Oral Health and
Preterm Delivery
Daniel Weber, MD
OBGYN In-house Medical Expert
Dept of State
Commonwealth of Pennsylvania
131,000,000 world births/year
2011 estimate
3,953,590 Births/Year
2011 data
142,000 Births/Year
2011 data
45,300 Pa. Medicaid
Births, 2011
USA Preterm Birth Data(<37wk)
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11.73% in 2011 (preliminary data)
5th consecutive year of decrease
Down 2% from 2010
Down 8% from 2006 peak
BREAKDOWN OF PREMATURE
BIRTHS
1990
2005
34-36 wk
7.3%
9.1%
32-33
1.4%
1.6%
<32
1.9%
2.0%
CDC/NCHS data, 2005
•460,000
Premies/year
80,000 very preterm birth/year in
USA
(<32 weeks)
“Microorganisms or their waste
products obtain entrance of parts of the
body adjacent to or remote from the
mouth.”
-- Focal Infection Theory, Dr Miller, 1891
“Gingivitis exacerbated by the hormonal changes of
pregnancy (Pregnancy Gingivitis) is considered the
most common oral manifestation of pregnancy and
has been reported in up to 100% of pregnant women.”
-Dental Manifestations of Pregnancy, Pirie et al. 2007
“When questioned, 36.4% of women in the study felt
that the condition of their teeth had deteriorated
during pregnancy.”
-Dental Manifestations of Pregnancy, Y. Turok, 2007
Pregnancy Gingivitis
Periodontal Tissues
Systemic Organs
Pathogenic flora leads
to endotoxin release,
including
LipoPolySaccharides
Periodontal Tissues
Exposure to LPS and
host mediators
leading to increased
cytokines
Local release of
inflammatory mediators,
IL- lB, TNF-a, PGE2
Fetoplacental Unit
Increased IL-IB, PGE2 levels
Uterine Contraction
Cervical Dilation
mothers withperiodontal infection:
• Case control study, 93 mothers
• 7 fold increase of PLBW infant
(Preterm delivery of LBW infant)
• 18% of PLBW infants might be
attributable to periodontal disease
Offenbacher, J. Periodontology, 1996
• Fetal cord blood IgM study
• PLBW: 33.3%
• Term: 17.9%
“Elevated human IgM suggests
in utero exposure to periodontal
pathogens” Offenbacher, J Dent
Res,1999
Oral Conditions And Pregnancy
(OCAP)
• Clinical data from first 812 deliveries
• DNA probes to identify periodontal
organisms within maternal periodontal
plaque at delivery
• Maternal postpartum IgG antibody, and
umbilical IgM level to 15 pathogens
• Pathogens divided into Orange and Red
complexes
OCAP findings
• 2.9 fold higher prevalence of IgM for one or more of
Orange or Red complexes amongst PTD vs term
• + IgM to Campylobacter rectus: 20% for premies, 6%
for term.
• Lack of maternal IgG antibody to Red complex
associated with 2.2 odds ratio of premie. (maternal
antibody protecting fetus theory)
• 66.7% premature rate with neg maternal IgG to Red
Complex, and positive fetal IgM to Orange complex.
Madianos, Offenbacher, UNC, Ann Periodontol, 2001
Periodontal Infection and
Preterm Birth – Results of a
Prospective Study
▪N = 1313 pregnant patients
▪Patients with severe or generalized
periodontal dz, 4.45 odds ratio for preterm
delivery < 37wks
▪< 35 weeks, odds ratio 5.28
▪< 32 weeks, odds ratio 7.07
Jeffcoat, J Am Dent Assoc, 2001
• 59 pts with preterm birth <32 weeks
• 32 pts with indicated preterm birth < 32 weeks
• 44 pts with uncomplicated term delivery (>37 weeks)
• Association between severe periodontal
dz and preterm birth (odds ratio 3.4)
• Periodontal dz not associated with
selected markers of upper genital tract
inflammation (cultures of placenta,
umbilical cord blood, cord interleukin-6
levels, and histopathologic placental
pathology)
Goepfert, Jeffcoat, et.al., Periodontal Disease and Upper Genital Tract
Inflammation in
Early Spontaneous Birth, Obstetrics & Gynecology 2004
•1020 prenatal patients
•Preterm birth: 11.2% among periodontally
healthy women / 28.6% with moderatesevere periodontal disease
•Very preterm birth, <32 weeks: 6.4% with
periodontal disease progression vs. 1.8%
without disease progression
Offenbacher, Obstetrics and Gynecology, 2006
Treatment of Periodontal Disease and the Risk
of Preterm Birth
• 813 prenatal patients
• Treatment group: scaling and root planing, monthly tooth
polishing, oral hygiene instruction.
• Control group: monthly brief dental exam, treatment pp.
• Conclusions: Treatment of periodontitis in pregnancy
improves periodontal disease, and is safe, but does not
significantly alter rates of PTD, LBW, or IUGR
• Delivery <32 wks: control 4.4%, treatment 2.5%
• Delivery ,37wks: control 12.8%, treatment 12.0%
Michalowicz, DDS, et al, NEJM, Nov 2006
Maternal Oral Therapy to
Reduce Obstetric Risk
(MOTOR)
• NIH funded, 1806 women, 3 sites, opened 2004
• Scaling and root planing in 2nd trimester vs within 4 weeks
postpartum.
• Offenbacher, UNC
• Effect of Periodontal Therapy on Rate of Premature
Delivery: A Randomized Controlled Study, (OBGYN Sept
2009)
• Conclusion: Perio therapy did not reduce incidence of
prematurity
Obstetric outcomes after treatment of periodontal disease
during pregnancy: systematic review and meta-analysis
Nikolaos P Polyzos; Ilias P Polyzos; Apostolos Zavos; Antonis Valachis;
Davide Mauri; Evangelos G Papanikolaou; Spyridon Tzioras; Daniel Weber;
Ioannis E Messinis.
British Medical Journal
December, 2010
Polyzos meta-analysis
conclusions
Treatment of periodontal disease with scaling and root
planing cannot be considered to be an efficient
way of reducing the incidence of preterm birth. Women
may be advised to have periodical dental examinations
during pregnancy to test their dental status and may have
treatment for periodontal disease. However, they should
be told that such treatment during pregnancy is unlikely
to reduce the risk of preterm birth or low birthweight
infants.
Self Reported Dental Habits and
Preterm Birth
1000 consecutive women surveyed during immediate
postpartum stay, 2011, Women & Babies, LG Health
● demographics
● prior OB history
● dental home
● last dental visit
● oral piercing
● flossing
● brushing
● smoking
● birth outcome
Dental Habits study, preliminary
findings
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demographics: 69% white, 18% latino, 6% black.
MA: 51.4%
smokers: 11.7%
Brush once/day 23.6%
Floss: 62% at least 1/week
dental home: 62%
dental visit in this pregnancy: 54% (MA 50%,
commercial health insurance 57%)
● overall PTB: 8.2%
Dental Habits study, Preliminary
Findings
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no impact upon prematurity: dental home,
dental visit in pregnancy, flossing
frequency, oral piercing.
smoking: RR of PTB 2.5, but freq of
brushing no additive impact for smokers
brushing 1/day: RR of PTB 2.3
Follow up research
opportunities
intervention trial: once/day brushers
randomized to routine brushing habits vs.
BID brushing
Future research opportunities
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Micro RNAs: short non-coding molecules
expressed in different tissues which
regulate transcription of different genes
Highly specific
Very sturdy
133,000,000 Births/Year
Dr. Dan Weber, contact
information:
weberobgyn@gmail.com