Commentary on "obstetricians' knowledge and practice behaviors concerning periodontal health and preterm delivery and lower birth weight".

* Wilder R, Robinson C, Hared HL, Lieff S, Boggess K. Obstetricians' knowledge and practice behaviors concerning periodontal health and preterm delivery and low birth weight. Journal of Dental Hygiene, Vol. 81, No. 4, Fall 2007.

Abstract

Introduction: Investigators have reported that periodontal disease may be a risk factor for pregnancy complications including preterm delivery (PTD) and low birth weight (LBW). This study assessed obstetricians' knowledge and practice behaviors concerning periodontal disease and its role in adverse pregnancy outcomes.

Methods: One hundred ninety four practicing obstetricians in a 5 county area in central North Carolina were surveyed. Of the 138 eligible physicians, 55 responded yielding a 40% response rate.

Results: Most answered correctly when asked about the description of gingivitis (95%). A lower number of respondents were correct when asked about the description of periodontitis (67%). When asked about what causes periodontal disease or what is associated with periodontal disease, most answered correctly with bacteria (94%), although many answered tooth decay (73%), aging (69%), and excess dietary sugar (51%). Most were correct in responding that periodontitis was more serious than gingivitis (80%). Twenty-two percent looked into patients' mouths at initial prenatal examination, 9% periodically, and 48% only when a problem was mentioned by the patient. Forty-nine percent rarely or never recommended a dental examination. Most (84%) considered periodontal disease to be as important a risk factor to adverse pregnancy events as those currently known in obstetrics practice.

Conclusions: Data from this study demonstrate that there is knowledge of periodontal disease and its potential role as a pregnancy risk factor but suggest limited incorporation of dental care into clinical medical practice.

Key Words: Dental Hygiene; Physicians' Knowledge; Oral Health; Low Birth Weight; Preterm Labor; Physicians' Practice Behaviors; Pregnancy; Periodontitis

Summary of Key Findings in This Article

Preterm-birth and low-birth-weight infants are a major health concern in the United States and the world. A preterm delivery (PTD) occurs when an infant is born at less than 37 weeks of gestation. (1) An infant is considered to have low birth weight (LBW) when weighing less than 2,500 g. (2) Children who are born premature or with LBW have an increased risk for neurodevelopmental problems, learning disabilities, health disparities and mortality. Seven of every 1,000 infants die before their first birthday, and of all live births in 2004, 12.5% were born premature while 8.1% were of low birth weight. (3)

Identifying risk factors associated with PTD and LBW is an important consideration in attempting to lower the statistics related to adverse pregnancy outcomes. Recent research has suggested that periodontal disease may be a risk factor for PTD and LBW. The biologic plausibility of the association between periodontal disease and adverse pregnancy outcomes points to several mechanisms: metastatic spread of infection from the oral cavity as a result of transient bacteria, metastatic inflammation caused by immunological injury induced by oral organisms, and metastatic injury from the effects of circulating oral microbial toxins. (4-6) Periodontal infection serves as a chronic reservoir of lipopolysaccharides (LPS) and inflammatory mediators, such as TNF-[alpha] and [PGE.sub.2]. These products can act as a potential source of fetotoxic cytokines that can effect the onset of labor by signaling the body that it is time for delivery, irrespective of the age of the fetus. (7)

Animal studies have demonstrated that exposure to Porphyromonas gingivalis, Escherichia coli and Fusobacterium nucleatum, common oral species, can cause challenges leading to decreased fetal weight and increased fetal mortality. (8-10) Studies of pregnant women have also demonstrated that periodontal infections pose a risk for abnormal pregnancy outcomes. Results of one study demonstrated that four organisms associated with periodontal infection were detected at higher levels in preterm labor and LBW mothers, including Actinobacillus actinomycetemcomitans, Tannerella forsythia, Porphyromonas gingivals and Treponema denticola, while another study found that preterm labor and LBW mothers had greater numbers of Tannerella forsythia and Campylobacter rectus and higher counts of all other organisms than mothers who delivered at term. (11) Findings of other studies noted that elevated prostaglandins ([PGE.sub.2]) in the gingival crevicular fluid (GCF) are positively associated with amniotic fluid levels of [PGE.sub.2] and may indicate the presence of cytokines in amniotic fluid. (12)

Although some studies suggest an association between periodontal disease and PTD and LBW, not all studies have demonstrated this association. Recently, two studies found no association between periodontitis and adverse pregnancy outcomes. (13,14) Nevertheless, concern remains that there is a connection between oral health and adverse pregnancy outcomes.

