SMFM Consult Series Peridontal disease and preterm birth Society of Maternal Fetal Medicine with the assistance of Kim Bogess, MD Published in Contemporary OB/GYN / Dec 2012

Definition & Incidence  Dental caries, gingivitis, and periodontal infection are conditions commonly encountered in children, young adults, and women of reproductive age.  Adult periodontal infection affects up to 40% of women of reproductive age. Dental caries is considered an infectious and transmissible disease of multifactorial origin.  Gingivitis (inflammation of the gum tissue) is a nondestructive periodontal disease. In the absence of treatment, gingivitis may progress to periodontitis (inflammation of tissues that surround and support the teeth), which is a destructive form of periodontal disease.  Periodontitis involves progressive loss of the alveolar bone around the teeth and if left untreated can lead to the loosening and subsequent loss of teeth. This process involves both direct tissue damage from plaque bacterial products and indirect damage through bacterial stimulation of local and systemic inflammatory and immune responses.  Subgingival colonization with Porphyromonas gingivalis and Prevotella intermedia leads to adult manifestations of oral infection because these organisms are able to induce inflammatory responses that lead to gingival edema, bleeding, and ultimately the tissue destruction characteristic of periodontal disease.  Gingivitis causes the gums to redden, swell, and bleed more easily. With time, bacterial plaque on the tooth surface spreads and grows below the gum line.  Treatment in pregnancy is safe.Most studies of treatment of periodontal disease during pregnancy use scaling and planning techniques. Scaling is debridement and nonsurgical cleaning below the gumline. Root planning involves the use of specialized curettes to mechanically remove plaque and calculus (hardened dental plaque) from below the gumline.

Does treatment of periodontal disease during pregnancy decrease the rate of preterm birth?  The Periodontal Infections and Prematurity Study was a multicenter, randomized, controlled trial (RCT) of pregnant women to determine whether treatment of periodontal disease (scaling and root planing vs placebo [tooth polishing]) decreased spontaneous PTB.  Of women screened for the study, 50% had periodontal disease. Treatment did not reduce spontaneous PTB before 35 weeks' gestation (8.6% treatment vs 5.5% placebo) or composite neonatal morbidity.

Does treatment of periodontal disease during pregnancy decrease the rate of preterm birth?  Jeffcoat and colleagues evaluated pregnant women with periodontal disease and compared the rate of PTB before 35 weeks among those with successful and unsuccessful treatment.  Lower rate of PTB in those with successful treatment and hypothesized that this may be the key to improvement, not just the use of periodontal therapy.  Polyzos and associates: meta-analysis and systematic review of 11 trials, 5 of which were of high methodologic quality.  The pooled results of these 5 high-quality RCTs did not indicate significant reduction in the risk of PTB after treatment for periodontal disease (odds ratio, 1.15; 95% CI, ; P=.15).  The current available data do not support this specific strategy and therapy as an intervention to decrease PTB.

Current recommendations for evaluation and treatment of periodontal disease in pregnancy  Oral health interventions during pregnancy should be performed as general health maintenance, rather than to improve specific pregnancy outcomes.  Despite the apparent inability of treatment of periodontal disease to reduce PTB rates, it is important to consider that treatment of maternal periodontal disease during pregnancy has also not been associated with increased risk of any adverse maternal or fetal outcomes. Thus there is no reason to delay indicated treatment.  Most treatment trials demonstrate that maternal oral health improves with antepartum periodontal therapy, a finding that is important for overall maternal health and well-being.  Several states have also issued practice guidelines for perinatal oral health. Key action items for obstetricians are listed in the table next slide.

Current recommendations for evaluation and treatment of periodontal disease in pregnancy

 The practice of medicine continues to evolve, and individual circumstances will vary. This opinion reflects information available at the time of its submission for publication and is neither designed nor intended to establish an exclusive standard of perinatal care. This presentation is not expected to reflect the opinions of all members of the Society for Maternal-Fetal Medicine.  These slides are for personal, non- commercial and educational use only Disclaimer

Disclosures  This opinion was developed by the Publications Committee of the Society for Maternal Fetal Medicine with the assistance of Stanley M. Berry, MD, Joanne Stone, MD, Mary Norton, MD, Donna Johnson, MD, and Vincenzo Berghella, MD, and was approved by the executive committee of the society on March 11, Dr Berghella and each member of the publications committee (Vincenzo Berghella, MD [chair], Sean Blackwell, MD [vice-chair], Brenna Anderson, MD, Suneet P. Chauhan, MD, Jodi Dashe, MD, Cynthia Gyamfi-Bannerman, MD, Donna Johnson, MD, Sarah Little, MD, Kate Menard, MD, Mary Norton, MD, George Saade, MD, Neil Silverman, MD, Hyagriv Simhan, MD, Joanne Stone, MD, Alan Tita, MD, Michael Varner, MD) have submitted a conflict of interest disclosure delineating personal, professional, and/or business interests that might be perceived as a real or potential conflict of interest in relation to this publication.