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Review of the oral disease-systemic disease link. Part II: preterm low birth weight babies, respiratory disease.

Canadian Dental Hygienists Association Position Statements

Preterm preterm /pre·term/ (-term´) before completion of the full term; said of pregnancy or of an infant.

 low birth weight babies

In light of the possible association between periodontal disease Periodontal Disease Definition

Periodontal diseases are a group of diseases that affect the tissues that support and anchor the teeth. Left untreated, periodontal disease results in the destruction of the gums, alveolar bone (the part of the jaws where
 and preterm low birth weight (PT/LBW) babies, women who are considering pregnancy or who are pregnant should have access to oral health services health services Managed care The benefits covered under a health contract  (including oral health promotion, disease prevention, and treatment), regardless of their income. In addition, dental hygienists should consider incorporating the following strategies into their practices:

* Educate pregnant women and those planning pregnancy regarding the possible impact of periodontal infection on pregnancy outcomes and benefits of treatment.

* Consider periodontal examinations and as-needed periodontal therapy as a necessary part of prenatal care prenatal care,
n the health care provided the mother and fetus before childbirth.
 for all women who are pregnant or planning pregnancy.

* Provide preventive oral care as early in pregnancy as possible, and throughout the pregnancy.

* Consider consultation with the clients' health care professionals to advise them of the diagnosis and treatment considerations.

* Increase interprofessional collaboration and communication between dental hygienists and public health prenatal programs in order to formalize support for pregnant women. These new opportunities can focus on oral/general health assessments, leadership capacity, policy development, surveillance, program delivery and evaluation.

Respiratory disease

In light of the clear association between periodontal disease and pneumonia in health-compromised seniors in intensive and long-term care long-term care (LTC),
n the provision of medical, social, and personal care services on a recurring or continuing basis to persons with chronic physical or mental disorders.
, high-risk seniors should have access to oral health services (including oral health promotion, disease prevention- and treatment), regardless of their income. In addition, dental hygienists should consider incorporating the following dental hygiene dental hygiene
The practice of keeping the mouth, teeth, and gums clean and healthy to prevent disease. Also called oral hygiene.
 diagnosis and treatment issues into their practices:

* Provide disease prevention and treatment services for individuals at high risk for pneumonia, who are in intensive care units and long-term care facilities.

* Provide in-service training on oral health education to intensive care unit and long-term care facility staff.

* Increase interprofessional collaboration and communication between dental hygienists and long-term care facilities, and critical care units of hospitals. These new opportunities can focus on oral/general health assessments, leadership capacity, policy development, surveillance, program delivery and evaluation.

Keywords: Infant, low birth weight; Meta-analysis; Oral hygiene Oral Hygiene Definition

Oral hygiene is the practice of keeping the mouth clean and healthy by brushing and flossing to prevent tooth decay and gum disease.
; Periodontal diseases; Respiratory tract respiratory tract
The air passages from the nose to the pulmonary alveoli, including the pharynx, larynx, trachea, and bronchi.

Respiratory tract 
 diseases; Review literature

Declarations de l'Association canadienne des hygienistes dentaires

Bebes prematures de poids insuffisant a la naissance

Compte tenu de l'association possible entre la maladie parodontale et les bebes prematures de poids insuffisant a la naissance, les femmes qui songent a une grossesse ou celles qui sont enceintes devraient avoir acces a des services de sante buccodentaire (incluant la promotion de la sante buccodentaire, la prevention de la maladie et le traitement) peu importe leurs revenus. De plus, les hygienistes dentaires devraient considerer l'integration des strategies suivantes dans leur pratique pra·tique  
Clearance granted to a ship to proceed into port after compliance with health regulations or quarantine.

[French, from Old French practique, from Medieval Latin

* Eduquer les femmes enceintes et celles qui planifient une grossesse concernant les repercussions repercussions nplrépercussions fpl

repercussions nplAuswirkungen pl 
 possibles d'une infection parodontale sur les resultats de la grossesse et sur les avantages du traitement.

* Considerer les examens parodontaux et, au besoin AU BESOIN. This is a French phrase, used in commercial law. When the drawer of a foreign bill of exchange wishes as a matter of precaution, and to save expenses, he puts in the corner of the bill, "Au besoin chez Messieurs or, in other words, "In case of need, apply to Messrs. , le traitement parodontal comme un element necessaire des soins prenatals pour toutes les femmes qui sont enceintes ou qui planifient une grossesse.

* Prodiguer des soins buccodentaires preventifs aussitot que possible dans la grossesse et tout au long de celle-ci.

* Considerer une consultation avec les professionnels en soins de sante des clientes afin de les informer du diagnostic et des traitements envisages.

* Augmenter la collaboration et la communication interprofessionnelles entre les hygienistes dentaires et les programmes prenatals des services de sante publique afin d'officialiser le soutien apporte aux femmes enceintes. Ces nouvelles possibilites d'action peuvent englober les evaluations de l'etat de sante generale et de l'etat de sante buccodentaire, la capacite de leadership, le developpement de politiques, la surveillance, la mise en oeuvre de programmes et l'evaluation.

Maladies respiratoires

Compte tenu de l'association evidente entre la maladie parodontale et la pneumonie chez chez  
At the home of; at or by.

[French, from Old French, from Latin casa, cottage, hut.]


at the home of [French]
 les personnes agees fragilisees admises dans les unites de soins intensifs et de soins de longue duree, les personnes agees a haut risque ris·qué  
Suggestive of or bordering on indelicacy or impropriety.

