Periodontal Disease and Adverse Pregnancy Outcomes

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.
200331135-66
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Defining Adverse Pregnancy Outcomes
Gestational Weeks Gestational Weeks
Birth Weight lt 37 Weeks 37 Weeks
lt 2500g PLBW LBW only
2500g PTB only Healthy
What About Small for Gestational Age???
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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

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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. 2001132875-79.
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Biologic Plausibility
Williams CECS, Davenport ES, Sterne JAC,
Sivapathasundaram V, Fearne JM, Curtis MA.
Mechanism of risk in preterm low-birthweight
infants. Periodontology 2000. 200023142-50.
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Research Question

• Is periodontitis a risk factor for preterm birth,
  low birth weight, neither, or both?

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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

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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. 200229S322-36.
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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

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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

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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

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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)

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Case-Control Results
Study PTB LBW PLBW Score
Offenbacher 1996 7.93 (1.52-41.4) 11
Dasanayake 1998 0.3 (0.12-0.72) 9
Offenbacher 1998 () 9
Dasanayake 2001 4.1 (1.3-12.8) 10
Madianos 2001 4.3 (2.1-8.9) 7
Davenport 2002 0.79 (0.64-0.99) 11
Romero 2002 () () 8
Goepfert 2004 3.2 (1.2-8.8) 10
Mokeem 2004 4.21 (1.99-8.93) 10
Radnia 2004 5.46 (1.72-17.32) 11
Buduneli 2005 (-) 11
Jarjoura 2005 2.75 (1.01-7.54) 12
Lunardelli 2005 2.6 (1.0-6.9) 12
Moliterno 2005 3.48 (1.17-10.26) 10
Moore 2005 (-) 11
Noack 2005 1.19 (0.46-3.11) 11
Controlled for small-for-gestational age
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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

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Cohort Results
Study PTB LBW PLBW Score
Jeffcoat 2001 4.45 (2.16-9.18) 12
Mitchell-Lewis 2001 (-) 8
Offenbacher 2001 () 12
Lopez 2002 3.5 (1.5-7.9) 15
Hasegawa 2003 () (-) 9
Dortbudak 2004 20.0 (1.95-201.7) 9
Holbrook 2004 (-) 12
Moore 2004 (-) (-) 14
Marin 2005 (-) 1.97 (0.4-9.2) 13
Moreu 2005 (-) 7
Oittinen 2005 5.5 (1.4-21.2) 11
Rajapakse 2005 1.9 (0.7-5.4) 16
Boggess 2006 2.3 (1.1-4.5)
Offenbacher 2006 1.6 (1.1-2.3)
assessed SGA
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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

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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. 2001132875-79.
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Recruitment of cohort and risk estimates
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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

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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

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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?

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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
  peoples 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.
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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

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Thank You

• Questions?

Disclaimer This study was funded by the Federal
Direct Student Loan program and my eternally
empty pocketbook