. However,the causality of how periodontitis influ-ences pregnancy outcomes has notbeen established.14-25

Treatment of periodontal infectionmay reduce the risk of other systemicconditions. In a randomized clinicaltrial to estimate the effect of peri-odontal therapy on traditional andnovel risk factors for cardiovasculardisease and on markers of inflamma-tion, D’Aiuto et al found that therapyreduced inflammatory cytokines,blood pressure, and cardiovascularrisk scores.26 In a small treatment trial,type 2 diabetic patients showedimproved diabetic control (lowerHbA1c levels) after periodontal treat-ment.27 Several investigators havereported similar effects of oral healthregimens on reduced risk for nosoco-mial respiratory infections. Treatmentof mechanically ventilated patientswith a daily oral hygiene regime con-sisting of an 0.12% chlorhexidinegluconate wash reduced the risk fornosocomial pneumonia.28,29 Recently,studies have been inconclusive on theeffects of periodontal therapy duringpregnancy for preventing adversepregnancy outcomes.30-32 Treatment oforal infections may represent a novelapproach to improving general health.

It is estimated that over 50% ofpregnant women suffer from someform of gingival disease, either gin-givitis or periodontitis,20,23 with thereports of prevalence fluctuatingbetween 30%-100% for gingivitis and5%-20% for periodontitis.33 The preva-lence of periodontal diseases duringpregnancy substantiates the strategy setforth by the surgeon general, in thatperiodontal treatment during preg-nancy may potentially improve mater-nal and infant health.5

PregnancyComplications

Maternal infections have long beenrecognized as increasing the risk forpregnancy complications such aspreterm birth and preeclampsia.

Preterm birth is delivery at less than37 weeks gestation. Prematurity ratescontinue to increase. The latest statis-tics from the National Center forHealth Statistics showed that for 2005the preterm birth rate grew to 12.7%.This is up from 12.5% in 2004 and thepreliminary reports for 2006 indicatean additional increase in the rates up to12.8%. Since 1990, the rate of pretermbirth has increased more than 20%.34

Understanding prematurity isimportant because it is the leadingcause of death in the first month, caus-ing up to 70% of all perinatal deaths.35

Even late premature infants, those bornbetween 34 and 366/7 weeks gestation,36

have a greater risk of feeding difficul-ties, thermal instability, respiratory dis-tress syndrome, jaundice, and delayedbrain development.34 Prematurity isresponsible for almost 50% of all neu-rological complications in newborns,and leads to lifelong complications inhealth, including but not limited tovisual problems, developmental delays,gross and fine motor delays, deafness,and poor coping skills. These compli-cations increase the health care dollarsspent on each child. On average, themedical cost alone for a preterm birthis 10 times greater than the medicalcosts for a full-term birth. In 2005, thenationwide cost of preterm birth wasmore than $26.2 billion for health care,educational costs, and lost productiv-ity.34 Although there have beenadvances in technology to help savethe infants who are born premature orlow birth weight, the lifelong problemsassociated with these conditions havenot been abated.

Periodontal Diseaseand Its Impact onPregnancy

Periodontal infection is one ofmany infections that have been asso-ciated with adverse pregnancy out-comes. The hypothesis that periodon-tal conditions influence the outcomeof a pregnancy is not a new idea. In1931, Galloway identified that thefocal infection found in teeth, tonsils,


sinuses, and kidneys pose a risk to thedeveloping fetus. His informationdated back to 1916 when pregnantguinea pigs were inoculated withstreptococci eluted from human still-born fetuses. This inoculation resultedin a 100% abortion rate. To show theimpact on humans, he obtained a fullmouth radiographic series on 242women presenting for prenatal care.Fifteen percent (n=57) had an apicalabscess and the suggested treatmentwas extraction of the affected tooth.Of those who were treated, noneresulted in a miscarriage or stillbirth.Galloway summarized that removalof a known focal infection, which hadclearly demonstrated to be a source ofdanger to any pregnant woman, wasmore beneficial than allowing theinfection to harbor throughout thepregnancy. He went on to suggest thatall foci of infection should beremoved early in pregnancy.37

It is widely recognized that good oralhealth maintains the structures withinthe oral cavity. However, it is not uni-versally accepted that oral health maybe an independent contributor to abnor-mal pregnancy outcomes. Many studieshave been conducted and the literatureis controversial on the role periodonti-tis has and its influence on adversepregnancy outcomes.

Recognition and understanding ofthe importance of oral health for sys-temic health has led to significantresearch into the role of maternal oralhealth and pregnancy outcomes. Dur-ing pregnancy, changes in hormonelevels promote an inflammatoryresponse that increases the risk ofdeveloping gingivitis and periodon-titis. As a result of varying hormonelevels without any changes in theplaque levels, 50%-70% of allwomen will develop gingivitis dur-ing their pregnancy, commonlyreferred to as pregnancy gingivitis.This type of gingivitis is typicallyseen between the second and eighthmonth of pregnancy.38 Increased lev-els of the hormones progesterone andestrogen can have an effect on thesmall blood vessels of the gingiva,making it more permeable.39,40 Thisincreases the mother’s susceptibility

to oral infections, allowing patho-genic bacteria to proliferate and con-tribute to inflammation in the gingiva.This hyperinflammatory stateincreases the sensitivity of the gin-giva to the pathogenic bacteria foundin dental biofilm. Females often seethese changes during other periods oftheir life when hormones are fluctu-ating, such as puberty, menstruation,pregnancy, and again at menopause.39-

41 Recent research suggests that thepresence of maternal periodontitis hasbeen associated with adverse preg-nancy outcomes, such as pretermbirth,19,20,23 preeclampsia,25 gestationaldiabetes,42 delivery of a small-for-ges-tational-age infant,14 and fetal loss.43

The strength of these associationsranges from a 2-fold to 7-foldincrease in risk. The increased riskssuggest that periodontitis may be anindependent risk factor for adversepregnancy outcomes.

In 1996, Offenbacher et al reporteda potential association betweenmaternal periodontal infection anddelivery of a preterm or low-birth-weight infant.19 In a case-controlstudy of 124 pregnant women, obser-vations suggested that women whodelivered at less than 37 weeks ges-tation or an infant weighed less than2500 g had significantly worse perio-dontal infection than control women.In another case-control study con-ducted by Dasanayake, women whodelivered a full-term infant weighingless than 2500 grams were matched towomen who delivered full terminfants weighing more than 2500grams. All women received a peri-odontal evaluation after delivery, andpoor periodontal health was deter-mined to be an independent risk fac-tor for delivering a low-birth-weightinfant.22

Two prospective cohort studies23,44

found that moderate to severe peri-odontitis identified early in pregnancyis associated with an increased riskfor spontaneous preterm birth, inde-pendent of other traditional risk fac-tors. In the first study, investigatorsfrom the University of Alabama con-ducted a prospective evaluation ofover 1300 pregnant women. Completemedical, behavioral, and periodontaldata were collected between 21 and24 weeks gestation. Generalized peri-odontal infection was defined as 90or more tooth sites with periodontalligament attachment loss of 3 mm ormore. The risk for preterm birth wasincreased among women with gener-alized periodontal infection; this riskwas inversely related to gestationalage. After adjusting for maternal age,race, tobacco use, and parity, this rela-tionship remained. The adjusted oddsratio for a preterm birth < 37 weeksfor those women who now had gen-eralized periodontal disease was 4.5(95% CI, 2.2-9.2). The adjusted oddsratio increased to 5.3 (95% CI, 2.1-13.6) for preterm birth < 35 weeksgestation, and to 7.1 (95% CI, 1.7-27.4) for preterm birth < 32 weeksgestation.23

In the second study, Offenbacheret al44 conducted a prospective studyof obstetric outcomes of over 1000women who received an antepartumand postpartum periodontal examina-tion. Moderate to severe periodontalinfection was defined as 15 or moretooth sites with pockets depth greaterthan or equal to 4 mm. The incidenceof increased periodontal pocketing,defined as clinical disease progres-sion, was determined by comparingsite-specific probing measurementsbetween the antepartum and postpar-tum examinations. Disease progres-


Myths regarding pregnancy and teeth

• It is not true that you lose a tooth for every pregnancy. Decay is oftenthe cause of tooth loss.