[French, from past participle of risquer, to risk, from risque, risk; see risk.]

 devraient avoir acces a des services de sante buccodentaire (incluant la promotion de la sante buccodentaire, la prevention de la maladie et le traitement) peu importe leurs revenus. De plus, les hygienistes dentaires devraient considerer l'integration des strategies suivantes de diagnostic et de traitement en hygiene dentaire dans leur pratique:

* Offrir des services de prevention et de traitement de la maladie aux personnes a haut risque pour la pneumonie qui se trouvent les unites de soins intensifs et dans les etablissements de soins de longue duree.

* Offrir de la formation interne in·terne
Variant of intern.
 portant sur l'education en sante buccodentaire au personnel des unites de soins intensifs et des etablissements de soins de longue duree.

* Augmenter la collaboration et la communication interprofessionnelles entre les hygienistes dentaires et les etablissements de soins de longue duree et les unites de soins intensifs des hopitaux. Ces nouvelles possibilites d'action peuvent englober les evaluations de l'etat de sante generale et l'etat de sante buccodentaire, la capacite de leadership, le developpement de politiques, la surveillance, la mise en oeuvre de programmes et l'evaluation.

CDHA CDHA Capital District Health Authority
CDHA Canadian Dental Hygienists Association
CDHA California Dental Hygienists' Association
CDHA Center for Demography of Health and Aging
CDHA Connecticut Dental Hygienists' Association
 Position Paper


IN 2004, CDHA PUBLISHED A PAPER TITLED "YOUR Mouth--Portal to Your Body. CDHA Position Paper on the Links between Oral Health and General Health. (1) The evidence from this paper, although preliminary, supports the conclusion that oral diseases may have an association with the occurrence and severity of the following conditions: diabetes mellitus diabetes mellitus

Disorder of insufficient production of or reduced sensitivity to insulin. Insulin, synthesized in the islets of Langerhans (see Langerhans, islets of), is necessary to metabolize glucose. In diabetes, blood sugar levels increase (hyperglycemia).
, heart disease, preterm low birth weight babies, and lung disease lung disease Pulmonary disease Pulmonology Any condition causing or indicating impaired lung function Types of LD Obstructive lung disease–↓ in air flow caused by a narrowing or blockage of airways–eg, asthma, emphysema, chronic bronchitis; . In addition, oral hygiene treatment was found to improve diabetic control of type 2 diabetes type 2 diabetes
See diabetes mellitus.
 and to reduce the risk of premature birth premature birth

Birth less than 37 weeks after conception. Infants born as early as 23–24 weeks may survive but many face lifelong disabilities (e.g., cerebral palsy, blindness, deafness).
 and low birth weight. Following the publication of the 2004 position paper, substantial new research on this topic has been published. This current position paper updates the 2004 paper with a growing body of research that supports a link between oral diseases and systemic diseases. This new position paper is divided into two sections; the first section covered heart disease and diabetes and was published in the November-December 2006 issue of this journal. The second section, in this issue of the journal, covers preterm low birth weight babies and respiratory disease.

Other oral health organizations have issued position papers on this topic that lend support to CDHA's position. These specific positions are identified in more detail in the separate sections of this paper.

The year following CDHA's first position paper on this topic, the Canadian Dental Association The Canadian Dental Association, also known as the Association dentaire canadienne in French was founded in 1902. It is a non-profit professional association representing Canada's 18,000 dentists.  (CDA (1) (Compact Disc Audio) The compact disc file extension that is seen on the computer in Explorer or some other file manager. CDA files are actually pointers to the locations of the individual tracks on the CD medium. See CD-DA. ) issued a statement that takes a reserved, somewhat cautious approach to the topic. Although the CDA notes that the U.S. Surgeon General The U.S. Surgeon General is charged with the protection and advancement of health in the United States. Since the 1960s the surgeon general has become a highly visible federal public health official, speaking out against known health risks such as tobacco use, and promoting disease  highlights a bi-directional interaction between oral and systemic health, CDA recommends that "further emphasis should be placed on research and educating dentists, physicians, students, residents, other healthcare professionals and most importantly patients regarding the importance of these possible relationships." (2)

Periodontal disease is considered the most prevalent chronic disease affecting children, adolescents, adults, and the elderly. (3) In addition, periodontal disease is an infectious disease Infectious disease

A pathological condition spread among biological species. Infectious diseases, although varied in their effects, are always associated with viruses, bacteria, fungi, protozoa, multicellular parasites and aberrant proteins known as prions.
 that may be transmitted from one person to another. In the United States, there are recent national statistics indicating the prevalence of periodontal disease is between 3.8% and 12.3% of the population. (4) Similar recent Canada--wide information is not available; however, 35 years ago, 15% of Canadians aged 19 years and over had periodontal pockets. (5)

A more recent but partial picture of Canadian data comes from several provincial studies. In 1986, a Saskatchewan study indicated that of those aged 30 to 44 years, 34% had 4 or 5 mm periodontal pockets and 15% had periodontal pockets ([greater than or equal to]) 6 mm. (6) In addition, a 2001 Quebec study indicates that people with low family income, men, and persons living in metropolitan areas are at higher risk of having at least one tooth with a pocket ([greater than or equal to]) 6 mm. (7) New developments indicate that Canada is beginning to address some of the oral health data gaps. Dr. Peter Cooney, Canada's Chief Dental Officer The Chief Dental Officer is an official position created by the Government of Canada to improve the oral health status of Canadians and to increase awareness about the prevention of oral diseases. , has developed an oral health component of the Canadian Health Measures Survey. The statistics gathered will not only provide us with national prevalence rates but will also assist in determining the extent of the relationship between oral health and systemic health.