The purpose of this article by Wilder, et al., was to assess the knowledge and practices of obstetricians concerning oral health and pregnancy outcomes. A descriptive study was employed using a survey instrument. Obstetricians practicing in five sites of North Carolina were investigated with respect to demographics, knowledge, attitudes and practice behavior variables. Of the 194 surveys sent, 139 obstetricians remained eligible for the study and 55 responded, yielding a response rate of 40 percent.

Findings of this study revealed that most obstetricians were current with regular dental checkups and few had periodontal disease. Most obstetricians were familiar with knowledge that gingivitis was a reversible infection with redness and swelling. Although 80 percent knew that periodontitis was more serious than gingivitis, results varied concerning understanding of the etiology of periodontitis. Respondents identified bacteria (94 percent), tooth decay (73 percent) aging (69 percent) and excess sugar (51 percent) as possible indicators for this disease.

With respect to knowledge of the relationship between pregnancy and oral health, 47 percent believed that excess decay definitely worsens or may worsen during pregnancy, while 91 percent answered that swelling of the gums definitely worsens or may worsen during pregnancy and 98 percent indicated that bleeding gums occurs or worsens during pregnancy. Maternal smoking was identified as the highest risk factor (98 percent) for pregnancy risk factors, PTD and LBW; followed by preeclampsia (94 percent), periodontal disease (84 percent), and bacterial vaginosis (79 percent). It was noted that younger female obstetricians who worked in a university-based practice answered knowledge questions more accurately than other participants in the study.

In terms of practices and recommendations, 100 percent of obstetricians recommended participation in childbirth classes, 89 percent recommended breastfeeding consultations, and 69 percent recommended genetic screening. Only 51 percent recommended that dental examinations occur during pregnancy. Few obstetricians performed an oral examination at the initial prenatal examination, and 49 percent rarely or never performed an oral exam. This study acknowledged that while there is some knowledge of periodontal disease as a potential risk factor for PTD and LBW among obstetricians studied, there is limited use of this knowledge in practice. The authors proposed that incorporating dental information into medical school curricula would increase knowledge of periodontal disease and its effects both locally and systemically. In addition, the authors plan further study, as this sample may not be representative of obstetric providers in the entire United States, which reflects a limitation to external validity.

What Are the Implications of this Article for Clinical Practice?

This study provides several important messages for dental hygienists and medical care providers working with pregnant women and those women who are trying to become pregnant.

1. Obstetricians and midwives need to monitor the oral health status of pregnant women as well as their general health status.

2. Oral health care providers should emphasize meticulous oral hygiene measures to pregnant women and those planning to become pregnant.

3. Obstetricians and oral health professionals should partner and use guidelines for providing preventive care.

Monitoring Oral Health Status of Pregnant Women

This study emphasized that few sampled obstetricians were monitoring the oral health status of pregnant women. Although many identified periodontal disease as a risk factor for adverse pregnancy outcomes, there was little attention placed on preventing or treating the disease. The study noted that medical school and nursing school curricula are limited in their teaching of oral health considerations and the link between oral health and systemic health. Incorporating this instruction into the curricula would be beneficial.

Obstetricians and midwives generally have an opportunity to examine pregnant women frequently during their three trimesters. Performing an oral examination during the initial prenatal exam and at subsequent appointments would provide an opening for educating and increasing the mother's awareness of periodontal disease as an infection and as a risk factor for PTD and LBW. Although the purpose of this study did not include determining obstetricians' ability to perform an oral examination, findings of other studies demonstrated that many medical professionals do not have the knowledge or confidence to perform an oral examination and identify periodontal and other oral conditions. Including formal instruction in school about the oral examination would increase the knowledge and expertise needed to incorporate routine oral assessment in practice.

In addition, referring mothers who are pregnant to a dentist or dental hygienist for further education and treatment would assist pregnant women in acknowledging the need for total health care during this special time.

Meticulous Oral Hygiene Measures

When dental hygienists encounter clients who are planning to become pregnant or are already pregnant, it is important to establish a prevention and treatment protocol that focuses on meticulous oral hygiene measures to control biofilm accumulation and periodontal disease. These women should be counseled about the risk factors for PTD and LBW, and emphasis should be placed on effective home care strategies.

During this phase in a woman's life, it is important to adopt a "zero tolerance" for biofilm accumulation and periodontal problems. These clients should be advised that periodic evaluation during the pregnancy, with debridement provided as needed, will help to maximize both oral and general health of the mother and the fetus. This is also an opportunity for the dental hygienist to provide instruction on oral health care for an infant and growing child. Pregnant clients may have questions about timing of the first dental appointment for their newborn, fluoride therapy, nutrition and home care instruction. Incorporating this education reinforces the need for early intervention with oral health care to prevent caries and other oral conditions.

