|Year : 2015 | Volume
| Issue : 1 | Page : 2-6
Relationship between periodontal diseases and preterm birth: Recent epidemiological and biological data
Moneet Walia1, Navdeep Saini2
1 Department of Gynecology and Obstetrics, Christian Medical College, Ludhiana, Punjab, India
2 Department of General Surgery, Christian Medical College, Ludhiana, Punjab, India
|Date of Submission||27-May-2014|
|Date of Acceptance||27-Jun-2014|
|Date of Web Publication||13-Jan-2015|
Department of General Surgery, Christian Medical College, Ludhiana, Punjab
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Preterm infants are born prior to completion of 37 weeks of gestation. These patients are seen on the rise despite the efforts put in to control them. Global incidence of preterm birth is around 9.6% of all birth representing 12.9 million births with regional disparities: From 12% to 13% in USA, from 5% to 9% in Europe, and 18% in Africa. First reported by Offenbacher et al. in 1996 relationship exist between maternal periodontal disease and delivery of a preterm infant. This article reviews the recent epidemiological and biological data. The articles were searched on Google, PubMed recent articles were selected. Mainly, three hypotheses by which periodontal bacteria can affect the outcome of pregnancy. Biological hypothesis: (a) Bacterial spreading, (b) Inflammatory products dissemination, (c) Role of fetomaternal immune response against oral pathogens. The promotion of the early detection and treatments of periodontal disease in young women before and during pregnancy will be beneficial especially for women at risk.
Keywords: Disease, infant, periodontal, preterm
|How to cite this article:|
Walia M, Saini N. Relationship between periodontal diseases and preterm birth: Recent epidemiological and biological data. Int J App Basic Med Res 2015;5:2-6
|How to cite this URL:|
Walia M, Saini N. Relationship between periodontal diseases and preterm birth: Recent epidemiological and biological data. Int J App Basic Med Res [serial online] 2015 [cited 2020 Nov 29];5:2-6. Available from: https://www.ijabmr.org/text.asp?2015/5/1/2/149217
between periodontal disease and PB incidence increases frequently with the severity of periodontitis, ,,, All these data suggest that women populations with a high prevalence of severe periodontitis are at risk for PB.
| Biological Hypothesis|| |
Considering epidemiological evidence, biological theories have been proposed to link PB and periodontal diseases.  Mainly, three hypotheses are developed - Bacterial spreading; Inflammatory products dissemination; and Role of fetomaternal immune response against oral pathogens.
The current paradigm indicates that the majority of intrauterine infection originates in the lower genital tract.  Despite this statement, number of studies report intrauterine infections caused by those species, which are not found in the urogenital tract. The bacterial spreading theory is based on the possible dissemination of oral bacteria including periodontal pathogens through blood circulation to the amniotic fluid and leading to chorioamniotic infections.  The frequent gingival inflammation of women presenting periodontal diseases especially the pregnancy associated gingivitis,  facilitates bacteremia process. Furthermore, the more periodontal pockets are deep, the more important is the exchange surface between bacteria biofilm and blood circulation (15-20 cm 2 in the most severe cases).  Many analyses of amniotic fluid or placenta have been performed and evidence the presence of different oral pathogens such as Bergeyella, Eikenella,  Fusobacterium nucleatum, or Porphyromonas gingivalis. ,,
Inside uterus, these pathogens could provoke an inflammatory response. The increase of inflammatory cytokines or metalloproteases synthesis and the neutrophil activation could induce PB process. 
In vivo studies show that the invasiveness of uterine tissues largely depends on the type of bacteria. Potential pathological mechanisms of certain periopathogens, especially for P. gingivalis and F. nucleatum, have been studied. For example, P. gingivalis could infect syncytiotrophoblasts, chorionic trophoblasts, decidual cells, and amniotic epithelial cells,  and promotes inflammatory process trough Toll-like receptor 4. 
Finally, a case-report study has been published in 2010 concerning a stillbirth caused by F. nucleatum from the mother's mouth.  This study highlights the fact that an oral periodontal pathogen can, by hematologic pathway, colonize placenta and provoke fetal complications. It is important to notice that such colonization may be dependent from mother's immunological status.