• Calcium is not taken from the mother’s teeth for the baby’s growth. Thisis provided through the mother’s diet and if it is inadequate then it istaken from the mother’s bone.

sion was considered present if 4 ormore tooth sites had an increase inpocket depths by 2 mm or more, withthe postpartum probing depth being 4mm or greater. Compared to womenwith periodontal health, the relativerisk for spontaneous preterm birth <37 weeks gestation was significantlyelevated for women with moderate-severe periodontal infection (adj RR2.0, 95% CI, 1.2-3.2), adjusting formaternal age, race, parity, previouspreterm birth, tobacco use, markers ofsocioeconomic status, and presenceof chorioamnionitis. Periodontal dis-ease progression was found to be anindependent risk factor for delivery <32 weeks gestation (adj RR 2.4, 95%1.1-5.2). The data from these 2 stud-ies are important given the relation-ship between maternal periodontaldisease and very preterm birth (< 32weeks gestation), and the significantneonatal morbidity and mortalityassociated with very preterm birth.44

Santos-Pereira et al studied 124women between the ages of 15-40 todetermine if chronic periodontitisincreased the risk of experiencingpreterm labor (PTL). In this cross-sec-tional trial, women who were admit-ted for preterm labor, with intravenoustocolysis, were enrolled into the PTL

group. The control group consisted ofterm pregnancies that were admittedfollowing the PTL mother. Periodon-tal examinations were performedwithin 36-48 hours after delivery andbefore discharge. Chronic periodon-titis was described as one site withclinical attachment loss (CAL) > 1mm with gingival bleeding. Theseverity of periodontitis was classi-fied as early (CAL <3mm), moderate(CAL > 3 mm and < 5 mm), andsevere (CAL >5mm). The extent ofperiodontitis was either localized,CAL < 30%, or generalized CAL >30%. They concluded that chronicperiodontitis increased the risk of hav-ing preterm labor {odds ratio of 4.7(95% CI: 1.9-11.9)}, preterm birth{odds ratio 4.9 (95% CI: 1.9-12.8)},and a low-birth-weight infant {OR4.2(95% CI: 1.3-13.3)}.45

Pitiphat et al conducted a prospec-tive study to determine if self-reportedperiodontitis was a risk factor for poorpregnancy outcomes. Women wereenrolled prior to 22 weeks gestationand completed a self-report question-naire during their second trimester.Demographic, medical and reproduc-tive history, smoking, prepregnancyweight, and physical activity wereassessed at the first prenatal visit. The

self-reported questionnaire was vali-dated by bitewing radiographs takenprior to delivery. The majority of theparticipants were white and middleclass. Of the 354 participants who hadbitewing radiographs available, theprevalence of self-reported periodon-titis was 3.7%. It was noted thatwomen who reported periodontitis hadsignificantly higher mean radiographicbone loss than those that did not(p<0.001). There was no significantincreased risk of having a pretermbirth or small-for-gestational-ageinfant when adjusting for smoking,race/ethnicity, socioeconomic status,BMI, history of preterm delivery, pres-ence of genitourinary infection,weekly weight gain, and history ofdental check-ups. However, there wasa significant increase in risk for thosewho reported having periodontitis andpoor pregnancy outcomes (adj OR 2.2:95%CI 1.05-4.85). The authors con-cluded that periodontitis is an inde-pendent risk factor for poor pregnancyoutcomes. However, caution should betaken when interpreting these resultsdue to the sample size and the indirectmeasurement of periodontitis.46

In yet another prospective cohort,Agueda et al enrolled over 1200women to evaluate the associationbetween periodontitis and pretermbirth and/or low birth weight. Allwomen were between the ages of 18-40 and were enrolled between 20-24weeks gestation. Demographic data,socioeconomic status, and medical andobstetric history were collected. Fullmouth periodontal examinations, (PD,CAL, BOP) were performed by a sin-gle calibrated examiner and recordedat 6 sites per tooth. Periodontal dis-ease was defined as 4 or more teethwith one or more sites with PD > 4mmand CAL > 3mm at the same site.14

After adjusting for confounding vari-ables, a significant association wasfound between preterm birth and peri-odontitis (Adj OR 1.7 95% CI: 1.08-2.88) . However no significant associ-ation was found between low birthweight and periodontitis.47

While there are data suggesting arelationship between maternal peri-odontal infection and preterm birth,


These Drugs May Be FDA These Drugs May Not FDAUsed in Pregnancy Category Be Used in Pregnancy Category

Antibiotics AntibioticsPenicillin B Tetracyclines** DAmoxicillin B Erythromycin Cephalosporins B in the estolate form BClindamycin B Quinolones CErythromycin (except for Clarithromycin C

estolate form) B

ANALGESICS ANALGESICSAcetaminophen B Aspirin CAcetaminophen with codeine C*Codeine C*Hydrocodone C*Meperidine BMorphine B

After 1st trimester for 24to 72 hrs only

Ibuprofen BNaprosyn B

Category C should be used with caution (NY State Dept of Health 2006)**Tetracycline and its derivatives are contraindicated in pregnancy


several studies have failed to demon-strate such an association.31,42,48-50 Inone of the largest studies to date,Moore et al examined the relationshipbetween multiple periodontal param-eters, including mean probing depths,percent of tooth sites with probingdepths greater than or equal to 4 mm,percent of sites with bleeding on prob-ing, and percent of sites with clinicalattachment loss greater than or equalto either 2 or 3 mm. Moore found nodifference in the periodontal parame-ters between women with pretermbirth and without preterm birth.42

However, they did find a positiveassociation between maternal peri-odontal infection and spontaneousabortion between 12 and 24 weeks(adj OR 2.5, 95% CI 1.2-5.4).43 In acase-control study, Budeneli and col-leagues found no differences in peri-odontal infection between womenwho delivered preterm versus fullterm.49 However, women were at sig-nificantly increased risk for pretermbirth if either P. gingivalis or C. rectuswere found in the subgingival plaque.49

In a more recent case-controlstudy, Vettore et al recruited 542 post-partum women who were over 30years old.51 The investigators soughtto explore the relationship betweenperiodontal disease and preterm lowbirth weight. Cases were divided into3 groups: low birth weight (n = 96),preterm (n = 110), and preterm andlow birth weight (n = 63). Cases werecompared to controls who were non-preterm and non-low-birth-weightindividuals (n = 393). Periodontalmeasurements were collected andlater stratified into 15 definitions ofperiodontal disease for analysis.Other covariates were also recordedand used for analysis. The results ofthis study indicated that periodontaldisease levels were higher in controlindividuals than in cases, and that theextent of periodontal disease did notincrease risk of preterm low birthweight. They also showed that in thepreterm low birth weight group thatthe mean pocket depth and the fre-quency of sites with CAL > 3 mmwere lower than in the control group.It was concluded that periodontal dis-

ease was not more severe in womenwith preterm low-birth-weight babies.51

Two recent meta-analyses of theassociation between maternal peri-

odontal disease and preterm birth havebeen published. Vergnes et al exam-ined 17 studies and reported a pooledestimate odds ratio for preterm birth

Definitions: Terms Used in Periodontitis and Pregnancy Outcomes Studies

Antepartum:Time between conception and the onset of labor; usually used todescribe the period when a woman is pregnant.