The methodological approach in this paper is a comprehensive review of systematic reviews, meta-analysis, literature reviews, and clinical trials on the connection between periodontal diseases and systemic diseases, specifically preterm/low birth weight babies, and respiratory disease. The research question was: What is the relationship between periodontal disease and preterm low birth weight babies and respiratory disease? This question was used to develop the following search terms: periodontal disease, periodontal diseases, periodontitis periodontitis

Inflammation of soft tissues around the teeth (see tooth). Poor dental hygiene leads to deposition of bacterial plaque on the teeth below the gum line, irritating and eroding nearby tissues.
, preterm birth, preterm births, low birth weight, low birth weights, pregnancy and pregnancy outcomes, respiratory disease, respiratory diseases, and chronic obstructive pulmonary disease chronic obstructive pulmonary disease
n. Abbr. COPD
A chronic lung disease, such as asthma or emphysema, in which breathing becomes slowed or forced.
, pneumonia, lung disease, and respiratory tract infections.

The literature was limited to English language human studies in MedLine, Cochrane controlled trials register, and Google Scholar from 2003 to March 2006. The database search retrieved four articles pertaining to PT/LBW and four articles pertaining to respiratory disease; all of these articles were included in this review as they met quality standards. The search also included reference lists of published review papers to identify additional articles. The search also included "gray" literature--information not reported in the scientific periodical literature--and web sites known to contain publications on this topic. Consultation with two recognized topic experts, Salme Lavigne and Dr. Howard Tenenbaum, took place at a number of developmental stages and a consultation on the draft paper took place with CDHA members and other topic experts.


Literature Review

The World Health Organization defines preterm birth as birth prior to 37 weeks of gestation and low birth weight as babies born under 2500 grams. (8) In Canada, the preterm birth rate has been increasing recently. In 2000, the preterm birth rate was 7.6 per 100 live births, compared with 6.6 per 100 live births in 1991. (9) There is regional variation in this rate, with a low of 5.8 in Prince Edward Island Prince Edward Island, province (2001 pop. 135,294), 2,184 sq mi (5,657 sq km), E Canada, off N.B. and N.S. Geography

One of the Maritime Provinces, Prince Edward Island lies in the Gulf of St.
 to a high of 10.4 in Nunavut. (9) There has also been a recent rise in the incidence of low birth weight, which may be explained by a decline in infant mortality rate infant mortality rate
The ratio of the number of deaths in the first year of life to the number of live births occurring in the same population during the same period of time.
 and an increase in multiple births. Low birth weight rates in Canada in 1996 ranged from a low of 4% in the Yukon to a high of 9% in Newfoundland. (10)

The consequences of preterm birth (PTB PTB Physikalisch Technische Bundesanstalt (Germany)
PTB Partido Trabalhista Brasileiro (Brazilian Labor Party)
PTB Phosphotyrosine-Binding
PTB Powers That Be
PTB Power Tab
) and PT/LBW babies are staggering. The infant morbidity and mortality Morbidity and Mortality can refer to:
  • Morbidity & Mortality, a term used in medicine
  • Morbidity and Mortality Weekly Report, a medical publication
See also
  • Morbidity, a medical term
  • Mortality, a medical term
 (11) associated with PT/LBW create a significant economic drain on the health system, and social and emotional problems for the families involved who often manage long-term disabilities in their children. Preterm birth accounts for 75% to 85% of all perinatal mortality in Canada and is considered an important determinant of neonatal and infant morbidity, including neurodevelopmental handicaps, such as cerebral palsy cerebral palsy (sərē`brəl pôl`zē), disability caused by brain damage before or during birth or in the first years, resulting in a loss of voluntary muscular control and coordination. ; chronic respiratory problems; infections; and ophthalmological problems. (12)

Research as early as 1931 found that periodontal diseases in the mother may have harmful effects on the developing fetus. (13) CDHA's 2004 position paper reports on the results from case-controlled, prospective, and intervention studies intervention studies, the epidemiologic investigations designed to test a hypothesized cause and effect relation by modifying the supposed causal factor(s) in the study population.
 and two randomized controlled trials. It concludes that there is a possible link or correlation between periodontal disease and PLBW and preterm birth and that women with periodontal disease may have a 4 to 7.9 odds ratio (OR) of having a preterm birth than women with good oral health. (1) These findings are consistent with former studies that indicate chronic infection plays an important role in PT/LBW, including bacterial vaginosis Bacterial Vaginosis Definition

Bacterial vaginosis (BV) is a type of vaginal infection in which the normal balance of bacteria in the vagina is disrupted, allowing the overgrowth of harmful anaerobic bacteria at the expense of protective bacteria.
 (BV), (14,15) genitourinary genitourinary /gen·i·to·uri·nary/ (jen?i-to-u´ri-nar-e) pertaining to the genital and urinary organs.