Hematogenous dissemination of inflammatory products
Acute inflammation is responsible for a substantial fraction of PB.  In 1998, Offenbacher et al.  suggested that the cytokines produced by local inflammation in periodontal tissues affected by periodontitis have systemic effects after diffusion of such cytokines through blood flow. Locally, studies show that periodontal diseases increase secretion of several cytokines, notably prostaglandin E2 (PGE-2), tumor necrosis factor-α, interleukin 6 (IL-6) or interleukin 1β (IL-1β)., Analysis of amniotic fluid obtained at the time of PB shows elevated levels of inflammatory cytokines.  It can be hypothesize that cytokines produced in periodontal tissues promote inflammation in maternal-fetal unit. Clinically, high-gingival crevicular fluid levels of PGE-2, IL-1β, or IL-6 have been associated with their elevated levels in amniotic fluid.  The inflammatory response appears to be the privileged pathway of the pathogenic periodontal disease influence on pregnancy, as suggested for other major systemic diseases, including cardiovascular diseases or diabetes. 
Role of fetomaternal immune response
The immune and genetic characteristics of the fetus and pregnant women are one of the potential mechanisms linking periodontal diseases to PB. Numerous studies have analyzed fetal and maternal antibodies directed against oral pathogens during pregnancy. In the study of Boggess et al.,  35.2% of samples are IgM positive for at least one oral pathogen, and 26.6% are positive for more than one. The presence of IgM is associated to an increased risk of PB. This immune response against oral pathogens could be associated with an inflammatory response, and the synergy between the two mechanisms increases significantly the risk. The mechanisms linking periodontal diseases and PB are not well defined. Further investigations should be performed to evaluate the impact of each theory. Nevertheless, it can be hypothesized that the influence of periodontal diseases on PB is the result of inflammation of the fetomaternal unit that is amplified in women presenting particular phenotype.
| Effects of Periodontal Treatment on Preterm Birth Incidence|| |
Considering periodontal diseases as a risk factor for PB, interventional studies have been performed to evaluate the impact of periodontal treatment on pregnancy outcomes. Case-control studies including a relative large number of pregnant women (>400) show some apparent contradictory results and different conclusions. ,,,,, Indeed, the periodontal treatment may improve periodontal conditions and or pregnancy outcomes or not. , A recent meta-analysis indicates that the treatment of periodontal diseases does not reduce the rate of PB.  However, as discussed above for epidemiological studies, the conclusions of this analysis could be balanced by the relative heterogeneity of studied populations, according to risk factors ethnicity, smoking, socio-educative levels, and periodontal status definition. For instance, the percentage of black people varies considerably between studies: 50-65% of Hispanic and Caucasian; , 45-87% of Afro-American. , Furthermore, the modalities of periodontal care in the different studies display some differences that may influence periodontal outcomes. A first session of etiologic periodontal treatment, including oral hygiene instructions, scaling, and root planning was generally performed at the end of the first trimester of pregnancy (before 20-28 weeks). This first session could be unique, , or reinforced by regular control visits and complementary treatments if necessary until delivery. , The local effects of periodontal treatments are generally positive. Gingival inflammation and mean probing pocket depth are reduced, especially in the study using reinforced periodontal treatment modalities. However, a relative high rate of patients demonstrating a periodontitis progression is observed in some studies 70%,  , 50%,  and 68%,  suggesting that periodontal treatments do not work so efficiently than in a general population.  Indeed, the relative "narrow therapeutic window" to perform periodontal treatment and to obtain a successful periodontal lesion cicatrization, and the aggressive profile of severe periodontitis in young women could be considered as limiting factors. , A recent study performed by Jeffcoat et al.,  confirms that the efficiency of periodontal treatment should be considered before the analysis of results. In this study, 322 pregnant women with periodontal disease have been followed, 160 have received randomly complete periodontal treatment, and 162 have served as control without treatment. No significant difference was found in the term of PB incidence between the two groups. However, after considering the effect of periodontal therapy, the results demonstrate a strong and significant relationship between successful periodontal treatment and full-term birth ratio (OR = 6.02).