ChorioamnionitisInflammation of the chorion and the amnion, the membranes that sur-round the fetus. Chorioamnionitis usually is associated with a bacterialinfection. This may be due to bacteria ascending from the mother'sgenital tract into the uterus to infect the membranes and the amnioticfluid. Chorioamnionitis is dangerous to the mother and child. It greatlyincreases the risk of preterm labor and, if the child survives, the risk ofcerebral palsy.

HbA1c levelsHbA1c is a test that measures the amount of glycosylated hemoglobinin the blood. Glycosylated hemoglobin is a molecule in red blood cellsthat has glucose (blood sugar) attached to it. A person will have moreglycosylated hemoglobin if they have more glucose in their blood forlong periods of time. The test gives a good estimate of how well dia-betes has been managed over the previous 2 or 3 months.

inflammatory cytokinesProteins produced predominantly by activated immune cells that areinvolved in the amplification of inflammatory reactions.

Low birth weightAny birth when the infant weighs less than 2500 grams (5 pounds 8ounces)

NormotensiveNormal blood pressure

Post partumIn the period after delivery

PreeclampsiaA condition in pregnancy characterized by abrupt hypertension (asharp rise in blood pressure), albuminuria (leakage of large amountsof the protein albumin into the urine) and edema (swelling) of thehands, feet, and face. Preeclampsia is one of the most common com-plications of pregnancy. It affects about 5% of pregnancies. It usuallyoccurs in the third trimester of pregnancy.

Pregnancy gingivitisGingivitis in which the host response to bacterial plaque is presumablyexacerbated by hormonal alterations occurring during puberty, preg-nancy, oral contraceptive use, or menopause.

Preterm birthAny birth prior to 37 weeks gestational age

TeratogenicityThe capability of producing fetal malformations

Very preterm birthAny delivery of a live born infant less than 32 weeks gestational age

of 2.83 (95% CI: 1.95-4.10, P <.0001).52 Xiong et al performed a sys-tematic review and meta-analysis of44 studies (26 case control, 13 cohort,and 5 controlled trials) to examine therelationship between maternal peri-odontal disease and adverse pregnancyoutcome.53 The meta-analysis showedthat maternal treatment of periodontaldisease reduced the rate of preterm lowbirth weight infants as a group (pooledRR 0.53, 95% CI: 0.30-0.95, P< .05),but not preterm or low birth weightindividually.

Inconsistencies with PreviousStudies

While there are conflicting dataregarding the association of periodon-tal diseases and adverse pregnancyoutcomes, the reasons have yet to beidentified. However, there are severaldifferences and biases among the pub-lished data worth addressing. Whilethe definitions of preterm birth, verypreterm birth, low birth weight, smallfor gestational age, and other obstetricfindings are well defined, no consen-sus has yet been achieved on the defi-nition of periodontitis in periodontalresearch. A consensus on a definitionis essential to optimize the interpreta-tion, comparison, and validation ofclinical data.54 With no universallyagreed upon definition, any prior def-initions may prove to be obsolete aswe gain further information regardingthe pathophysiology of the associa-tions reported. Clinical markers ofperiodontal disease, such as gingivalrecession, clinical attachment loss, orbleeding on periodontal probing, maybe late manifestations of the localinfection, such that bacterial exposuremay have already occurred with sub-sequent downstream deleteriouseffects. Recognition of the variationin clinical criteria used to define peri-odontal infection is important whencritiquing the literature. In addition tothe lack of a consistent clinical defini-tion, several of the studies43,48,49 with noassociation between maternal peri-odontal disease and adverse pregnancyoutcomes did not control for potential

confounding variables. Another poten-tial reason for the disparate findingsamong studies is the differences inpopulations studied. Most studies thatshowed an association between peri-odontal disease and adverse pregnancyoutcomes have consistently beenfound in populations with a high inci-dence of preterm deliveries and withineconomically-challenged families.Quite the opposite is true for thosestudies that did not show an associa-tion. They were usually conducted incountries with universal health careand a lower incidence of preterm birthor low-birth-weight infants. Differen-tial access to health care insurance,dental care, and prenatal care, mayconfound the relationship betweenmaternal periodontal disease andadverse pregnancy outcome. Dispari-ties in oral health may also be partiallyexplained by racial differences ininflammatory and immune responses,as discussed previously (Table 1).

Another factor to consider whenreviewing studies and synthesizing theresults is the study design. The studydesign will influence the ability toreach a conclusion or determine causal-ity. Case-control studies are limited intheir experimental design because theycannot demonstrate causality. Prospec-tive studies offer an advantage ofstudying the cause-effect relationshipsince the experiment can be designedand participants enrolled and followedover time with the outcome variableunknown at enrollment. Cohort studiesinvolve 2 groups of people and com-pare a particular outcome of interest ingroups that are alike in many ways butdiffer in some characteristics. Cross-sectional studies investigate a popula-tion at a point in time without regard toinfluencing factors that occurred priorto the study. The randomized clinicaltrial eliminates study bias by randomlyassigning participants to the studygroups. Neither the participant nor theresearcher has any influence on whichparticipant is assigned to each group.Random assignment to study groupsprevents foreknowledge of study out-comes (Table 2).

Despite the controversy regardingthe association between maternal peri-

odontal infection and adverse preg-nancy outcomes, several investigatorshave reported that periodontal treat-ment during pregnancy leads to areduction in preterm birth risk.55-57

Lopez et al enrolled over 800 womenin a randomized trial of periodontaltreatment during pregnancy versusdelayed treatment, and found almosta 5-fold reduction in preterm birthamong women treated during preg-nancy.55 In a pilot trial of periodontaltreatment, Offenbacher et al found atrend toward reduced preterm birthamong women treated during preg-nancy compared with those whodelayed therapy until postpartum Thisstudy demonstrated that women whowere treated during pregnancy had asignificant improvement in oral healthmeasures and a reduction in oralpathogen burden.56 The women treatedduring pregnancy showed an improve-ment in clinical markers of periodon-tal infection, with reduction in clini-cal attachment loss and reduction inbleeding on dental probing. In anotherrandomized, intent to treat study,Tarannum and Faizuddin found thatnonsurgical periodontal treatment dur-ing pregnancy reduced the risk ofpreterm births (p<0.001) and low birthweight (p<0.002). An inverse correla-tion existed between CAL and birthweight in the control group, whichmay suggest that higher CAL wereassociated with lower birth weights.There was also an inverse correlationbetween gestational age and peri-odontal characteristic in both groups.This may suggest that shorter gesta-tional ages were associated with highervalues among periodontal parame-ters.58 These data are encouraging, asmost periodontal diseases are both pre-ventable and treatable, and thus wouldbe of significant public health interestin pregnancy if a cause-effect rela-tionship with preterm birth can bedemonstrated.