adj. Abbr.
 infections, (16,17) kidney infection kidney infection Pyelonephritis, see there  and pneumonia. (11) The CDHA position paper also indicated that there is preliminary evidence that periodontal treatment during pregnancy may reduce the incidence of adverse pregnancy outcomes. (1) Other research not included in the CDHA position paper and conducted following the publication of the paper also support this conclusion. (18,19)

The American Academy of Periodontology American Academy of Periodontology (AAP), a nonprofit professional association of dental professionals specializing in the prevention, diagnosis, and treatment of diseases affecting the periodontium and in the placement and maintenance of dental implants.
 issued a position statement in 2004, the same year as CDHA's first statement, recommending that "women who are pregnant or planning pregnancy undergo periodontal examinations ..." and that "preventive oral care services should be provided as early in pregnancy as possible. However, women should be encouraged to achieve a high level of oral hygiene prior to becoming pregnant and throughout their pregnancies." (13) Other groups approved the content of this statement, including the American College of Obstetricians and Gynecologists The American College of Obstetricians and Gynecologists (ACOG) is a professional association of medical doctors specializing in obstetrics and gynecology in the United States. It has a membership of over 49,000[1] and represents 90 percent of U.S. , the U.S. March of Dimes
For the Canadian charitable organization, see Ontario March of Dimes and March of Dimes Canada.
March of Dimes is the name of a United States health charity, whose mission is to improve the health of babies.
, and the U.S. National Nursing Association. (20) Furthermore, consumer groups are also taking a stand on this topic to demand better services for the public. In 2001, the U.S. National Healthy Mothers, Healthy Babies Coalition published the following position statement, "... oral health care during pregnancy is crucial and should be made available to all women, regardless of their income level." (21)

Another measure of the growing importance of this topic in our society is the degree of emphasis that research centres place on this topic. At present, the U.S. National Institute of Dental and Craniofacial Research The National Institute of Dental and Craniofacial Research (NIDCR), is part of the U.S. National Institutes of Health, and as such its function is to the promote the general health of the American people, by improving their oral, dental and craniofacial health.  (NIDCR NIDCR National Institute of Dental and Craniofacial Research. ) has made a significant investment in research on this topic, with a large $20 million research project that includes two independent multi-centre clinical trials. This research involves approximately 2,600 pregnant women.

Although the mechanism of action is still unclear, three mechanisms (figure 1) have been proposed to explain how periodontal disease may influence preterm low birth weight babies: (1)


* Periodontal infection causes the release of prostaglandins into systemic circulation systemic circulation
Circulation of blood throughout the body through the arteries, capillaries, and veins, which carry oxygenated blood from the left ventricle to various tissues and return venous blood to the right atrium.

* Lipopolysaccharides lipopolysaccharides
(lip´ōpol´ēsak´rādz´), a compound or complex of lipid and carbohydrate.
 from cell walls of periodontal pathogens trigger the release or production of prostaglandins.

* Translocation translocation /trans·lo·ca·tion/ (trans?lo-ka´shun) the attachment of a fragment of one chromosome to a nonhomologous chromosome. Abbreviated t.  of the periodontal micro-organisms to the fetoplacental unit fetoplacental unit Obstetrics A functional compartment responsible for synthesizing hormones that maintain pregnancy. See Estriol.  and stimulate the release of prostaglandins.


In 2003, a systematic review of twelve studies concluded that periodontal disease may be a risk factor for PT/LBW and there is preliminary evidence suggesting that periodontal intervention may reduce adverse pregnancy outcomes. (22) The review included six case control, (23-28) three cross-sectional and longitudinal, (29-31) and three intervention studies. (18,19,32) Due to study heterogeneity, meta-analysis was not possible.

A 2004 review on this topic included nine studies: four case control, (23,25-27) two prospective, (24,29) one prospective cohort, (32) one intervention, (19) and one cohort. (18) The review concludes that periodontal disease may act as a risk factor for PLBW. (33)

A 2005 meta-analysis of five observational studies observational studies, an investigational method involving description of the associations be-tween interventions and outcomes. Outcomes research and practice audits are examples of this investigational method.
 concludes that periodontal diseases in the pregnant mother significantly increase the risk of preterm birth or low birth weight. (12) This meta-analysis included two case-control studies and three prospective cohort studies. (18,23,24,29) These studies showed that pregnant women with periodontal disease have an adjusted odds ratio of 4.28 (95% CI, 2.62-6.99; P<0.005) for preterm birth and 5.28 (95% CI, 2.21-12.62; P<0.005) for preterm low birth weight babies. The authors identify several limitations to this meta-analysis; the most striking limitations include the poor-to-fair quality of the studies and the considerable variation in the definition of exposures and outcomes from one study to the next.

In 2006, a systematic review of 25 studies, from 14 countries, concluded that periodontal disease may be associated with an increased risk of adverse pregnancy outcome (including PT/LBW, LBW LBW Low birth weight, see there , preterm birth weight by gestational age ges·ta·tion·al age
See estimated gestational age.

Gestational age
The estimated age of a fetus expressed in weeks, calculated from the first day of the last normal menstrual period.
, miscarriage or pregnancy loss, and preeclampsia preeclampsia /pre·eclamp·sia/ (pre?e-klamp´se-ah) a toxemia of late pregnancy, characterized by hypertension, proteinuria, and edema.

