7838 Periodontal Diseases and Adverse Pregnancy Outcomes

Journal
2008
Journal of
Dental Hygiene
Supplement
to ADHA Access
of
Dental
Hygiene
THE AMERICAN DENTAL HYGIENISTS’ ASSOCIATION
Periodontal Diseases and Adverse Pregnancy

Outcomes: A Review of the Evidence and
Implications for Clinical Practice
• Initiative on Oral Health Care
• Periodontal Disease and Other Systemic
Conditions
• Pregnancy Complications
• Periodontal Disease and Its Impact
on Pregnancy
• Implications for Dental Hygiene
Assessment, Diagnosis, and Treatment
• Oral Health Knowledge in the
Medical Community
• Future Projections in Care of Pregnant
Patients
• Future Directions for Research and
Education
This supplement is sponsored by Philips Sonicare.
CEUs available online—see page 1.
From the Editor-in-Chief of the
Journal of Dental Hygiene
pleased to be able to bring you this thoroughly reviews the literature on

timely CE supplement on a topic that the topic as well as explains the study
is of interest to every practicing den- designs of the many investigations
tal hygienist. Estimates are that over conducted over the years. A quick ref-
50% of pregnant women have some erence guide to relevant studies is
form of gingival disease either from included as well as information about
gingivitis or periodontitis. Infections which dental procedures are deemed
in the mother have been identified as safe during pregnancy. The authors
increasing the risk for pregnancy have also provided you with pub-
complications such as preterm birth lished practice guidelines for care and
and preeclampsia. In addition, preg- web sites for easy reference.
nancy complications substantially Another important feature of this
increase the burden to the public by supplement is the collaboration
escalating health care costs (estimated between dental hygiene and medicine
at billions of dollars per year), not to in the writing of this piece. Heather
mention the emotional trauma to fam- Jared, BSDH, MS, is a graduate of
ilies who experience an adverse preg- the University of North Carolina,
nancy outcome. where she received both her BS
This supplement will update every degree and MS degree in Dental
H ow many of you have received

questions from your patients
and other health care providers
about the importance and safety of
dental hygienist on the latest evidence
about the impact of periodontal dis-
ease on pregnancy and includes the
Hygiene. While in graduate school,
Heather conducted her thesis project
on the topic of adverse pregnancy out-
most recent treatment recommenda- comes and it grew into a full-time job
treating pregnant patients? We are so tions for pregnant patients. The paper as a research associate professor at
UNC. Heather is now part of the Cen-
ter of Oral and Systemic Diseases,
about the authors with the primary responsibility of

planning and conducting clinical tri-
als. Kim Boggess, MD, an obstetri-
cian, is an associate professor in the
■ Heather Jared, BSDH, MS, is a research School of Medicine at the University
associate professor in the Department of of North Carolina and part of an inter-
Dental Ecology and conducts research in disciplinary research team investigat-
the Center for Oral Systemic Disease at the ing the effect of periodontal disease
University of North Carolina School of on adverse pregnancy outcomes. Col-
Dentistry, Chapel Hill, NC. laboration with other health care pro-
fessionals is vital to the improvement
of health for our patients and for mov-
ing our profession forward in the
future.
■ Kim A. Boggess, MD, is an associate Finally, I want to extend sincere
professor of Obstetrics & Gynecology in the appreciation to Philips Sonicare for
Division of Maternal-Fetal Medicine at the their support of this supplement and
University of North Carolina in Chapel Hill, their dedication to the improvement
NC. of oral health throughout the world.
Rebecca S. Wilder, RDH, BS, MS

Editor-in-Chief, Journal of Dental Hygiene
[email protected]
Inside
Journal of Dental Hygiene
Message
IFC From the Editor-in-Chief of the Journal of Dental Hygiene
Supplement
Periodontal Diseases and Adverse Pregnancy Outcomes: A
Review of the Evidence and Implications for Clinical Practice
Heather Jared, BSDH, MS and Kim A. Boggess, MD
3 Introduction
4 Initiative on Oral Health Care
4 Periodontal Disease and Other Systemic Conditions
4 Pregnancy Complications
5 Periodontal Disease and Its Impact on Pregnancy

8 Inconsistencies with Previous Studies
12 Implications for Dental Hygiene Assessment, Diagnosis,

and Treatment
13 First State Practice Guidelines for Treatment of Pregnant Patients
14 Oral Health Knowledge in the Medical Community
17 Future Projections in Care of Pregnant Patients
17 Future Directions for Research and Education
18 Conclusion
This special issue of the Journal of Dental Hygiene was funded

by an educational grant from Philips Sonicare.
This supplement can also be accessed online at
www.adha.org/CE_courses/
To obtain one hour of continuing education credit, complete the
test at www.adha.org/CE_courses/course19
Special supplement The Journal of Dental Hygiene 1

■ STATEMENT OF PURPOSE
The Journal of Dental Hygiene is the refereed, scientific publication of the

Journal American Dental Hygienists’ Association. It promotes the publication of
original research related to the profession, the education, and the practice of
dental hygiene. The journal supports the development and dissemination of a
of dental hygiene body of knowledge through scientific inquiry in basic, applied,

and clinical research.
Dental ■ EDITORIAL REVIEW BOARD
Celeste M. Abraham, DDS, MS

Cynthia C. Amyot, BSDH, EdD
Heather L. Jared, RDH, BS, MS
Wendy Kerschbaum, RDH, MA, MPH
Hygiene Joanna Asadoorian, AAS, BScD, MSc

Caren M. Barnes, RDH, BS, MS
Phyllis L. Beemsterboer, RDH, MS, EdD
Salme Lavigne, RDH, BA, MSDH
Jessica Y. Lee, DDS, MPH, PhD
Deborah S. Manne,RDH,RN,MSN,OCN
Stephanie Bossenberger, RDH, MS Ann L. McCann, RDH, BS, MS, PhD
special supplement Kimberly S. Bray, RDH, MS Stacy McCauley, RDH, MS
Lorraine Brockmann, RDH, MS Gayle McCombs, RDH, MS
Patricia Regener Campbell, RDH, MS Tricia Moore, RDH, BSDH, MA, EdD
Dan Caplan, DDS, PhD Christine Nathe, RDH, MS
Barbara H. Connolly, PT, EdD, FAPTA Kathleen J. Newell, RDH, MA, PhD
Valerie J. Cooke, RDH, MS, EdD Johanna Odrich, RDH, MS, DrPh
MaryAnn Cugini, RDH, MHP Pamela Overman, BSDH, MS, EdD
EXECUTIVE DIRECTOR Susan J. Daniel, AAS, BS, MS Vickie Overman, RDH, BS, MEd
Ann Battrell, RDH, BS, MSDH Michele Darby, BSDH, MS Fotinos S. Panagakos, DMD, PhD, MEd
Catherine Davis, RDH, PhD. FIDSA M. Elaine Parker, RDH, MS, PhD
[email protected]
Susan Duley, BS, MS, EdS, EdD, LPC, CEDS Ceib Phillips, MPH, PhD
Jacquelyn M. Dylla, DPT, PT Marjorie Reveal, RDH, MS, MBA
DIRECTOR OF COMMUNICATIONS Kathy Eklund, RDH, BS, MHP Pamela D. Ritzline, PT, EdD
Jeff Mitchell Deborah E. Fleming, RDH, MS Judith Skeleton, RDH, BS, MEd, PhD
[email protected] Jane L. Forrest, BSDH, MS, EdD Ann Eshenaur Spolarich, RDH, PhD
Jacquelyn L. Fried, RDH, BA, MS Sheryl L. Ernest Syme, RDH, MS
EDITOR EMERITUS Kathy Geurink, RDH, BS, MA Terri Tilliss, RDH, BS, MS, MA, PhD
Mary Alice Gaston, RDH, MS Mary George, RDH, BSDH, MEd Lynn Tolle, BSDH, MS
Ellen Grimes, RDH, MA, MPA, EdD Nita Wallace, RDH, PhD
EDITOR-IN-CHIEF JoAnn R. Gurenlian, RDH, PhD Margaret Walsh, RDH, MS, MA, EdD
Linda L. Hanlon, RDH, BS, MEd, PhD Donna Warren-Morris, RDH, MS, MEd
Kitty Harkleroad, RDH, MS Cheryl Westphal, RDH, MS
[email protected] Lisa F. Harper Mallonee,BSDH,MPH,RD/LD Karen B. Williams, RDH, PhD
Harold A. Henson, RDH, MEd Charlotte J. Wyche, RDH, MS
STAFF EDITOR Laura Jansen Howerton, RDH, MS Pamela Zarkowski, BSDH, MPH, JD
Katie Barge
[email protected] ■ BOOK REVIEW BOARD
LAYOUT/DESIGN Sandra Boucher-Bessent, RDH, BS Cassandra Holder-Ballard, RDH, MPA