However, excitement over peri-odontal treatment to prevent pretermbirth must be tempered in light of arecently published study on periodon-tal treatment during pregnancy.Michalowicz et al studied 814 womenat 3 clinical facilities.30 Women were



Studies that found associations or relationships between periodontitis and pregnancy outcomes

Author/Year Study Definition ofJournal Country Design Periodontal Disease Summary Findings

Kunnen/2007 Netherlands Case-Control Healthy PD: pocket depths 52 women Periodontal disease moreJ Clin Periodontol < 4mm Cases: prevalent among cases vs.

Mild PD:1-15 tooth sites with preeclampsia controls (82% vs. 37%)pocket depths > 4mm and < 34 weeksBOP present

Severe PD: >15 tooth sites with pocket depths > 4mm and BOP present

Novak/2006 US Case-Control Periodontal disease (PD) was NHANES III: role Women with history of GDMJ Public Health Dent defined as one or more teeth of gestational twice as likely to have

with one or more sites with diabetes (GDM) periodontal diseaseprobing depth > or = 4mm, in periodontalloss of attachment > or = disease2 mm,and bleeding on probing

Xiong/2006 US Case-Control Periodontal disease (PD) was NHANES III: role Women with periodontal Am J Obstet Gynecol defined as one or more teeth with of periodontal disease 3x more likely to

one or more sites with probing disease in GDM develop GDMdepth > or = 4mm, loss of attachment > or = 2mm, and bleeding on probing

Cota/2006 Brazil Case-Control Periodontal disease was 4 or 588 women Women with periodontalJ Periodontol more teeth with one or more sites Cases: disease at 1.8-fold increased

with pocket depths > 4mm and preeclampsia risk for preeclampsiaCAL > 3mm at the same site

Jarjoura/2005 US Case-Control Presence of 5 or more sites per 203 women Periodontal diseaseAm J Obstet Gynecol subject with CAL of 3 mm or greater Cases: PTB/LBW associated with PTB/LBW

Goepfert/2004 US Case-Control Periodontal Health- no attachment 103 women Periodontal disease moreAm J Obstet Gynecol loss or gingival inflammation Cases: common among cases vs.

Gingivitis- gingival inflammation spontaneous controlsand no attachment loss PTB < 32 weeks

Mild periodontitis- 3-5 mm of attachment loss in any one sextant

Severe periodontitis- >5 mm of attachment loss in any one sextant

Cankci/2004 Turkey Case-Control The presence of four or more teeth 82 women Periodontal diseaseAust N Z J with one or more sites with PD Cases: associated with increased riskObstet Gynecol > 4 mm that bled on probing, and preeclampsia of preeclampsia, OR 3.5

with a clinical attachment loss (1.1-11.9)> 3 mm at the same site, was diagnosed as periodontal disease.

Dasanayake/1998 Thailand Case-Control Periodontal health was defined 100 women Periodontal disease Ann Periodontol using CPITN and DMFT scores Cases: LBW associated with LBW,

OR 3.0 (1.39 – 8.33)

Offenbacher/1996 US Case-Control Extent of sites with clinical 124 women Periodontal diseaseJ Periodontol attachment level > 2, 3 or 4 mm Cases: associated with PTB/LBW,

PTB/LBW OR 7.5 (1.9-28.8)

Santo-Pereira/2007 Brazil Cross-sectional Periodontitis was classified as 124 women Periodontal disease moreJ Clin Periodontol 53 Early- CAL<3mm Preterm labor prevalent in women with

Moderate CAL > 3mmand <5mm defined as < 37 preterm vs. term labor (62%Severe CAL > 5mm and as weeks vs. 27%)

localized (CAL < 30%) or generalized (CAL >30%

Table 1. Summary of Relevant Literature on Association between MaternalPeriodontal Disease and Adverse Pregnancy Outcomes by Study Design

Table 1 continues on the following page


Studies that found associations or relationships between periodontitis and pregnancy outcomes, continued


Offenbacher/2006 US Prospective Healthy PD: pocket depths 1020 women Women with periodontal Am J Obstet Gynecol 44 < 3mm without BOP received an ante- disease at increased risk for

Mild PD: 1-15 sites with pocket partum and post- PTB < 32 weeksdepths > 4mm or 1 or more partum perio-sites with BOP dontal exam.

Moderate/Severe PD: 15 or more sites with pocket depths > 4mm

Boggess/2005 US Prospective Healthy PD: pocket depths 640 Umbilical Fetal inflammation and Am J Obstet < 3mm without BOP Cord Blood immune response to oral Gynecol 54 Mild PD: 1-15 sites with pocket Samples pathogens increased preterm

depths > 4mm or 1 or more sites birth (PTB) riskwith BOP

Moderate/Severe PD: 15 or more sites with pocket depths > 4mm

Pitiphat/2006 US Prospective Self reported periodontitis 101 Women Periodontal disease mayJ Periodontol validated by radiographs taken increase C-Reactive Protein

prior to pregnancy levels during pregnancy

Boggess/2003 US Prospective Healthy PD: pocket depths < 4mm 850 women Periodontal diseaseObstet Gynecol Mild PD:1-15 tooth sites with associated with preeclampsia,

pocket depths > 4mm and BOP OR 2.4 (1.1-5.3)present

Severe PD: >15 tooth sites withpocket depths > 4mm and BOPpresent

Lopez/2002 Chile Prospective Presence of 4 or more teeth 639 women Periodontal diseaseJ Dent Res Intervention showing one or more sites with associated with PTB/LBW,

Study probing depth 4 mm or higher, and RR 3.5(1.5-7.9)with clinical attachment loss 3 mmor higher at the same site

Jeffcoat/2001 US Prospective Periodontitis - > 3 sites with 1313 women Periodontal diseaseJ Am Dent Assoc Observational attachment loss of 3 mm or more; associated with PTB,

generalized periodontal disease OR 4.5 (2.2-9.2)90 or more sites with attachment loss of 3 mm or more

Healthy Periodontium <3 siteswith 3 mm of attachment loss

Mitchell-Lewis/2001 US Prospective Not defined Prospective Women with PTB had higherEur J Oral Sci 58 Intervention intervention study levels of oral pathogens in

Study 164 women mouth; PTB rate less amongtreated women

Lopez/2005 Chile Randomized Gingival inflammation with Randomized Treatment significantlyJ Periodontol Clinical Trial > 25%of sites with bleeding on clinical trial of reduced PTB/LBW (6%

Intervention probing, and no sites with clinical periodontal among untreated vs. 2%Study attachment loss >2 mm treatment among treated)

women 870 withgingivitis

Lopez/2002 Chile Randomized Periodontal disease- > 4 teeth Randomized Periodontitis was a risk factor J Periodontol Clinical Trial with pocket depths > 4mm and clinical trial of for PTB/LBW and therapy

Intervention CAL> 3mm at the same site antepartum vs. reduced the rates ofStudy delay periodontal PTB/LBW

treatment to reduce PTB400 women

Table 1 continued.

randomized to scaling and root planing(SCRP) during before 21 weeks ges-tational age (treatment group) or afterdelivery (control group). Women inboth groups, who experienced pro-gressive periodontal disease definedas an increase of 3mm or more in clin-ical attachment loss, received SCRPin those areas. The study found noreduction in preterm births < 37 weeksgestation among women in the treat-ment group. On closer examination,there were almost twice as many deliv-eries that occurred before 32 weeksgestation among women in the controlgroup (n=18) compared to womenwho were treated (n=10) during preg-nancy. While not statistically signifi-cant, this is suggestive evidence thatperiodontal disease treatment might

benefit those women at risk for the ear-liest and most morbid preterm births.