Despite apparent conflicting data, the majority of studies report that periodontal treatment is safe for pregnant women and improve periodontal status. ,, A pregnant woman is a particular patient. In order to decrease the impact of periodontal disease on PB incidence, the early diagnosis promotion of periodontal disease for young women especially for those presenting major risk factors should be recommended.
| Conclusion|| |
Periodontal diseases appear to be a potential risk factor for PB. As well as other modifiable risk factors, these diseases must be taken in charge. Cooperation between obstetricians or general practitioners and periodontists should be developed. The promotion of the early detection and treatments of periodontal disease in young women before and during pregnancy will be beneficial, especially for women at risk.
| References|| |
Honest H, Forbes CA, Durée KH, Norman G, Duffy SB, Tsourapas A, et al
. Screening to prevent spontaneous preterm birth: Systematic reviews of accuracy and effectiveness literature with economic modelling. Health Technol Assess 2009;13:1-627.
Goldenberg RL, Hauth JC, Andrews WW. Intrauterine infection and preterm delivery. N Engl J Med 2000;342:1500-7.
Goldenberg RL, Culhane JF, Iams JD, Romero R. Epidemiology and causes of preterm birth. Lancet 2008;371:75-84.
Beck S, Wojdyla D, Say L, Betran AP, Merialdi M, Requejo JH, et al.
The worldwide incidence of preterm birth: A systematic review of maternal mortality and morbidity. Bull World Health Organ 2010;88:31-8.
Rakoto-Alson S, Tenenbaum H, Davideau JL. Periodontal diseases, preterm births, and low birth weight: Findings from a homogeneous cohort of women in Madagascar. J Periodontol 2010;81:205-13.
Martin JA, Hamilton BE, Sutton PD, Ventura SJ, Menacker F, Kirmeyer S, et al.
Births: Final data for 2005. Natl Vital Stat Rep 2007;56:1-103.
WHO Collaborating Centre for Training and Research in Newborn Care. National Neonatal Perinatal Database Network. National Neonatal Perinatal - Database Report 2002-2003. National Neonatology Forum NNPD Network, India; 2005. p. 13.
Reedy NJ. Born too soon: The continuing challenge of preterm labor and birth in the United States. J Midwifery Womens Health 2007;52:281-90.
Gopichandran V, Luke DM, Vinodhini R, Rau R, Savitha MS, Mohan VR, et al
. Psycho-socio-economic stress as a risk factor for preterm labour: A community-based, case-control study from rural South India. Natl Med J India 2010;23:184-5.
Orr ST, Reiter JP, Blazer DG, James SA. Maternal prenatal pregnancy-related anxiety and spontaneous preterm birth in Baltimore, Maryland. Psychosom Med 2007;69:566-70.
Hodnett ED, Fredericks S. Support during pregnancy for women at increased risk of low birthweight babies. Cochrane Database Syst Rev 2003;3: CD000198. Available from: http://apps.who.int/rhl/reviews/langs/CD000198.pdf [last assessed 2014 Nov 14].
Iams JD, Romero R, Culhane JF, Goldenberg RL. Primary, secondary, and tertiary interventions to reduce the morbidity and mortality of preterm birth. Lancet 2008;371:164-75.
O'Reilly PG, Claffey NM. A history of oral sepsis as a cause of disease. Periodontol 2000 2000;23:13-8.
Offenbacher S, Katz V, Fertik G, Collins J, Boyd D, Maynor G, et al.
Periodontal infection as a possible risk factor for preterm low birth weight. J Periodontol 1996;67:1103-13.
Boggess KA, Lieff S, Murtha AP, Moss K, Beck J, Offenbacher S. Maternal periodontal disease is associated with an increased risk for preeclampsia. Obstet Gynecol 2003;101:227-31.