Jean Majeski Jacqueline R. Carpenter, RDH Lynne Carol Hunt, RDH, MS
Paul R. Palmer Mary Cooper, RDH, MSEd Shannon Mitchell, RDH, MS
Heidi Emmerling, RDH, PhD Kip Rowland, RDH, MS
Margaret J. Fehrenbach, RDH, MS Lisa K. Shaw, RDH, MS
Cathryn L. Frere, BSDH, MSEd Margaret Six, RDH, BS, MSDH
Patricia A. Frese, RDH, BS, MEd Ruth Fearing Tornwall, RDH, BS, MS
Joan Gibson-Howell, RDH, MSEd, EdD Sandra Tuttle, RDH, BSDH
Anne Gwozdek,RDH, BA, MA Jean Tyner, RDH, BS
■ SUBSCRIPTIONS
The Journal of Dental Hygiene is published quarterly, online-only, by the American

Dental Hygienists’ Association, 444 N. Michigan Avenue, Chicago, IL 60611. Copy-
right 2008 by the American Dental Hygienists’ Association. Reproduction in whole or
part without written permission is prohibited. Subscription rates for nonmembers are
one year, $45; two years, $65; three years, $90; prepaid.
■ SUBMISSIONS
Please submit manuscripts for possible publication in the Journal of Dental Hygiene
to Katie Barge at [email protected].
2 The Journal of Dental Hygiene Special supplement

Supplement
Periodontal Diseases and Adverse Pregnancy
Outcomes: A Review of the Evidence and
Implications for Clinical Practice
Heather Jared, BSDH, MS, and Kim A. Boggess, MD
Introduction
Abstract
Periodontal diseases are a group of Periodontal diseases affect the majority of the population either as gingivitis
conditions that cause inflammation or periodontitis. Recently there have been many studies that link or seek
and destruction to the supporting to find a relationship between periodontal disease and other systemic dis-
structures of the teeth. These chronic eases including, cardiovascular disease, diabetes, stroke, and adverse
oral infections are characterized by pregnancy outcomes. For adverse pregnancy outcomes, the literature is
the presence of a biofilm matrix that inconclusive and the magnitude of the relationship between these 2 has not
been fully decided. The goal of this paper is to review the literature regard-
adheres to the periodontal structures
ing periodontal diseases and adverse pregnancy outcomes, and provide
and serves as a reservoir for bacteria. oral health care providers with resources to educate their patients. Alter-
Dental plaque biofilm is a complex natively, this paper will also discuss what is occurring to help increase the
structure of bacteria that is marked by availability of care for pregnant women and what oral health care providers
the excretion of a protective and adhe- can do to help improve these issues.
sive matrix.1 Within this matrix are
Keywords: gingivitis, periodontitis, preterm labor, preterm birth, low birth
gram-negative anaerobic and micro- weight
aerophilic bacteria that colonize on
the tooth structures, initiate the
inflammatory process, and can lead to
bone loss and the migration of the genic bacteria modulates how the periodontal disease have at least one
junctional epithelium, resulting in disease is initiated and progresses. risk factor that increases their sus-
periodontal pocketing and periodontal This is evidenced by the fact that gin- ceptibility to the infectious process
disease. This bacterial insult can result givitis does not always progress into and subsequent tissue damage. Often
in destruction of the periodontal tis- periodontitis. multiple factors are present.3-4
sues which precipitates a systemic Over the years, several risk factors
inflammatory and immune response.2 for periodontitis have been identified.
For many years, it was believed For example, stress, poor dietary Initiative on Oral Health
that specific pathogenic bacteria habits with high sugar intake, smok- Care
found within dental plaque biofilm ing and tobacco use, obesity, age, and
were solely responsible for peri- poor dental hygiene all contribute to The first-ever Surgeon General’s
odontal diseases. While it is known the development of periodontal dis- Report on Oral Health in 2000 out-
that pathogenic bacteria are one facet ease. Other major risk factors include lined the prevalence of oral diseases
of the disease process and are con- clinching or grinding teeth, genetic such as dental caries and periodontal
sistently present, it is not the only factors, other family factors, other infection. It also identified vulnera-
cause of periodontitis. The host medical diseases such as diabetes, ble populations that have a higher
response to the bacterial insult mod- cancer, or AIDS, defective dental prevalence of oral disease, and that
ulates the severity of the disease by restorations medication use, and con- significant racial/ethnic and socioe-
activating the immune system to ditions that change estrogen levels conomic disparities exist in the
mediate the disease process. How (puberty, pregnancy, menopause).3-4 United States. Subsequently, the sur-
well the host responds to the patho- Eighty percent of individuals with geon general put forth a call for action

to promote access to oral health care weight, risk for preeclampsia, mortal- Preterm birth is delivery at less than
for all, reduce the morbidity of oral ity, and growth restriction. However, 37 weeks gestation. Prematurity rates
diseases, and eliminate oral health the causality of how periodontitis influ- continue to increase. The latest statis-
disparities. The report concluded that ences pregnancy outcomes has not tics from the National Center for
oral diseases can be associated with been established.14-25 Health Statistics showed that for 2005
systemic conditions, including dia- Treatment of periodontal infection the preterm birth rate grew to 12.7%.
betes, heart disease, and adverse preg- may reduce the risk of other systemic This is up from 12.5% in 2004 and the
nancy outcomes. Specifically, the conditions. In a randomized clinical preliminary reports for 2006 indicate
report stressed that periodontal treat- trial to estimate the effect of peri- an additional increase in the rates up to
ment during pregnancy is an impor- odontal therapy on traditional and 12.8%. Since 1990, the rate of preterm
tant strategy to potentially improve novel risk factors for cardiovascular birth has increased more than 20%.34
maternal and infant health.5 disease and on markers of inflamma- Understanding prematurity is
Oral health and its relationship to tion, D’Aiuto et al found that therapy important because it is the leading
systemic health is important to society reduced inflammatory cytokines, cause of death in the first month, caus-
because up to 90% of the worldwide blood pressure, and cardiovascular ing up to 70% of all perinatal deaths.35
population is affected by periodontal risk scores.26 In a small treatment trial, Even late premature infants, those born
disease—either gingivitis or periodon- type 2 diabetic patients showed between 34 and 366/7 weeks gestation,36
titis.6 Reports indicate that up to 30% of improved diabetic control (lower have a greater risk of feeding difficul-
the general population has a genetic HbA1c levels) after periodontal treat- ties, thermal instability, respiratory dis-
predisposition to periodontitis and a ment. 27 Several investigators have tress syndrome, jaundice, and delayed
conservative estimate is that over 35 reported similar effects of oral health brain development.34 Prematurity is
million people in the United States regimens on reduced risk for nosoco- responsible for almost 50% of all neu-
have periodontitis.7 mial respiratory infections. Treatment rological complications in newborns,
of mechanically ventilated patients and leads to lifelong complications in
with a daily oral hygiene regime con- health, including but not limited to
Periodontal Disease sisting of an 0.12% chlorhexidine visual problems, developmental delays,
gluconate wash reduced the risk for gross and fine motor delays, deafness,
and Other Systemic nosocomial pneumonia.28,29 Recently, and poor coping skills. These compli-
Conditions studies have been inconclusive on the cations increase the health care dollars
effects of periodontal therapy during spent on each child. On average, the
There is considerable interest in the pregnancy for preventing adverse medical cost alone for a preterm birth
link between oral and systemic health pregnancy outcomes.30-32 Treatment of is 10 times greater than the medical
among dental and medical providers. oral infections may represent a novel costs for a full-term birth. In 2005, the
Current evidence suggests that peri- approach to improving general health. nationwide cost of preterm birth was
odontal disease is associated with an It is estimated that over 50% of more than $26.2 billion for health care,
increased risk for cardiovascular dis- pregnant women suffer from some educational costs, and lost productiv-
ease,8,9 diabetes,10,11 community and form of gingival disease, either gin- ity. 34 Although there have been
hospital acquired respiratory infec- givitis or periodontitis,20,23 with the advances in technology to help save
tions,12 and adverse pregnancy out- reports of prevalence fluctuating the infants who are born premature or
comes.13-15 Individuals with periodontal between 30%-100% for gingivitis and low birth weight, the lifelong problems
disease have approximately a 1.5 – 1.9 5%-20% for periodontitis.33 The preva- associated with these conditions have
increased odds for developing cardio- lence of periodontal diseases during not been abated.
vascular disease.8,16 There appears to be pregnancy substantiates the strategy set
a bidirectional relationship between forth by the surgeon general, in that
periodontal disease and diabetes with a periodontal treatment during preg- Periodontal Disease
2- to 3-fold increased risk for diabetes nancy may potentially improve mater-
among individuals with tooth loss. nal and infant health.5 and Its Impact on
Teeth and periodontium may serve as a Pregnancy
reservoir and may contribute to respi-
ratory infections. Individuals with poor Periodontal infection is one of
oral hygiene such as dental decay have
Pregnancy many infections that have been asso-
a 2- to 9-fold increase odds for pneu- Complications ciated with adverse pregnancy out-
monia.12 Many recent studies have comes. The hypothesis that periodon-
reported that maternal periodontal dis- Maternal infections have long been tal conditions influence the outcome
ease may be an independent contribu- recognized as increasing the risk for of a pregnancy is not a new idea. In
tor to abnormal pregnancy outcomes pregnancy complications such as 1931, Galloway identified that the
including preterm birth, low birth preterm birth and preeclampsia. focal infection found in teeth, tonsils,