The data on the role of maternalperiodontal infection and other adversepregnancy outcomes are even lessclear. Evidence suggests a role forinflammation and endothelial activa-tion in the pathophysiology of pre-eclampsia;59,60 periodontal infection isone of many potential stimuli for thesehost responses. A 2-fold increased riskfor preeclampsia was found amongwomen with periodontal infectiondiagnosed at delivery.25 Others havealso reported an association betweenmaternal periodontal infection andpreeclampsia.61,62 In a recent case-con-trol study, Contreras et al62 found thatwomen with preeclampsia were twiceas likely to have chronic periodonti-

tis. Also, preeclamptic women weremore likely to have Porphyromonasgingivalis, Tannerella forsythensis,and Eikenella corrodens, known peri-odontal pathogens, compared to nor-motensive women. However, severalother investigators have been unable toconfirm an association between mater-nal periodontal infection and pre-eclampsia.63,64 The conflicting resultshave yet to be resolved. While otherless common adverse pregnancy out-comes (eg, diabetes, small-for- gesta-tional-age birth weight, miscarriage)may also be associated with maternalperiodontal infection, data are cur-rently too sparse to draw definitiveconclusions regarding these associa-tions and the potential benefits of treat-ment during pregnancy (Table 1).


Studies that found no association between periodontitis and pregnancy outcomes


Bassani/2007 Brazil Case-Control Mild PD-> 3 sites in 3 or more 915 women Similar rate of periodontal J Clin Periodontol teeth with CAL of > 3 mm and Cases defined as disease among cases and

<5 mm LBW or stillbirth controlsModerate PD: > 3 sites in 3 or > 28 weeks or more teeth with CAL of > 5 mm > 1000 gmand <7 mm

Severe PD: > 3 sites in 3 or moreteeth with CAL of > 7mm

Moore/2005 UK Case-Control Not defined 154 women No association betweenJ Clin Periodontol However, only 2 sites per tooth Cases: perio- periodontal disease and

were evaluated for PD dontal disease pregnancy outcome

Buduneli/2005 Turkey Case-Control Not specified 181 women No difference in periodontal J Clin Periodontol Cases: PTB/LBW disease between cases and

controls

Davenport/2002 UK Case-Control Severe periodontal disease 743 women Similar PTB rate amongJ Dent Res defined as CPITN score 4 cases and controls

Holbrook/2004 Iceland Prospective At least probing depth > 4mm 96 women No association betweenActa Odontol Scand 48 periodontal disease and PTB

Moore/2004 UK Prospective Not specified in this article or 3738 women No association betweenBr Dent J 43 the article it refers to for more periodontal disease and

details. However, only two sites PTB/LBW; periodontal per tooth evaluated disease association with

miscarriage or stillbirth, OR 2.5 (1.2-5.4)

Michalowicz/2006 US Randomized > 4 teeth with a probing depth of Randomized Similar preterm birth rateNew Engl J Med 56 Clinical Trial at least 4 mm and a CAL of at clinical trial of among treated and delayed

Intervention least 2 mm and at least 35% BOP antepartum vs. groupsStudy delayed perio-

dontal treatment to reduce PTB823 women

*GDM-gestational diabetes

Implications for DentalHygiene Assessment,Diagnosis, andTreatment

Periodontal diseases are silentinfections that have periods of exac-erbation and quiescence that often goundiagnosed until irreparable damageoccurs to the teeth and oral structures.

Maintaining good oral hygiene beforeand during pregnancy is crucial forpreventing gingivitis and periodonti-tis. Prevention and treatment of peri-odontal infection is aimed at control-ling the bacterial biofilm, arrestingprogressive infection, and restoringlost tooth support.65 Dental profes-sionals can facilitate this level of oralhealth through assessment, education,and proper treatment planning. Veri-

fying the hormonal status and otherrisk factors for periodontal diseases andpoor pregnancy outcomes of womenduring the medical history processwill enable the provider to customizethe treatment plan and oral hygieneinstructions. Behavioral interventionssuch as smoking cessation, exercise,healthy diet, and maintenance of opti-mal weight are also useful preventivemeasures against periodontal dis-


Adjusted odds ratio In a multiple logistic ratio model where the response variable is the presence or absence of adisease, an odds ratio for a binomial exposure variable is an adjusted odds ratio for the levelsof all other risk factor included in the model. It is also possible to calculate the adjusted oddsratio for a continuous exposure variable. It can be calculated when stratified data areavailable as contingency tables by Mantel-Haenszel test.

Case Control Study A study that compares two groups of people: those with the disease or condition under study(cases) and a very similar group of people who do not have the disease or condition(controls). Researchers study the medical and lifestyle histories of the people in each group tolearn what factors may be associated with the disease or condition-use this one andreference the NCI.

Cohort Study A research study that compares a particular outcome (birth weight or gestational age atdelivery) in groups of individuals who are alike (pregnant) in many ways but differ by a certaincharacteristic (periodontal disease or no periodontal disease).(National Cancer Institutewww.cancer.gov)

Cross-Sectional Study A study of a subset of a population of items all at the same time, in which, groups can becompared at different ages with respect of independent variables, such as IQ and memory.Cross-sectional studies take place at a single point in time.

Meta analysis The statistical synthesis of the data from a set of comparable studies of a problem with theresult of yielding a quantitative summary of the pooled results. It is the process of aggregatingthe data and results of a set of studies that have used the same or similar methods andprocedures; reanalyzing the data from all these combined studies; and generating largernumbers and more stable rates and proportions for statistical analysis and significance testingthan can be achieved by any single study. (www.answers.com)

Odds Ratio The odds ratio is a way of comparing whether the probability of a certain event is the samefor two groups.

An odds ratio of 1 implies that the event is equally likely in both groups. An odds ratio greaterthan one implies that the event is more likely in the first group. An odds ratio less than oneimplies that the event is less likely in the first group.

Prospective Study A study in which participants are identified, enrolled and then followed forward in time. Usedin cohort and randomized clinical trials

Randomized Clinical Trial A study in which the participants are assigned by chance to separate groups that comparedifferent treatments; neither the researchers nor the participants can choose which group.Using chance to assign people to groups means that the groups will be similar and that thetreatments they receive can be compared objectively. At the time of the trial, it is not knownwhich treatment is best. (National Cancer Institute www.cancer.gov)

Retrospective Study A retrospective study looks backwards and examines exposures to suspected risk orprotection factors in relation to an outcome that is established at the start of the study.