Partnering to Provide Better Care

Given the body of knowledge that suggests an association between oral health and PTD and LBW, the Wilder, et al. study mentioned the need for guidelines for providing better care for pregnant women. The New York State Department of Health, Bureau of Dental Health, created guidelines for oral care in pregnancy. These guidelines, entitled "Oral Health Care During Pregnancy and Early Childhood" promote the use of deliberate and planned care and provide recommendations for use of radiographs, prescription drugs and pain medication. (15)

In addition, both obstetricians and oral health providers have recognized the need to partner to provide effective preconceptual care and necessary referrals for medical and dental interventions. Preconceptional care involves preventive care and counseling that addresses both maternal and fetal risk; pre-existing health complications such as diabetes mellitus, hypertension, clotting disorders, systemic lupus erythematosus or epilepsy; and medication use. (16,17) Current preconceptional care for medical providers includes assessment of maternal health, screening for conditions harmful to the fetus and counseling.

Witt, et al. (17) proposed a model of shared responsibility among dental providers, medical providers and social service providers based on a paradigm of 5As:

* Ask about the risk factor

* Advise about reducing risk for an adverse pregnancy outcome

* Assess willingness to engage in risk-reduction behavior

* Assist by providing specific materials, referrals and/or interventions as needed, and

* Arrange for a referral or follow-up as appropriate

The authors advocate use of this model as well as cross-training to ensure that specific skills in preconceptional care are available to all members of the health care team.

In Conclusion

The Wilder study proposed that better instruction be provided within medical school curricula concerning the association between oral health and systemic diseases including adverse pregnancy outcomes. Witt, et al. (17) recommend the following strategies for fostering an oral-systemic shift in client care.

* Develop direct referral systems between nurses and dental hygienists.

* Modify questionnaires used in dental environments to obtain information about risk factors (e.g., folic acid supplementation, alcohol consumption, tobacco use).

* Improve screening competencies for gingivitis or early periodontitis in health care facilities serving women of childbearing age.

* Expand guidelines for health promotion and primary prevention in preconceptional care that include all key elements.

* Develop assessment instruments for use by all health professionals to assess signs of periodontal inflammation.

* Implement evidence-based intervention strategies.

* Increase extramural clinical experiences to ensure cross-training for medical/nursing students in periodontal care environments and for dental/dental hygienist students in obstetrical environments.

* Expand knowledge and skills through scholarly venues such as continuing education and creative interdisciplinary education opportunities, such as extramural rotations and education curricula available on professional Web sites; including

--PowerPoint presentations

--Case examples for learners to analyze and develop clinical maps

--Role-playing of patient interview questions to explore periodontal disease risk factors and appropriate counseling and referral.

This framework provides specific approaches that will help medical, nursing, dental and dental hygiene students and practitioners provide comprehensive preconceptional care, and offers an opportunity for all health care providers to ensure "best-practice" outcomes for pregnant women and fetuses.

References

(1.) Goldenberg RL, Rouse DJ: Prevention of premature births. N Engl J Med 1998; 339(5):313-20.

(2.) McGaw T: Periodontal disease and preterm delivery of low-birth-weight infants. J Can Dent Assoc 2002; 68(3): 165-9.

(3.) National Center for Health Statistics. Final mortality data, 1990-1994; and period linked birth/infant death data, 1995-2002. Available at www.marchofdimes.com/ peristats. Accessed Jan. 25, 2007.

(4.) Gurenlian JR: Inflammation: the role between oral health and systemic health. Access 2006; 20(4) Suppl: 2-9.

(5.) Scannapieco FA: Periodontal inflammation: from gingivitis to systemic disease? Compend Cont Educ Dent 2004; 25 (7) (Suppl 1): 16-25.

(6.) Epstein SE: The multiple mechanisms by which infection may contribute to atherosclerosis development and course. Circ Result 2002; 90: 2-4.

(7.) Offenbacher S, Katz V, Fertik G, et al: Periodontal infections as a possible risk factor for preterm low birth weight. J Periodontol 1996; 10 (Suppl): 1103-13.

(8.) Collins JG, Windley HW, Arnold RR, Offenbacher S: Effects of a porphyromonas gingivalis infection on inflammatory mediator response and pregnancy outcome in hamsters. Infect Immun 1994; 62:4356-61.