sinuses, and kidneys pose a risk to the
developing fetus. His information Myths regarding pregnancy and teeth
dated back to 1916 when pregnant • It is not true that you lose a tooth for every pregnancy. Decay is often
guinea pigs were inoculated with the cause of tooth loss.
streptococci eluted from human still-
born fetuses. This inoculation resulted • Calcium is not taken from the mother’s teeth for the baby’s growth. This
in a 100% abortion rate. To show the is provided through the mother’s diet and if it is inadequate then it is
impact on humans, he obtained a full taken from the mother’s bone.
mouth radiographic series on 242
women presenting for prenatal care.
Fifteen percent (n=57) had an apical to oral infections, allowing patho- Two prospective cohort studies23,44
abscess and the suggested treatment genic bacteria to proliferate and confound that moderate to severe peri-
was extraction of the affected tooth. tribute to inflammation in the gingiva. odontitis identified early in pregnancy
Of those who were treated, none This hyperinflammatory state is associated with an increased risk
resulted in a miscarriage or stillbirth. increases the sensitivity of the gin- for spontaneous preterm birth, inde-
Galloway summarized that removal giva to the pathogenic bacteria found pendent of other traditional risk fac-
of a known focal infection, which had in dental biofilm. Females often see tors. In the first study, investigators
clearly demonstrated to be a source of these changes during other periods of from the University of Alabama con-
danger to any pregnant woman, was their life when hormones are fluctu- ducted a prospective evaluation of
more beneficial than allowing the ating, such as puberty, menstruation, over 1300 pregnant women. Complete
infection to harbor throughout the pregnancy, and again at menopause.39- medical, behavioral, and periodontal
pregnancy. He went on to suggest that 41
Recent research suggests that the data were collected between 21 and
all foci of infection should be presence of maternal periodontitis has 24 weeks gestation. Generalized peri-
removed early in pregnancy.37 been associated with adverse preg- odontal infection was defined as 90
It is widely recognized that good oral nancy outcomes, such as preterm or more tooth sites with periodontal
health maintains the structures within birth,19,20,23 preeclampsia,25 gestational ligament attachment loss of 3 mm or
the oral cavity. However, it is not uni- diabetes,42 delivery of a small-for-ges- more. The risk for preterm birth was
versally accepted that oral health may tational-age infant,14 and fetal loss.43 increased among women with gener-
be an independent contributor to abnor- The strength of these associations alized periodontal infection; this risk
mal pregnancy outcomes. Many studies ranges from a 2-fold to 7-fold was inversely related to gestational
have been conducted and the literature increase in risk. The increased risks age. After adjusting for maternal age,
is controversial on the role periodonti- suggest that periodontitis may be an race, tobacco use, and parity, this rela-
tis has and its influence on adverse independent risk factor for adverse tionship remained. The adjusted odds
pregnancy outcomes. pregnancy outcomes. ratio for a preterm birth < 37 weeks
Recognition and understanding of In 1996, Offenbacher et al reported for those women who now had gen-
the importance of oral health for sys- a potential association between eralized periodontal disease was 4.5
temic health has led to significant maternal periodontal infection and (95% CI, 2.2-9.2). The adjusted odds
research into the role of maternal oral delivery of a preterm or low-birth- ratio increased to 5.3 (95% CI, 2.1-
health and pregnancy outcomes. Dur- weight infant. 19 In a case-control 13.6) for preterm birth < 35 weeks
ing pregnancy, changes in hormone study of 124 pregnant women, obser- gestation, and to 7.1 (95% CI, 1.7-
levels promote an inflammatory vations suggested that women who 27.4) for preterm birth < 32 weeks
response that increases the risk of delivered at less than 37 weeks ges- gestation.23
developing gingivitis and periodon- tation or an infant weighed less than In the second study, Offenbacher
titis. As a result of varying hormone 2500 g had significantly worse perio- et al44 conducted a prospective study
levels without any changes in the dontal infection than control women. of obstetric outcomes of over 1000
plaque levels, 50%-70% of all In another case-control study con- women who received an antepartum
women will develop gingivitis dur- ducted by Dasanayake, women who and postpartum periodontal examina-
ing their pregnancy, commonly delivered a full-term infant weighing tion. Moderate to severe periodontal
referred to as pregnancy gingivitis. less than 2500 grams were matched to infection was defined as 15 or more
This type of gingivitis is typically women who delivered full term tooth sites with pockets depth greater
seen between the second and eighth infants weighing more than 2500 than or equal to 4 mm. The incidence
month of pregnancy.38 Increased lev- grams. All women received a peri- of increased periodontal pocketing,
els of the hormones progesterone and odontal evaluation after delivery, and defined as clinical disease progres-
estrogen can have an effect on the poor periodontal health was deter- sion, was determined by comparing
small blood vessels of the gingiva, mined to be an independent risk fac- site-specific probing measurements
making it more permeable.39,40 This tor for delivering a low-birth-weight between the antepartum and postpar-
increases the mother’s susceptibility infant.22 tum examinations. Disease progres-

These Drugs May Be FDA These Drugs May Not FDA self-reported questionnaire was vali-
Used in Pregnancy Category Be Used in Pregnancy Category dated by bitewing radiographs taken
prior to delivery. The majority of the
Antibiotics Antibiotics participants were white and middle
Penicillin B Tetracyclines** D class. Of the 354 participants who had
Amoxicillin B Erythromycin bitewing radiographs available, the
Cephalosporins B in the estolate form B
Clindamycin B Quinolones C prevalence of self-reported periodon-
Erythromycin (except for Clarithromycin C titis was 3.7%. It was noted that
estolate form) B women who reported periodontitis had
significantly higher mean radiographic
ANALGESICS ANALGESICS bone loss than those that did not
Acetaminophen B Aspirin C
Acetaminophen with codeine C* (p<0.001). There was no significant
Codeine C* increased risk of having a preterm
Hydrocodone C* birth or small-for-gestational-age
Meperidine B infant when adjusting for smoking,
Morphine B race/ethnicity, socioeconomic status,
After 1st trimester for 24 BMI, history of preterm delivery, pres-
to 72 hrs only ence of genitourinary infection,
Ibuprofen B weekly weight gain, and history of
Naprosyn B dental check-ups. However, there was
Category C should be used with caution (NY State Dept of Health 2006)
a significant increase in risk for those
**Tetracycline and its derivatives are contraindicated in pregnancy who reported having periodontitis and
poor pregnancy outcomes (adj OR 2.2:
95%CI 1.05-4.85). The authors con-
sion was considered present if 4 or group. The control group consisted of cluded that periodontitis is an inde-
more tooth sites had an increase in term pregnancies that were admitted pendent risk factor for poor pregnancy
pocket depths by 2 mm or more, with following the PTL mother. Periodon- outcomes. However, caution should be
the postpartum probing depth being 4 tal examinations were performed taken when interpreting these results
mm or greater. Compared to women within 36-48 hours after delivery and due to the sample size and the indirect
with periodontal health, the relative before discharge. Chronic periodon- measurement of periodontitis.46
risk for spontaneous preterm birth < titis was described as one site with In yet another prospective cohort,
37 weeks gestation was significantly clinical attachment loss (CAL) > 1 Agueda et al enrolled over 1200
elevated for women with moderate- mm with gingival bleeding. The women to evaluate the association
severe periodontal infection (adj RR severity of periodontitis was classi- between periodontitis and preterm
2.0, 95% CI, 1.2-3.2), adjusting for fied as early (CAL <3mm), moderate birth and/or low birth weight. All
maternal age, race, parity, previous (CAL > 3 mm and < 5 mm), and women were between the ages of 18-
preterm birth, tobacco use, markers of severe (CAL >5mm). The extent of 40 and were enrolled between 20-24
socioeconomic status, and presence periodontitis was either localized, weeks gestation. Demographic data,
of chorioamnionitis. Periodontal dis- CAL < 30%, or generalized CAL > socioeconomic status, and medical and
ease progression was found to be an 30%. They concluded that chronic obstetric history were collected. Full
independent risk factor for delivery < periodontitis increased the risk of hav- mouth periodontal examinations, (PD,
32 weeks gestation (adj RR 2.4, 95% ing preterm labor {odds ratio of 4.7 CAL, BOP) were performed by a sin-
1.1-5.2). The data from these 2 stud- (95% CI: 1.9-11.9)}, preterm birth gle calibrated examiner and recorded
ies are important given the relation- {odds ratio 4.9 (95% CI: 1.9-12.8)}, at 6 sites per tooth. Periodontal dis-
ship between maternal periodontal and a low-birth-weight infant {OR ease was defined as 4 or more teeth
disease and very preterm birth (< 32 4.2(95% CI: 1.3-13.3)}.45 with one or more sites with PD > 4mm
weeks gestation), and the significant Pitiphat et al conducted a prospec- and CAL > 3mm at the same site.14
neonatal morbidity and mortality tive study to determine if self-reported After adjusting for confounding vari-
associated with very preterm birth.44 periodontitis was a risk factor for poor ables, a significant association was
Santos-Pereira et al studied 124 pregnancy outcomes. Women were found between preterm birth and peri-
women between the ages of 15-40 to enrolled prior to 22 weeks gestation odontitis (Adj OR 1.7 95% CI: 1.08-
determine if chronic periodontitis and completed a self-report question- 2.88) . However no significant associ-
increased the risk of experiencing naire during their second trimester. ation was found between low birth
preterm labor (PTL). In this cross-sec- Demographic, medical and reproduc- weight and periodontitis.47
tional trial, women who were admit- tive history, smoking, prepregnancy While there are data suggesting a
ted for preterm labor, with intravenous weight, and physical activity were relationship between maternal peri-
tocolysis, were enrolled into the PTL assessed at the first prenatal visit. The odontal infection and preterm birth,