Systematic review A review of a clearly formulated question that uses systematic and explicit methods to identify,select and critically appraise relevant research, and to collect and analyze data from thestudies that are included in the review. Statistical methods (meta-analysis) may or may not beused to analyze and summarize the results of the included studies

Table 2. Definitions of Research Study Terms


ease.66 While the mechanisms of theseinterventions is unknown, they likelyoperate by reducing conditions thatpromote growth of pathologic bacte-ria, improving immune function,reducing inflammatory responses, andimproving glucose control.

In 2004, the American Academy ofPeriodontology (AAP) issued a posi-tion statement regarding dental carefor pregnant women. The AAP rec-ommended that all women who werepregnant or planning a pregnancyshould receive preventive dental care,including a periodontal examination,a prophylaxis, and restorative treat-ment. They also proposed that scal-ing and root planing should be com-pleted early in the second trimesterand that any presence of acute infec-tion or abscess should be treatedimmediately, irrespective of gesta-tional age. Treating infection as earlyas possible will remove a potentialsource of infection that could beharmful to the mother and the baby.67

In 2006, after a treatment trial30 failedto show an effect of scaling and rootplaning on birth outcomes, the AAPconfirmed that treatment of periodon-titis in pregnant women is safe andshould be performed to improve theoral health of the woman.68 This con-clusion was substantiated by Dr. LarryTabak, director of the National Insti-tutes of Dental and CraniofacialResearch (NIDCR), when he said“Dental care during pregnancy haslong been an issue dominated by cau-tion more than data. The finding thatperiodontal treatment during preg-nancy did not increase adverse eventsis important news for women, espe-cially for those who will need to havetheir periodontal disease treated dur-ing pregnancy.”69 The Academy ofGeneral Dentistry (AGD) recom-mends a dental visit for pregnantwomen or for those planning a preg-nancy.70 Their recommendations aresimilar to the AAP but they suggestthat pregnant women have a tieredtreatment plan to include an examina-tion in the first trimester, a dentalcleaning in the second trimester, andthen, depending on the patient, an-other appointment early in the third

trimester.69 They also recommendcommunication between the dentalprovider and the obstetrician for anydental emergency that would requireanesthesia or other medication to beprescribed. The American DentalAssociation (ADA) suggestions aresimilar to the AAP and the AGD;however, they also address the safetyissues surrounding taking a dentalradiograph during pregnancy. If aradiograph is needed for diagnosis ortreatment, as they often are, then preg-nant women should have the radio-graphs taken. Matteson et al estimatedthat a full mouth series of radiographs,with 20 radiographs, exposes themother to <1 mrem of radiation. Thefetus is usually exposed to approxi-mately 75 mrems of naturally occur-ring radiation during a pregnancy.Therefore, dental radiographs con-tribute to a negligible amount of radi-ation exposure.71 Care and cautionshould be taken to prevent furtherexposure by using a leaded apron witha thyroid collar.72

In 2004, Bright Futures Practice inOral Health published an oral healthpocket guide designed to providehealth care providers with an over-view of preventative oral health super-vision for 5 developmental periods,including pregnancy and postpartum.Bright Futures began in 1990 and wasinitiated by the Health Resources andServices Administration (HSRA)Maternal and Child Health Bureau(MCHB). The guidelines suggest thathealth care providers assess the riskof oral disease and provide generalsuggestion to prevent carious lesionsin pregnant women. Other suggestionsor recommendations for the prevention

of carious lesions included to expec-torate and not rinse the mouth afterbrushing with a fluoridated toothpasteto allow the fluoride additional time toprotect the teeth. They recommendedthat pregnant women use an alcohol-free, over the counter fluoridated mouthrinse at night. While carious lesionsdo not lead to periodontal diseases,the accumulation of bacterial plaquebiofilm is a culprit in these diseases.Like many other initiatives, BrightFutures recommends that pregnantwomen visit an oral health care pro-vider for an examination and restora-tion of all active carious lesions assoon as possible.73

First State Practice Guidelines forTreatment of Pregnant Patients

In 2006, the New York State Depart-ment of Health published practiceguidelines for oral health care duringpregnancy and early childhood. Theseguidelines were developed in responseto a lack of information regarding thesafety of dental treatment during preg-nancy, which urged actions to reducehealth disparities. These disparitieswere brought to national attention bythe Surgeon General’s Report, OralHealth in America,5 and a follow-upreport titled “A National Call to Actionto Promote Oral Health.”74 The com-prehensive guidelines provide by theNew York Department of Health offersstructure for oral health care providersso they can provide the best care forpregnant women. Providing dentalcare in pregnancy and early childhoodare important to prevent lifelong con-sequences of poor oral health.73,75-79

Periodontal diseases are silent infections thathave periods of exacerbation and quiescence thatoften go undiagnosed until irreparable damage

occurs to the teeth and oral structures.


Due to the reluctance of some den-tal professionals to provide dental careduring pregnancy, the state of NewYork established guidelines to addressthis problem. This comprehensivereport recommends that oral healthcare should be coordinated amongprenatal and oral health careproviders. Communication betweenthe dental community and the med-ical community is a necessity and aconsultation form was developed tohelp facilitate this process (Figure 1).The New York guidelines suggest andrecommend that dental treatment beprovided during pregnancy, includingthe first trimester. However, early inthe second trimester (14-20 weeksgestation) is the most favorable timeto perform dental procedures. Duringthis gestational age there is no threatof teratogenicity, nausea and vomit-ing have usually subsided, and theuterus is below the umbilicus, pro-viding more comfort to the mother.Unrestored carious lesions should berestored as soon as possible as somepregnant women require general anes-thesia with intubation at delivery.Some physicians are hesitant to intu-bate due to the increased risk of air-way obstruction due to the decreasedintegrity of decayed teeth that couldbreak off. If treatment is provided inthe last trimester, care should be takento prevent suppression of the inferiorvena cava by keeping the woman inan upright position. Ultimately allhealth care providers should advisewomen that maintaining good oralhealth during pregnancy is not onlysafe but necessary to reduce the risk ofinfection to the mother and possiblythe fetus.

While it remains inconclusivewhether maternal periodontal treat-ment improves pregnancy outcome,it is clear that treatment of varyingdegrees of clinical periodontal dis-ease during pregnancy is safe andimproves maternal oral health.56,57 Inseveral studies of periodontal treat-ment during pregnancy, oral healthparameters improved following ther-apy.30,56 All dental services should beavailable to pregnant women; how-ever, studies have shown that some

treatments are best provided only dur-ing certain gestational ages (Table 3).Despite the benefit of treatment, peri-odontal infection in women of child-bearing age remains highly prevalent,particularly among low-incomewomen and members of racial andethnic minority groups. Regrettably,some subgroups of women who lackaccess to dental care will likely missout on dental care during pregnancy.Oral health care professionals musthelp bridge this gap.

Dentists and dental hygienistsmust actively participate in provid-ing treatment to pregnant women tohelp maintain maternal health.Knowledge of research studies (Table1) and published guidelines can helpeliminate the timidity that prevails inthe dental community regarding pro-viding dental care to pregnantwomen. In fact, the dental commu-nity must embrace this shift in prac-tice guidelines. By embracing thechanges, better overall health care canbe provided to all women, especiallythose of child bearing age.

