Effect of Periodontal Infections on Fetal Development & Pregnancy Outcomes

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Presented at the National Academy for State Health Policy's 20th Annual State Health Policy Conference in Denver, Colorado. Author: Gary Armitage

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  • 1. Effect of Periodontal Infections on Fetal Development & Pregnancy Outcomes National Academy for State Health Policy Denver, ColoradoOctober 15, 2007 Gary C. Armitage, DDS, MS Professor of Periodontology, UCSF

2. Special Supplement Scientific American (October 2006) Growing evidence suggests that poor oral hygiene during pregnancy can adversely affect the health of newborns. For reprints: Call Crest Oral-B North American Customer Service at 800-543-2577. 3. Two Major Questions 1.Does the presence of periodontal (or oral) infectionsincreasethe risk of experiencing adverse pregnancy outcomes?[Risk factor question] 2.Does the treatment of periodontal (or oral) infectionsdecreasethe risk of experiencing adverse pregnancy outcomes?[Intervention question] 4. Systemic Diseases Caused by Oral Infections (1916) Ophthalmic Disturbances (infectious conjunctivitis,suppurating keratitis, scleritis, cyclitis, iritis, retinitis, opticneuritis, glaucoma) Aural Disturbances (otitis media, otlagia) Diseases of the Alimentary Canal (septic gastritis,septic enteritis, colitis, appendicitis, proctitis, gastric andduodenal ulcers) Diseases of the Blood (pernicious anemia, septic anemia) Infectious Diseases of the Heart (pericarditis, myo-carditis, endocarditis) Affections of the Nervous System (neuritis, trifacial neuralgia, chorea, mental depression and melancholia) Diseases of the Joints (acute arthritis, gouty arthritis) 5. Potential Associations Between Periodontal Infections and Adverse Systemic Outcomes

  • Heart Diseases
  • Infective endocarditis
  • Coronary heart disease (Atherosclerosis)
  • Arthritisand Failure of Artificial Joints
  • Neurological Diseases
  • Cerebrovascular disease (Nonhemorrhagicstroke)
  • Brain abscesses
  • Alzheimers disease
  • Meningitis

2007 6. Potential Associations Between Periodontal Infections and Adverse Systemic Outcomes

  • Adverse Pregnancy Outcomes
  • Preterm birth; Preeclampsia
  • Fetal growth restriction
  • Pulmonary Diseases
  • Aspiration & Ventilator-associated pneumonia
  • Chronic obstructive pulmonary disease
  • Diabetes Mellitus (Onset & Control)
  • Gastrointestinal Diseases
  • Gastric ulcers
  • Stomach cancer