). (34) The studies included 13 observational studies, case control, cross-sectional, (23,26,27,35-44) 9 cohort studies, (9,19,28-30,45-48) and 3 controlled trials (2 were RCTs). (18,32,49)

There were 18 studies suggesting an association between periodontal disease and increased risk of adverse pregnancy outcome (ORs ranging from 1.10 to 20.0) and 7 studies found no evidence of an association (ORs ranging from 0.78 to 2.54). Three clinical trial intervention studies, two of which were randomized controlled trials, suggest that oral prophylaxis periodontal treatment can lead to a 57% reduction in PT/LBW (pooled RR 0.43; 95% CI 0.24-0.78) and a 50% reduction in preterm births (RR 0.5; 95% CI 0.20-1.30). The authors note that it was not appropriate to calculate the pooled risk in the case-control and cohort studies, due to heterogeneity. The authors also note some of the drawbacks to the studies, which include a large variation in the definition of periodontal disease status, small sample size in many of the studies, and a potential bias due to confounding effect of other variables, which were not controlled for in 15 of the 23 studies. (The two RCTs did not have potential bias from confounding variables.) The authors note that the effects of periodontal disease on adverse pregnancy outcomes may be different according to the socio-economic status and access to dental care, with studies of economically disadvantaged women.

In 2006, a systematic review concluded that periodontal disease is not a causal risk factor for PT/LBW. (50) Of the nine case-control studies, five found a relationship between periodontal disease and PT/LBW with odds ratios ranging from 3.4 to 7.9. Of the four cohort studies, two supported an association and two did not. Of the four intervention studies, two found a reduction in the incidence of PT/LBW following dental hygiene treatment, with one of these studies using a randomized ran·dom·ize  
tr.v. ran·dom·ized, ran·dom·iz·ing, ran·dom·iz·es
To make random in arrangement, especially in order to control the variables in an experiment.
 controlled methodology. Two other intervention studies found no reduction in the incidence of PT/LBW. Of the two systematic reviews, both concluded that periodontal disease may be a risk factor for PT/LBW, but the evidence is limited.

Another 2005 randomized controlled trial was not included in the above reviews and is therefore reported separately. (51) Study participants included 870 pregnant women with gingivitis gingivitis (jĭn'jəvī`tĭs), inflammation of the gums. It may be acute, subacute, chronic, or recurrent. The gums usually become red, swollen, and spongy, and bleed easily. . At 28 weeks, the treatment group received plaque removal, scaling every two to three weeks and daily rinsing with 0.12% chlorhexidine chlorhexidine /chlor·hex·i·dine/ (klor-heks´i-den) an antibacterial effective against a wide variety of gram-negative and gram-positive organisms; used also as the acetate ester, as a preservative for eyedrops, and as the gluconate or . After adjusting for several known risk factors, women with gingivitis in the control group had a significantly higher risk of PT/LBW than women who received periodontal treatment (OR 2.76; 95% CI 1.29-5.88; P=0.008).


There are several drawbacks to the reviews. First, although there is an internationally accepted World Health Organization definition of low birth weight (birth weight of <2500g), (52) some of the reviews did not report on their adherence to this definition. In addition, a number of the studies did not use consistent definitions of periodontal disease. Second, the 2003 systematic review by Scannapieco et al. identifies some of the drawbacks to comparing the studies, including the lack of a standard measure for periodontal disease, or which periodontal disease is being measured. Third, since risk factors such as race, low socio-economic status, low educational levels, tobacco, drug and alcohol abuse are common risk factors for PLBW and periodontitis, (22) the studies should have more consistently mentioned controlling for these variables, or used subsets of these risk factors. Fourth, the 2005 meta-analysis of five observational studies indicates a wide range in the confidence interval confidence interval,
n a statistical device used to determine the range within which an acceptable datum would fall. Confidence intervals are usually expressed in percentages, typically 95% or 99%.
 for PTLBW PTLBW Preterm and Low Birth Weight  OR, pointing to caution in the claim.

Cassolato et al.'s 2006 review (50) sets out to determine a causal link between periodontal disease and PT/LBW and concludes that none exists. However, only RCTs can determine this. This means that although the literature does not support a causal link, it does not mean that one does not exist. It simply means that the research available for analysis did not allow an assessment of this question. A second critique of this review is that the authors appear to treat all of the studies equally. However, Lopez's RCT RCT Randomized Controlled Trial
RCT Regimental Combat Team (infantry regiment with their own artillery, engineers, medical and tanks)
RCT Rollercoaster Tycoon
RCT Randomized Clinical Trial
RCT Rhondda Cynon Taff
 may have been given extra weight in the argument, given that it was a gold standard research design.

The balance of this preliminary evidence supports an association between periodontal disease and PT/LBW. This review included a total of 51 studies, with 44 studies concluding that there may be an association between periodontal disease and preterm low birth weight babies. Only 7 studies concluded that there is no evidence of an association and these studies were not high-level evidence, as the studies were observational, case control, cross-sectional, and cohort. The strongest evidence comes from the one controlled trial (CT) and three randomized controlled trials, which are considered the gold standard. The CT shows striking evidence that dental hygiene services may be associated with a 50% risk reduction in PT/LBW and one RCT (Lopez et al. 2005) shows that dental hygiene services result in an OR of 2.76.

Meta-analysis using randomized control trials (RCTs) is the gold standard; however, the 2005 meta-analysis reports only on a meta-analysis of observational studies. Meta-analyses such as the one reported here, using observational studies, have become popular in biomedical bi·o·med·i·cal
1. Of or relating to biomedicine.

