Periodontal Diseases and Adverse Pregnancy Outcomes

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STATEMENT OF PURPOSE

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

2 The Journal of Dental Hygiene Special supplement

Journalof

DentalHygienespecial 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, MS

Catherine 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, MEd

M. 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

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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

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The Journal of Dental Hygieneis published quarterly, online-only, by the AmericanDental HygienistsAssociation, 444 N. Michigan Avenue, Chicago, IL 60611. Copy-right 2008 by the American Dental HygienistsAssociation. 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].


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Special supplement The Journal of Dental Hygiene 3

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 on

the 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 to

the 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 Generals

Report 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 andImplications 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


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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 242

women 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 that

all 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 mothers 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 who

delivered 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 weeks

for 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 mothers teeth for the babys growth. Thisis provided through the mothers diet and if it is inadequate then it istaken from the mothers bone.


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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 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 had

significantly higher mean radiographicbone loss than those that did not(p 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 ErythromycinCephalosporins 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


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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 periodontal

disease 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 Periodontitisand 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 (a

sharp 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

Teratogenicity

The capability of producing fetal malformationsVery preterm birth

Any delivery of a live born infant less than 32 weeks gestational age


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of 2.83 (95% CI: 1.95-4.10, P 4mm or 1 or more partum perio-sites with BOP dontal exam.

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

Boggess/2005 US Prospective Healthy PD: pocket depths 640 Umbilical Fetal inflammation andAm J Obstet < 3mm without BOP Cord Blood immune response to oralGynecol54 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 moresites 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 attachmentloss of 3 mm or more

Healthy Periodontium 25%of sites with bleeding on clinical trial of reduced PTB/LBW (6%

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

women 870 with

gingivitis

Lopez/2002 Chile Randomized Periodontal disease- > 4 teeth Randomized Periodontitis was a risk factorJ 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 toreduce PTB400 women

Table 1 continued.


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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 weeks

gestation 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 these

host 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,andEikenella 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 results

have 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

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

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

3 sites in 3 or > 28 weeks or

more teeth with CALof > 5 mm > 1000 gm

and 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 periodontalJ 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 J43 the article it refers to for more periodontal disease and

details. However, only two sites PTB/LBW; periodontalper 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 Med56 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 treatmentto reduce PTB823 women

*GDM-gestational diabetes


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Implications for Dental

Hygiene 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 before

and 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 other

risk 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 aggregating

the 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 compare

different 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


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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 saidDental 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 safety

issues 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


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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

* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * *DENTISTS 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 Care

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


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In a recent issue of the American

Journal of Maternal Child Nursing,nurses were called to action to helpfacilitate better access to oral healthcare. Based on the surgeon generalsreport5 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 Washingtons medicalschool is reporting some success.85 In

addition, the New York University

Dental 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


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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 effect

on 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 dental

provider 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 toUtahs 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 Controls 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. Pregnantwomens 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 health

importance 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 association

of periodontal disease and its effect on birth

outcomes, it is clear the treating periodontaldisease during pregnancy is beneficial for the

mother and may be beneficial for the fetus.


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References

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12. Azarpazhooh A, Leake JL. Systematic review of the asso-ciation between respiratory diseases and oral health. J Peri-odontol. 2006;77(9):1465-82.

13. Beck JD, Eke PI, Heiss G, et al. Periodontal disease andcoronary heart disease: a reappraisal of the exposure. Cir-culation. 2005(1);112:19-24.

14. Boggess KA, Beck JD, Murtha AP, et al. Maternal peri-odontal disease in early pregnancy and risk for a small-for-gestational-age infant. Am J Obstet Gynecol. 2006;194(5):131622.

15. Lopez NJ, Smith PC, Gutierrez J. Higher risk of pretermbirth and low birth weight in women with periodontal dis-ease. J Dent Res. 2002;81(1):58-63.

16. Dasanayake AP, Russell S, Boyd D, et al. Preterm low birthweight and periodontal disease among African Americans.Dent Clin North Am. 2003;47(1):115-25, x-xi

17. Goepfert AR, Jeffcoat MK, Andrews WW, et al. Periodontaldisease and upper genital tract inflammation in early spon-taneous preterm birth. Obstet Gynecol. 2004;104(4):777-83.

18. Kunnen A, Blaauw J, van Doormaal JJ, et al. Women witha recent history of early-onset pre-eclampsia have a worseperiodontal condition. J Clin Periodontol. 2007;34(3):202-7.

19. Offenbacher S, Katz V, Fertik G, et al. Periodontal infectionas a possible risk factor for preterm low birth weight. J Peri-odontol. 1996;67(10 suppl):1103-13.

20. Offenbacher S, Lieff S, Boggess KA, et al. Maternal peri-odontitis and prematurity. Part I: Obstetric outcome of pre-maturity and growth restriction. Ann Periodontol. 2001;6(1):164-74.

21. Madianos PN, Lieff S, Murtha AP, et al. Maternal periodon-titis and prematurity: Part II. Maternal infection and fetalexposure. Ann Periodontol. 2001;6(1):17582.

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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 recommended

for all dental procedures for thoseindividuals at high risk for infectiveendocarditis. Pregnant women whomeet American Heart Associationguidelines for infective endocarditisprophylaxis93and 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.

Conclusion

The importance of providing oralhealth 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 accomplished

between 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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92. Gaffield ML, Gilbert BJ, Malvitz DM, Romaguera R. Oralhealth during pregnancy: an analysis of information col-lected by the pregnancy risk assessment monitoring system.J Am Dent Assoc 2001;132(17):1009-16

93. Wilson W, Taubert KA, Gewitz M, et al. Prevention of infec-tive endocarditis: guidelines from the American Heart Asso-ciation. A Guideline From the American Heart AssociationRheumatic Fever, Endocarditis and Kawasaki DiseaseCommittee, Council on Cardiovascular Disease in theYoung, and the Council on Clinical Cardiology, Council onCardiovascular Surgery and Anesthesia, and the Quality ofCare and Outcomes Research Interdisciplinary WorkingGroup. J Am Dent Assoc. 2008;139(suppl):3S-24S.



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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 Periodontologywww.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 Healthwww.healthypeople.gov/Document/HTML/Volume2/21Oral.htm

Oral Health America www.oralhealthamerica.orgMaternal and Child Health Library: Knowledge Path Oral Health and Children and Adolescents

www.mchlibrary.info/KnowledgePaths/kp_oralhealth.html

Childrens 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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Periodontal Diseases and Adverse Pregnancy Outcomes

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Transcript of Periodontal Diseases and Adverse Pregnancy Outcomes