Oral Health Knowledgein the MedicalCommunity

To provide better oral health care,more knowledge needs to be madeavailable to the medical community.Few studies have tried to determine ifthe medical community has theknowledge to help educate patientsabout the importance of better oralcare. Siriphant et al conducted focusgroups with nurse practitioners (NP)in Maryland to determine the level ofknowledge regarding oral cancer.They found nurse practitioners inMaryland did not recognize oral can-cer as a health problem and that themain barrier for performing oral can-cer screening was a lack of knowl-edge.80 In another survey of nursepractitioners, it was established thatfew recognized the signs of early oralcancer. NPs who reported attending acontinuing education course on oralcancer within the last 2-5 years were3.1 times more likely to have more

knowledge regarding the risk factorsfor oral cancer and 2.9 times morelikely to have more knowledgeregarding risk factors and diagnosticprocedures for oral cancer.81

Only a few studies have beenreported in the literature that assessmedical and nursing professionals’knowledge about periodontal diseaseand adverse pregnancy outcomes.Wilder et al surveyed practicing obste-tricians in 5 counties in North Car-olina to assess their knowledge ofperiodontal disease and to determinetheir practice behaviors regarding oraldisease and adverse pregnancy out-comes. While 94 % of those surveyedcould correctly identify bacteria as acause of periodontitis, only 22%looked in a patient’s mouth at an ini-tial visit. And while most (84%) con-sidered periodontal disease a risk fac-tor for adverse pregnancy outcomes,49% rarely or never recommended adental visit during pregnancy.82 In arecent study conducted in North Car-olina, 504 nurse practitioners, physi-cian assistants and certified nursemidwives were surveyed. The surveyassessed the knowledge, behavior, andopinions about periodontal diseaseand its relationship to adverse preg-nancy outcomes. Forty eight percentresponded (n=204). Of those respon-dents, 63% reported looking in thepatient’s mouth to screen for oralproblems at the initial visit. Twentypercent felt that their knowledge ofperiodontal disease was current, andall agreed that their discipline shouldreceive instruction regarding peri-odontal disease. Ninety-five percentfelt that a collaborative effort betweenthe health care provider and the oralhealth care professionals was neededand would reduce the patient’s risk ofhaving an adverse pregnancy out-come.83 It is clear from the lack ofstudies available regarding oral healthknowledge in the medical communitythat further studies are needed. Onelimitation to the future of oral healthcare is the lack of knowledge regard-ing oral care in the medical commu-nity. More education is needed withinthe medical community to helpachieve better oral health care.


Consultation Form for Pregnant Women to Receive Oral Health Care

Referred to: ______________________________________________ Date: __________________

Patient Name: (Last) ______________________________ (First) __________________________

DOB: __________ Estimated delivery date: ___________ Week of gestation today: __________

KNOWN ALLERGIES: ________________________________________________________________

PRECAUTIONS: ■■ NONE ■■ SPECIFY (If any): _____________________________________________________________________________________________________________________________________________________________________________________________________________________

This patient may have routine dental evaluation and care, including but not limited to:■■ Oral health examination■■ Dental x-ray with abdominal and neck lead shield■■ Dental prophylaxis■■ Local anesthetic with epinephrine■■ Scaling and root planing■■ Root canal■■ Extraction■■ Restorations (amalgam or composite) filling cavities

Patient may have: (Check all that apply) ■■ Acetaminophen with codeine for pain control■■ Alternative pain control medication: (Specify) ____________________________■■ Penicillin■■ Amoxicillin■■ Clindamycin■■ Cephalosporins■■ Erythromycin (Not estolate form)

Prenatal Care Provider: ___________________________________ Phone: ___________________

Signature: ______________________________________________ Date: ___________________

DO NOT HESITATE TO CALL FOR QUESTIONS

* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * *DENTIST’S REPORT

(for the Prenatal Care Provider)

Diagnosis: ______________________________________________________________________________________________________________________________________________________________

Treatment Plan: _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

NAME: ______________________________ Date: ______________ Phone: ______________

Signature of Dentist: __________________________________________________________________

*Appendix A NY State guidelines

Figure 1. Consultation Form for Pregnant Women to Receive Oral Health CareNY State Oral Health Care during Pregnancy and Early Childhood Practice Guidelineswww.health.state.NY.US/publications/0824/pda/windows_mobile/0824.pdf


In a recent issue of the AmericanJournal of Maternal Child Nursing,nurses were called to “action” to helpfacilitate better access to oral healthcare. Based on the surgeon general’sreport5 and the National Call to Actionto Promote Oral Health,74 these authorssuggested that nurses need to partnerwith other key stakeholders to preventoral disease. The nurses were calledto provide, promote, and protect

women by increasing their knowledge,attitudes, awareness, and skills regard-ing oral health. By collaborating withother health professionals’ access tooral health care can be improved.84

Providing oral health education inmedical and nursing curricula mightbe one way to begin this process. Areported oral health curriculum at theUniversity of Washington’s medicalschool is reporting some success.85 In

addition, the New York UniversityDental School is collaborating withthe NYU School of Nursing to pro-vide care to patients. This is a funda-mental step in providing collaborativetreatment to patients across many dis-ciplines.84 Oral health care profes-sionals can take the lead in educatingother providers about the importanceof oral health and what should betaught to pregnant women.

Dental Procedure Safe in Rationale and recommendationsPregnancy

Prophylaxis Yes Dental cleanings are safe during pregnancy.

Scaling and Studies suggest the best gestational age for SCR&P is betweenRoot Planing 14-20 weeks gestational age. However, the benefit outweighs the risk at later

gestational ages

Dental Radiographs Yes Radiographs are safe during pregnancy. A full mouth series with 20 radi-ographs is estimated to deliver <1mrem. During pregnancy the mother typi-cally receives about 75mrem from naturally occurring radiation. The benefitsof radiographs outweigh any negligible risks. (Matteson et al 1991 MCN;ADA 2004)

Restorations Yes Replacement of old amalgams should be completed using a rubber dam andhigh speed suction. (NY State Dept. of Public Health)

Emergency Dental Yes Removal of an infection or bacterial load will not only Treatment help the mother but possibly the fetus.

Local Anesthetics Yes Category B anesthetics (including lidocaine with epinephrine andCategory B prilocane)

Local Anesthetics No Mepivacaine and bupivacaineCategory C

Analgesics for Pain Yes Acetaminophen, meperidine, morphine; do not exceed Category B recommended doses

Analgesics for Pain With Codeine, hydrocodone may be used with cautionCategory C Caution *Ibuprophen and Naprosyn should only be used in the first trimester and only

for 72 hours or less

Antibiotic Prophylaxis for Yes For those who meet the AHA guidelines for antibiotic prophylaxis.Infective endocarditis Primary prophylaxis is 2gms of amoxicillin 1 hour prior to treatment

For those allergic to penicillin one of the following regimens can be given onehour prior to treatment

Cephalexin 2gm OR Clindamycin 600mg OR Azithromycin or clarithromycin 500 mg

Nitrous Oxide With caution Only use when topical or local are inadequate and only after approval fromthe obstetrician. Precautions should be taken to avoid hypoxia, hypotension,and aspiration. Lower levels may achieve sedation for a pregnant patient.(NY State 2006; FDA Guidelines for drugs in pregnancy)

Adapted from Russell SL, Mayberry W. Pregnancy and Oral Health. MCN. 2008; 331(1):32-37.