Rajapakse PS, Nagarathne M, Chandrasekra KB, Dasanayake AP. Periodontal disease and prematurity among non-smoking Sri Lankan women. J Dent Res 2005;84:274-7.
Herrera JA, Chaudhuri G, López-Jaramillo P. Is infection a major risk factor for preeclampsia? Med Hypotheses 2001;57:393-7.
Lunardelli AN, Peres MA. Is there an association between periodontal disease, prematurity and low birth weight? A population-based study. J Clin Periodontol 2005;32:938-46.
Offenbacher S, Lieff S, Boggess KA, Murtha AP, Madianos PN, Champagne CM, et al.
Maternal periodontitis and prematurity. Part I: Obstetric outcome of prematurity and growth restriction. Ann Periodontol 2001;6:164-74.
López NJ, Smith PC, Gutierrez J. Periodontal therapy may reduce the risk of preterm low birth weight in women with periodontal disease: A randomized controlled trial. J Periodontol 2002;73:911-24.
Siqueira FM, Cota LO, Costa JE, Haddad JP, Lana AM, Costa FO. Intrauterine growth restriction, low birth weight, and preterm birth: Adverse pregnancy outcomes and their association with maternal periodontitis. J Periodontol 2007;78:2266-76.
Toygar HU, Seydaoglu G, Kurklu S, Guzeldemir E, Arpak N. Periodontal health and adverse pregnancy outcome in 3,576 Turkish women. J Periodontol 2007;78:2081-94.
Agueda A, Ramón JM, Manau C, Guerrero A, Echeverría JJ. Periodontal disease as a risk factor for adverse pregnancy outcomes: A prospective cohort study. J Clin Periodontol 2008;35:16-22.
Heimonen A, Janket SJ, Kaaja R, Ackerson LK, Muthukrishnan P, Meurman JH. Oral inflammatory burden and preterm birth. J Periodontol 2009;80:884-91.
Gomes-Filho IS, Cruz SS, Rezende EJ, Dos Santos CA, Soledade KR, Magalhães MA, et al.
Exposure measurement in the association between periodontal disease and prematurity/low birth weight. J Clin Periodontol 2007;34:957-63.
Khader Y, Al-Shishani L, Obeidat B, Khassawneh M, Burgan S, Amarin ZO, et al.
Maternal periodontal status and preterm low birth weight delivery: A case-control study. Arch Gynecol Obstet 2009;279:165-9.
Moore S, Ide M, Coward PY, Randhawa M, Borkowska E, Baylis R, et al.
A prospective study to investigate the relationship between periodontal disease and adverse pregnancy outcome. Br Dent J 2004;197:251-8; discussion 247.
Noack B, Klingenberg J, Weigelt J, Hoffmann T. Periodontal status and preterm low birth weight: A case control study. J Periodontal Res 2005;40:339-45.
Nabet C, Lelong N, Colombier ML, Sixou M, Musset AM, Goffinet F, et al.
Maternal periodontitis and the causes of preterm birth: The case-control Epipap study. J Clin Periodontol 2010;37:37-45.
Davenport ES, Williams CE, Sterne JA, Murad S, Sivapathasundram V, Curtis MA. Maternal periodontal disease and preterm low birthweight: Case-control study. J Dent Res 2002;81:313-8.
Bassani DG, Olinto MT, Kreiger N. Periodontal disease and perinatal outcomes: A case-control study. J Clin Periodontol 2007;34:31-9.
Vettore MV, Leal Md, Leão AT, da Silva AM, Lamarca GA, Sheiham A. The relationship between periodontitis and preterm low birthweight. J Dent Res 2008;87:73-8.
Xiong X, Buekens P, Fraser WD, Beck J, Offenbacher S. Periodontal disease and adverse pregnancy outcomes: A systematic review. BJOG 2006;113:135-43.
Manau C, Echeverria A, Agueda A, Guerrero A, Echeverria JJ. Periodontal disease definition may determine the association between periodontitis and pregnancy outcomes. J Clin Periodontol 2008;35:385-97.
