Periodontal disease and premature low-birth-weight babies.

In America, nearly 12 percent of babies are born prematurely, increasing their risk of death and developmental and intellectual disabilities, vision and hearing loss, and lung and gastrointestinal problems. (1) Studies have shown that women with periodontal disease are seven times more likely to deliver low-birthweight babies prematurely. (1) This disease may be as harmful to pregnancy as alcohol and smoking. In light of this research, it is a dental professional's duty to inform their pregnant patients of the risks associated with periodontal disease. By explaining this disease, identifying its risk factors and discussing its treatment with pregnant women, we can reduce this statistic and promote the well-being of mother and child. Although much more research into the relationship of periodontal disease and poor birth outcomes is needed, dental hygienists can apply their knowledge of preventive oral health care in treating and educating the pregnant patient.

As periodontal pathogens (e.g., Porphyromonas gingivalis, Escherichia coil and Fusobacteriurn nucleaturn) exist in periodontal pockets, they have the ability to travel in the bloodstream and affect other areas of the body. As this happens, the body will attempt to fight off the bacteria by producing prostaglandin, a natural fatty acid involved with inflammation control and smooth muscle contraction that induces labor. High levels of prostaglandins may signal to the body to begin labor, and the baby may be born prematurely. (3) As early as the early 1900s, it had been hypothesized that oral infection such as periodontitis could act as a source of bacteria and inflammatory mediators that could reach the fetal-placental unit via blood circulation and induce pregnancy complications. (4)

According to the National Institute of Dental and Craniofacial Research, as many as 18 percent of preterm, low-birth-weight babies born in the United States each year may result from oral infections (Mayo Foundation for Medical Education and Research). (5) Over half of all pregnant women today experience signs and symptoms of gingivitis. Studies show that if gingivitis is left untreated, it may progress into periodontal disease. (2) A five-year study conducted at the University of North Carolina states that pregnant women with mild to severe periodontal disease are seven times more likely to deliver a premature low-birth-weight baby. (1) Periodontal disease releases toxins into the mother's bloodstream, and this has the potential to prematurely trigger cytokines and prostaglandin.

One of the bacteria strongly associated with premature, low-birth-weight babies is P. gingivalis. Once the toxin from this bacterium reaches the placenta, it can interfere with the growth and development of the fetus. (1) Periodontal disease can also stimulate a pregnant woman's body to produce inflammatory chemicals that can cause the cervix to dilate and set off uterine contractions, resulting in a premature low-birth-weight baby. (6)

Preterm birth is gestation that lasts less than 37 weeks. Low birth-weight is a weight less than 5 pounds 8 ounces. (6) It is suggested that bacteria from the oral cavity may be transmitted through the body to the amniotic fluid, which in turn could cause intrauterine infection. (8) The same oral bacteria that cause periodontal disease has also been found in the amniotic fluid. (7) In one study, George Gamonal, faculty of dentistry, University of Chile, evaluated 26 pregnant women with a diagnosis of threatened premature labor. The researchers found P. gingivalis in both the oral cavity and the amniotic fluid of 30 percent of the subjects. (7) In a similar study, another type of bacteria contributing to periodontitis was found in both the oral cavity and intrauterine fluid. This study examined bacterial DNA from a patient who had an intrauterine infection. The researchers identified bacteria contributing to periodontitis in the oral cavity but not the vaginal tract; therefore, the lower genital tract could not have been the source of the bacteria. This evidence suggests that the bacteria involved in the intrauterine infection could have originated in the oral cavity. (8)

During pregnancy, a woman's body undergoes major changes, including hormonal changes that alter the gingival tissues. This, alone or in combination with poor oral hygiene, can predispose the patient to gingivitis. When gingivitis is evident, both the dental hygienist and the pregnant patient should make every effort to reverse or control the progress of the disease. One of the first things that should be discussed with the expectant mother is proper toothbrushing and flossing techniques. If the patient is vomiting as a consequence of her pregnancy, she should be advised to rinse the mouth with water and then brush her teeth to neutralize the acid. It may also be beneficial to suggest a well-balanced diet including plenty of vitamins C and B 12.

