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    Periodontal disease and preterm birth

    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.

    Q What are the current recommendations for evaluation and treatment of periodontal disease in pregnancy?


    TABLE Practical actions to integrate oral health into prenatal services
    A Oral health interventions during pregnancy should be performed as general health maintenance, rather than to improve specific pregnancy outcomes. Despite the apparent inability of treatment of periodontal disease to reduce PTB rates, it is important to consider that treatment of maternal periodontal disease during pregnancy has also not been associated with increased risk of any adverse maternal or fetal outcomes. Thus there is no reason to delay indicated treatment.

    In addition, most treatment trials demonstrate that maternal oral health improves with antepartum periodontal therapy, a finding that is important for overall maternal health and well-being.

    Following the US Surgeon General's call to action,4 the American Dental Association, the American Academy of Pediatric Dentistry, and the American Academy of Periodontology have all issued statements for improving the oral health of pregnant women and young children.5,6,15-17

    Several states have also issued practice guidelines for perinatal oral health. Key action items for obstetricians are listed in the table above.

    DR. BOGGESS is a professor within the Division of Maternal Fetal Medicine of the Department of Obstetrics and Gynecology at University of North Carolina School of Medicine, Chapel Hill, North Carolina.

    This opinion was developed by the Society for Maternal-Fetal Medicine (SMFM) with the assistance of Kim A. Boggess, MD, and was approved by the Executive Committee of the Society on November 5, 2012. Neither Dr. Boggess nor any member of the Publications Committee (see the list of 2012 members at www.smfm.org) has a conflict of interest to disclose with regard to the content of this article.

    (DISCLAIMER: The practice of medicine continues to evolve and individual circumstances will vary. Clinical practices may reasonably vary. This opinion reflects information available at the time of acceptance for publication and is not designed nor intended to establish an exclusive standard of perinatal care. This publication is not expected to reflect the opinions of all members of the Society for Maternal-Fetal Medicine.)

    REFERENCES

    1. Rose LF, Genco RJ, Mealey BL, Cohen WD. Periodontal Medicine. Hamilton, Ont: BC Decker Inc; 2000.

    2. Boggess KA; Society for Maternal-Fetal Medicine Publications Committee. Maternal oral health in pregnancy. Obstet Gynecol. 2008;111(4):976-986.

    3. Jeffcoat MK. Prevention of periodontal diseases in adults: strategies for the future. Prev Med. 1994;23(5):704-708.

    4. US Department of Health and Human Services. Oral Health in America: A Report of the Surgeon General. Rockville, MD: US Department of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institutes of Health; 2000.

    5. Task Force on Periodontal Treatment of Pregnant Women, American Academy of Periodontology. American Academy of Periodontology statement regarding periodontal management of the pregnant patient. J Periodontol. 2004;75(3):495.

    6. California Dental Association Foundation; American College of Obstetricians and Gynecologists, District IX. Oral health during pregnancy and early childhood: evidence-based guidelines for health professionals. J Calif Dent Assoc. 2010;38(6):391-403, 405-440.

    7. Goldenberg RL, Culhane JF. Preterm birth and periodontal disease. N Engl J Med. 2006;355(18):1925-1927.

    8. Boggess KA, Moss K, Madianos P, Murtha AP, Beck J, Offenbacher S. Fetal immune response to oral pathogens and risk of preterm birth. A.m. J Obstet Gynecol. 2005;193(3 pt 2):1121-1126.

    9. Bearfield C, Davenport ES, Sivapathasundaram V, Allaker RP. Possible association between amniotic fluid micro-organism infection and microflora in the mouth. BJOG. 2002;109(5):527-533.

    10. Vergnes JN, Sixou M. Preterm low birth weight and maternal periodontal status: a meta-analysis. Am J Obstet Gynecol. 2007;196(2):135.e1-135.e7.

    11. Macones GA, Parry S, Nelson DB, et al. Treatment of localized periodontal disease in pregnancy does not reduce the occurrence of preterm birth: results from the Periodontal Infections and Prematurity Study (PIPS). AmJ Obstet Gynecol. 2010;202(2):147.e1-147.e8.

    12. Jeffcoat M, Parry S, Sammel M, Clothier B, Catlin A, Macones G. Periodontal infection and preterm birth: successful periodontal therapy reduces the risk of preterm birth. BJOG. 2011;118(2):250-256.

    13. Polyzos NP, Polyzos IP, Zavos A, et al. Obstetric outcomes after treatment of periodontal disease during pregnancy: systematic review and meta-analysis. BMJ. 2010;341:c7017.

    14. Horton AL, Boggess KA. Periodontal disease and preterm birth. Obstet Gynecol Clin North Am. 2012;39(1):17-23, vii.

    15. For the dental patient. Pregnant? Tips for keeping your smile healthy. J Am Dent Assoc. 2004;135(1):127.

    16. Hale KJ; American Academy of Pediatrics Section on Pediatric Dentistry. Oral health risk assessment timing and establishment of the dental home. Pediatrics. 2003;111(5 pt 1): 1113-1116.

    17. Kumar J, Samelson R. Oral health care during pregnancy recommendations for oral health professionals. NY State Dent J. 2009;75(6):29-33.

    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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