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    Periodontal disease and preterm birth

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    Q The patient is a 36-year-old gravida 1 para 0 who presents to your office for a new obstetric appointment. She has had extensive dental work because of early onset periodontal disease. How might this affect her pregnancy?

    A Dental caries, gingivitis, and periodontal infection are conditions commonly encountered in children, young adults, and women of reproductive age.1,2 Adult periodontal infection affects up to 40% of women of reproductive age. Dental caries is considered an infectious and transmissible disease of multifactorial origin.

    Gingivitis (inflammation of the gum tissue) is a nondestructive periodontal disease. In the absence of treatment, gingivitis may progress to periodontitis (inflammation of tissues that surround and support the teeth), which is a destructive form of periodontal disease.

    Periodontitis involves progressive loss of the alveolar bone around the teeth and if left untreated can lead to the loosening and subsequent loss of teeth. This process involves both direct tissue damage from plaque bacterial products and indirect damage through bacterial stimulation of local and systemic inflammatory and immune responses.1,3,4

    Subgingival colonization with Porphyromonas gingivalis and Prevotella intermedia leads to adult manifestations of oral infection because these organisms are able to induce inflammatory responses that lead to gingival edema, bleeding, and ultimately the tissue destruction characteristic of periodontal disease.4 Gingivitis causes the gums to redden, swell, and bleed more easily. With time, bacterial plaque on the tooth surface spreads and grows below the gum line.

    Treatment in pregnancy is safe.5,6 Most studies of treatment of periodontal disease during pregnancy use scaling and planing techniques. Scaling is debridement and nonsurgical cleaning below the gumline. Root planing involves the use of specialized curettes to mechanically remove plaque and calculus (hardened dental plaque) from below the gumline.

    Q Does treatment of periodontal disease during pregnancy decrease the rate of preterm birth?

    A Maternal periodontal infection has received recent attention as an important condition because of its association with cardiovascular disease, diabetes, respiratory infection, and preterm birth (PTB).7

    Researchers have speculated that periodontal infection leads to the release of pathogens and proinflammatory cytokines, which then affect the pregnancy through hematogenous transport.8,9

    Several large prospective observational studies found a strong association between maternal periodontal infection and PTB. In a meta-analysis of observation studies published in 2007, periodontal disease was associated with a 2.8-fold increase in risk of PTB.10

    These positive observation studies led to intervention trials to determine whether identification and treatment of maternal periodontal disease reduced PTB risk.

    Data from 2 recently completed clinical trials shed light on the complexity of the information. The Periodontal Infections and Prematurity Study was a multicenter, randomized, controlled trial (RCT) of pregnant women to determine whether treatment of periodontal disease (scaling and root planing vs placebo [tooth polishing]) decreased spontaneous PTB.11

    Of women screened for the study, 50% had periodontal disease. However, treatment did not reduce spontaneous PTB before 35 weeks' gestation (8.6% treatment vs 5.5% placebo, respectively; relative risk, 1.56; 95% confidence interval [CI], 0.62-2.28) or composite neonatal morbidity.

    Jeffcoat and colleagues evaluated pregnant women with periodontal disease and compared the rate of PTB before 35 weeks among those with successful and unsuccessful treatment.12 After adjustment for confounding factors, they found a lower rate of PTB in those with successful treatment and hypothesized that this may be the key to improvement, not just the use of periodontal therapy.

    Polyzos and associates published a meta-analysis and systematic review of 11 trials, 5 of which were of high methodologic quality.13 The pooled results of these 5 high-quality RCTs did not indicate significant reduction in the risk of PTB after treatment for periodontal disease (odds ratio, 1.15; 95% CI, 0.95-1.40; P=.15). Thus, the current available data do not support this specific strategy and therapy as an intervention to decrease PTB.

    The reasons why treatment of maternal periodontal disease failed to reduce PTB in RCTs remain unclear.14,15

    One possibility is that maternal periodontal disease is merely a marker for another mechanism that is stimulating PTB.

    Another possible reason is that there is no consensus on the definition of periodontal disease, and heterogeneity exists among different study populations. Yet another possible factor is the timing and frequency of periodontal treatment.

    All current published RCTs tested periodontal treatment during pregnancy. Because periodontal disease is associated with local and systemic inflammation, treating periodontal disease during pregnancy may be too late to reduce the inflammatory burden that is associated with adverse pregnancy outcomes.

    To date, there are also no studies evaluating the effects of prepregnancy or interpregnancy treatment to prevent PTB.

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    Kim A. Boggess, MD
    DR. BOGGESS is Associate Professor, Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of North ...

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