Early detection and prevention of periodontitis is essential to having a healthy, full-term baby. Prevention of gingivitis and periodontal disease depends on the expectant mother's keeping her regular hygiene appointments and performing excellent oral hygiene care at home. This is why it is imperative that patients understand proper oral hygiene instructions. Research has found that if women who are pregnant would receive proper periodontal care and treatment of periodontal disease, premature births might be reduced by about 45,000 each year, representing a cost savings of almost $1 billion in intensive neonatal care. (9) A report published in the Journal of Periodontology states that women less than 35 weeks pregnant who received scaling and root planing reduced premature births by 84 percent. (8)

Motivation to protect an unborn child in every way possible should be every expectant mother's main priority. The pregnant woman should take care of herself in all aspects of her life because everything that affects her also has the potential to affect her baby. Pregnant women should be advised to seek dental care early in pregnancy and continue with regular dental hygiene appointments. Health care providers from different disciplines can work together to ensure that pregnant patients get the help they need to avoid pregnancy complications. In addition to educating the pregnant patient, the dental hygienist is an ideal health provider to provide oral health information to her other health care providers, including obstetricians, physicians, nurses and assistants. (4)

Although the exact association between oral bacteria and low-birth-weight babies is not clear, having gingivitis or periodontal disease appears to trigger substances that induce labor. Further study on this topic is needed. In the meantime, having pregnant women understand risk factors and importance of meticulous oral hygiene during pregnancy can only be beneficial to the health of mother and child.

References

(1.) Nevada State Health Division Web site. http://health2k.state.nv.us/oral/ SpeciaIFolder/pg.4index.html. Accessed Mar. 2008.

(2.) Capelli D, Mobley C. Epidemiology/biology of periodontal diseases. In Capelli D, Shulman J. Prevention in clinical oral health care. St. Louis: Mosby; 2008:14

(3.) Pitiphat W, Joshipura KJ, Gilman MW et al. Maternal periodontics and adverse pregnancy outcomes. Community Dent Oral Epidemiol 2008; 36: 3-11.

(4.) Gurenlian J. Commentary on "obstetricians' knowledge and practice behaviors concerning periodontal health and preterm delivery and lower birth weight. Access 2007; 21(10): 32-35.

(5.) Mayo Foundation for Medical Education and Research. Oral health and overall health: Why a healthy mouth is good for your body. www.mayoclinic.com/ healthy/dental/DE00001; 2005. Accessed Feb. 2008.

(6.) Brody JE. www.nytimes.com/Specials/women/warchive/961009-1309.html. Accessed May 2008.

(7.) Gamonal G. 'Mouth' bacteria found in amniotic fluid. Available at http://scientificblogging.com/news/mouth_bacteria found in amniotic_fluid. Accessed Jul. 25, 2008.

(8.) Ham Y, Ikegami A, Bissada Net al. Transmission of an uncultivated bergeyella strain from the oral cavity to amniotic fluid in a case of preterm birth. J Clin Microbiol 2006; 44: 1475-83.

(9.) Baby steps to healthy pregnancy and on time delivery. Available at http://perio.org/consumer/pregnancy.htm. Accessed June 2008.

Jennifer Aucoin, originally from Eunice, La., is a senior dental hygiene student at Louisiana State University (LSU) School of Dentistry in New Orleans, Louisiana. She is excited to begin her senior year, but even more excited to begin her career as a dental hygienist. Christina Hanes is a senior dental hygiene student at LSU School of Dentistry. She lives in LaPlace, La., with her younger brother and two wonderfully supportive parents. She is an active member of the student chapter of ADHA at LSU and is extremely proud of her success in the dental hygiene program. She can't wait to start her career as a dental hygienist! Jenna Hood is a native of Donaldsonville, La. She is currently in her second year of the dental hygiene program at LSU School of Dentistry. Rachel VonGruben grew up in Baton Rouge, La. She attended LSU and received a Bachelor of Science in Biological Sciences before attending LSU Health Science Center's School of Dental Hygiene. After school, she hopes to practice as a dental hygienist in a pediatric dentist's office.