several studies have failed to demon-
strate such an association.31,42,48-50 In Definitions: Terms Used in Periodontitis
one of the largest studies to date, and Pregnancy Outcomes Studies
Moore et al examined the relationship
between multiple periodontal param- Antepartum:
eters, including mean probing depths, Time between conception and the onset of labor; usually used to
percent of tooth sites with probing describe the period when a woman is pregnant.
depths greater than or equal to 4 mm, Chorioamnionitis
percent of sites with bleeding on prob- Inflammation of the chorion and the amnion, the membranes that sur-
ing, and percent of sites with clinical round the fetus. Chorioamnionitis usually is associated with a bacterial
attachment loss greater than or equal infection. This may be due to bacteria ascending from the mother's
to either 2 or 3 mm. Moore found no genital tract into the uterus to infect the membranes and the amniotic
difference in the periodontal parame- fluid. Chorioamnionitis is dangerous to the mother and child. It greatly
ters between women with preterm increases the risk of preterm labor and, if the child survives, the risk of
cerebral palsy.
birth and without preterm birth. 42
However, they did find a positive HbA1c levels
association between maternal peri- HbA1c is a test that measures the amount of glycosylated hemoglobin
odontal infection and spontaneous in the blood. Glycosylated hemoglobin is a molecule in red blood cells
abortion between 12 and 24 weeks that has glucose (blood sugar) attached to it. A person will have more
(adj OR 2.5, 95% CI 1.2-5.4).43 In a glycosylated hemoglobin if they have more glucose in their blood for
long periods of time. The test gives a good estimate of how well dia-
case-control study, Budeneli and col- betes has been managed over the previous 2 or 3 months.
leagues found no differences in peri-
odontal infection between women inflammatory cytokines
who delivered preterm versus full Proteins produced predominantly by activated immune cells that are
term.49 However, women were at sig- involved in the amplification of inflammatory reactions.
nificantly increased risk for preterm Low birth weight
birth if either P. gingivalis or C. rectus Any birth when the infant weighs less than 2500 grams (5 pounds 8
were found in the subgingival plaque.49 ounces)
In a more recent case-control Normotensive
study, Vettore et al recruited 542 post- Normal blood pressure
partum women who were over 30
Post partum
years old.51 The investigators sought In the period after delivery
to explore the relationship between
periodontal disease and preterm low Preeclampsia
birth weight. Cases were divided into A condition in pregnancy characterized by abrupt hypertension (a
3 groups: low birth weight (n = 96), sharp rise in blood pressure), albuminuria (leakage of large amounts
of the protein albumin into the urine) and edema (swelling) of the
preterm (n = 110), and preterm and
hands, feet, and face. Preeclampsia is one of the most common com-
low birth weight (n = 63). Cases were plications of pregnancy. It affects about 5% of pregnancies. It usually
compared to controls who were non- occurs in the third trimester of pregnancy.
preterm and non-low-birth-weight
individuals (n = 393). Periodontal Pregnancy gingivitis
measurements were collected and Gingivitis in which the host response to bacterial plaque is presumably
exacerbated by hormonal alterations occurring during puberty, preg-
later stratified into 15 definitions of nancy, oral contraceptive use, or menopause.
periodontal disease for analysis.
Other covariates were also recorded Preterm birth
and used for analysis. The results of Any birth prior to 37 weeks gestational age
this study indicated that periodontal Teratogenicity
disease levels were higher in control The capability of producing fetal malformations
individuals than in cases, and that the Very preterm birth
extent of periodontal disease did not Any delivery of a live born infant less than 32 weeks gestational age
increase risk of preterm low birth
weight. They also showed that in the
preterm low birth weight group that
the mean pocket depth and the fre- ease was not more severe in women odontal disease and preterm birth have
quency of sites with CAL > 3 mm with preterm low-birth-weight babies.51 been published. Vergnes et al exam-
were lower than in the control group. Two recent meta-analyses of the ined 17 studies and reported a pooled
It was concluded that periodontal dis- association between maternal peri- estimate odds ratio for preterm birth

of 2.83 (95% CI: 1.95-4.10, P < confounding variables. Another poten- odontal infection and adverse preg-
.0001).52 Xiong et al performed a sys- tial reason for the disparate findings nancy outcomes, several investigators
tematic review and meta-analysis of among studies is the differences in have reported that periodontal treat-
44 studies (26 case control, 13 cohort, populations studied. Most studies that ment during pregnancy leads to a
and 5 controlled trials) to examine the showed an association between peri- reduction in preterm birth risk. 55-57
relationship between maternal periodontal disease and adverse pregnancy Lopez et al enrolled over 800 women
odontal disease and adverse pregnancy outcomes have consistently been in a randomized trial of periodontal
outcome.53 The meta-analysis showed found in populations with a high inci- treatment during pregnancy versus
that maternal treatment of periodontal dence of preterm deliveries and within delayed treatment, and found almost
disease reduced the rate of preterm low economically-challenged families. a 5-fold reduction in preterm birth
birth weight infants as a group (pooled Quite the opposite is true for those among women treated during preg-
RR 0.53, 95% CI: 0.30-0.95, P< .05), studies that did not show an associa- nancy.55 In a pilot trial of periodontal
but not preterm or low birth weight tion. They were usually conducted in treatment, Offenbacher et al found a
individually. countries with universal health care trend toward reduced preterm birth
and a lower incidence of preterm birth among women treated during preg-
or low-birth-weight infants. Differen- nancy compared with those who
Inconsistencies with Previous tial access to health care insurance, delayed therapy until postpartum This
Studies dental care, and prenatal care, may study demonstrated that women who
confound the relationship between were treated during pregnancy had a
While there are conflicting data maternal periodontal disease and significant improvement in oral health
regarding the association of periodon- adverse pregnancy outcome. Dispari- measures and a reduction in oral
tal diseases and adverse pregnancy ties in oral health may also be partially pathogen burden.56 The women treated
outcomes, the reasons have yet to be explained by racial differences in during pregnancy showed an improve-
identified. However, there are several inflammatory and immune responses, ment in clinical markers of periodon-
differences and biases among the pub- as discussed previously (Table 1). tal infection, with reduction in clini-
lished data worth addressing. While Another factor to consider when cal attachment loss and reduction in
the definitions of preterm birth, very reviewing studies and synthesizing the bleeding on dental probing. In another
preterm birth, low birth weight, small results is the study design. The study randomized, intent to treat study,
for gestational age, and other obstetric design will influence the ability to Tarannum and Faizuddin found that
findings are well defined, no consen- reach a conclusion or determine causal- nonsurgical periodontal treatment dur-
sus has yet been achieved on the defi- ity. Case-control studies are limited in ing pregnancy reduced the risk of
nition of periodontitis in periodontal their experimental design because they preterm births (p<0.001) and low birth
research. A consensus on a definition cannot demonstrate causality. Prospec- weight (p<0.002). An inverse correla-
is essential to optimize the interpreta- tive studies offer an advantage of tion existed between CAL and birth
tion, comparison, and validation of studying the cause-effect relationship weight in the control group, which
clinical data.54 With no universally since the experiment can be designed may suggest that higher CAL were
agreed upon definition, any prior def- and participants enrolled and followed associated with lower birth weights.
initions may prove to be obsolete as over time with the outcome variable There was also an inverse correlation
we gain further information regarding unknown at enrollment. Cohort studies between gestational age and peri-
the pathophysiology of the associa- involve 2 groups of people and com- odontal characteristic in both groups.
tions reported. Clinical markers of pare a particular outcome of interest in This may suggest that shorter gesta-
periodontal disease, such as gingival groups that are alike in many ways but tional ages were associated with higher
recession, clinical attachment loss, or differ in some characteristics. Cross- values among periodontal parame-
bleeding on periodontal probing, may sectional studies investigate a popula- ters.58 These data are encouraging, as
be late manifestations of the local tion at a point in time without regard to most periodontal diseases are both pre-
infection, such that bacterial exposure influencing factors that occurred prior ventable and treatable, and thus would
may have already occurred with sub- to the study. The randomized clinical be of significant public health interest
sequent downstream deleterious trial eliminates study bias by randomly in pregnancy if a cause-effect rela-
effects. Recognition of the variation assigning participants to the study tionship with preterm birth can be
in clinical criteria used to define peri- groups. Neither the participant nor the demonstrated.
odontal infection is important when researcher has any influence on which However, excitement over peri-
critiquing the literature. In addition to participant is assigned to each group. odontal treatment to prevent preterm
the lack of a consistent clinical defini- Random assignment to study groups birth must be tempered in light of a
tion, several of the studies43,48,49 with no prevents foreknowledge of study out- recently published study on periodon-
association between maternal peri- comes (Table 2). tal treatment during pregnancy.
odontal disease and adverse pregnancy Despite the controversy regarding Michalowicz et al studied 814 women
outcomes did not control for potential the association between maternal peri- at 3 clinical facilities.30 Women were