Saddki N, Bachok N, Hussain NH, Zainudin SL, Sosroseno W. The association between maternal periodontitis and low birth weight infants among Malay women. Community Dent Oral Epidemiol 2008;36:296-304.
Fardini Y, Chung P, Dumm R, Joshi N, Han YW. Transmission of diverse oral bacteria to murine placenta: Evidence for the oral microbiome as a potential source of intrauterine infection. Infect Immun 2010;78:1789-96.
Seymour GJ, Ford PJ, Cullinan MP, Leishman S, Yamazaki K. Relationship between periodontal infections and systemic disease. Clin Microbiol Infect 2007;13 Suppl 4:3-10.
Gürsoy M, Könönen E, Gürsoy UK, Tervahartiala T, Pajukanta R, Sorsa T. Periodontal status and neutrophilic enzyme levels in gingival crevicular fluid during pregnancy and postpartum. J Periodontol 2010;81:1790-6.
Loos BG. Systemic markers of inflammation in periodontitis. J Periodontol 2005;76:2106-15.
Gonçalves LF, Chaiworapongsa T, Romero R. Intrauterine infection and prematurity. Ment Retard Dev Disabil Res Rev 2002;8:3-13.
Barak S, Oettinger-Barak O, Machtei EE, Sprecher H, Ohel G. Evidence of periopathogenic microorganisms in placentas of women with preeclampsia. J Periodontol 2007;78:670-6.
Katz J, Chegini N, Shiverick KT, Lamont RJ. Localization of P. gingivalis in preterm delivery placenta. J Dent Res 2009;88:575-8.
Arce RM, Barros SP, Wacker B, Peters B, Moss K, Offenbacher S. Increased TLR4 expression in murine placentas after oral infection with periodontal pathogens. Placenta 2009;30:156-62.
Han YW, Fardini Y, Chen C, Iacampo KG, Peraino VA, Shamonki JM, et al.
Term stillbirth caused by oral Fusobacterium nucleatum. Obstet Gynecol 2010;115:442-5.
Klebanoff M, Searle K. The role of inflammation in preterm birth - focus on periodontitis. BJOG 2006;113 Suppl 3:43-5.
Offenbacher S, Jared HL, O'Reilly PG, Wells SR, Salvi GE, Lawrence HP, et al.
Potential pathogenic mechanisms of periodontitis associated pregnancy complications. Ann Periodontol 1998;3:233-50.
Andrukhov O, Ulm C, Reischl H, Nguyen PQ, Matejka M, Rausch-Fan X. Serum cytokine levels in periodontitis patients in relation to the bacterial load. J Periodontol 2011;82:885-92.
Casarin RC, Ribeiro Edel P, Mariano FS, Nociti FH Jr, Casati MZ, Gonçalves RB. Levels of Aggregatibacter actinomycetemcomitans
, Porphyromonas gingivalis
, inflammatory cytokines and species-specific immunoglobulin G in generalized aggressive and chronic periodontitis. J Periodontal Res 2010;45:635-42.
Pressman EK, Thornburg LL, Glantz JC, Earhart A, Wall PD, Ashraf M, et al.
Inflammatory cytokines and antioxidants in midtrimester amniotic fluid: Correlation with pregnancy outcome. Am J Obstet Gynecol 2011;204:155.e1-7.
Davé S, Van Dyke T. The link between periodontal disease and cardiovascular disease is probably inflammation. Oral Dis 2008;14:95-101.
Boggess KA, Moss K, Madianos P, Murtha AP, Beck J, Offenbacher S. Fetal immune response to oral pathogens and risk of preterm birth. Am J Obstet Gynecol 2005;193:1121-6.
Michalowicz BS, Hodges JS, DiAngelis AJ, Lupo VR, Novak MJ, Ferguson JE, et al.
Treatment of periodontal disease and the risk of preterm birth. N Engl J Med 2006;355:1885-94.
Offenbacher S, Beck JD, Jared HL, Mauriello SM, Mendoza LC, Couper DJ, et al.