(9.) Collins JG, Kirkland BC, Arnold RR, Offenbacher S: Experimental periodontitis retards fetal growth. J Dent Res 1995: 74: 158.

(10.) Collins JG, Smith MA, Arnold RR, Offenbacher S: Effects of eschericia coli and porphyromonas gingivalis lipopolysaccharide on pregnancy outcome in the golden hamster. Infect Immun 1994; 62: 4652-5.

(11.) Offenbacher S, Jared HL, O'Reilly PG, et al.: Potential pathogenic mechanisms of perioclontitis-associated pregnancy outcomes. Ann Periodontol 1998:3 (1): 233-50.

(12.) Damare SM, Wells S, Offenbacher S: Eicosanoids in periodontal diseases: potential for systemic involvement. Advised in Exp Medical & Bio 1997; 433: 23-35.

(13.) Michalowicz BS, Hodges JS, DiAngelis AJ et al.: Treatment of periodontal disease and the risk of preterm birth. N Engl J Med 2006; 355 (180): 1885-94.

(14.) Moore S, IDe M, Coward PY: A prospective study to investigate the relationship between periodontal disease and adverse pregnancy outcome. Br Dent J 2004; 197 (5): 251-8.

(15.) Burakoff R: New York state leading the way in establishing guidelines for oral care in pregnancy. Grand Rounds 2006; 1(4): 50-2.

(16.) Kerpen SJ, Fleischer A: An obstetrician and periodontist translate periodontal-systemic research to preserve the health of pregnant women at risk for adverse pregnancy outcomes. Grand Rounds 2006; 1(4): 23-38.

(17.) Witt JS, Williams KB, Kelly PJ: Engaging hygienists, nurses and social service professionals in an interdisciplinary model for prevention and early care of oral diseases in women of childbearing age. Grand Rounds 2006; 1(4): 40-8.

* Glossary of Terms

Preterm Delivery (PTD)--Gestational age less than 37 weeks.

Low Birth Weight (LBW)--Births weighing less than 2,500 g or 5.5 lbs.

Preeclampsia--A common hypertensive disorder of pregnancy that contributes to maternal and infant morbidity and mortality characterized by edema, proteinuria ahd hypertension, also known as toxemia of pregnancy.

Cytokines--Include lymphokines, monokines, and other polypeptides that regulate immunologic, inflammatory, and reparative host responses.

Prostaglandins--Any of a group of naturally occurring, chemically related, long-chain hydroxy fatty acids that stimulate contractility of the uterine and other smooth muscle; they also can lower blood pressure, regulate acid secretion of the stomach, regulate body temperature and platelet aggregation, control inflammation and vascular permeability and cause pain.

Matrix metalloproteinases (MMP)--Enzymes that include more than 20 members that degrade collagen and other extracellular matrix proteins.

Bacterial vaginosis (BV)--Infection of the genitourinary tract generally associated with a decrease in the normal lactobacillus-dominated flora of the vagina and an increase in gram-negative anaerobes and facultative species.

Lipopolysaccharides (LPS)--Bacterial endotoxin that is a large component of the outer cell wall of a gram-negative bacteria.

Control Group--Those subjects who do not receive the experimental treatment.

Experimental Group--Those subjects who do receive the experimental treatment.

Prospective Study--Experimental study in which an investigator manipulates and controls one or more independent variables and observes the dependent variables to determine the effects of the independent variable.

Descriptive Study - may include case studies, surveys, developmental studies, document analysis, trend studies and correlational studies designed to establish baselines for future comparisons

External Validity--the degree to which a study accurately reflects events that would occur in a real situation so that findings can be generalized to a larger population

By JoAnn R. Gurenlian, RDH, PhD

JoAnn R. Gurenlian, RDH, PhD, is the owner of Gurenlian & Associates, offering consulting and continuing education programs for health care providers. She has experience in general, periodontic, pediatric and orthodontic practices and works part-time in a medical practice. She is an internationally recognized speaker on the topics of oral pathology, oral medicine, diabetes and women's health. Dr. Gurenlian volunteers with local cancer, health and political organizations and currently serves as vice president of the International Federation of Dental Hygienists.

ADHA members can access the full article online by linking directly to the Journal of Dental Hygiene through the Members section of the ADHA Web site. To view journal articles, log in to the Members section of the ADHA Web site and click on the Member Resources link. Scroll down to the Journal of Dental Hygiene link, which will take you directly to a list of all the available issues online.

This column was made possible by an educational grant sponsored by Colgate Oral Pharmaceuticals.