Table 1. Summary of Relevant Literature on Association between Maternal
Periodontal Disease and Adverse Pregnancy Outcomes by
Study Design
Studies that found associations or relationships between periodontitis and pregnancy outcomes
Author/Year Study Definition of

Journal Country Design Periodontal Disease Summary Findings
Kunnen/2007 Netherlands Case-Control Healthy PD: pocket depths 52 women Periodontal disease more
J Clin Periodontol < 4mm Cases: prevalent among cases vs.
Mild PD:1-15 tooth sites with preeclampsia controls (82% vs. 37%)
pocket depths > 4mm and < 34 weeks
BOP present
Severe PD: >15 tooth sites
with pocket depths > 4mm
and BOP present
Novak/2006 US Case-Control Periodontal disease (PD) was NHANES III: role Women with history of GDM
J Public Health Dent defined as one or more teeth of gestational twice as likely to have
with one or more sites with diabetes (GDM) periodontal disease
probing depth > or = 4mm, in periodontal
loss of attachment > or = disease
2 mm,and bleeding on probing
Xiong/2006 US Case-Control Periodontal disease (PD) was NHANES III: role Women with periodontal
Am J Obstet Gynecol defined as one or more teeth with of periodontal disease 3x more likely to
one or more sites with probing disease in GDM develop GDM
depth > or = 4mm, loss of
attachment > or = 2mm, and
bleeding on probing
Cota/2006 Brazil Case-Control Periodontal disease was 4 or 588 women Women with periodontal
J Periodontol more teeth with one or more sites Cases: disease at 1.8-fold increased
with pocket depths > 4mm and preeclampsia risk for preeclampsia
CAL > 3mm at the same site
Jarjoura/2005 US Case-Control Presence of 5 or more sites per 203 women Periodontal disease
Am J Obstet Gynecol subject with CAL of 3 mm or greater Cases: PTB/LBW associated with PTB/LBW
Goepfert/2004 US Case-Control Periodontal Health- no attachment 103 women Periodontal disease more
Am J Obstet Gynecol loss or gingival inflammation Cases: common among cases vs.
Gingivitis- gingival inflammation spontaneous controls
and no attachment loss PTB < 32 weeks
Mild periodontitis- 3-5 mm of
attachment loss in any one sextant
Severe periodontitis- >5 mm of
attachment loss in any one sextant
Cankci/2004 Turkey Case-Control The presence of four or more teeth 82 women Periodontal disease
Aust N Z J with one or more sites with PD Cases: associated with increased risk
Obstet Gynecol > 4 mm that bled on probing, and preeclampsia of preeclampsia, OR 3.5
with a clinical attachment loss (1.1-11.9)
> 3 mm at the same site, was
diagnosed as periodontal disease.
Dasanayake/1998 Thailand Case-Control Periodontal health was defined 100 women Periodontal disease
Ann Periodontol using CPITN and DMFT scores Cases: LBW associated with LBW,
OR 3.0 (1.39 – 8.33)
Offenbacher/1996 US Case-Control Extent of sites with clinical 124 women Periodontal disease
J Periodontol attachment level > 2, 3 or 4 mm Cases: associated with PTB/LBW,
PTB/LBW OR 7.5 (1.9-28.8)
Santo-Pereira/2007 Brazil Cross-sectional Periodontitis was classified as 124 women Periodontal disease more
J Clin Periodontol 53 Early- CAL<3mm Preterm labor prevalent in women with
Moderate CAL > 3mmand <5mm defined as < 37 preterm vs. term labor (62%
Severe CAL > 5mm and as weeks vs. 27%)
localized (CAL < 30%) or
generalized (CAL >30%
Table 1 continues on the following page

Table 1 continued.
Studies that found associations or relationships between periodontitis and pregnancy outcomes, continued

Offenbacher/2006 US Prospective Healthy PD: pocket depths 1020 women Women with periodontal
Am J Obstet Gynecol 44 < 3mm without BOP received an ante- disease at increased risk for
Mild PD: 1-15 sites with pocket partum and post- PTB < 32 weeks
depths > 4mm or 1 or more partum perio-
sites with BOP dontal exam.
Moderate/Severe PD: 15 or more
sites with pocket depths > 4mm
Boggess/2005 US Prospective Healthy PD: pocket depths 640 Umbilical Fetal inflammation and
Am J Obstet < 3mm without BOP Cord Blood immune response to oral
Gynecol 54 Mild PD: 1-15 sites with pocket Samples pathogens increased preterm
depths > 4mm or 1 or more sites birth (PTB) risk
with BOP
Moderate/Severe PD: 15 or more
sites with pocket depths > 4mm
Pitiphat/2006 US Prospective Self reported periodontitis 101 Women Periodontal disease may
J 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 disease
Obstet 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 with
pocket depths > 4mm and BOP
present
Lopez/2002 Chile Prospective Presence of 4 or more teeth 639 women Periodontal disease
J 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 mm
or higher at the same site
Jeffcoat/2001 US Prospective Periodontitis - > 3 sites with 1313 women Periodontal disease
J 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 attachment
loss of 3 mm or more
Healthy Periodontium <3 sites
with 3 mm of attachment loss
Mitchell-Lewis/2001 US Prospective Not defined Prospective Women with PTB had higher
Eur J Oral Sci 58 Intervention intervention study levels of oral pathogens in
Study 164 women mouth; PTB rate less among
treated women
Lopez/2005 Chile Randomized Gingival inflammation with Randomized Treatment significantly

J Periodontol Clinical Trial > 25%of sites with bleeding on clinical trial of reduced PTB/LBW (6%
Intervention probing, and no sites 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 factor
J 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 of
Study delay periodontal PTB/LBW
treatment to
reduce PTB
400 women

Studies that found no association between periodontitis and pregnancy outcomes

Bassani/2007 Brazil Case-Control Mild PD-> 3 sites in 3 or more 915 women Similar rate of periodontal
J Clin Periodontol teeth with CAL of > 3 mm and Cases defined as disease among cases and
<5 mm LBW or stillbirth controls
Moderate PD: > 3 sites in 3 or > 28 weeks or
more teeth with CAL of > 5 mm > 1000 gm
and <7 mm
Severe PD: > 3 sites in 3 or more
teeth with CAL of > 7mm
Moore/2005 UK Case-Control Not defined 154 women No association between