2. Of, relating to, or involving biological, medical, and physical sciences.
 literature and there are guidelines for reporting them. (53) The odds ratio estimate from the meta-analysis of observational studies reported in Khader et al. (12) (5.28 for PT/LBW and 4.28 for PTB) is consistent with the odds ratio from an RCT reported in the 2004 CDHA position paper. However, there are a number of limitations to Khader's meta-analysis. First, it does not follow accepted guidelines for reporting meta-analysis of observational studies. Second, there are limitations in the use of the odds ratio, since observational studies are commonly influenced by confounding and selection bias, which may distort the findings. In fact, some authors claim that statistical combination of data should not be a prominent feature of reviews of observational studies. (54) Third, the author combines results from different study designs without a discussion of the heterogeneity of the studies and the limitations of this approach. The results may indicate a possible association; however, the authors' conclusions that "periodontal disease significantly increases the risk of PLBW" may have somewhat limited applicability given the limitations of the study. These concerns point to caution in the claim for a causal relationship between periodontal disease and PT/LBW babies.

To determine a causal relationship will require a meta-analysis of high-quality randomized controlled trials. Therefore, additional longitudinal, randomized controlled clinical trials randomized controlled clinical trials, medical research studies in which one or more groups are formed by random assignment to treatments and controls. Allows groups to be more equivalent when comparing he effects of treatment.
 are needed that evaluate the efficacy and cost-effectiveness of different types of periodontal intervention on adverse pregnancy outcomes.

In light of the possible association between periodontal disease and PT/LBW, there should be increased interprofessional collaboration and communication between dental hygienists and prenatal programs in order to formalize support for pregnant women. These new opportunities can focus on oral/general health assessments, leadership capacity, policy development, surveillance, program delivery and evaluation. Due to the high social and economic costs associated with PT/LBW, the role of preventing oral infection in pregnant women may be an important one when planning the public health of Canadians. Dental hygienists should become more involved in educating clients about this association and providing early oral hygiene services for pregnant women and those considering pregnancy. This can be accomplished through a greater role for dental hygienists in public health programs targeting pregnant women, such as the Public Health Agency of Canada's Prenatal Nutrition Program. Dental hygienists could play an important role in achieving the program goal of reducing unhealthy birth weights.


Literature Review

The 2004 CDHA position paper concludes that there is a moderate association between periodontal disease and respiratory disease, with an odds ratio of approximately 3.04 for those at risk of developing respiratory disease. (1) The following statistics on respiratory disease incidence, impact on health, and health system expenses provide a rationale for the need to continue this research.

Respiratory disease is a leading cause of death in Canada, accounting for approximately 10% of all deaths.55 In Canada in 2000-2001, approximately 11% of hospitalizations were due to respiratory diseases. (56) Over 3 million people of all ages in Canada were coping with serious respiratory diseases in 2001, and the expenses associated with these diseases account for nearly $12.18 billion of expenditures per year, including direct and indirect costs. (57)

Many of the studies examining the link between periodontal disease and lung disease focus on nosocomial nosocomial /noso·co·mi·al/ (nos?o-ko´me-il) pertaining to or originating in a hospital.

1. Of or relating to a hospital.

 (hospital-acquired) pneumonia, or community-acquired pneumonia community-acquired pneumonia Pneumonia caused by an infection currently present in the community; CAP is the most common cause of infectious death–US, and number 6 killer overall; of the 57% of CAPs in which a pathogen is identified, S pneumoniae . In Canada, nosocomial pneumonia nosocomial pneumonia An infection of lungs–bronchoalveolar unit–in a Pt who has been hospitalized ≥ 48 hrs, and directly attributable to pathogens acquired during the hospital visit Etiology Pseudomonas spp, S aureus, Legionella  may be the second most common type of infection acquired in hospital. It is associated with the highest mortality rate57 and substantial morbidity in intubated, mechanically ventilated ven·ti·late  
tr.v. ven·ti·lat·ed, ven·ti·lat·ing, ven·ti·lates
1. To admit fresh air into (a mine, for example) to replace stale or noxious air.

 clients. (58,59) In acute care hospitals, as many as 13.7% of patients develop this infection. (60) The seriousness of hospital-acquired infections Hospital-Acquired Infections Definition

A hospital-acquired infection is usually one that first appears three days after a patient is admitted to a hospital or other health care facility.
 is underlined by the Canadian Nosocomial Infection Nosocomial infection
An infection that can be acquired in a hospital. ABPA is a nosocomial infection.

Mentioned in: Allergic Bronchopulmonary Aspergillosis, Hospital-Acquired Infections, Pseudomonas Infections

 Surveillance Program, in place since 1995. A 2005 report from the surveillance program indicates that rates of nosocomial acquisition of methicillin-resistent staphylococcus aureus (MRSA MRSA Methicillin-resistant Staphylococcus aureus. See MARSA. ) are on the rise with the rate of .91 out of 1000 admissions in 1997 increasing to 3.66 out of 1000 admissions in 2001. (61) In the United States, reported mortality rates from nosocomial pneumonia range from 20% to 50% and estimates place the total costs of this complication at $1.2 billion per year. (62) In Canada, community-acquired pneumonia accounts for 60,000 hospitalizations per year costing $100 million. (62)

Several biological mechanisms are hypothesized to explain the link between poor oral health and pneumonia. (1,63-66) (See figure 2.)

