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Periodontal Disease and Adverse Pregnancy Outcomes

Periodontal Disease and Adverse Pregnancy Outcomes. By Michael Paustian, M.S. University of Michigan Dec 8, 2006. Periodontal Disease. Chronic bacterial infection that affects the gums and bone supporting the teeth Risk factors for periodontitis Diabetes Smoking Low socioeconomic status

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Periodontal Disease and Adverse Pregnancy Outcomes

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  1. Periodontal Disease and Adverse Pregnancy Outcomes By Michael Paustian, M.S. University of Michigan Dec 8, 2006

  2. Periodontal Disease • Chronic bacterial infection that affects the gums and bone supporting the teeth • Risk factors for periodontitis • Diabetes • Smoking • Low socioeconomic status • Race & ethnicity • Genetics • Lack of access to dental care

  3. Measuring periodontitis • Full mouth versus selected teeth • Probing measures • Probing Depth (PD) • Clinical Attachment Loss (CAL) • Bleeding on Probing (BOP) • Indexes • CPITN • Russell Ebersole JL. Humoral immune responses in gingival crevice fluid: local and systemic implications. Periodontology 2000. 2003;31:135-66

  4. Defining Adverse Pregnancy Outcomes What About Small for Gestational Age???

  5. Prematurity & Low Birth Weight • Prematurity • 10-11% of all births • Half of all child neurologic disorders and 75% of neonatal infant mortality • Inflammatory process? • Low Birth Weight • 6-7% of all births • Intrauterine growth & inflammation • Overlaps prematurity

  6. Known risk factors for PTB & LBW Jeffcoat MK, Geurs NC, Reddy MS, Cliver SP, Goldenberg RL, Hauth JC. Periodontal infection and preterm birth: results from a prospective study. JADA. 2001;132:875-79.

  7. Biologic Plausibility Williams CECS, Davenport ES, Sterne JAC, Sivapathasundaram V, Fearne JM, Curtis MA. Mechanism of risk in preterm low-birthweight infants. Periodontology 2000. 2000;23:142-50.

  8. Research Question Is periodontitis a risk factor for preterm birth, low birth weight, neither, or both?

  9. Methodology • Medline Search • 4 different searches (subheading & keywords) • Periodontitis or Periodontal Disease • Premature Birth, or Low Birth Weight, or Very Low Birth Weight, or Pregnancy Outcome • Limited • Between 1996-2005 (Offenbacher et al, 1996) • English Language • Availability through UM library

  10. Quality assessment of the exposure • Adequate: Full mouth probing, with measures of probing depth and attachment loss • Inadequate: Partial mouth probing, use of a periodontal index, or self-report • Unclear: Not explicitly described Madianos PN, Bobetsis GA, Kinane DF. Is periodontitis associated with an increased risk of coronary heart disease and preterm and/or low birth weight births? Journal of Clinical Periodontology. 2002;29S3:22-36.

  11. Quality assessment of the outcome • Adequate: Gestational age confirmed via ultrasound during pregnancy • Inadequate: Gestational age measured by another method • Unclear: Measurement of gestational age unexplained

  12. Additional quality assessment for case-control studies • Are cases and controls representative of the populaton? • Were controls drawn from the same source population? • Were exclusion criteria applied to both cases and controls? • Were appropriate statistical methods used? • Was there adjustment for confounding? • Maternal age, race/ethnicity, smoking, drug use, diabetes, bacterial vaginosis, SES, previous preterm birth

  13. Additional quality assessment for prospective studies • Were the populations of exposed and unexposed adequately described? • Was the follow-up similar between exposed and unexposed? • Were appropriate statistical analyses performed? • Was there adjustment for confounding? • Maternal age, race/ethnicity, smoking, drug use, diabetes, bacterial vaginosis, SES, previous preterm birth

  14. Search Results • Periodontitis and Periodontal Disease: 53,415 results • PTB, LBW, VLBW, Pregnancy Outcome: 63,990 results • 167 articles when combined • 155 after limiting to English • 151 after limiting to 1996-2005 • Case-control (18) • Cohort (14) • RCT (6) • Meta-analysis (1)

  15. Case-Control Results *Controlled for small-for-gestational age

  16. Case-control results • Case-control studies have improved in quality since initial studies • PTB or PLBW • 11/15 (73%) found an association • Range of 2.60-7.93 • Positive association, 2.60-2.75 among best • LBW or PLBW • 8/13 (62%) found an association • Range of 3.20-7.93 • No association found among best • SGA accounted for in one study • Association w/ PTB but not LBW

  17. Cohort Results

  18. Cohort Results • PTB or PLBW • 7/11 (64%) found an association • Mixed results among best • Range of 3.5-20.0 • LBW or PLBW • 3/9 (33%) found an association but 1/6 specifically for LBW • One positive association • SGA was positive, but only assessed in one study

  19. Dose-response Relationship Jeffcoat MK, Geurs NC, Reddy MS, Cliver SP, Goldenberg RL, Hauth JC. Periodontal infection and preterm birth: results from a prospective study. JADA. 2001;132:875-79.

  20. Recruitment of cohort and risk estimates

  21. RCT Results • Scaling & root planning (SRP) treatment groups were less likely to have PTB or PLBW in all but one study • There was no difference in risk for LBW in any of the four studies that addressed it • Interesting Tidbit • Antibiotic treatment with SRP increased risk of PTB & PLBW

  22. Meta-analysis results • Initial meta-analysis consisted of five early studies • Publication bias not found • Odds ratio • 4.28 (2.62-6.99) for PTB • 5.28 (2.21-12.62) for PLBW • 2.30 (1.21-4.38) for PTB or LBW

  23. Conclusions • Improved quality of case-control studies • Association w/ PTB may be lower • Need to address SGA • Cohort studies thus far have given mixed results • More support for PTB than LBW • Association dependent on recruitment and/or timing of assessment?

  24. Limitations • Periodontitis Case Definitions • “What goes unappreciated is the minute changes in gingival tissues, the damn millimeters that could conceivably have the most profound impacts on people’s lives.” • Limited power to detect associations • Need to address the measurement of smoking Steven Kerpen. The Damn Millimeter. New York State Dental Journal, March 2005.

  25. Implications • Need for improved prospective studies • Prospective studies should address biases that may result with the time period of recruitment • Review literature for the effect of periodontitis case-definition on adverse pregnancy outcome • Increasing need to address SGA if LBW is to be considered an outcome of periodontitis • Preconceptual and interpregnancy treatment of periodontitis

  26. Thank You Questions? Disclaimer: This study was funded by the Federal Direct Student Loan program and my eternally empty pocketbook

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