J 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 periodontal

J Clin Periodontol Cases: PTB/LBW disease between cases and
controls
Davenport/2002 UK Case-Control Severe periodontal disease 743 women Similar PTB rate among
J Dent Res defined as CPITN score 4 cases and controls
Holbrook/2004 Iceland Prospective At least probing depth > 4mm 96 women No association between
Acta Odontol Scand 48 periodontal disease and PTB
Moore/2004 UK Prospective Not specified in this article or 3738 women No association between
Br Dent J 43 the article it refers to for more periodontal disease and
details. However, only two sites PTB/LBW; periodontal
per 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 rate
New Engl J Med 56 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. groups
Study delayed perio-
dontal treatment
to reduce PTB
823 women
*GDM-gestational diabetes
randomized to scaling and root planing benefit those women at risk for the ear- tis. Also, preeclamptic women were
(SCRP) during before 21 weeks ges- liest and most morbid preterm births. more likely to have Porphyromonas
tational age (treatment group) or after The data on the role of maternal gingivalis, Tannerella forsythensis,
delivery (control group). Women in periodontal infection and other adverse and Eikenella corrodens, known peri-
both groups, who experienced pro- pregnancy outcomes are even less odontal pathogens, compared to nor-
gressive periodontal disease defined clear. Evidence suggests a role for motensive women. However, several
as an increase of 3mm or more in clin- inflammation and endothelial activa- other investigators have been unable to
ical attachment loss, received SCRP tion in the pathophysiology of pre- confirm an association between mater-
in those areas. The study found no eclampsia;59,60 periodontal infection is nal periodontal infection and pre-
reduction in preterm births < 37 weeks one of many potential stimuli for these eclampsia.63,64 The conflicting results
gestation among women in the treat- host responses. A 2-fold increased risk have yet to be resolved. While other
ment group. On closer examination, for preeclampsia was found among less common adverse pregnancy out-
there were almost twice as many deliv- women with periodontal infection comes (eg, diabetes, small-for- gesta-
eries that occurred before 32 weeks diagnosed at delivery.25 Others have tional-age birth weight, miscarriage)
gestation among women in the control also reported an association between may also be associated with maternal
group (n=18) compared to women maternal periodontal infection and periodontal infection, data are cur-
who were treated (n=10) during preg- preeclampsia.61,62 In a recent case-con- rently too sparse to draw definitive
nancy. While not statistically signifi- trol study, Contreras et al62 found that conclusions regarding these associa-
cant, this is suggestive evidence that women with preeclampsia were twice tions and the potential benefits of treat-
periodontal disease treatment might as likely to have chronic periodonti- ment during pregnancy (Table 1).

Table 2. Definitions of Research Study Terms
Adjusted odds ratio In a multiple logistic ratio model where the response variable is the presence or absence of a
disease, an odds ratio for a binomial exposure variable is an adjusted odds ratio for the levels
of all other risk factor included in the model. It is also possible to calculate the adjusted odds
ratio for a continuous exposure variable. It can be calculated when stratified data are
available 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 to
learn what factors may be associated with the disease or condition-use this one and
reference the NCI.
Cohort Study A research study that compares a particular outcome (birth weight or gestational age at
delivery) in groups of individuals who are alike (pregnant) in many ways but differ by a certain
characteristic (periodontal disease or no periodontal disease).(National Cancer Institute
www.cancer.gov)
Cross-Sectional Study A study of a subset of a population of items all at the same time, in which, groups can be
compared 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 the
result 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 and
procedures; reanalyzing the data from all these combined studies; and generating larger
numbers and more stable rates and proportions for statistical analysis and significance testing
than 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 same
for two groups.
An odds ratio of 1 implies that the event is equally likely in both groups. An odds ratio greater
than one implies that the event is more likely in the first group. An odds ratio less than one
implies 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. Used
in 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 the
treatments they receive can be compared objectively. At the time of the trial, it is not known
which treatment is best. (National Cancer Institute www.cancer.gov)
Retrospective Study A retrospective study looks backwards and examines exposures to suspected risk or
protection 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 the
studies that are included in the review. Statistical methods (meta-analysis) may or may not be
used to analyze and summarize the results of the included studies
Implications for Dental Maintaining good oral hygiene before fying the hormonal status and other
and during pregnancy is crucial for risk factors for periodontal diseases and
Hygiene Assessment, preventing gingivitis and periodonti- poor pregnancy outcomes of women
Diagnosis, and tis. Prevention and treatment of peri- during the medical history process
Treatment odontal infection is aimed at control- will enable the provider to customize
ling the bacterial biofilm, arresting the treatment plan and oral hygiene
Periodontal diseases are silent progressive infection, and restoring instructions. Behavioral interventions
infections that have periods of exac- lost tooth support.65 Dental profes- such as smoking cessation, exercise,
erbation and quiescence that often go sionals can facilitate this level of oral healthy diet, and maintenance of opti-
undiagnosed until irreparable damage health through assessment, education, mal weight are also useful preventive
occurs to the teeth and oral structures. and proper treatment planning. Veri- measures against periodontal dis-

ease.66 While the mechanisms of these
interventions is unknown, they likely
operate by reducing conditions that
promote growth of pathologic bacte-
ria, improving immune function, Periodontal diseases are silent infections that
reducing inflammatory responses, and have periods of exacerbation and quiescence that
improving glucose control.
In 2004, the American Academy of often go undiagnosed until irreparable damage
Periodontology (AAP) issued a posi- occurs to the teeth and oral structures.
tion statement regarding dental care
for pregnant women. The AAP rec-
ommended that all women who were
pregnant or planning a pregnancy
should receive preventive dental care, trimester. 69 They also recommend of carious lesions included to expec-
including a periodontal examination, communication between the dental torate and not rinse the mouth after
a prophylaxis, and restorative treat- provider and the obstetrician for any brushing with a fluoridated toothpaste
ment. They also proposed that scal- dental emergency that would require to allow the fluoride additional time to
ing and root planing should be com- anesthesia or other medication to be protect the teeth. They recommended
pleted early in the second trimester prescribed. The American Dental that pregnant women use an alcohol-
and that any presence of acute infec- Association (ADA) suggestions are free, over the counter fluoridated mouth
tion or abscess should be treated similar to the AAP and the AGD; rinse at night. While carious lesions
immediately, irrespective of gesta- however, they also address the safety do not lead to periodontal diseases,
tional age. Treating infection as early issues surrounding taking a dental the accumulation of bacterial plaque
as possible will remove a potential radiograph during pregnancy. If a biofilm is a culprit in these diseases.
source of infection that could be radiograph is needed for diagnosis or Like many other initiatives, Bright
harmful to the mother and the baby.67 treatment, as they often are, then preg- Futures recommends that pregnant
In 2006, after a treatment trial30 failed nant women should have the radio- women visit an oral health care pro-
to show an effect of scaling and root graphs taken. Matteson et al estimated vider for an examination and restora-
planing on birth outcomes, the AAP that a full mouth series of radiographs, tion of all active carious lesions as
confirmed that treatment of periodon- with 20 radiographs, exposes the soon as possible.73
titis in pregnant women is safe and mother to <1 mrem of radiation. The
should be performed to improve the fetus is usually exposed to approxi-
oral health of the woman.68 This con- mately 75 mrems of naturally occur- First State Practice Guidelines for
clusion was substantiated by Dr. Larry ring radiation during a pregnancy. Treatment of Pregnant Patients
Tabak, director of the National Insti- Therefore, dental radiographs con-
tutes of Dental and Craniofacial tribute to a negligible amount of radi- In 2006, the New York State Depart-
Research (NIDCR), when he said ation exposure.71 Care and caution ment of Health published practice
“Dental care during pregnancy has should be taken to prevent further guidelines for oral health care during
long been an issue dominated by cau- exposure by using a leaded apron with pregnancy and early childhood. These
tion more than data. The finding that a thyroid collar.72 guidelines were developed in response
periodontal treatment during preg- In 2004, Bright Futures Practice in to a lack of information regarding the
nancy did not increase adverse events Oral Health published an oral health safety of dental treatment during preg-
is important news for women, espe- pocket guide designed to provide nancy, which urged actions to reduce
cially for those who will need to have health care providers with an over- health disparities. These disparities
their periodontal disease treated dur- view of preventative oral health super- were brought to national attention by
ing pregnancy.”69 The Academy of vision for 5 developmental periods, the Surgeon General’s Report, Oral
General Dentistry (AGD) recom- including pregnancy and postpartum. Health in America,5 and a follow-up
mends a dental visit for pregnant Bright Futures began in 1990 and was report titled “A National Call to Action
women or for those planning a preg- initiated by the Health Resources and to Promote Oral Health.”74 The com-
nancy.70 Their recommendations are Services Administration (HSRA) prehensive guidelines provide by the
similar to the AAP but they suggest Maternal and Child Health Bureau New York Department of Health offers
that pregnant women have a tiered (MCHB). The guidelines suggest that structure for oral health care providers
treatment plan to include an examina- health care providers assess the risk so they can provide the best care for
tion in the first trimester, a dental of oral disease and provide general pregnant women. Providing dental
cleaning in the second trimester, and suggestion to prevent carious lesions care in pregnancy and early childhood
then, depending on the patient, an- in pregnant women. Other suggestions are important to prevent lifelong con-
other appointment early in the third or recommendations for the prevention sequences of poor oral health.73,75-79