Table 3. Dental Procedures and Pregnancy


Future Projections inCare of PregnantPatients

Amid the evidence that preventiveand restorative dental services are ben-eficial for oral health and can help ormodify systemic diseases, some insur-ance companies have begun to pay forexpanded dental services.86 Insurancecompanies found that the cost of prov-ing expanded dental services for someof its members decreases the amountspent on medical treatment.87 Based onthis information, many companies havebegun to offer additional dental bene-fits for those who have the most to gainsuch as pregnant women and patientswith cardiovascular disease. While theliterature is not clear on the associa-tion of periodontal disease and its effecton birth outcomes, it is clear the treat-ing periodontal disease during preg-nancy is beneficial for the mother andmay be beneficial for the fetus. As partof these expanded services, Cigna,Delta Dental, United Health Care, andothers have increased their dental ben-efits to include additional dental clean-ings, including scaling and root planingas indicated for pregnant women. Thisrepresents a shift in the insuranceindustry that is beneficial to both thecompany and its members.87-89

Some state governments haveanswered the call to promote better oralhealth care by providing dental benefitsto those who typically have none. In2004, the Minnesota Department ofHealth partnered with the MinnesotaBoard of Dentistry and MinnesotaDepartment of Human Services tomake available resources and programsaimed at providing better access todental care. This was accomplished byproviding critical access dentalprovider designations, expandedauthorization for dental hygienists andexpanded duties for dental auxiliaries,a dental practice donation program,providing licensure of foreign traineddentists and retired dentists, and estab-lishing a dentist loan-forgiveness pro-gram.90 In 2003, the Utah Departmentof Health (UDH) launched a programthat served as a pilot study, which

enabled pregnant women on Medicaidto receive dental examinations, treat-ment of decayed teeth, and a prophy-laxis.91 UDH followed this up byexpanding dental benefits available toUtah’s pregnant Medicaid population.These women now have access toreceive free dental check-ups, includ-ing x-rays, dental prophylaxis, restora-tions, root canals, and emergency treat-ment.91 As states and companiescontinue to expand their dental serv-ices provided for pregnant women, theoverall health benefit will becomeapparent.

Future Directions forResearch and Education

Future directions of oral healthresearch should target oral health carebefore, during and after pregnancy.Studies that utilize the Centers for Dis-ease Control’s Pregnancy Risk Assess-ment Monitoring System (PRAMS)report that only 23%-43% of pregnantwomen receive dental care during preg-nancy,92 a rate which is only one-halfto two-thirds the overall use of dentalservices among US women.92 In addi-tion, data explaining the racial/ethnicdisparities in oral health among preg-nant women are lacking. Pregnantwomen’s perceptions of oral health, andthe barriers and motivations to theirseeking dental care, must be assessed toadequately introduce preventive infor-mation on oral health into their prena-tal care, which is one of the first stepsin reducing health disparities.

Further studies are needed to betterunderstand the mechanism of peri-

odontal disease-associated pretermbirth and to tailor treatment to thosewomen who might benefit the most.Confirmation of periodontal infectionas an independent risk factor foradverse pregnancy outcomes andidentification of those at greatest riskwould be of significant public healthimportance because periodontal infec-tion is both preventable and curable.At present, however, there is insuffi-cient evidence for health care policyrecommendations to provide mater-nal periodontal treatments for the pur-pose of reducing the risk of adversepregnancy outcome regardless of itsother benefits.

Further educational opportunitiesneed to be provided for allied healthprofessionals and the medical com-munity to help alleviate the problemswith access to dental care. Relation-ships between professional schoolsneed to be forged so that cross-educa-tional opportunities can be provided toall disciplines. Training and educationshould be expanded to prepare dentalhygienists to partner with physiciansand nurse practitioners to provide aminimum level of care for those whohave no access to dental care. Theseservices could include an oral screen-ing, oral hygiene instructions, tooth-brush prophylaxis, referrals if needed,application of fluoride, and nutritionalcounseling. The dental communitycould partner with the medical com-munity to provide dental and medicalservices within the same office, pro-viding better access to care.

Given the relationship betweenmaternal and infant oral health andperiodontal infection and general

While the literature is not clear on the associationof periodontal disease and its effect on birthoutcomes, it is clear the treating periodontaldisease during pregnancy is beneficial for the

mother and may be beneficial for the fetus.


References

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health and well-being, oral health careshould be a goal in its own right for allindividuals, including reproductive-aged and pregnant women. There isno evidence to suggest that dentalexamination or treatment is deleteri-ous to the pregnant woman or herdeveloping fetus. Infective endo-carditis prophylaxis is recommendedfor all dental procedures for thoseindividuals at high risk for infectiveendocarditis. Pregnant women whomeet American Heart Associationguidelines for infective endocarditisprophylaxis93 and undergo these dentalprocedures should be treated similarto nonpregnant individuals.

Regardless of the potential forimproved oral health to improve preg-

nancy outcomes, public policies thatsupport comprehensive dental serv-ices for vulnerable women of child-bearing age should be expanded sothat their own oral and general healthis safeguarded, and the morbidity ofchildhood caries reduced. Mecha-nisms to educate women and theirhealth care providers about the impor-tance of oral health need to be inplace, and improvement in the accessto care for all must occur if oral healthinterventions are to make an impor-tant impact on pregnancy outcomes.

ConclusionThe importance of providing oral

health care for pregnant women can-

not be disputed. Data suggest thatmaternal oral health impacts preg-nancy health; further research on thecausal nature of this association isongoing to determine if there is a rela-tionship. Current guidelines and datasuggest that dental care during preg-nancy is safe. However, scaling androot planing is best accomplishedbetween 14-20 weeks gestational age.Providing dental care for pregnantwomen will help remove potentiallyharmful bacteria from disseminationand possibly leading to other compli-cations. As oral health care providerswe can educate our patients regardingthe importance of oral health and onimportant preventive measures tomaintain oral health.


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Additional References

Web sites

American Dental Hygienists’ Associationwww.adha.org

National Institutes of Healthwww.nih.gov

National Institute of Dental and Craniofacial Researchwww.nidcr.nih.gov

Centers for Disease Control and Preventionwww.cdc.gov

American Dental Associationwww.ada.org

American Academy of Periodontology www.perio

NY State Oral Health Care during Pregnancy and Early Childhood Practice Guidelineswww.health.state.ny.us/publications/0824/pda/windows_mobile/0824.pdf

Oral Health in America: A Report of the Surgeon General (executive summary)www.nidrc.hig.gov/AboutNIDRR/Surgeon General/ExecutiveSummary.htm

American Pregnancy Associationwww.americanpregnancy.org

Academy of General Dentistrywww.agd.org

Healthy People 2010: Section 21, Oral Health www.healthypeople.gov/Document/HTML/Volume2/21Oral.htm

Oral Health America www.oralhealthamerica.org Maternal and Child Health Library: Knowledge Path – Oral Health and Children and Adolescents

www.mchlibrary.info/KnowledgePaths/kp_oralhealth.html

Children’s Dental Health Projectwww.cdhp.org

Brochures

Dental Care for Your BabyAmerican Academy of Pediatric Dentistry

www.aapd.org/publications/brochures/babycare.asp

A Healthy Mouth for Your BabyNational Institutes of Health

www.nidcr.nih.gov/HealthInformation/DiseasesAndConditions/ChildrensOralHealth/Healthy-Mouth/default.htm

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