* Respiratory pathogens colonize col·o·nize  
v. col·o·nized, col·o·niz·ing, col·o·niz·es
1. To form or establish a colony or colonies in.

2. To migrate to and settle in; occupy as a colony.

 the oral cavity, dental plaque, and oral mucosa. These pathogens may be aspirated into the lower airway to cause infection in health compromised clients.

* Cytokines Cytokines
Chemicals made by the cells that act on other cells to stimulate or inhibit their function. Cytokines that stimulate growth are called "growth factors.
 originating from periodontal tissues may enter the blood and contribute to respiratory inflammation.


A 2006 Systematic Review classified the research evidence using the Canadian Task Force on Preventive Health Care: Quality of Evidence and Grades of Recommendations.67 Using evidence from 5 studies (four prospective cohort and one case-control, (68-72) they conclude that there is fair evidence of an association between respiratory diseases and oral health concludes (II-2, grade B recommendation). The odds ratio ranged from 1.2 to 9.6, depending on the oral health indicators. Using evidence from 10 studies (9 clinical trials, 3 non-randomized, (73-82) they found good evidence (I, grade A recommendation) that improved oral hygiene and frequent professional oral health care reduces occurrence of respiratory diseases among high-risk elderly adults in long-term care facilities and intensive care units. There was a low number needed to treat number needed to treat Decision-making The minimum number of Pts to whom a particular intervention must be administered in a trial or controlled study to prevent a single target event. See Absolute risk reduction, Odds ratio, Relative risk reduction, Threshold NNT.  (NNT NNT Number needed to Treat (medical)
NNT Numero Necesario a Tratar (Spanish: number needed to treat)
NNT Nassim Nicholas Taleb (author, essayist)
NNT Neural Network Toolbox
 = 2 to 16) and a high relative risk reduction (RRR See Required Rate of Return.  =34% to 83%). Using the evidence from four poor-to-fair studies, (83-86) they found a weak association between periodontal disease and chronic obstructive pulmonary disease (COPD COPD chronic obstructive pulmonary disease.

chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease (COPD) 

A 2003 systematic review of 21 studies reports on the impact of periodontal disease and other indicators of poor oral health on the initiation or progression of pneumonia. (87) The following studies on pneumonia in intensive care and nursing homes were included: 11 case control and cohort, (68-72,83,88-93) and 7 controlled trials (5 randomized). (73,76-80,94)

A large variety of different interventions were included in the 7 controlled trials, including the following: regular cleaning of the oral cavity vs. regular oral hygiene; PNV PNV Partido Nacionalista Vasco (Basque Political Party)
PNV Potential Natural Vegetation
PNV Prenatal Vitamins
PNV Park 'n View (trucker's term for park in view at truckstops)
PNV Potential Network Value
 (150mg of polymyxin B sulfate polymyxin B sulfate (sul´fāt),
n brand names: Aerosporin;
drug class: ophthalmic antiinfective;
action: inhibits cell wall permeability in susceptible organism;
, 1g of neomycin sulfate, 1 g of vancomycin hydrochloride per 60mL of 5% dextrose dextrose: see glucose. ) solution vs. placebo; chlorhexidine (CHX See Chicago Stock Exchange.


See Chicago Stock Exchange (CHX).
) oral rinse vs. placebo; CHX vs. isotonic isotonic /iso·ton·ic/ (-ton´ik)
1. denoting a solution in which body cells can be bathed without net flow of water across the semipermeable cell membrane.

 bicarbonate and oropharyngeal oropharyngeal /oro·pha·ryn·ge·al/ (-fah-rin´je-al)
1. pertaining to the mouth and pharynx.

2. pertaining to the oropharynx.
 aspiration; CHX oral rinse with ventilator weaning weaning,
n the period of transition from breast feeding to eating solid foods.


the act of separating the young from the dam that it has been sucking, or receiving a milk diet provided by the dam or from artificial sources.
 protocol(WP) vs. placebo and WP; topical antimicrobial prophylaxis: orabase[R] with gentamicin/colostin/vancomycin vs. placebo control: orabase[R] without antibiotics vs. control: no treatment; professional dental care once/day, plus gargling Gargling is a common method of cleansing the throat, especially if one has a sore throat or upper-respiratory virus or infection. The physical act of gargling usually requires that one tilts the head back, allowing a mouthful of liquid to sit in the upper throat.  swabbing with povidone iodine. A meta-analysis of the 5 randomized controlled trials with institutionalized in·sti·tu·tion·al·ize  
tr.v. in·sti·tu·tion·al·ized, in·sti·tu·tion·al·iz·ing, in·sti·tu·tion·al·iz·es
a. To make into, treat as, or give the character of an institution to.

 clients showed that a number of oral hygiene interventions, such as mechanical and/or topical chemical disinfection disinfection,
n the process of destroying pathogenic organisms or rendering them inert.

disinfection, full oral cavity,
n a procedure used to reduce active periodontal disease, usually completed within a certain short time frame.
 or antibiotics, reduced the incidence of nosocomial pneumonia by an average of 40%, in high-risk subjects.