Due to the reluctance of some den- treatments are best provided only dur- knowledge regarding the risk factors
tal professionals to provide dental care ing certain gestational ages (Table 3). for oral cancer and 2.9 times more
during pregnancy, the state of New Despite the benefit of treatment, peri- likely to have more knowledge
York established guidelines to address odontal infection in women of child- regarding risk factors and diagnostic
this problem. This comprehensive bearing age remains highly prevalent, procedures for oral cancer.81
report recommends that oral health particularly among low-income Only a few studies have been
care should be coordinated among women and members of racial and reported in the literature that assess
prenatal and oral health care ethnic minority groups. Regrettably, medical and nursing professionals’
providers. Communication between some subgroups of women who lack knowledge about periodontal disease
the dental community and the med- access to dental care will likely miss and adverse pregnancy outcomes.
ical community is a necessity and a out on dental care during pregnancy. Wilder et al surveyed practicing obste-
consultation form was developed to Oral health care professionals must tricians in 5 counties in North Car-
help facilitate this process (Figure 1). help bridge this gap. olina to assess their knowledge of
The New York guidelines suggest and Dentists and dental hygienists periodontal disease and to determine
recommend that dental treatment be must actively participate in provid- their practice behaviors regarding oral
provided during pregnancy, including ing treatment to pregnant women to disease and adverse pregnancy out-
the first trimester. However, early in help maintain maternal health. comes. While 94 % of those surveyed
the second trimester (14-20 weeks Knowledge of research studies (Table could correctly identify bacteria as a
gestation) is the most favorable time 1) and published guidelines can help cause of periodontitis, only 22%
to perform dental procedures. During eliminate the timidity that prevails in looked in a patient’s mouth at an ini-
this gestational age there is no threat the dental community regarding pro- tial visit. And while most (84%) con-
of teratogenicity, nausea and vomit- viding dental care to pregnant sidered periodontal disease a risk fac-
ing have usually subsided, and the women. In fact, the dental commu- tor for adverse pregnancy outcomes,
uterus is below the umbilicus, pro- nity must embrace this shift in prac- 49% rarely or never recommended a
viding more comfort to the mother. tice guidelines. By embracing the dental visit during pregnancy.82 In a
Unrestored carious lesions should be changes, better overall health care can recent study conducted in North Car-
restored as soon as possible as some be provided to all women, especially olina, 504 nurse practitioners, physi-
pregnant women require general anes- those of child bearing age. cian assistants and certified nurse
thesia with intubation at delivery. midwives were surveyed. The survey
Some physicians are hesitant to intu- assessed the knowledge, behavior, and
bate due to the increased risk of air- Oral Health Knowledge opinions about periodontal disease
way obstruction due to the decreased in the Medical and its relationship to adverse preg-
integrity of decayed teeth that could nancy outcomes. Forty eight percent
break off. If treatment is provided in Community responded (n=204). Of those respon-
the last trimester, care should be taken To provide better oral health care, dents, 63% reported looking in the
to prevent suppression of the inferior more knowledge needs to be made patient’s mouth to screen for oral
vena cava by keeping the woman in available to the medical community. problems at the initial visit. Twenty
an upright position. Ultimately all Few studies have tried to determine if percent felt that their knowledge of
health care providers should advise the medical community has the periodontal disease was current, and
women that maintaining good oral knowledge to help educate patients all agreed that their discipline should
health during pregnancy is not only about the importance of better oral receive instruction regarding peri-
safe but necessary to reduce the risk of care. Siriphant et al conducted focus odontal disease. Ninety-five percent
infection to the mother and possibly groups with nurse practitioners (NP) felt that a collaborative effort between
the fetus. in Maryland to determine the level of the health care provider and the oral
While it remains inconclusive knowledge regarding oral cancer. health care professionals was needed
whether maternal periodontal treat- They found nurse practitioners in and would reduce the patient’s risk of
ment improves pregnancy outcome, Maryland did not recognize oral can- having an adverse pregnancy out-
it is clear that treatment of varying cer as a health problem and that the come.83 It is clear from the lack of
degrees of clinical periodontal dis- main barrier for performing oral can- studies available regarding oral health
ease during pregnancy is safe and cer screening was a lack of knowl- knowledge in the medical community
improves maternal oral health.56,57 In edge. 80 In another survey of nurse that further studies are needed. One
several studies of periodontal treat- practitioners, it was established that limitation to the future of oral health
ment during pregnancy, oral health few recognized the signs of early oral care is the lack of knowledge regard-
parameters improved following ther- cancer. NPs who reported attending a ing oral care in the medical commu-
apy.30,56 All dental services should be continuing education course on oral nity. More education is needed within
available to pregnant women; how- cancer within the last 2-5 years were the medical community to help
ever, studies have shown that some 3.1 times more likely to have more achieve better oral health care.

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

******************************************************************************************
DENTIST’S 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 Guidelines
www.health.state.NY.US/publications/0824/pda/windows_mobile/0824.pdf

Table 3. Dental Procedures and Pregnancy
Dental Procedure Safe in Rationale and recommendations
Pregnancy
Prophylaxis Yes Dental cleanings are safe during pregnancy.
Scaling and Studies suggest the best gestational age for SCR&P is between
Root 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 <1mrem. During pregnancy the mother typi-
cally receives about 75mrem from naturally occurring radiation. The benefits
of radiographs outweigh any negligible risks. (Matteson et al 1991 MCN;
ADA 2004)
Restorations Yes Replacement of old amalgams should be completed using a rubber dam and
high speed suction. (NY State Dept. of Public Health)
Emergency Dental Yes Removal of an infection or bacterial load will not only
Treatment help the mother but possibly the fetus.
Local Anesthetics Yes Category B anesthetics (including lidocaine with epinephrine and
Category B prilocane)
Local Anesthetics No Mepivacaine and bupivacaine

Category C
Analgesics for Pain Yes Acetaminophen, meperidine, morphine; do not exceed

Category B recommended doses
Analgesics for Pain With Codeine, hydrocodone may be used with caution
Category C Caution *Ibuprophen and Naprosyn should only be used in the first trimester and only
for 72 hours or less
Antibiotic Prophylaxis for Yes For those who meet the AHA guidelines for antibiotic prophylaxis.
Infective endocarditis
Primary prophylaxis is 2gms of amoxicillin 1 hour prior to treatment
For those allergic to penicillin one of the following regimens can be given one
hour prior to treatment
Cephalexin 2gm OR
Clindamycin 600mg OR
Azithromycin or clarithromycin 500 mg
Nitrous Oxide With caution Only use when topical or local are inadequate and only after approval from
the obstetrician. Precautions should be taken to avoid hypoxia, hypotension,
and aspiration. Lower levels may achieve sedation for a pregnant patient.
(NY State 2006; FDA Guidelines for drugs in pregnancy)
Adapted from Russell SL, Mayberry W. Pregnancy and Oral Health. MCN. 2008; 331(1):32-37.
In a recent issue of the American women by increasing their knowledge, addition, the New York University
Journal of Maternal Child Nursing, attitudes, awareness, and skills regard- Dental School is collaborating with
nurses were called to “action” to help ing oral health. By collaborating with the NYU School of Nursing to pro-
facilitate better access to oral health other health professionals’ access to vide care to patients. This is a funda-
care. Based on the surgeon general’s oral health care can be improved.84 mental step in providing collaborative
report5 and the National Call to Action Providing oral health education in treatment to patients across many dis-
to Promote Oral Health,74 these authors medical and nursing curricula might ciplines.84 Oral health care profes-
suggested that nurses need to partner be one way to begin this process. A sionals can take the lead in educating
with other key stakeholders to prevent reported oral health curriculum at the other providers about the importance
oral disease. The nurses were called University of Washington’s medical of oral health and what should be
to provide, promote, and protect school is reporting some success.85 In taught to pregnant women.

