Oral Health and Preterm Delivery

Daniel Weber, MD

OBGYN In-house Medical ExpertDept of State

Commonwealth of Pennsylvania

131,000,000 world births/year

2011 estimate

3,953,590 Births/Year2011 data

142,000 Births/Year2011 data

45,300 Pa. MedicaidBirths, 2011

USA Preterm Birth Data(<37wk)

● 11.73% in 2011 (preliminary data)● 5th consecutive year of decrease● Down 2% from 2010● Down 8% from 2006 peak

BREAKDOWN OF PREMATURE BIRTHS

1990

34-36 wk 7.3%

32-33 1.4%

<32 1.9%CDC/NCHS data, 2005

2005

9.1%

1.6%

2.0%

•460,000 Premies/year

80,000 very preterm birth/year in USA (<32 weeks)

“Microorganisms or their waste products obtain entrance of parts of the body adjacent to or remote from the mouth.” -- Focal Infection Theory, Dr Miller, 1891

“Gingivitis exacerbated by the hormonal changes of pregnancy (Pregnancy Gingivitis) is considered the most common oral manifestation of pregnancy and has been reported in up to 100% of pregnant women.”

-Dental Manifestations of Pregnancy, Pirie et al. 2007

“When questioned, 36.4% of women in the study felt that the condition of their teeth had deteriorated

during pregnancy.”

-Dental Manifestations of Pregnancy, Y. Turok, 2007

Pregnancy Gingivitis

Periodontal Tissues

Pathogenic flora leads to endotoxin release,

including LipoPolySaccharides Systemic Organs

Exposure to LPS and host mediators

leading to increased cytokines

Periodontal Tissues

Local release of inflammatory mediators,

IL- lB, TNF-a, PGE2

Fetoplacental Unit

Increased IL-IB, PGE2 levels

Uterine Contraction

Cervical Dilation

mothers withperiodontal infection:

• Case control study, 93 mothers

• 7 fold increase of PLBW infant (Preterm delivery of LBW infant)

• 18% of PLBW infants might be attributable to periodontal disease

     

Offenbacher, J. Periodontology, 1996

• Fetal cord blood IgM study 

• PLBW: 33.3%

• Term: 17.9%

“Elevated human IgM suggests in utero exposure to periodontal pathogens” Offenbacher, J Dent Res,1999

Oral Conditions And Pregnancy(OCAP)

• Clinical data from first 812 deliveries

• DNA probes to identify periodontal organisms within maternal periodontal plaque at delivery

• Maternal postpartum IgG antibody, and umbilical IgM level to 15 pathogens

• Pathogens divided into Orange and Red complexes

OCAP findings

• 2.9 fold higher prevalence of IgM for one or more of Orange or Red complexes amongst PTD vs term

• + IgM to Campylobacter rectus: 20% for premies, 6% for term.

• Lack of maternal IgG antibody to Red complex associated with 2.2 odds ratio of premie. (maternal antibody protecting fetus theory)

• 66.7% premature rate with neg maternal IgG to Red Complex, and positive fetal IgM to Orange complex.

Madianos, Offenbacher, UNC, Ann Periodontol, 2001

▪N = 1313 pregnant patients▪Patients with severe or generalized periodontal dz, 4.45 odds ratio for preterm delivery < 37wks▪< 35 weeks, odds ratio 5.28▪< 32 weeks, odds ratio 7.07

Periodontal Infection and Preterm Birth – Results of a

Prospective Study

Jeffcoat, J Am Dent Assoc, 2001

• Association between severe periodontal dz and preterm birth (odds ratio 3.4)

• Periodontal dz not associated with selected markers of upper genital tract inflammation (cultures of placenta, umbilical cord blood, cord interleukin-6 levels, and histopathologic placental pathology)  Goepfert, Jeffcoat, et.al., Periodontal Disease and Upper Genital Tract

Inflammation in Early Spontaneous Birth, Obstetrics & Gynecology 2004

• 59 pts with preterm birth <32 weeks• 32 pts with indicated preterm birth < 32 weeks

• 44 pts with uncomplicated term delivery (>37 weeks)

•1020 prenatal patients •Preterm birth:  11.2% among periodontally

healthy women /  28.6% with moderate-severe periodontal disease

•Very preterm birth, <32 weeks:  6.4% with periodontal disease progression vs. 1.8%

without disease progression

Offenbacher, Obstetrics and Gynecology, 2006

• 813 prenatal patients• Treatment group: scaling and root planing, monthly tooth polishing, oral hygiene instruction.• Control group: monthly brief dental exam, treatment pp.• Conclusions: Treatment of periodontitis in pregnancy improves periodontal disease, and is safe, but does not significantly alter rates of PTD, LBW, or IUGR• Delivery <32 wks: control 4.4%, treatment 2.5%• Delivery ,37wks: control 12.8%, treatment 12.0%

Michalowicz, DDS, et al, NEJM, Nov 2006

Treatment of Periodontal Disease and the Risk of Preterm Birth

Maternal Oral Therapy to Reduce Obstetric Risk

(MOTOR)

• NIH funded, 1806 women, 3 sites, opened 2004

• Scaling and root planing in 2nd trimester vs within 4 weeks postpartum.

• Offenbacher, UNC

• Effect of Periodontal Therapy on Rate of Premature Delivery: A Randomized Controlled Study, (OBGYN Sept 2009)

• Conclusion: Perio therapy did not reduce incidence of prematurity

Obstetric outcomes after treatment of periodontal diseaseduring pregnancy: systematic review and meta-analysis

Nikolaos P Polyzos; Ilias P Polyzos; Apostolos Zavos; Antonis Valachis; Davide Mauri; Evangelos G Papanikolaou; Spyridon Tzioras; Daniel Weber; Ioannis E Messinis.

British Medical Journal

December, 2010

Polyzos meta-analysis conclusions

Treatment of periodontal disease with scaling and root planing cannot be considered to be an efficient

way of reducing the incidence of preterm birth. Women

may be advised to have periodical dental examinations

during pregnancy to test their dental status and may have

treatment for periodontal disease. However, they should

be told that such treatment during pregnancy is unlikely

to reduce the risk of preterm birth or low birthweight

infants.

Self Reported Dental Habits and Preterm Birth

1000 consecutive women surveyed during immediate postpartum stay, 2011, Women & Babies, LG Health

●demographics

●prior OB history

●dental home

●last dental visit

●oral piercing

●flossing

●brushing

●smoking

●birth outcome

Dental Habits study, preliminary findings

● demographics: 69% white, 18% latino, 6% black.

● MA: 51.4%

● smokers: 11.7%

● Brush once/day 23.6%

● Floss: 62% at least 1/week

● dental home: 62%

● dental visit in this pregnancy: 54% (MA 50%, commercial health insurance 57%)

● overall PTB: 8.2%

Dental Habits study, Preliminary Findings

● no impact upon prematurity: dental home, dental visit in pregnancy, flossing frequency, oral piercing.

● smoking: RR of PTB 2.5, but freq of brushing no additive impact for smokers

● brushing 1/day: RR of PTB 2.3

Follow up research opportunities

intervention trial: once/day brushers randomized to routine brushing habits vs. BID brushing

Future research opportunities

● Micro RNAs: short non-coding molecules expressed in different tissues which regulate transcription of different genes

● Highly specific● Very sturdy

133,000,000 Births/Year

Dr. Dan Weber, contact information:weberobgyn@gmail.com