2007 7. 28 y.o. WF Common Gingival Changes During Pregnancy: Pyogenic Granuloma (Pregnancy Tumor) Pregnancy Gingivitis Second Trimester 30 y.o. WF Second Trimester In addition to the pyogenic granuloma in this patient there is marked gingival inflam- mation around most teeth (arrows). 8. Initiation & Progression of Periodontal Disease(The HealthGingivitisPeriodontitis Paradigm) Shallow gingival sulcus Apical termination of JE at CEJ Shallow periodontal pocket Apical termination of JE at CEJ Inflamed connective tissue Deepened periodontal pocket Loss of CT attachment &bone JE on root surface Inflamed connective tissue 9. Clinical Appearance of Healthy & Diseased Periodontal Tissues No signs of inflammation No gingival recession Shallow probing depths Normal architecture (shape) Signs of inflammation Gingival recession Deep probing depths (pockets) Abnormal architecture 10. Purulent Exudate (Pus) is Often Seen in Cases of Chronic Periodontitis Redness & Swelling Purulent Exudate (Pus) Purulent exudate is a sign of inflammation. 55 y.o. WF 11. Bleeding on probing (BOP) is sign of periodontal inflammation. D C BOP occurs because the epithelial lining of the pocket wall is thin & often ulcerated (arrow). a D = DentinC= Cementum a= artifact x16 12. Alveolar Bone (Offenbacher S.Scientific American2006 (October);Special Supplement, pp. 24-29.)Tooth Enamel (Crown) Root of Tooth Dental Biofilm (Dental Plaque and Calculus) Periodontal Pocket (with ulcerated wall) 13. BREAKING THROUGH: When oral bacteria in the mothers blood breaches the placenta and reaches the fetus, it triggers an immune and inflammatory response, stressing the unborn child. Infections may account for up to 50% of premature births. What Every Woman Needs to Know Steven Offenbacher Scientific American (Special Supplement: October, 2006) Campylobacter rectus Bergeyellasp. clone AF14 (AK152) 14. A higher percentage of fetal cord blood samples from preterm infants (20.0%) are positive for IgM againstC. rectusthan those obtained from term infants (6.3%) [P < 0002]. S OM CM 0.1 m (Borinski & Holt.Infect Immun1990;58:2770-2776.) (Sra & Sleytr.J Bacteriol2000;182:859-868.) 100 nm S-Layer ofC. rectus Production of IgMby the fetus clearlyshows that certainoral bacteria crossthe placenta andgain access to theimmune system of the baby. (Madianos et al. Ann Periodontol 2001;6:175-182.) 15. Lines of Evidence Suggesting Periodontal Disease as a Risk Factor for Preterm Birth & Low Birthweight Natal Tooth; Navajo Baby Girl; 1-day oldSome epidemiologic studies Detection of fetal cord blood IgM againstC. rectusandP. intermedia .* Many plausible mechanisms by which periodontal bacteria and inflammatory mediators (PGE 2 ) might trigger preterm birth. Preliminary intervention data suggest that periodontal treatment lowers risk.** *Madianos et al.Ann Periodontol2001;6:175-182. **Lpez et al.J Periodontol2002;73:911-924. **Jeffcoat et al.J Periodontol2003;74:1214-1218. 16. Mothers who gave birth to preterm low birthweight infants had statistically significant increased amounts of mean clinical attachment loss (CAL) OCAP Study Results.(Offenbacher et al.J Periodontol1996;67:1103-1113.) Primi = primiparous (no previous birth); NBW = Normal Birth Weight OR = 7.5(CI, 1.95 28.8) N = 93 cases and 31 controls 17. Periodontal infection and preterm birth.Results of a prospective study.(Jeffcoat et al.J Am Dent Assoc2001;132:875-880) Adjusted odds ratios for preterm births in patients with generalized periodontitis.The odds ratios have been adjusted for smoking, parity, race, and maternal age. 4.45 5.28 7.07 Number in each group not specified. < 37 weeks (OR = 4.45;C, I2.16-9.18) < 35 weeks (OR = 5.28; CI, 2.05-13.60) < 32 weeks (OR = 7.07; CI, 1.70-27.40) N = 167 (estimated) Periodontitis Case = Women with 90 sites with 3 mm of attachment loss. 18. Higher risk of preterm birth and low birth weight in women with periodontal disease. (Lpez et al.J Dent Res2002;81:58-63.) Adjusted Risk Ratios and P Values for Risk Factors Associated with Preterm Birth/Low Birth Weight (PLBW) and with Preterm Birth (PTB) Risk RatioRisk Ratio for PLBWfor PTB (95% CI)P Value(95% CI)P Value Previous PLBW4.8 (1.6-14.0)0.00047.5 (2.2-24.8)0.001 < 6 Prenatal visits4.7 (1.9-11.1)< 0.00017.5 (2.6-20.6)0.0001 Periodontitis3.5(1.5-7.9)0.0032.9(1.0-8.1)0.045 Low maternalweight gain2.6 (1.1-6.5)0.030 19. Rate of delivery of a small-for-gestational-age (SGA) infant by maternal periodontal disease category (health vs. mild vs. moderate/severe) and serum C-reactive protein quartiles. Q1 Q2 Q3 Q4 CRP Quartiles Periodontal Health Mild Periodontitis Moderate-Severe Periodontitis SGA (%) 20 15 10 5 0 (Boggess et al.Am J Obstet Gynecol2006;194:1316-1322.) North Carolina Population (University of North Carolina & Duke Medical Center) [N = 1,017 women of whom 67 (6.6%) delivered an SGA infant] (n = 145) (n = 588) (n = 284) 13.8% 6.5% 3.2% (P < 0.001) 20. (Offenbacher at al.Obstet Gynecol2006;107:29-36.) Maternal age (P < 0.001) African American (P < 0.001) Not married (P < 0.005) Food stamp eligible (P < 0.05) No medical insurance (P < 0.05) Previous preterm delivery (P < 0.001) Chorioamnionitis (P < 0.001) [However, n = only 10/13] Moderate-Severe PeriodontalDisease (P < 0.001) Progression of Periodontal Disease (P < 0.001) 21. Kaplan-Meier curves for pregnancy-gestational age outcomes among 891 mothers when both antepartum and postpartum periodontal exam data were available. Delivery outcomes for mothers with no progression of periodontal disease (n = 658) or with progress- ion (n = 233).Progression was defined as 4 sites with 2 mm increase in probing depths (PD), with the postpartum PD 4 mm. (Offenbacher at al. Progressive periodontal disease and risk of very preterm delivery. Obstet Gynecol2006;107:29-36.) 22. Definition of Preeclampsia A complication of pregnancy characterized by hypertension, edema, and/or proteinuria; when convulsions and coma are associated it is calledeclampsia . Rich et al. Periodontal disease increases the risk of preterm delivery among preecalamptic women.Ann Periodontol2002;7:95-101. Boggess et al. Maternal periodontal disease is associated with an increased risk of preeclampsia.Obstet Gynecol2003;101:227-231. 23. General linear model of the effect of changes in periodontal status during pregnancy on the adjusted rates of preterm delivery in preeclamptic and non-preeclamptic mothers. From: Rich et al.Ann Periodontol2002;7:95-101 . Estimates of prevalence rates were adjusted for maternal race, age, marital status, food stamp usage, insurance, previous preterm deliv- ery, and chorioamnion- itis. *P = 0.26 (NS) P = 0.0006 24. A Predictable Event Edematous tissue will shrink after the teeth are cleaned. Gingivitis (Pretreatment) Redness Swelling (edema) Bleeding on probing Health (Post-treatment) Absence of inflammation Improved architecture Better tissue tone 23 y.o. WF Baseline 3 Months post-treatment 25. Periodontal therapy may reduce the risk of preterm low birth weight in women with periodontal disease: A randomized controlled study. I.(Lpez et al.J Periodontol2002;73:911-924.) Purpose was to determine if periodontal therapy in pregnant women with periodontal disease reduces the risk of preterm low birth weig