Three additional intervention studies were published following the 2003 systematic review. They are included in this review as two of them are lengthy studies and the third is an RCT, which provides substantive weight to the argument for a connection between periodontal disease and respiratory disease. The findings from these studies are consistent with the systematic review findings. The first study examined 141 elderly persons in nursing homes who received weekly oral health care by dental hygienists for 24 months. The researchers found a ratio of fatal aspiration pneumonia that was significantly lower in the treatment group (2/40) than in the control group (non-treatment) (8/48) (p<.05). (74) The second study was a randomized clinical trial randomized clinical trial,
n a clinical study where volunteer participants with comparable characteristics are randomly assigned to different test groups to compare the efficacy of therapies.
 that included 561 subjects who were undergoing heart surgery. (75) The treatment group received Peridex 0.12% chlorhexidine gluconate oral rinse and the control group received Listerine (phenolic phe·no·lic
Of, relating to, containing, or derived from phenol.

Any of various synthetic thermosetting resins, obtained by the reaction of phenols with simple aldehydes and used as adhesives.
 mixture). For the patients intubated for more than 24 hours, the pneumonia rate was reduced by 58% (P=.06)

The third additional intervention study followed 417 participants from 11 nursing homes for two years. The participants were randomly assigned to an oral care group or a control group who received no oral care provided by caregivers or dental hygienists. (81) In the former group, nurses or caregivers brushed the residents' teeth after each meal with no dentifrice dentifrice /den·ti·frice/ (den´ti-fris) a preparation for cleansing and polishing the teeth; it may contain a therapeutic agent, such as fluoride, to inhibit dental caries.

, and a dental hygienist or a dentist administered plaque and calculus control as necessary once each week and povidone iodine was used in some cases. Pneumonia and death from pneumonia were both significantly lower in the oral care group, with a relative risk (RR) of 1.67 (95%CI= 1.01-2.75, P< .05) for the former and an RR of 2.40 (95%CI = 1.54-3.74, P<.01) for the later. The edentate e·den·tate
Lacking teeth.


1. an animal without teeth, e.g. giant anteater.

2. used in the proper sense a member of the animal order Edentata, including anteaters and sloths.
 and the dentate dentate /den·tate/ (den´tat) notched; tooth-shaped.

Edged with toothlike projections; toothed.
 residents showed similar results.


The conclusion from this research is that there may be an association between periodontal disease and pneumonia. There are 12 high-quality randomized controlled trials (RCTs) that provide moderate evidence of a link between periodontal disease and nosocomial pneumonia in institutionalized clients and evidence that oral hygiene (mechanical or chemical approaches) may reduce the incidence of pneumonia. The low number needed to treat (NNT = 2 to 16), combined with a high relative risk reduction for pneumonia (RRR =34% to 83%), provides solid evidence for a call for dental hygienists to work with high-risk elderly adults in long-term care facilities and intensive care units.

These conclusions are consistent with the biological evidence indicating that pneumonia can be the result of anaerobic bacteria. (95) Dental plaque with anaerobic bacteria seems to be a logical source of the bacteria that causes pneumonia.

Given that dental hygiene services are inexpensive and easy to deliver and that pneumonia causes significant morbidity, mortality, and cost to the health care system, dental hygiene services may have a significant impact on individual's lives and reduce health costs. It is less costly to provide dental hygiene services than to treat a client with pneumonia in a hospital setting. In fact, some of the costs have been estimated: the cost of using Peridex in one hospital to try to prevent nosocomial pneumonia in all cardiovascular surgery patients was $700 a year, less than 10% of the cost associated with a single case of nosocomial pneumonia. (75) Oral rinses are inexpensive and easy to apply and may be readily used in hospital and long-term care settings.

Given that many seniors in long-term care facilities have poor oral health due to difficulty accessing professional oral health care and inadequate personal oral hygiene care, (96) it may be warranted to provide high-risk seniors in long-term care and hospital settings with access to oral health services. In addition, there should be increased collaboration and communication between dental hygienists and long-term care facilities, and critical care units of hospitals. These new opportunities can focus on oral/general health assessments, leadership capacity, policy development, surveillance, program delivery and evaluation.

One of the drawbacks of attempting to combine the results from the randomized controlled trials (RCTs) is that there was a high degree of difference in the interventions in the studies. Therefore, there is a need for increased RCTs that focus on the same treatment approach. This may help to strengthen the evidence. In addition, determining a causal relationship between periodontal disease and pneumonia will require a meta-analysis of high-quality RCTs. Also needed are large RCTs comparing different types of intervention with high-risk clients to determine the impact on nosocomial- and community-acquired pneumonia. Since there is growing international research on this topic, there is also a need to develop international standards. These would allow the pooling of original data, which would avoid the possibility of combining the odds ratios and P values from two non-significant studies that may give significant results. There is also a need for ongoing research to clarify if periodontitis or higher levels of oral bacteria and biofilm Biofilm

An adhesive substance, the glycocalyx, and the bacterial community which it envelops at the interface of a liquid and a surface. When a liquid is in contact with an inert surface, any bacteria within the liquid are attracted to the surface and adhere
 are implicated im·pli·cate  
tr.v. im·pli·cat·ed, im·pli·cat·ing, im·pli·cates
1. To involve or connect intimately or incriminatingly: evidence that implicates others in the plot.

 in the relationship with respiratory disease. This would clarify the need to focus on plaque and biofilm removal, or the periodontal diseases themselves.


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This article has been peer reviewed.

by Judy Lux, BA, MSW (MicroSoft Word) See Microsoft Word.  
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Publication:Canadian Journal of Dental Hygiene
Geographic Code:1CANA
Date:Jan 1, 2007
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