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Pre-conception Treatment of Periodontal Disease as a Way to Reduce the Incidence of Preterm Births and Low Birth Weight Infants

Preterm delivery, delivery before 37 completed weeks of gestation, has been shown to cause  significant morbidity in infants and to be a cause of lifelong health problems in these children. The World Health Organization (WHO) reports,

 

Preterm birth is a leading cause of neonatal and infant mortality as well as short- and long-term disability. Rates for preterm birth range between 6% and 12% in developed countries and are generally higher in developing countries. About 40% of all preterm births occur before 34 weeks and 20% before 32 weeks. The contribution of these preterm births to overall perinatal morbidity and mortality is more than 50%.”

 

Low birth weight—below 5 lbs 8 ounce (or 2500 grams)—is usually a consequence of preterm birth but is also a singularly significant cause of morbidity and mortality in neonates and children. According to the March of Dimes, 67% of preterm infants are low birth weight and in the United States, they estimate that about 1 in every 12 infants is born low birth weight.

 

Despite attempts to positively impact maternal health and nutrition, and aggressively treat preterm labor, the rates of preterm birth and low birth infants are still on the rise globally. Physicians and researchers continue to examine cases and studies trying to identify potential causes and treatments that could slow, halt and eventually reverse these trends. In 1996, Offenbacher et al first reported an association between periodontal disease and preterm birth. Since that time, evidence has been growing to support the idea that periodontal disease may be associated with preterm birth, low birth weight and other adverse birth outcomes.

 

Xu Xiong et al hypothesize in their article, Optimal timing of periodontal disease treatment for prevention of adverse pregnancy outcomes: before or during pregnancy?, that since periodontal disease treatment during pregnancy has not been shown to significantly reduce the rates of preterm birth and low birth weight, that preconception treatment (either in the year prior to conception in primiparas or between pregnancies in multiparous women) may be more effective.

 

Xiong and his colleagues reached this conclusion following a systematic review of the observational studies which showed that there is an association between periodontal disease and adverse birth outcomes (especially in lower socioeconomic populations), and meta analyses of randomized control trials (RCT’s); one in which preterm birth was the end point and one in which low birth weight was the end point. RCT’s performed in low to middle-income countries found a stronger link between treatment of periodontal disease during pregnancy and reduction in adverse pregnancy outcomes. RCT’s performed in high income countries such as the United States only showed that treating periodontal disease during pregnancy may reduce the rates of low birth weight. With these findings, Xiong and his colleagues present the following recommendations for future RCT’s to determine whether or not treating periodontal disease prior to conception can actually reduce the rates of preterm birth, low birth weight and other adverse pregnancy outcomes.

 

  • Study participants would be women planning to conceive within one year and with documented periodontal disease
  • Participants would be randomized to treatment vs. non treatment groups
  • Treatment groups would receive intense periodontal therapies and use of antibiotics to aggressively treat and eradicate periodontal disease
  • Endpoints of the studies would be delivery, and assessment of rates of adverse pregnancy outcomes would determine the efficacy of the intervention.

 

Xiong et al hypothesize that if preconception periodontal treatments reduce adverse pregnancy outcomes lowering infant morbidity and mortality, then improving oral health prior to pregnancy could be recommended, especially in low and middle income nations, as a means of reducing infant morbidity and mortality worldwide.

 

At face value Xiong’s hypothesis may seem like a lot of “ifs.” However, the presumed link between periodontal disease and adverse birth outcomes provides a simple portal for intervention and measurement of effect. While it may be more difficult to amass study participants as most women don’t receive preconception care, Xiong suggests recruitment within communities. He also suggests training of dental professionals so that the diagnoses and treatments of periodontal disease remain as uniform as possible worldwide.

 

I agree with Xiong’s hypothesis and proposed course of action. My concern is that here in the United States, many citizens are without dental coverage and will be unable to afford the preconception periodontal treatments should they become a standard of preconception care. While women may receive treatment during the study, how will low income and/or uninsured women receive such treatment once preconception treatment becomes a recommendation? Medicaid doesn’t cover dental procedures “for health” and preconception would need to be listed as treatment of overall health and that may prove a difficult task—at least initially. Medicaid is currently facing increasing budget cuts nationwide so adding another benefit may not be admissible, despite being effective in lowering other health care costs associated with the long term care of preterm and low birth weight infants.

 

While I hope that Xiong’s hypothesis is proven and preconception periodontal treatment is a solution to help reduce the rates of preterm birth and low birth weight infants, I fear that as a solution, it may not be available to many women, especially in the United States, due to costs. I hope that worldwide, if preconception periodontal treatment is effective in reducing adverse pregnancy outcomes, resources will be allocated for such treatment as it will reduce not only infant morbidity and mortality but also the burden of life long care costs for these children.

 

 

Posted by:  Darline Turner-Lee, BS, MHS, PA-C

 

 

 

References

Stacy Beck, Daniel Wojdyla, Lale Say, Ana Pilar Betran, Mario Merialdi, Jennifer Harris Requejo, Craig Rubens, Ramkumar Menon & Paul FA Van Look

The worldwide incidence of preterm birth: a systematic review of maternal mortality and morbidity   Bulletin 37 World Health Organizaton 2010;88:31–38 | doi:10.2471/BLT.08.062554

 

The March of Dimes  http://www.marchofdimes.com/medicalresources_lowbirthweight.html

 

Steven Offenbacher, Vern Katz, Gregory Fertik, John Collins, Doryck Boyd, Gayle Maynor, Rosemary McKaig, and James Beck

“Periodontal Infection as a Possible Risk Factor for Preterm Low Birth Weight”

Journal of Periodontology October 1996, Vol. 67, No. 10s, Pages 1103-1113,

DOI 10.1902/jop.1996.67.10s.1103 (doi:10.1902/jop.1996.67.10s.1103)

 

Xiong X, Buekens P, Goldenberg RL, et al. “Optimal timing of periodontal disease treatment for prevention of adverse pregnancy outcomes: before or during pregnancy?” American Journal of Obstetrics and Gynecology 2011; 205:111.e1-6.

Pre-term Birth, Preconception Care, Prenatal Illness, Research Opportunities, Science & Sensibility, Uncategorized , , , ,

  1. avatar
    sara r.
    August 30th, 2011 at 08:17 | #1

    To anyone who has read Nutrition and Physical Degeneration by Dr. Weston A. Price (written in the 1930′s), this makes perfect sense and should have been common knowledge by now. Periodontal disease compromises the immune system constantly, providing a direct path for pathogenic bacteria to enter the body, and I personally feel that most preterm births can be directly linked to autoimmune conditions and infections. Dr. Price was a dentist who found that his patients with the worst teeth also had the most degenerative diseases- he studied over a dozen healthy groups of people around the world and found that the Western diet was woefully lacking in vital nutrients that kept these other people healthy without medical (or dental) care. Most of these cultures also had special foods that they reserved for women and children, realizing that these foods were especially high in nutrients. (Fish Roe, butter oil, liver, etc) He also noted that native women had remarkably easy pregnancies and births. As soon as they deviated from their native diet, their teeth deteriorated, along with their health, and pregnancies became more difficult and babies born not as healthy and strong. It’s sad that this dentist’s research, published in the 30′s, is not well-known. Of course our diet has gotten even worse than it was in the 30′s, with GMO’s and vegetable fats more common than ever, and most food that we are encouraged to eat is almost bereft of essential nutrients (especially for those in low income brackets), so the further increase in preterm birth is not surprising to me, nor would it surprise Dr. Price if he were around today.
    I think that this is a great study, but I feel that dental care is not the answer- a person eating a diet high in essential nutrients does not need dental care- most of the natives that Dr. Price studied had never seen a toothbrush, yet had perfect teeth, and plenty of room in their mouths for their teeth, so orthodontics were also not needed. They also ate WAY more animal fat than we are told is healthy, about 40-60% of their diet on average. A body which is being fed properly will maintain and repair itself, whereas a diet lacking in nutrients will destroy the body. Until nutritionists encourage people to eat foods that are REALLY healthy, and the government subsidizes food that can keep them healthy as opposed to kill them, preterm birth will continue to rise in this country and others who take our terrible advice.

  2. August 30th, 2011 at 16:05 | #2

    Sara, your point is very well taken. While I have not read Dr. Price’s work, I do know the benefits of proper nutrition. Ensuring that pregnant receive adequate nutrition would go far in improving birth outcomes. But given our current nutritional status worldwide, I believe that treating periodontal disease preconceptionally may prove to be a plausible intervention

  3. August 30th, 2011 at 16:16 | #3

    Sara, what I meant to say before my computer glitched is that a regular diet of well balanced nutrient dense food would certainly be optimum for all citizens. However, given the malnourished status of a vast majority of the world’s citizens, if preconception treatment of periodontal disease proves beneficial in lowering rates of adverse birth outcomes, it most certainly should be employed as standard of care-in addition to working towards better nutrition worldwide.

  4. avatar
    sara r.
    August 31st, 2011 at 18:00 | #4

    @Darline Turner-Lee
    agreed :) Anything that helps, should be employed. I just wish that immune deficiencies were addressed in pregnancy- current research has made it obvious that the state of the immune system has a huge effect on preterm labor, yet even women and doctors in developed, affluent countries are not given the information needed to determine if they are at risk. The data is out there, but no one is putting it together and actually warning women. Probably because if they admitted the key instigators, it would be too damning on those societies as a whole.

  5. November 9th, 2011 at 16:28 | #5

    Great article! As in any disease treatment, the primary goal in Periodontal Disease Treatment is to stop the spread of the infection.

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