Future Projections in
Care of Pregnant
Patients
While the literature is not clear on the association
Amid the evidence that preventive of periodontal disease and its effect on birth
and restorative dental services are ben-
eficial for oral health and can help or outcomes, it is clear the treating periodontal
modify systemic diseases, some insur- disease during pregnancy is beneficial for the
ance companies have begun to pay for
expanded dental services.86 Insurance mother and may be beneficial for the fetus.
companies found that the cost of prov-
ing expanded dental services for some
of its members decreases the amount
spent on medical treatment.87 Based on enabled pregnant women on Medicaid odontal disease-associated preterm
this information, many companies have to receive dental examinations, treat- birth and to tailor treatment to those
begun to offer additional dental bene- ment of decayed teeth, and a prophy- women who might benefit the most.
fits for those who have the most to gain laxis.91 UDH followed this up by Confirmation of periodontal infection
such as pregnant women and patients expanding dental benefits available to as an independent risk factor for
with cardiovascular disease. While the Utah’s pregnant Medicaid population. adverse pregnancy outcomes and
literature is not clear on the associa- These women now have access to identification of those at greatest risk
tion of periodontal disease and its effect receive free dental check-ups, includ- would be of significant public health
on birth outcomes, it is clear the treating x-rays, dental prophylaxis, restora- importance because periodontal infec-
ing periodontal disease during preg- tions, root canals, and emergency treat- tion is both preventable and curable.
nancy is beneficial for the mother and ment.91 As states and companies At present, however, there is insuffi-
may be beneficial for the fetus. As part continue to expand their dental serv- cient evidence for health care policy
of these expanded services, Cigna, ices provided for pregnant women, the recommendations to provide mater-
Delta Dental, United Health Care, and overall health benefit will become nal periodontal treatments for the pur-
others have increased their dental ben- apparent. pose of reducing the risk of adverse
efits to include additional dental clean- pregnancy outcome regardless of its
ings, including scaling and root planing other benefits.
as indicated for pregnant women. This Future Directions for Further educational opportunities
represents a shift in the insurance Research and Education need to be provided for allied health
industry that is beneficial to both the professionals and the medical com-
company and its members.87-89 Future directions of oral health munity to help alleviate the problems
Some state governments have research should target oral health care with access to dental care. Relation-
answered the call to promote better oral before, during and after pregnancy. ships between professional schools
health care by providing dental benefits Studies that utilize the Centers for Dis- need to be forged so that cross-educa-
to those who typically have none. In ease Control’s Pregnancy Risk Assess- tional opportunities can be provided to
2004, the Minnesota Department of ment Monitoring System (PRAMS) all disciplines. Training and education
Health partnered with the Minnesota report that only 23%-43% of pregnant should be expanded to prepare dental
Board of Dentistry and Minnesota women receive dental care during preg- hygienists to partner with physicians
Department of Human Services to nancy,92 a rate which is only one-half and nurse practitioners to provide a
make available resources and programs to two-thirds the overall use of dental minimum level of care for those who
aimed at providing better access to services among US women.92 In addi- have no access to dental care. These
dental care. This was accomplished by tion, data explaining the racial/ethnic services could include an oral screen-
providing critical access dental disparities in oral health among preg- ing, oral hygiene instructions, tooth-
provider designations, expanded nant women are lacking. Pregnant brush prophylaxis, referrals if needed,
authorization for dental hygienists and women’s perceptions of oral health, and application of fluoride, and nutritional
expanded duties for dental auxiliaries, the barriers and motivations to their counseling. The dental community
a dental practice donation program, seeking dental care, must be assessed to could partner with the medical com-
providing licensure of foreign trained adequately introduce preventive infor- munity to provide dental and medical
dentists and retired dentists, and estab- mation on oral health into their prena- services within the same office, pro-
lishing a dentist loan-forgiveness pro- tal care, which is one of the first steps viding better access to care.
gram.90 In 2003, the Utah Department in reducing health disparities. Given the relationship between
of Health (UDH) launched a program Further studies are needed to better maternal and infant oral health and
that served as a pilot study, which understand the mechanism of peri- periodontal infection and general

health and well-being, oral health care nancy outcomes, public policies that not be disputed. Data suggest that
should be a goal in its own right for all support comprehensive dental serv- maternal oral health impacts preg-
individuals, including reproductive- ices for vulnerable women of child- nancy health; further research on the
aged and pregnant women. There is bearing age should be expanded so causal nature of this association is
no evidence to suggest that dental that their own oral and general health ongoing to determine if there is a rela-
examination or treatment is deleteri- is safeguarded, and the morbidity of tionship. Current guidelines and data
ous to the pregnant woman or her childhood caries reduced. Mecha- suggest that dental care during preg-
developing fetus. Infective endo- nisms to educate women and their nancy is safe. However, scaling and
carditis prophylaxis is recommended health care providers about the impor- root planing is best accomplished
for all dental procedures for those tance of oral health need to be in between 14-20 weeks gestational age.
individuals at high risk for infective place, and improvement in the access Providing dental care for pregnant
endocarditis. Pregnant women who to care for all must occur if oral health women will help remove potentially
meet American Heart Association interventions are to make an impor- harmful bacteria from dissemination
guidelines for infective endocarditis tant impact on pregnancy outcomes. and possibly leading to other compli-
prophylaxis93 and undergo these dental cations. As oral health care providers
procedures should be treated similar we can educate our patients regarding
to nonpregnant individuals.
Conclusion the importance of oral health and on
Regardless of the potential for The importance of providing oral important preventive measures to
improved oral health to improve preg- health care for pregnant women can- maintain oral health.
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Additional References
Web sites
American Dental Hygienists’ Association

www.adha.org
National Institutes of Health
www.nih.gov
National Institute of Dental and Craniofacial Research
www.nidcr.nih.gov
Centers for Disease Control and Prevention
www.cdc.gov
American Dental Association
www.ada.org
American Academy of Periodontology
www.perio
NY State Oral Health Care during Pregnancy and Early Childhood Practice Guidelines
www.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 Association
www.americanpregnancy.org
Academy of General Dentistry
www.agd.org
Healthy People 2010: Section 21, Oral Health
www.healthypeople.gov/Document/HTML/Volume2/21Oral.htm
Oral Health America www.oralhealthamerica.org
Maternal and Child Health Library: Knowledge Path – Oral Health and Children and Adolescents
www.mchlibrary.info/KnowledgePaths/kp_oralhealth.html
Children’s Dental Health Project
www.cdhp.org
Brochures
Dental Care for Your Baby

American Academy of Pediatric Dentistry
www.aapd.org/publications/brochures/babycare.asp
A Healthy Mouth for Your Baby
National Institutes of Health
www.nidcr.nih.gov/HealthInformation/DiseasesAndConditions/ChildrensOralHealth/Healthy-
Mouth/default.htm

7838 Periodontal Diseases and Adverse Pregnancy Outcomes

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Journal

Periodontal Diseases and Adverse Pregnancy

pleased to be able to bring you this thoroughly reviews the literature on

H ow many of you have received

about the authors with the primary responsibility of

Rebecca S. Wilder, RDH, BS, MS

4 Initiative on Oral Health Care

4 Periodontal Disease and Other Systemic Conditions

5 Periodontal Disease and Its Impact on Pregnancy

12 Implications for Dental Hygiene Assessment, Diagnosis,

14 Oral Health Knowledge in the Medical Community

17 Future Projections in Care of Pregnant Patients

17 Future Directions for Research and Education

This special issue of the Journal of Dental Hygiene was funded

Special supplement The Journal of Dental Hygiene 1

The Journal of Dental Hygiene is the refereed, scientific publication of the

of dental hygiene body of knowledge through scientific inquiry in basic, applied,

Dental ■ EDITORIAL REVIEW BOARD

Celeste M. Abraham, DDS, MS

Hygiene Joanna Asadoorian, AAS, BScD, MSc

LAYOUT/DESIGN Sandra Boucher-Bessent, RDH, BS Cassandra Holder-Ballard, RDH, MPA

The Journal of Dental Hygiene is published quarterly, online-only, by the American

2 The Journal of Dental Hygiene Special supplement

Special supplement The Journal of Dental Hygiene 3

4 The Journal of Dental Hygiene Special supplement

Special supplement The Journal of Dental Hygiene 5

6 The Journal of Dental Hygiene Special supplement

Special supplement The Journal of Dental Hygiene 7

8 The Journal of Dental Hygiene Special supplement

Author/Year Study Definition of

Table 1 continues on the following page

Special supplement The Journal of Dental Hygiene 9

Author/Year Study Definition of

Lopez/2005 Chile Randomized Gingival inflammation with Randomized Treatment significantly

10 The Journal of Dental Hygiene Special supplement

Author/Year Study Definition of

Moore/2005 UK Case-Control Not defined 154 women No association between

Buduneli/2005 Turkey Case-Control Not specified 181 women No difference in periodontal

Special supplement The Journal of Dental Hygiene 11

12 The Journal of Dental Hygiene Special supplement

Special supplement The Journal of Dental Hygiene 13

14 The Journal of Dental Hygiene Special supplement

Patient Name: (Last) ______________________________ (First) __________________________

KNOWN ALLERGIES: ________________________________________________________________

PRECAUTIONS: ■ NONE ■ SPECIFY (If any):

Patient may have: (Check all that apply)

Prenatal Care Provider: ___________________________________ Phone: ___________________

Signature: ______________________________________________ Date: ___________________

DO NOT HESITATE TO CALL FOR QUESTIONS

Treatment Plan: _____________________________________________________________________

NAME: ______________________________ Date: ______________ Phone: ______________

Signature of Dentist: __________________________________________________________________

*Appendix A NY State guidelines

Special supplement The Journal of Dental Hygiene 15

Prophylaxis Yes Dental cleanings are safe during pregnancy.

Local Anesthetics No Mepivacaine and bupivacaine

Analgesics for Pain Yes Acetaminophen, meperidine, morphine; do not exceed

16 The Journal of Dental Hygiene Special supplement

Special supplement The Journal of Dental Hygiene 17

References in patients with type 1 diabetes mellitus. J Int Acad Peri-

Patient Name: (Last) ____ (First)

Prenatal Care Provider: _________________ Phone: _

Signature: ____________________________ Date: _

NAME: ______________ Date: Phone: