Effect of pregnancy on gingival inflammation in systemically healthy women: a systematic review

The association of reproductive health factors with periodontitis in 45-80 years old US women from NHANES 2009-2014

OBJECTIVES

We investigated the association of female reproductive factors with periodontitis.

MATERIALS AND METHODS

This cross-sectional study analyzed data from the US National Health and Nutrition Examination Survey 2009-2014 on 2321 women aged 45-80 years who had full-mouth periodontal examination and reproductive questionnaire. The 2018 World Workshop Classification of Periodontal and Peri-implant Diseases was used to classify periodontitis stages.

RESULTS

After adjustment, > 3 pregnancies or live births were associated with increased stage III/IV periodontitis but age at first birth (AFB) > 23 years and female hormone use were associated with decreased stage III/IV periodontitis, while there were no associations of oral contraceptive use or menopause status with stage III/IV periodontitis. Stage III/IV periodontitis was more common in women with > 3 pregnancies or live births and AFB ≤ 23 years or never using female hormones but less common in women with ≥ 3 pregnancies or > 3 live births and AFB > 23 years or using female hormones. >3 pregnancies or live births were related with increased stage III/IV periodontitis and increased AFB was related with lowered stage III/IV periodontitis in overweight and smoking subgroups but using female hormone was related with reduced stage III/IV periodontitis in nonsmoking, non-overweight and black subgroups.

CONCLUSIONS

>3 pregnancies/live births were related with severe periodontitis but AFB > 23 years and female hormone use were related with ameliorating periodontitis.

CLINICAL RELEVANCE

Women with > 3 pregnancies/live births should receive intensive periodontal interventions. Female hormone therapy or AFB > 23 years may be beneficial for periodontal health of > 3 pregnancies/live births women.

The Impact of Periodontal Disease on Preterm Birth and Preeclampsia

This review delves into the possible connection between periodontitis and negative pregnancy outcomes, such as preeclampsia and preterm birth. It highlights the potential influence of an unidentified microbial factor on preeclampsia and the effects of inflammatory responses on the rate of preterm births. Furthermore, it underscores the prevalent occurrence of oral ailments within the populace and their significant repercussions on quality of life. Hormonal fluctuations during pregnancy may exacerbate oral conditions such as pregnancy gingivitis and periodontitis, necessitating bespoke therapeutic approaches that take into account potential fetal ramifications. Periodontal disease, characterized by microbial attack and inflammatory response, results in tissue destruction and tooth loss. The oral cavity's susceptibility to bacterial colonization, which is primarily due to its role as a site for food intake, is highlighted. Furthermore, research indicates a correlation between inflammatory responses and factors such as prostaglandin E2 and IL-1β, and preterm birth. Therapeutic interventions are a focus of international research, with efforts being aimed at optimizing outcomes through larger studies involving pregnant women.

Measuring quality of dental care during pregnancy

BACKGROUND

The authors aimed to develop and validate 2 Dental Quality Alliance measures of dental care access during pregnancy (Utilization of Services During Pregnancy, Oral Evaluation During Pregnancy) using claims and enrollment data and to report performance on these measures for a sample of Medicaid and Children's Health Insurance Program beneficiaries.

METHODS

The authors used Transformed Medicaid Statistical Information System enrollment and claims data for 7,767,806 people enrolled in 5 state Medicaid programs and Children's Health Insurance Programs during 2018. The authors used split-half reliability testing to assess measure reliability. The authors calculated 95% CIs to assess statistically significant variation in performance between programs.

RESULTS

The intraclass correlation coefficient used to assess agreement between the split samples was 0.992 (95% CI, 0.941 to 0.999; P < .0001) for Utilization of Services During Pregnancy and 0.983 (95% CI, 0.879 to 0.998; P < .0001) for Oral Evaluation During Pregnancy. Performance scores ranged from 20% through 34% of beneficiaries receiving any dental service during pregnancy (Utilization of Services During Pregnancy) and from 14% through 23% of beneficiaries receiving a periodic or comprehensive oral evaluation during pregnancy (Oral Evaluation During Pregnancy), with statistically significant differences between programs.

CONCLUSIONS

The measures reliably assessed access to dental services and can distinguish performance between programs.

PRACTICAL IMPLICATIONS

These measures can be used to advance population health by means of supporting national efforts to improve access to dental care during pregnancy.

Awareness of Periodontal Health among Pregnant Females in Government Setting in United Arab Emirates

OBJECTIVE

 Periodontal disease is one of the most common infectious diseases. Several factors are associated with increased susceptibility of periodontal disease such as hormonal changes during pregnancy. Although pregnancy does not directly cause gingivitis, it can aggravate preexisting periodontal disease. This study aimed to evaluate knowledge of the association between periodontal disease and pregnancy in pregnant females.

MATERIALS AND METHODS

 A convenience sample of pregnant females attending two United Arab Emirates government hospitals was recruited for this study. A 23-item questionnaire was developed with four sections, covering sociodemographic details, oral hygiene, oral symptoms during pregnancy, and knowledge of periodontal health during pregnancy. The study was conducted between April and October 2017. All participants consented to the survey.

RESULTS

 A total of 100 participants with a mean age of 31 years (± 5.9) completed the survey. Most respondents brushed their teeth 2 to 3 times a day (65%), used a manual toothbrush (93%) but only visited the dentist when in pain (62%). Few respondents self-reported any gingival signs and symptoms during pregnancy; 38% had bleeding gums, 27% had no gum swelling, and 34% had bad odor/taste/smell. Only 21% of pregnant females lost a tooth/teeth during pregnancy, 15% believed that pregnancy increased the likelihood of gum disease, and 66% of gynecologists did not advise a visit to the dentist.Housewives were significantly less knowledgeable about periodontal health than students/employed respondents (p = 0.01). Quality of knowledge was not associated with educational attainment (< 0.06). Respondents > 30 years of age were more likely to believe in "a tooth for a baby" than younger participants aged < 30 years (p < 0.05). A logistic regression model showed that educational attainment was not a predictor for the belief in "a tooth for a baby" but age was a significant predictor (odds ratio = 2.0).

CONCLUSION

 Protocols should be developed in antenatal clinics in order to improve periodontal health in pregnant females and to prevent complications that can result in adverse pregnancy outcomes.

Factors associated with periodontal diseases in pregnancy: Findings of the 2015 Pelotas Birth Cohort Study

Although periodontal disease is common during pregnancy, little is known about socioeconomic, behavioral, or biological determinants related to clinically assessed periodontal condition during this period. We assessed the prevalence of periodontal disease and associated factors in pregnant women. This population-based survey used data used from the 2015 Pelotas Birth Cohort Study, Brazil. Pregnant women expected to give birth between December 2014 and May 2016 were interviewed and clinically examined by trained dentist, with periodontal measures collected in all teeth, six sites per tooth. Outcomes were periodontitis (using the 2012 Centers for Disease Control and Prevention and the American Academy of Periodontology criteria) and gingivitis (by the 2018 European Federation of Periodontology/ American Academy of Periodontology classification). Multivariate hierarchical Poisson regression was used to assess the associations between socioeconomic, systemic, and clinical oral factors and periodontal disease. A total of 2,474 pregnant women participated in the study. Prevalence of periodontitis and gingivitis was 14.63% and 21.67%, respectively. Lower educational level and calculus were associated with higher prevalence periodontitis and gingivitis (P<0.05). Smoking was also associated with periodontitis (P=0.05), and lower frequency of toothbrushing (P=0.005) with gingivitis. Periodontal disease, especially gingivitis, was prevalent in pregnant women and their determinants were socioeconomic, environmental, and clinical oral health factors.

Preconception Periodontitis and Risk of Spontaneous Abortion in a Prospective Cohort Study

Few studies have evaluated the association between periodontitis and spontaneous abortion (SAB), and all had limitations. We used data from the Pregnancy Study Online (PRESTO), a prospective preconception cohort study of 3,444 pregnancy planners in the United States and Canada (2019-2022), to address this question. Participants provided self-reported data on periodontitis diagnosis, treatment, and symptoms of severity (i.e., loose teeth) via the enrollment questionnaire. SAB (pregnancy loss at <20 weeks' gestation) was assessed via bimonthly follow-up questionnaires. Participants contributed person-time from the date of a positive pregnancy test to the gestational week of SAB, loss to follow-up, or 20 weeks' gestation, whichever came first. We fitted Cox regression models with weeks of gestation as the time scale to estimate adjusted hazard ratios (HRs) and 95% confidence intervals (CIs), and we used inverse probability of treatment weighting to account for differential loss to follow-up. We used probabilistic quantitative bias analysis to estimate the magnitude and direction of the effect of exposure misclassification bias on results. In weighted multivariable models, we saw no appreciable association between preconception periodontitis diagnosis (HR = 0.97, 95% CI: 0.76, 1.23) or treatment (HR = 1.01, 95% CI: 0.79, 1.27) and SAB. A history of loose teeth was positively associated with SAB (HR = 1.38, 95% CI: 0.88, 2.14). Quantitative bias analysis indicated that our findings were biased towards the null but with considerable uncertainty in the bias-adjusted results.

A Randomized Controlled Clinical Trial of Prenatal Oral Hygiene Education in Pregnancy-Associated Gingivitis

INTRODUCTION

Research shows there is a significant increase in gingival inflammation during pregnancy. This study was conducted to determine if an oral health intervention (OHI), including oral hygiene education delivered by nurse-led staff and an advanced over-the-counter (OTC) oral home care regimen, improved gingival inflammation in pregnant women with moderate-to-severe gingivitis compared with a standard oral hygiene control group.

METHODS

This was a multicenter, randomized, controlled, single-masked, parallel group clinical trial conducted in obstetrics clinics of 2 medical centers. A total of 750 pregnant women between 8 and 24 weeks of pregnancy with at least 20 natural teeth and moderate-to-severe gingivitis (>30 intraoral bleeding sites) were enrolled. Participants were randomized to either the OHI group, which included oral hygiene instructions supplemented with an educational video and advanced OTC antibacterial/mechanical oral hygiene products, or the control group receiving oral hygiene instructions and standard products. Both groups received oral hygiene instructions from nurse-led staff. Experienced, masked examiners measured whole mouth gingival index (GI) and periodontal probing depths (PDs) at baseline and months 1, 2, and 3.

RESULTS

Participants enrolled in this study presented with moderate-to-severe gingivitis at baseline. Both the OHI and control groups exhibited significant reductions in GI (P < .001) and PD (P < .03) from baseline that persisted throughout the study period. The OHI group exhibited modest, yet statistically greater, reductions in GI (P ≤ .044) compared with the control at all time points. The reduction in PD directionally favored the OHI group, but between-group differences were small (<0.03 mm) and not statistically significant (P > .18).

DISCUSSION

Significant gingivitis was prevalent among participants in this study and identifies an opportunity to improve gingival health during pregnancy by providing oral health education during the course of prenatal care when coupled with an advanced OTC oral hygiene regimen.

Periodontitis and edentulism as risk indicators for mortality: Results from a prospective cohort study with 20 years of follow-up

AIM

To investigate the association between periodontitis and edentulism with cardiovascular disease (CVD) and all-cause mortality.

METHODS

Baseline data of 506 subjects including 256 angiographically verified coronary artery disease patients and 250 matched participants in cardiovascular health from the Kuopio Oral Health and Heart study were collected from 1995-1996. Mortality data were accrued until May 31, 2015, and related to baseline periodontal health and edentulism, assessed as exposure and collected by means of clinical and radiographic examination by a single examiner. Cox proportional hazards regression models were fit using covariates such as age, gender, smoking, BMI, and education. The final sample size for the periodontitis models ranged from 358 to 376, while the edentate models included 413 to 503 subjects for CVD and all-cause mortality, respectively with no missing values in the predictor, confounders, and outcome.

RESULTS

The strongest association was found between edentulism and CVD and all-cause mortality (HR: 1.9 ^CVD , HR: 1.6^all-cause ; p < .01).

CONCLUSIONS

Edentulism considered as a poor oral health marker was associated strongly with CVD mortality while periodontitis was not.

Prevalence of periodontal disease in pregnancy: A systematic review and meta-analysis

OBJECTIVES

The purpose of this study was to systematically assess the epidemic trend of periodontal disease in pregnancy.

DATA

Eligibility criteria comprised studies that reported periodontitis and the periodontal indicators of BOP (+) or CAL≥4 mm or PD≥4 mm among pregnant women. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were applied where applicable. Risk of bias was assessed using the Critical Appraisal Checklist for prevalence studies proposed by The Joanna Briggs Institute (JBI). Meta-analyses were conducted to estimate the pooled effect measures. Q-statistic, I² statistic, subgroup and sensitivity analyses assessed study heterogeneity.

SOURCES

Electronic search of articles was conducted using PubMed, Web of Science, EMBASE, Scopus, and Ovid from January 2000 to January 2022.

RESULTS

A total of 20 studies were included in the meta-analysis. The prevalence of periodontitis among pregnancy was 40% (95% Confidence Interval (CI): [0.15, 1.00]). The prevalence rates were 67% (CI [0.56, 0.80]), 42% (CI [0.27, 0.57]) and 24% (CI [0.12, 0.37]) for BOP (+), PD≥4 mm and CAL≥4 mm respectively. Regarding subgroup meta-analyses, the prevalence rates of BOP (+) and PD≥4 mm presented a gradual increase throughout pregnancy, while the highest prevalence rate of CAL≥4 mm was in the 2nd trimester.

CONCLUSIONS

It was observed a high prevalence of periodontal disease in pregnancy. However, heterogeneity was high among included studies. More high-quality epidemiologic investigations on periodontal disease in pregnancy are still needed.

CLINICAL SIGNIFICANCE

Periodontal disease in pregnancy is highly prevalent which results in a reduced quality of life, frequent systemic pathologies and adverse pregnancy outcomes. Given the unhealthy consequences, public health impact, and expansive disease burden, it is worthwhile to investigate more aspects of periodontal disease during pregnancy.

A Nested Case-Control Study of the Relationship between Salivary Inflammatory Mediators, Periodontal Parameters, and Preterm Birth in a Chinese Population

Background

To explore whether salivary inflammatory mediators and periodontal indices at different gestational stages can be taken as indicators of preterm birth (PTB).

Methods

This nested case-control study enrolled systemically healthy pregnant women at 9 to 36 weeks of gestation. Periodontal indices were measured at the enrollment date, and interleukin-1β (IL-1β), IL-6, tumor necrosis factor (TNF-α), prostaglandin E2 (PGE2), and 8-hydroxy-deoxyguanosine (8-OHdG) in the saliva were determined by enzyme-linked immunosorbent assay (ELISA). The birth outcome was recorded.

Results

PTB occurred in 26 women. A total of 104 matched women with full-term birth (FTB) were used as controls. The PTB women enrolled at 24-28 gestational weeks displayed a significantly greater bleeding index (BI), probing pocket depth (PD), PD ≥ 4 mm sites (%), saliva-TNF-α, and saliva-PGE2 (P < 0.05). BI and PGE2 in the saliva were found to be positively associated with PTB (OR = 4.79, P = 0.048, 95%CI = 1.014 to 22.628; OR = 1.07, P = 0.04, 95%CI = 1.004 to 1.135, respectively). The areas under the receiver operating characteristic curve (ROC) of BI and saliva-PGE2 were 0.82 and 0.78, respectively, and that of the combined detection was 0.91, which was larger than either marker alone, although the differences were not significant (P > 0.05).

Conclusions

The combination of BI and PGE2 in saliva at 24-28 gestational weeks could be a predictor of PTB in asymptomatic women. However, the results should be further explored with larger sample size.

Increase in Bifidobacterium is a characteristic of the difference in the salivary microbiota of pregnant and non-pregnant women

Background

The establishment of symbiotic microbiota in pregnant women is important for both the mother and her offspring. Little is known about the salivary symbiotic bacteria in pregnancy, and analysis of composition of microbiome (ANCOM) is useful to detect small differences in the number of bacteria. The aim of this study was to investigate the differences in the salivary bacteria between healthy pregnant and non-pregnant women using ANCOM.

Methods

Unstimulated saliva samples were collected from 35 healthy pregnant women at 35 weeks gestation and 30 healthy non-pregnant women during menstruation. All participants underwent a periodontal examination. Estradiol and progesterone levels were examined by enzyme-linked immunosorbent assay. DNA extracted from the saliva was assessed by 16S ribosomal RNA amplicon sequencing and real-time PCR.

Results

Salivary estradiol and progesterone levels were significantly increased in pregnant women. The alpha and beta diversities were higher in pregnant women than in non-pregnant women. The largest effect size difference noted when the microbiota of the pregnant and non-pregnant women were analyzed was that for Bifidobacteriales. Levels of Bifidobacterium dentium, but not of Bifidobacterium adolescentis, were significantly increased in pregnant women, and the levels were significantly correlated with progesterone concentration.

Conclusion

The results suggest that Bifidobacterium and progesterone levels are elevated in the saliva of healthy pregnant women compared with non-pregnant women.

The association of reproductive history with hypertension and obesity according to menopausal status: the J-MICC Study

Previous studies have reported that the number of pregnancies and childbirths affected the risk of cardiovascular diseases (CVDs). However, the influence of reproductive history on hypertension and obesity, which are important risk factors for CVDs, is still unclear. Moreover, this association may vary depending on menopausal status. We evaluated the association of reproductive history with hypertension and obesity using a large cross-sectional dataset from the Japan Multi-Institutional Collaborative Cohort Study (J-MICC Study). At the baseline survey, physical data, blood samples, and self-reported health questionnaires were collected. Participants with insufficient data were excluded, and 24,558 women from eight study regions were included in this study. Logistic regression analysis was conducted to evaluate the association of reproductive history with hypertension and obesity using multivariable-adjusted odds ratios. In premenopausal women, childbirth showed a generally protective effect on hypertension but not on obesity. In postmenopausal women, childbirth was positively associated with obesity and hypertension but not with hypertension after adjusting for BMI. In conclusion, reproductive history was associated with hypertension and obesity in a large Japanese population, and this association differed between premenopausal and postmenopausal women.

Association between Pre-Pregnancy BMI and Inflammatory Profile Trajectories during Pregnancy and Postpartum in Brazilian Women with Periodontitis: The IMPROVE Trial

This study aimed to explore the association between pre-pregnancy BMI and longitudinal changes in inflammatory markers from the second trimester of pregnancy to 6-8 weeks postpartum in women with periodontitis. This is a secondary exploratory analysis of 68 women who took part in a feasibility clinical trial in Rio de Janeiro, Brazil. Inflammatory markers included C-reactive protein (CRP), interleukin-6 (IL-6), interleukin-10 (IL-10), and matrix metalloproteinase-9 (MMP-9) blood concentrations at 11-22 (T0) and 30-36 gestational weeks (T1), and 6-8 weeks postpartum (T3). Longitudinal generalised linear mixed-effects models were used to identify possible associations between pre-pregnancy BMI and changes in concentrations of inflammatory markers. Pre-pregnancy excess weight (β = 4.39; 95% CI, 2.12-6.65) was significantly associated with increased CRP levels from pregnancy to postpartum. There were no significant associations between pre-pregnancy BMI and longitudinal changes in IL-6, IL-10 and MMP-9. Our findings provide evidence that a higher pre-pregnancy BMI may lead to increases in CRP levels during pregnancy in women with periodontitis, irrespective of the severity of clinical periodontal parameters. Further studies need to investigate if predictors of changes in inflammatory markers can be used as prognostic factors for gestational outcomes.

Periodontology and pregnancy: An overview of biomedical and epidemiological evidence

Women are particularly susceptible to developing gingival problems during pregnancy. In addition, periodontal disease in pregnant women may lead to adverse outcomes for both mother and infant, which have serious clinical and public health implications. Both scenarios have been extensively researched, helping to bring attention to pregnant women as an important and vulnerable population as it concerns periodontal health. The increase in gingival inflammation caused by hormonal changes in pregnant women is undisputed and has been studied and documented since the 1960s, although the exact etiology is not fully understood. The relationship between periodontal disease during pregnancy and adverse pregnancy outcomes is less substantiated, because of conflicting evidence. This review of the biomedical and epidemiologic literature provides an overview of both sides of this relationship and examines the potential mechanisms for developing periodontal disease during pregnancy and the proposed mechanisms by which periodontal disease leads to adverse pregnancy outcomes.

Oral mucosal lesions in pregnant women: A population-based study

OBJECTIVE

To evaluate the prevalence of oral mucosal lesions (OML) and oral self-examination and their associated factors among pregnant women from the 2015 Pelotas Birth Cohort Study, Brazil.

METHODS

Pregnant women who would deliver babies in 2015 were included in the antenatal study. Data related to demographic, socio-economic and behavioural conditions were collected using questionnaires. Participants were also clinically assessed for oral health outcomes. The outcomes were the presence of OMLs and oral self-examination. Size, location, time of onset and symptomatology of the lesions were collected. Descriptive and bivariate analysis, and Poisson regression were performed. p-Value <0.05 was set to indicate statistical significance.

RESULTS

Data from 2481 pregnant women were analysed. Four hundred and nine (16.5%) had at least one OML. The most prevalent lesions were exostosis (80/16.6%), coated tongue (70/14.5%) and benign oral brownish pigmentation (68/14.1%). Non-white skin colour was associated with a higher prevalence of OMLs (PR 1.3; 95% CI 1.1-1.6), while daily use of dental floss was positively associated with the prevalence of oral self-examination (PR 1.4; 95% CI 1.2; 1.5).

CONCLUSIONS

Almost 20% of pregnant women presented OML, which were more prevalent in non-white individuals. Women with better oral care were more likely to perform oral self-examination.

Periodontal Conditions and Pathogens Associated with Pre-Eclampsia: A Scoping Review

BACKGROUND

Pre-eclampsia, the second most frequent direct source of maternal mortality, is a multisystem gestational disorder characterized by proteinuria and maternal hypertension after the 20th gestational week. Although the causes of pre-eclampsia are still discussed, research has suggested that the placenta has a central place in the pathogenesis of this disease. Moreover, current surveys indicated that periodontal disorders observed during the pregnancy and more particularly, periodontal pathogens could be link to the risk of pre-eclampsia.

OBJECTIVES

This article aims to review recent studies focusing on periodontal conditions and pathogens associated with pre-eclampsia.

METHODS

The process followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews guidelines.

RESULTS

Metabolic conditions, immunological changes, fluctuating progesterone and estrogen levels of the pregnant woman induce a dysbiosis of the oral microbiota and contribute to increase inflammation of periodontal tissues. Periodontal pathogens could diffuse through the bloodstream inducing a placenta inflammatory response as well as inflammatory molecules produced in response to periodontopathogens could migrate through the bloodstream leading to a placenta inflammatory response. Also, periodontopathogens can colonize the vaginal microbiota through the gastrointestinal tract or during oro-genital contacts.

CONCLUSION

A cumulative bi-directional relationship between periodontal conditions, pathogens and the pre-eclampsia exists.

Factors associated with oral health-related quality of life during pregnancy: a prospective observational study

PURPOSE

To evaluate the evolution of perceived quality of life in relation to oral health during pregnancy and to determine the risk factors involved in this process.

METHODS

A follow-up study was carried out with pregnant Spanish women. Two oral examinations and an oral health-related quality of life (OHRQoL) assessment, using the OHIP-14 questionnaire, were performed in the first and third trimester of pregnancy. Data on sociodemographic characteristics, medical history, O'Sullivan Test measures, oral hygiene habits, history of caries, and periodontal status of participants were collected through structured medical-dental questionnaires.

RESULTS

A complete dataset comprising 246 pregnant women was available for analysis. Overall scores for negative impacts on the OHIP questionnaire were significantly higher during late pregnancy (74%). This indicated a deterioration in oral health-related quality of life amongst participants. Items describing "painful aching", "self-consciousness", "unsatisfactory diet", and "interrupted meals" showed the greatest increase between the first and third trimester of gestation. Multivariate analysis showed that pre-gestational/gestational diabetes mellitus and poor oral hygiene habits during the first trimester of gestation were directly associated with worse oral health-related quality of life during the third trimester of gestation (hyperglycemia: OR 2.86; 95% CI 1.019-8.050: p = 0.043 / oral hygiene: OR 1.33; 95% CI 0.970-1.836; p = 0.076).

CONCLUSIONS

In the present research, hyperglycemia during pregnancy and poor oral hygiene habits during the first trimester of gestation led to a higher risk of poor oral quality of life during late pregnancy.

Association between periodontal indexes and biomarkers in gingival crevicular fluid and preterm birth in pregnancy: a nested case-control study

OBJECTIVES

This study aimed to investigate the association between periodontal indexes and biomarkers in gingival crevicular fluid (GCF) and preterm birth (PTB) in pregnancy, as well as to assess the clinical value of these indexes as predictors of PTB.

METHODS

A nested case-control study was conducted. A total of 300 systematically healthy pregnant women were selected within 36 weeks of gestation and grouped according to the enrolled weeks. Periodontal indexes, including probing depth (PD), bleeding index (BI), gingival index (GI), and five biomarkers in GCF, including interleukin (IL)-1β, IL-6, tumor necrosis factor-α (TNF-α), prostaglandin E2 (PGE2), and 8-hydroxy-2-deoxyguanosine (8-OHdG) were measured at the enrolled date. The detailed birth outcome was recorded.

RESULTS

Only women at 24-28 weeks of gestation per PTB case (four full-term births) were selected as controls subjects, PTB displayed significantly greater GI, BI, and 8-OHdG (P<0.05). Logistic regression analysis revealed that BI and 8-OHdG were the dependent risk factors of PTB (OR=5.90, P=0.034; OR=1.18, P=0.045, respectively). The areas under the receiver operating characteristic curve (ROC) of BI and 8-OHdG were 0.80 and 0.69, and that of the combined detection was 0.82, which was larger than the individual detection, although the differences were not significant (P>0.05).

CONCLUSIONS

Increased BI and 8-OHdG at 24-28 weeks of gestation are risk factors for PTB. Their combined detection may have some value in the prediction of PTB, but further studies with a larger sample size are needed to explore it and thus provide experiment evidence for establishing an early warning system for PTB in pregnant women with periodontal disease.

Exploratory Efficacy of Calcium-Vitamin D Milk Fortification and Periodontal Therapy on Maternal Oral Health and Metabolic and Inflammatory Profile

In this 2 × 2 factorial, outcome-assessor blinded, feasibility randomised trial we explored the effect of a non-pharmaceutical multi-component intervention on periodontal health and metabolic and inflammatory profiles among pregnant women with periodontitis receiving prenatal care in a Brazilian public health centre. 69 pregnant women (gestational age ≤20 weeks, T0) were randomly allocated into four groups: (1) fortified sachet (vitamin D and calcium) and powdered milk plus periodontal therapy during pregnancy (early PT) (n = 17); (2) placebo sachet and powdered milk plus early PT (n = 15); (3) fortified sachet and powdered milk plus late PT (after delivery) (n = 19); (4) placebo sachet and powdered milk plus late PT (n = 18). Third trimester (T1) and 6-8 weeks postpartum (T2) exploratory outcomes included periodontal health (% sites with bleeding on probing (BOP)), glucose, insulin, C-Reactive Protein, serum calcium and vitamin D. The mean BOP was significantly reduced in the early PT groups, while BOP worsened in the late PT groups. No significant effect of fortification on BOP was observed. Changes in glucose levels and variation on birthweight did not differ among groups This feasibility trial provides preliminary evidence for estimating the minimum clinically important differences for selected maternal outcomes. A large-scale trial to evaluate the interventions' clinical benefits and cost-effectiveness is warranted.

Regulation of matrix metalloproteinases-8, -9 and endogenous tissue inhibitor-1 in oral biofluids during pregnancy and postpartum

OBJECTIVE

During pregnancy, mothers undergoe considerable physiological changes affecting the whole body including periodontal tissues. Susceptibility to gingival inflammation during pregnancy could be mediated by modulation of matrix metalloproteinases (MMPs) and their tissue inhibitors (TIMPs). Therefore, the aim of this study was to investigate salivary and gingival crevicular fluid (GCF) levels of MMPs and TIMPs during the second and third trimester of pregnancy and postpartum.

DESIGN

Saliva and GCF samples were collected from 96 pregnant women (PW) before and after giving birth. The sixty matched non-pregnant women (N-PW) were recruited as a control group and full-mouth periodontal examination was performed. The levels of MMP-8, MMP-9 and TIMP-1 were determined by immunofluorometric and enzyme-linked immunosorbent assays.

RESULTS

The PW group exhibited significantly higher levels of MMP-8 and MMP-9 in their saliva than the N-PW group while corresponding salivary TIMP-1 levels were significantly lower in NPW compared to the postpartum stage. This resulted in significantly higher MMP-8/TIMP-1 and MMP-9/TIMP-1ratio in the saliva from PW before and after birth than in that from N-PW. MMP-8, MMP-9 and TIMP-1 levels were higher in GCF from PW and postpartum than in that from N-PW.

CONCLUSIONS

MMP-8 and MMP-9 levels in saliva and GCF reflect inflammatory burden during pregnancy. They could be used for monitoring the inflammatory state of gingival tissues during pregnancy.

Vitamin D and Calcium Milk Fortification in Pregnant Women with Periodontitis: A Feasibility Trial

This study aims to assess the acceptability, adherence, and retention of a feasibility trial on milk fortification with calcium and vitamin D (Ca+VitD) and periodontal therapy (PT) among low income Brazilian pregnant women with periodontitis (IMPROVE trial). This 2 × 2 factorial feasibility trial used a mixed-methods evaluation. In total, 69 pregnant women were randomly allocated to four groups: 1. fortified sachet with Ca+VitD and milk plus early PT (throughout gestation); 2. placebo and milk plus early PT; 3. fortified sachet with Ca+VitD and milk plus late PT after childbirth; 4. placebo and milk plus late PT. Data were collected via questionnaires, field notes, participant flow logs, treatment diary, and focal group discussions. Quantitative and qualitative data were analysed using appropriate descriptive statistics and content analysis, respectively. Eligibility rate (12%) was below the target of 15%, but participation (76.1%) and recruitment rate (2 women/week) exceeded the targets. Retention rate (78.6%) was slightly below the target (80%). Adherence to the PT was significantly higher in the early treatment groups (98.8%) compared to the late treatment groups (29%). All women accepted the random allocation, and baseline groups were balanced. There was no report of adverse events. This multi-component intervention is acceptable, well-tolerated, and feasible among low-risk pregnant women in Brazil.

Early pregnancy levels of gingival crevicular fluid matrix metalloproteinases-8 and -9 are associated with the severity of periodontitis and the development of gestational diabetes mellitus

BACKGROUND

Gestational diabetes mellitus (GDM) is increasing worldwide and women with a history of GDM are at risk of developing type 2 diabetes which is a risk factor for periodontitis. The aim of this study was to explore the association between the concentrations of matrix metalloproteinase (MMP)-8 and -9 in gingival crevicular fluid (GCF) during early pregnancy with the periodontal diagnosis and the risk of GDM development.

METHODS

A prospective cohort study, including 314 women, enrolled at 11 to 14 weeks of pregnancy was conducted. A complete maternal/obstetric and periodontal exam was performed, and GCF samples were obtained for the MMP-8 and -9 determination by Multiplex Elisa Assays. Mann-Whitney test; Spearman's correlation and log-binomial regression model estimated the association between MMPs concentration in GCF and GDM.

RESULTS

Fourteen percent of the pregnancies were diagnosed with GDM. An increase in the concentration of MMP-8 and -9 in women with periodontitis stage III and IV compared to periodontitis stage I was observed (99.31 ng/mL [IQR: 85.32] versus 71.95 ng/mL [IQR: 54.04], and 262.4 ng/mL [IQR: 312.55] versus 114.1 ng/mL [IQR: 184.94], respectively). Women who developed GDM showed increased concentrations of MMP-8 and -9 in GCF since the beginning of pregnancy (P = 0.0381; P = 0.0302, respectively). MMP-8 concentration in GCF was associated with GDM (RR: 1.19; P = 0.045; CI 95% 1.00 to 1.40; and RR: 1.20; P = 0.063; CI 95% 0.99 to 1.45 in the adjusted model).

CONCLUSION(S)

GCF concentrations of MMP-8 and -9 at early of pregnancy are increased in women with severe periodontitis and associated with the GDM development.

Risk of preterm birth associated with maternal gingival inflammation and oral hygiene behaviours in rural Nepal: a community-based, prospective cohort study

OBJECTIVES

Observational studies have identified associations between periodontitis and adverse pregnancy outcomes, but randomised controlled trials evaluating the efficacy of periodontal therapy have yielded inconsistent results. Few studies have explored relationships between gingival inflammation and these outcomes or been conducted in rural, low-income communities, where confounding risk factors differ from other settings.

METHODS

We conducted a community-based, prospective cohort study with the aim of estimating associations between the extent of gingival inflammation in pregnant women and incidence of preterm birth in rural Nepal. Our primary exposure was gingival inflammation, defined as bleeding on probing (BOP) ≥10%, stratified by BOP <30% and BOP ≥30%. A secondary exposure, mild periodontitis, was defined as ≥2 interproximal sites with probing depth (PD) ≥4 mm (different teeth) or one site with PD ≥5 mm. Our primary outcome was preterm birth (<37 weeks gestation). We used Poisson regression to model this relationship, adjusting for potential confounders.

RESULTS

Of 1394 participants, 554 (39.7%) had gingival inflammation, 54 (3.9%) mild periodontitis and 197 (14.1%) delivered preterm. In the adjusted regression model, increasing extent of gingival inflammation was associated with a non-significant increase in risk of preterm birth (BOP ≥30% vs no BOP: adjusted relative risk (aRR) 1.37, 95% CI: 0.81 to 2.32). A secondary analysis, stratifying participants by when in pregnancy their oral health status was assessed, showed an association between gingival inflammation and preterm birth among women examined in their first trimester (BOP ≥30% vs no BOP: aRR 2.57, 95% CI: 1.11 to 5.95), but not later in pregnancy (BOP ≥30% vs no BOP: aRR 1.05, 95% CI: 0.52 to 2.11).

CONCLUSIONS

Gingival inflammation in women examined early in pregnancy and poor oral hygiene behaviours were risk factors for preterm birth. Future studies should evaluate community-based oral health interventions that specifically target gingival inflammation, delivered early in or before pregnancy, on preterm birth.

TRIAL REGISTRATION NUMBER

Nepal Oil Massage Study, NCT01177111.

Sociodemographic Differences in Health Awareness and Oral Health in Pregnant Women

Objective The aim of this study was to determine the present oral health status of pregnant women depending on selected sociodemographic differences and deduce any resulting consequences for health prevention.

Methods The participantsʼ data of relevance to the study such as age, school leaving qualification, migration background, smoking habits or last dentist visit were recorded using a questionnaire. The subsequent dental check-up concentrated on open carious lesions, any initiated root canal treatments and missing teeth. Finally, the Periodontal Screening Index was recorded to diagnose the presence of any gingivitis or periodontitis. The subsequent biometric evaluation comprised descriptive data analysis, χ2 test and logistical regression.

Results The higher the school leaving qualification, the lower the probability that a pregnant woman smoked prior to pregnancy (OR 0.291; 95% CI 0.114 – 0.743) and that tartar was diagnosed (OR 0.424; 95% CI 0.185 – 0.973). Regular dentist visits (OR 4.026; 95% CI 1.613 – 10.049) increase with the attained school leaving qualification. There is a greater chance that women born in Germany taking part in the study were aware of dental risks in pregnancy (OR 2.652; 95% CI 1.285 – 5.472) and attended the dentist during pregnancy (OR 2.507; 95% CI 1.281 – 4.907).

Conclusion The rate of awareness of the risks and consequences of pregnancy for oral health must be increased. The main aim for primary prophylaxis should be a reduction in the periodontal bacteria and caries of the mother and father.

Periodontal disease and adverse pregnancy outcomes

Periodontal diseases are considered not only to affect tooth-supporting tissues but also to have a cause-and-effect relationship with various systemic diseases and conditions, such as adverse pregnancy outcomes. Mechanistic studies provide strong evidence that periodontal pathogens can translocate from infected periodontium to the feto-placental unit and initiate a metastatic infection. However, the extent and mechanisms by which metastatic inflammation and injury contribute to adverse pregnancy outcomes still remain unclear. The presence of oral bacteria in the placenta of women with term gestation further complicates our understanding of the biology behind the role of periodontal pathogens in pregnancy outcomes. Epidemiological studies demonstrate many methodological inconsistencies and flaws that render comparisons difficult and conclusions insecure. Therefore, despite the fact that a number of prospective studies show a positive association between periodontal diseases and various adverse pregnancy outcomes, the evidence behind it is still weak. Future well-designed explanatory studies are necessary to verify this relationship and, if present, determine its magnitude. The majority of high-quality randomized controlled trials reveal that nonsurgical periodontal therapy during the second trimester of gestation does not improve pregnancy outcomes. From a biological standpoint, this can be partially explained by the fact that therapy rendered at the fourth to sixth months of pregnancy is too late to prevent placental colonization by periodontal pathogens and consequently incapable of affecting pathogen-induced injury at the feto-placental unit. Thus, interventions during the preconception period may be more meaningful. With the increase in our understanding on the potential association between periodontal disease and adverse pregnancy outcomes, it is clear that dental practitioners should provide periodontal treatment to pregnant women that is safe for both the mother and the unborn child. Although there is not enough evidence that the anti-infective therapy alters pregnancy outcomes, it improves health-promoting behavior and periodontal condition, which in turn advance general health and risk factor control.

Salivary proteome signatures in the early and middle stages of human pregnancy with term birth outcome

The establishment and maintenance of pregnancy in humans proceed through a continuous change of biochemical and biophysical processes. It requires a constant interaction between the fetus and the maternal system. The present prospective study aims to elucidate changes in salivary proteome from the early to middle stages of term pregnancy, and establishing an expressional trajectory for modulated proteins. To date, a comprehensive characterization of the longitudinal salivary proteome in pregnancy has not been performed and it is our immediate interest. In the discovery phase, maternal saliva (N = 20) at 6–13, 18–21, and 26–29 weeks of gestation was analyzed using level-free proteomics (SWATH-MS) approach. The expression levels of 65 proteins were found to change significantly with gestational age and distributed into two distinct clusters with a unique expression trajectory. The results revealed that altered proteins are involved in maternal immune modulation, metabolism, and host defense mechanism. Further, verification of 12 proteins was employed using targeted mass spectrometry (MRM-MS) in a separate subset of saliva (N = 14). The MRM results of 12 selected proteins confirmed a similar expression pattern as in SWATH-MS analysis. Overall, the results not only demonstrate the longitudinal maternal saliva proteome for the first time but also set the groundwork for comparative analysis between term birth and adverse pregnancy outcomes.

Hormone-related events and periodontitis in women

AIM

While the short-term effects of hormonal events on gingival inflammation have been well described, long-term effects on the periodontium have received less attention. The aim of this cross-sectional population-based study was to evaluate the association between hormone-related events and periodontitis in a representative sample of the postmenopausal women of South Korea.

MATERIALS AND METHODS

A total of 10,273 postmenopausal women representative of 6.1 million of Koreans were examined. Periodontitis and severe periodontitis were defined according to the Community Periodontal Index (CPI ≧ 3 and CPI = 4, respectively). Univariate and multivariate regression analyses using 3 different models were applied controlling for age, smoking, marital status, educational level, income, BMI, hypertension, stress and frequency of toothbrushing.

RESULTS

Severe periodontitis was directly associated with a longer reproductive life (p-trend = .027) and with a longer duration of breastfeeding (48-72 vs. 1-17 months: OR = 1.49; 95% CI: 1.01-2.21). Conversely, early menopausal age (<46 vs. 49-50 years: OR = 0.74; 95% CI: 0.56-0.97), history of artificial menopause (OR = 0.72; 95% CI: 0.53-0.97), having had more than 6 pregnancies (vs. 4: OR = 0.73; 95% CI: 0.55-0.97), having had more than three abortions (vs. 0: OR = 0.51; 95% CI: 0.28-0.93) and having had the first birth age >26 years (vs. <21 years: OR = 0.71; 95% CI: 0.52-0.97) were inversely associated with severe periodontitis.

CONCLUSIONS

In this large nationally representative population, severe periodontitis was related to menopausal age, reproductive life length, number of pregnancies/abortions, first birth age and breastfeeding duration, while it was not to oral contraceptive and hormone replacement therapy usages.

Dental plaque-induced gingival conditions

OBJECTIVE

This review proposes revisions to the current classification system for gingival diseases and provides a rationale for how it differs from the 1999 classification system.

IMPORTANCE

Gingival inflammation in response to bacterial plaque accumulation (microbial biofilms) is considered the key risk factor for the onset of periodontitis. Thus, control of gingival inflammation is essential for the primary prevention of periodontitis.

FINDINGS

The clinical characteristics common to dental plaque-induced inflammatory gingival conditions include: a) clinical signs and symptoms of inflammation that are confined to the gingiva: b) reversibility of the inflammation by removing or disrupting the biofilm; c) the presence of a high bacterial plaque burden to initiate the inflammation; d) systemic modifying factors (e.g., hormones, systemic disorders, drugs) which can alter the severity of the plaque-induced inflammation and; e) stable (i.e., non-changing) attachment levels on a periodontium which may or may not have experienced a loss of attachment or alveolar bone. The simplified taxonomy of gingival conditions includes: 1) introduction of the term "incipient gingivitis;" 2) a description of the extent and severity of gingival inflammation; 3) a description of the extent and severity of gingival enlargement and; 4) a reduction of categories in the dental plaque-induced gingival disease taxonomy.

CONCLUSIONS

Dental plaque-induced gingival inflammation is modified by various systemic and oral factors. The appropriate intervention is crucial for the prevention of periodontitis.

A Framework for Understanding the Role of Psychological Processes in Disease Development, Maintenance, and Treatment: The 3P-Disease Model

Health psychology is multidisciplinary, with researchers, practitioners, and policy makers finding themselves needing at least some level of competency in a variety of areas from psychology to physiology, public health, and others. Given this multidisciplinary ontology, prior attempts have been made to establish a framework for understanding the role of biological, psychological, and socio-environmental constructs in disease development, maintenance, and treatment. Other models, however, do not explain how factors may interact and develop over time. The aim here was to apply and adapt the 3P model, originally developed and used in the treatment of insomnia, to couch the biopsychosocial model in a way that explains how diseases develop, are maintained, and can be treated. This paper outlines the role of predisposing, precipitating, and perpetuating factors in disease states and conditions (the 3Ps) and provides examples of how this model may be adapted and applied to a number of health-related diseases or disorders including chronic pain, gastrointestinal disorders, oral disease, and heart disease. The 3P framework can aid in facilitating a multidisciplinary, theoretical approach and way of conceptualizing the study and treatment of diseases in the future.

Estrogen signaling impacts temporomandibular joint and periodontal disease pathology

Women experience a higher incidence of oral diseases including periodontal diseases and temporomandibular joint disease (TMD) implicating the role of estrogen signaling in disease pathology. Fluctuating levels of estrogen during childbearing age potentiates facial pain, high estrogen levels during pregnancy promote gingivitis, and low levels of estrogen during menopause predisposes the TMJ to degeneration and increases alveolar bone loss. In this review, an overview of estrogen signaling pathways in vitro and in vivo that regulate pregnancy-related gingivitis, TMJ homeostasis, and alveolar bone remodeling is provided. Deciphering the specific estrogen signaling pathways for individual oral diseases is crucial for potential new drug therapies to promote and maintain healthy tissue.

Relationship between dental plaque formation and salivary cortisol level in pregnant women

Purpose:

Understanding how increased level of salivary cortisol contributes to the development of dental biofilm during pregnancy can help inthe prevention of dental caries and periodontal diseases. This study aims to evaluate the relationship between salivary cortisol level and dental biofilm formation in pregnant women.

Patients and methods:

This descriptive-analytic study was conducted in Hamadan, Iran in 2011. Forty consecutive pregnant women with no history of abortion, stillbirth, or any known physical or psychological disorders at weeks 25 and 33 of gestation were included. Salivary samples were collected for measurement of cortisol levels by Enzyme Linked Immunoabsorbent Assay (ELISA) method. The amount and extension of dental biofilms were determined by using a disclosing agent. Data were analyzed using descriptive and analytical statistics in SPSS version 16.

Results:

The mean levels of salivary cortisol at weeks 25 and 33 of gestation were respectively, 2.45 ± 1.56 μg/dl and 5.24 ± 4.07 μg/dl which demonstrates a significant difference (P<0.001). Evaluation of dental biofilm at two time intervals revealed a significant increase in amount of dental biofilm at week 33 of gestational period (34.65 ± 10.9% vs. 42.45 ± 12.35%, P<0.001). Elevated levels of dental biofilm were significantly correlated with salivary cortisol levels at week 33 (r=0.494, P=0.001),however, it was not significant at week 25 of gestation (r=0.148, P=0.361).

Conclusion:

The findings suggested that increased levels of salivary cortisol can predict dental biofilm formation and accumulation in pregnant women in the last weeks of gestation.

Oral hygiene, prevalence of gingivitis, and associated risk factors among pregnant women in Sarlahi District, Nepal

BACKGROUND

The oral health status of pregnant women in low-resource communities such as Nepal has not been well characterized. This sub-population is also of specific interest given associations between poor oral health and adverse pregnancy outcomes previously documented in other settings. We explored relationships between gingivitis and risk factors among pregnant women in rural Nepal.

METHODS

The design was a community-based, cross-sectional study in a sub-area of Sarlahi District, Nepal. Pregnant women < 26 weeks gestation underwent clinical periodontal exams conducted by community-based oral health workers. Exams included a full mouth assessment measuring bleeding on probing (BOP), probing depth (PD) (six sites per tooth), and gingival recession, the distance from the cemento-enamel junction to the free gingival margin (two direct sites per tooth). Data on participant risk factors were collected through household surveys, including demographic characteristics, oral health behaviors, care seeking, and health attitudes. Multivariable logistic regression modeling was used to assess relationships between gingivitis and risk factors.

RESULTS

We enrolled 1452 participants, of which 40% (n = 582) had signs of clinical gingivitis and 60% (n = 870) clinical health. Average participant age was 23. Most participants (88%) had never received oral health care. Participants averaged 10% of sites with BOP with most (79%) having ≥1 site with BOP. Nine percent of participants had ≥1 site with PD ≥4 mm, although very few participants (0.7%) had sites with PD ≥5 mm. Few participants (13%) had any recession (≥1 mm). In the final adjusted model, odds of gingivitis increased by 3% for each year of age (aOR 1.03, 95% CI 1.00, 1.06) and were higher for women of short maternal stature (< 150 cm) (aOR 1.43, 95% CI: 1.14, 1.79) and among women reporting cost to be a barrier to seeking dental care (aOR 2.13, 95% CI: 1.09, 4.15).

CONCLUSIONS

Gingivitis was common and associated with age, maternal stature, self-reported high cost of dental care, and other risk factors among pregnant women in rural Nepal.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01177111 (Nepal Oil Massage Study) and NCT02788786 (Pilot Trial).

Pregnancy-induced periodontal inflammation: Influence of salivary cytokines and antimicrobial proteins

The aim of this study was to evaluate the association between pregnancy-induced periodontal inflammation and levels of some salivary cytokines and antimicrobial proteins (AMPs). The study was a cohort longitudinal study that included pregnant women attending a secondary health facility. Consented participants had oral examination and saliva sampling during pregnancy and post-partum (three months after pregnancy). Saliva samples were used for the analysis of cytokines (TNF-α, IFN-gamma and IL-1β) and AMPs (Lactoferin, Lysozyme, and β defensin-1) using ELISA. Data are presented as median with interquartile range and compared using related sample Wilcoxon signed rank test. Correlations between levels of the salivary factors and indices of periodontal inflammation were determined using Spearman’s correlation test. Salivary flow rate, pH, levels of salivary IL-1β and IFN-gamma were significantly lower; while gingival index, periodontal index and level of salivary TNF-α were significantly higher during pregnancy compared with postpartum period. However, salivary lactoferin, lysozyme and β defensin-1 did not show significant difference comparing during pregnancy and postpartum period. Level of salivary IFN-gamma showed negative correlation with gingival index while level of salivary TNF-α showed positive correlation with gingival and periodontal indices. Lower levels of salivary IL-1β and IFN-gamma along with higher TNF-α concentration during pregnancy suggest their contributions to the pathophysiology of pregnancy-induced periodontal inflammation.

Pregnancy, parity and periodontal disease

Many women believe that their dental condition deteriorated during pregnancy or as a result of having children. Epidemiological studies have reported an association between higher parity and tooth loss, and higher parity and periodontal attachment loss. Several possible explanations for this association exist. First, hormonal changes during pregnancy affect the immune response to bacterial plaque and drive vascular and gingival changes that may contribute to heightened gingival inflammation. These changes are transient, without irreversible loss of periodontal attachment, and post-partum resolution can be expected for most women. For women with destructive periodontal disease, the effects of pregnancy and parity are unclear. Second, it is also plausible that parity and socioeconomic position (SEP) have shared risk factors, increasing the incidence of disease or influencing its management. Education, one aspect of SEP, is an important determining factor for women's fertility rate, with a gradient of fewer children with higher educational attainment. Higher levels of education are also favourably associated with behaviours conducive to oral health, and a lower incidence of damaging health behaviours. Thus, the potential for confounding is considerable. This review examines the literature on the association between pregnancy, parity and periodontal health, and explores sociobehavioural mechanisms for the observed association.

Oral health related quality of life among pregnant women: a randomized controlled trial

The aim of the present study was to compare negative impacts of oral conditions in Oral Heath Related Quality of Life (OHRQoL) assessed by the Oral Health Impact Profile-14 (OHIP-14) scores in pregnant women receiving or not comprehensive periodontal treatment. This randomized controlled clinical trial included pregnant women aged between 18 and 35 years old. Participants were randomized in a test group with 96 and a control group with 114 women. Patients in the test group received comprehensive periodontal treatment, supra and subgingival scaling and root-planning and periodontal maintenance appointments. The OHIP-14 was applied before and after treatment. The primary outcome was changes in OHIP-14 scores after follow-up period. The impact of having received or not comprehensive periodontal treatment on the change of the OHIP-14 scores was also investigated. Both groups showed significant reduction in OHIP-14 scores and effect size for the test group was 0.60 and 0.36 for the control group. Multinomial logistic regression analysis showed that participants of the control group had 5.9-fold odds (CI 95% 1.88-18.52) of worsening in OHIP-14 scores and their perception of oral conditions in relation to test group. Comprehensive periodontal treatment during pregnancy can reduce the negative impacts in OHRQoL.

Determinants of Dental Care Attendance during Pregnancy: A Systematic Review

Despite the fact that dental care attendance during pregnancy has been recommended by guidelines and institutions, the demand for dental services is still low among pregnant women. The aim of this study was to identify and analyze the determinants of dental care attendance during pregnancy. We performed a systematic literature search in the electronic databases PubMed, Scopus, Web of Science, Latin American and Caribbean Health Sciences Literature, Brazilian Library in Dentistry, Cumulative Index to Nursing and Allied Health Literature, and Medline using relevant keywords. Studies were filtered by publication year (2000-2016) and language (English, Portuguese, Spanish, and French). The included studies were assessed for quality. Their characteristics and statistically significant factors were reported. Fourteen papers were included in the review. The prevalence of dental service usage during pregnancy ranged from 16 to 83%. Demographic factors included women's age, marital status, parity, and nationality. The socioeconomic factors were income, educational level, and type of health insurance. Many psychological and behavioral factors played a role, including oral health practices, oral health and pregnancy beliefs, and health care maintenance. Referred symptoms of gingivitis, dental pain, or dental problems were perceived need. Demographic, socioeconomic, psychological, behavioral factors and perceived need were associated with the utilization of dental services during pregnancy. More well-designed studies with reliable outcomes are required to confirm the framework described in this review.

Anterior Bite Opening in Adulthood

Objectives

To study anterior bite opening of unknown cause presenting in adulthood regarding prevalence, symptoms of Temporomandibular Dysfunction (TMD) and possible causes of the bite opening.

Methods

Patients referred to two Orofacial Pain and TMD clinics with the complaint of recent anterior bite opening, presenting in adulthood and of unknown cause, were considered for the study. Patients with systemic rheumatic or neuromuscular diseases, degenerative joint disease, previous fractures of the jaws or orthodontic treatment, were excluded. The clinical examination was according to DC/TMD and extended for the occlusion. Reported symptoms, clinical signs, the occlusion and diagnoses found are presented. According to the information gained from the patient's history, previous occlusion and appearance, and present signs of parafunction, a possible association with the bite opening was suggested.

Results

Anterior bite opening was found in 1.6% of the referred patients. Symptoms of tiredness and/or orofacial pain were reported by 62%, headache by 41%, TMJ clicking by 24% and sensitive/tender teeth by 41%. Parafunction or bruxism was reported by 2/3 of the patients. A previous period in life of TMD symptoms, before the bite opening, was reported by 66%. Myalgia and headache associated with TMD were frequently diagnosed. The use of a partial dental splint, tongue pressure and pregnancy were possible causes found for the bite opening.

Conclusion

Anterior bite opening can occur in adulthood without organic or systemic disease of the TMJ or masticatory muscles, and was frequently associated with muscle TMD symptoms.

Treating periodontal disease for preventing adverse birth outcomes in pregnant women

BACKGROUND

Periodontal disease has been linked with a number of conditions, such as cardiovascular disease, stroke, diabetes and adverse pregnancy outcomes, all likely through systemic inflammatory pathways. It is common in women of reproductive age and gum conditions tend to worsen during pregnancy. Some evidence from observational studies suggests that periodontal intervention may reduce adverse pregnancy outcomes. There is need for a comprehensive Cochrane review of randomised trials to assess the effect of periodontal treatment on perinatal and maternal health.

OBJECTIVES

To assess the effects of treating periodontal disease in pregnant women in order to prevent or reduce perinatal and maternal morbidity and mortality.

SEARCH METHODS

Cochrane Oral Health's Information Specialist searched the following databases: Cochrane Oral Health's Trials Register (to 6 October 2016), Cochrane Pregnancy and Childbirth's Trials Register (to 7 October 2016), the Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 9) in the Cochrane Library, MEDLINE Ovid (1946 to 6 October 2016), Embase Ovid (1980 to 6 October 2016), and LILACS BIREME Virtual Health Library (Latin American and Caribbean Health Science Information database; 1982 to 6 October 2016). ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform were searched for ongoing trials on 6 October 2016. We placed no restrictions on the language or date of publication when searching the electronic databases.

SELECTION CRITERIA

We included all randomised controlled trials (RCTs) investigating the effects of periodontal treatment in preventing or reducing perinatal and maternal morbidity and mortality. We excluded studies where obstetric outcomes were not reported.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened titles and abstracts and extracted data using a prepiloted data extraction form. Missing data were obtained by contacting authors and risk of bias was assessed using Cochrane's 'Risk of bias' tool. Where appropriate, results of comparable trials were pooled and expressed as risk ratios (RR) or mean differences (MD) with 95% confidence intervals (CI) . The random-effects model was used for pooling except where there was an insufficient number of studies. We assessed the quality of the evidence using GRADE.

MAIN RESULTS

There were 15 RCTs (n = 7161 participants) meeting our inclusion criteria. All the included studies were at high risk of bias mostly due to lack of blinding and imbalance in baseline characteristics of participants. The studies recruited pregnant women from prenatal care facilities who had periodontitis (14 studies) or gingivitis (1 study).The two main comparisons were: periodontal treatment versus no treatment during pregnancy and periodontal treatment versus alternative periodontal treatment. The head-to-head comparison between periodontal treatments assessed a more intensive treatment versus a less intensive one.Eleven studies compared periodontal treatment with no treatment during pregnancy. The meta-analysis shows no clear difference in preterm birth < 37 weeks (RR 0.87, 95% CI 0.70 to 1.10; 5671 participants; 11 studies; low-quality evidence) between periodontal treatment and no treatment. There is low-quality evidence that periodontal treatment may reduce low birth weight < 2500 g (9.70% with periodontal treatment versus 12.60% without treatment; RR 0.67, 95% CI 0.48 to 0.95; 3470 participants; 7 studies).It is unclear whether periodontal treatment leads to a difference in preterm birth < 35 weeks (RR 1.19, 95% CI 0.81 to 1.76; 2557 participants; 2 studies; ) and < 32 weeks (RR 1.35, 95% CI 0.78 to 2.32; 2755 participants; 3 studies), low birth weight < 1500 g (RR 0.80, 95% CI 0.38 to 1.70; 2550 participants; 2 studies), perinatal mortality (including fetal and neonatal deaths up to the first 28 days after birth) (RR 0.85, 95% CI 0.51 to 1.43; 5320 participants; 7 studies; very low-quality evidence), and pre-eclampsia (RR 1.10, 95% CI 0.74 to 1.62; 2946 participants; 3 studies; very low-quality evidence). There is no evidence of a difference in small for gestational age (RR 0.97, 95% CI 0.81 to 1.16; 3610 participants; 3 studies; low-quality evidence) when periodontal treatment is compared with no treatment.Four studies compared periodontal treatment with alternative periodontal treatment. Data pooling was not possible due to clinical heterogeneity. The outcomes reported were preterm birth < 37 weeks, preterm birth < 35 weeks, birth weight < 2500 g, birth weight < 1500 g and perinatal mortality (very low-quality evidence). It is unclear whether there is a difference in < 37 weeks, preterm birth < 35 weeks, birth weight < 2500 g, birth weight < 1500 g and perinatal mortality when different periodontal treatments are compared because the quality of evidence is very low.Maternal mortality and adverse effects of the intervention did not occur in any of the studies that reported on either of the outcomes.

AUTHORS' CONCLUSIONS

It is not clear if periodontal treatment during pregnancy has an impact on preterm birth (low-quality evidence). There is low-quality evidence that periodontal treatment may reduce low birth weight (< 2500 g), however, our confidence in the effect estimate is limited. There is insufficient evidence to determine which periodontal treatment is better in preventing adverse obstetric outcomes. Future research should aim to report periodontal outcomes alongside obstetric outcomes.

Anemia and Dental Caries in Pregnant Women: a Prospective Cohort Study

The objective was to evaluate the effect of anemia during pregnancy on the risk of dental caries development in pregnant women. A prospective cohort including a sample of pregnant women in a prenatal care unit of São Luís, Brazil, was done. The incidence of dental caries during pregnancy, according to Nyvad's criteria, was the outcome. The main independent variables were serum iron, ferritin, hemoglobin, erythrocyte, hematocrit, mean corpuscular volume (MCV), mean corpuscular hemoglobin (MCH), mean corpuscular hemoglobin concentration (MCHC), and red cell distribution width (RDW). Pregnant women (n = 121) were evaluated at two moments: up to 16th week of gestational age (T1) and in the last trimester of pregnancy (T2). Crude and adjusted associations were estimated by the incidence ratio risk (IRR) and respective 95% confidence intervals (95%CI). After adjustment, higher serum concentrations of ferritin (IRR = 0.97, 95%CI 0.95-0.99) in T1, and Fe (IRR = 0.99, 95%CI 0.98-0.99), ferritin (IRR = 0.99, 95%CI 0.98-0.99), erythrocyte (IRR = 0.71, 95%CI 0.50-0.99), hemoglobin (IRR = 0.84, 95%CI 0.73-0.96), hematocrit (IRR = 0.93, 95%CI 0.88-0.98), MCV (IRR = 0.91, 95%CI 0.86-0.96), and MCH (IRR = 0.83, 95%CI 0.74-0.93) in T2, were associated with fewer incidence of dental caries in pregnant women. Iron deficiency anemia during pregnancy is a risk factor for the incidence of dental caries in these women.

Periodontal status during pregnancy and postpartum

Objectives

Different studies have documented an association between periodontal disease and low birth-weight delivery. Hence, knowledge of periodontal status during pregnancy and postpartum is important in order to reduce the risks of both diseases. This study aimed to analyze periodontal status at successive stages of pregnancy and 3–6 weeks postpartum in women with initial periodontal alterations.

Materials and methods

Ninety-six pregnant women were examined at 8–10 weeks (pregnancy diagnosis, baseline), 21–23 weeks and 34–36 weeks of gestation and at 40 days postpartum to record plaque scores, clinically assessed gingival inflammation and probing depth (mean depth and % sites with depth >3 mm). Bivariate and multivariate analyses were performed. Type 1 (α) error was established at 0.05

Results

Plaque Index increased (p = 0.043) throughout pregnancy (baseline, 42%±0.18); 21–23 weeks, 42.6%±0.14; 34–36 weeks, 45.6%±0.13 and decreased postpartum (44.8%±0–13). Gingival Index increased (p<0.001) throughout pregnancy (baseline, 56.7%±0.20; 21–23 weeks, 66.36%±0.17; 34–36 weeks, 74.5%±0.18) and decreased postpartum (59.3%±0.21). Probing Depth increased (p<0.001) throughout pregnancy (baseline, 2.51±0.05; 21–23 weeks, 2.63±0.053; 34–36 weeks 2.81±0.055) and decreased postpartum (2.54±0.049). Percentage of sites with Probing Depth >3 mm increased (p<0.001) throughout pregnancy (baseline, 17.6%±0.16; 21–23 weeks, 23.9%±0.17; 34–36 weeks, 31.1%±0.17) and decreased postpartum (21.2%±0.17) but remained significantly (p<0.02) higher than at baseline.

Conclusion

Periodontal status deteriorates during gestation but improves postpartum.

Periodontal Health Status and Associated Factors: Findings of a Prenatal Oral Health Program in South Brazil

Objective. The aims of this study were to evaluate the periodontal health of pregnant women and to investigate the association of periodontal status with demographic and socioeconomic characteristics, as well as medical and dental history. Materials and Methods. A total of 311 pregnant women were interviewed to obtain sociodemographic data along with medical and dental histories. Clinical examinations were performed to record the presence of visible plaque, gingival bleeding, and caries activity. The periodontal condition was evaluated by Community Periodontal Index of Treatment Needs (CPITN) in one tooth of each sextant (16, 11, 26, 36, 31, and 46). Results. After the adjustment analysis, the presence of visible plaque remained the main determinant of gingival bleeding (OR = 2.91, CI = 1.91–4.48). First-trimester pregnancy status was also a predictor, with a lower prevalence of gingival bleeding observed in the second (OR = 0.87, CI = 0.77–0.99) and third (OR = 0.82, CI = 0.73–0.93) trimesters. Conclusion. In pregnant women, the presence of dental plaque and first-trimester pregnancy status were the main implicated factors predicting gingival bleeding.

Salivary antimicrobial defensins in pregnancy

AIM

Susceptibility to and severity of gingival inflammation are enhanced during pregnancy; however, regulation of oral innate immune response, including antimicrobial peptides, during pregnancy is still unknown. We analysed salivary levels of human beta-defensin (hBD)-1, -2, -3, and human neutrophil peptide (HNP)-1 in pregnant women, and related those to their periodontal status.

MATERIAL AND METHODS

In this cohort study, 30 generally healthy, non-smoking Caucasian women without periodontitis were followed at three time points during pregnancy and twice post-partum. The non-pregnant group consisted of 24 women, who were examined three times at the following months. At each visit, periodontal status was recorded and stimulated saliva samples were collected. Salivary estradiol, progesterone, and defensin concentrations were measured by ELISA assays.

RESULTS

After adjusting for visible plaque and gingival bleeding, reduced salivary concentrations of hBD-1, hBD-2, and HNP-1 were found especially during the third trimester, whereas hBD-3 concentrations did not change during pregnancy and post-partum visits. Weak associations were observed between salivary defensin and hormone concentrations and clinical parameters.

CONCLUSION

There seems to be an independent regulation cascade for each antimicrobial defensin in the oral cavity during pregnancy, despite of the similarities between these antimicrobial peptides.