Effects of periodontal therapy on rate of preterm delivery: A randomized controlled trial. Obstet Gynecol 2009;114:551-9.
Newnham JP, Newnham IA, Ball CM, Wright M, Pennell CE, Swain J, et al.
Treatment of periodontal disease during pregnancy: A randomized controlled trial. Obstet Gynecol 2009;114:1239-48.
Macones GA, Parry S, Nelson DB, Strauss JF, Ludmir J, Cohen AW, et al.
Treatment of localized periodontal disease in pregnancy does not reduce the occurrence of preterm birth: Results from the Periodontal Infections and Prematurity Study (PIPS). Am J Obstet Gynecol 2010;202:147.e1-8.
Jeffcoat M, Parry S, Sammel M, Clothier B, Catlin A, Macones G. Periodontal infection and preterm birth: Successful periodontal therapy reduces the risk of preterm birth. BJOG 2011;118:250-6.
Polyzos NP, Polyzos IP, Zavos A, Valachis A, Mauri D, Papanikolaou EG, et al.
Obstetric outcomes after treatment of periodontal disease during pregnancy: Systematic review and meta-analysis. BMJ 2010;341:c7017.
Gürsoy M, Pajukanta R, Sorsa T, Könönen E. Clinical changes in periodontium during pregnancy and post-partum. J Clin Periodontol 2008;35:576-83.
|This article has been cited by|
||Factors Associated with Preterm Birth and Low Birth Weight in Abu Dhabi, the United Arab Emirates
| ||Zainab Taha,Ahmed Ali Hassan,Ludmilla Wikkeling-Scott,Dimitrios Papandreou |
| ||International Journal of Environmental Research and Public Health. 2020; 17(4): 1382 |
|[Pubmed] | [DOI]|
||Prediction of Chronic Periodontitis Severity Using Machine Learning Models Based On Salivary Bacterial Copy Number
| ||Eun-Hye Kim,Seunghoon Kim,Hyun-Joo Kim,Hyoung-oh Jeong,Jaewoong Lee,Jinho Jang,Ji-Young Joo,Yerang Shin,Jihoon Kang,Ae Kyung Park,Ju-Youn Lee,Semin Lee |
| ||Frontiers in Cellular and Infection Microbiology. 2020; 10 |
|[Pubmed] | [DOI]|
||Dental care during pregnancy based on the pregnancy risk assessment monitoring system in Utah
| ||Chandni Muralidharan,Ray M. Merrill |
| ||BMC Oral Health. 2019; 19(1) |
|[Pubmed] | [DOI]|
||Periodontal diseases and adverse pregnancy outcomes: Is there a role for vitamin D?
| ||Anne Marie Uwitonze,Peace Uwambaye,Moses Isyagi,Chrispinus H. Mumena,Alice Hudder,Afrozul Haq,Kamrun Nessa,Mohammed S. Razzaque |
| ||The Journal of Steroid Biochemistry and Molecular Biology. 2018; |
|[Pubmed] | [DOI]|
||Periodontal Disease, Inflammatory Cytokines, and PGE2 in Pregnant Patients at Risk of Preterm Delivery: A Pilot Study
| ||Catalina Latorre Uriza,Juliana Velosa-Porras,Nelly S. Roa,Stephani Margarita Quiñones Lara,Jaime Silva,Alvaro J. Ruiz,Francina Maria Escobar Arregoces |
| ||Infectious Diseases in Obstetrics and Gynecology. 2018; 2018: 1 |
|[Pubmed] | [DOI]|
||Prevention of Prematurity
| ||Balaji Govindaswami,Priya Jegatheesan,Matthew Nudelman,Sudha Rani Narasimhan |
| ||Clinics in Perinatology. 2018; 45(3): 579 |
|[Pubmed] | [DOI]|
||Impacto de la salud oral en la calidad de vida de la gestante
| ||Jose Manuel Garcia-Martin,Agueda Gonzalez-Diaz,Maria Jose Garcia-Pola |
| ||Revista de Salud Pública. 2017; 19(2): 145 |
|[Pubmed] | [DOI]|