Association between maternal dental periapical infections and pregnancy outcomes: results from a cross-sectional study in Malawi

Systemic Factors Affecting Prognosis and Outcome of Endodontic Therapy

The successful outcome of endodontic treatment is dependent on the immune response and the reparative potential of the individual. Alteration in the host immune response is a common characteristic shared by both apical periodontitis and systemic diseases. Although infection-induced periapical lesions occur in a localized environment, numerous epidemiologic studies in the last few decades have investigated the potential association between endodontic disease pathogenesis and systemic diseases. The goal of this review is to identify common systematic factors and discuss the effect they may or may not have on the prognosis and outcome of endodontic therapy.

Maternal inflammatory and microbial drivers of low birthweight in low- and middle-income countries

BACKGROUND

Low birthweight (LBW) is when an infant is born too soon or too small, and it affects one in seven infants in low- and middle-income countries. LBW has a significant impact on short-term morbidity and mortality, and it impairs long-term health and human capital. Antenatal microbial and inflammatory exposure may contribute to LBW.

METHODS

Ovid-Medline, Embase and Cochrane databases were searched for English-language articles evaluating inflammatory, microbial or infective causes of LBW, small-for-gestational age, intra-uterine growth restriction or prematurity. Inclusion criteria were human studies including published data; conference abstracts and grey literature were excluded. A narrative synthesis of the literature was conducted.

RESULTS

Local infections may drive the underlying causes of LBW: for example, vaginitis and placental infection are associated with a greater risk of prematurity. Distal infection and inflammatory pathways are also associated with LBW, with an association between periodontitis and preterm delivery and environmental enteric dysfunction and reduced intra-uterine growth. Systemic maternal infections such as malaria and HIV are associated with LBW, even when infants are exposed to HIV but not infected. This latter association may be driven by chronic inflammation, co-infections and socio-economic confounders. Antimicrobial prophylaxis against other bacteria in pregnancy has shown minimal impact in most trials, though positive effects on birthweight have been found in some settings with a high infectious disease burden.

CONCLUSION

Maternal inflammatory and infective processes underlie LBW, and provide treatable pathways for interventions. However, an improved understanding of the mechanisms and pathways underlying LBW is needed, given the impact of LBW on life-course.

Melatonin decreases plasma TNF-α and improves nonenzymatic antioxidant defence and insulin sensitivity in rats with apical periodontitis fed a high-fat diet

AIM

To analyse the effects of melatonin (ME) treatment on oxidative stress and insulin resistance (IR) in rats with apical periodontitis (AP) fed a high-fat diet (HFD).

METHODOLOGY

Eighty 60-day-old rats were divided into eight groups: control (CN), AP, HFD with AP (HFDAP), control with ME (CNME), AP with ME (APME), HFD with ME (HFDME) and HFD with AP+ME (HFDAPME). The animals from the HFD groups were fed a HFD throughout the experimental period. On day 7, the animals from the AP groups were subjected to experimental AP, and after 70 days, the ME groups were treated for 30 days. Glycaemia, insulinaemia, homeostatic model assessment for IR index, tumour necrosis factor-α (TNF-α), and interleukin-6 were analysed in plasma using biochemical tests and enzyme-linked immunosorbent assay. Thiobarbituric acid-reactive substances (TBARS), carbonyl protein (CP), superoxide dismutase (SOD), catalase, glutathione peroxidase, glutathione (GSH) and total antioxidant capacity (ferric reducing antioxidant power [FRAP]) were analysed in the gastrocnemius muscle.

RESULTS

(1) Association of AP and HDF exacerbated IR, and ME treatment improved this alteration; (2) AP and HFD and their association showed increased TNF-α, and ME reversed it; (3) TBARS increased in the AP and HFDAP groups, and ME reversed only in the group with the association of disease and diet; (4) CP increased in all HFD groups and improved in the ME groups; (5) GSH activity decreased in all experimental groups, and ME increased this parameter only in the CN and AP groups; (6) FRAP did not change between the groups, but ME treatment increased its activity in the AP and HFD groups; (7) ME increased SOD in the CN and AP groups.

CONCLUSION

Apical periodontitis and HFD promoted IR, and the association of AP with diet promoted IR exacerbation; this resistance might have been caused by an increase in TNF-α. AP promoted more intense changes in lipid oxidative damage than in protein oxidative damage. In non-enzymatic antioxidant defence, it was observed that both AP and HFD and their association promoted a decrease in GSH levels. Overall, ME treatment reversed changes such as oxidative stress and IR.

Effect of maternal true combined endodontic-periodontal lesion on insulin and inflammatory pathway in adult offspring

BACKGROUND

Maternal periodontal disease (PED) and apical periodontitis (AP) are associated insulin resistance (IR), increased tumor necrosis factor-α (TNF-α) levels, and alterations in insulin signaling (IS) in the gastrocnemius muscle (GM) of adult offspring. TNF-α stimulates I kappa B kinase (IKK) and c-Jun N-terminal protein kinase (JNK), resulting in IS attenuation. However, studies that investigated the maternal true endodontic-periodontal lesion (EPL) in offspring are scarce, and in this case, the impact could be even higher. This study aimed to evaluate the effects of EPL on the IR, IS, and inflammatory pathways on the offspring GM.

METHODS

Female Wistar rats were distributed into control, AP, PED, and EPL groups. After 30 days of oral inflammation induction, rats from all groups were allowed to mate with healthy rats. The bodyweight of the offspring was assessed from birth to 75 days of age. After 75 days, the following measurements were performed: glycemia, insulinemia, IR, TNF-α content, and IKKα/β, JNK, pp185 (Tyr), and IRS-1 (Ser) phosphorylation status in the GM.

RESULTS

Maternal PED and EPL were associated with low birth weights. All maternal oral inflammations promoted IR and IS impairment in the GM and only maternal PED and EPL caused an increase in TNF-α content and IKKα/β phosphorylation status in the GM of offspring. The EPL-o group showed worsening of metabolic changes when compared to offspring of rats with AP or PED.

CONCLUSION

Association of maternal AP and PED promoted a more pronounced worsening in the health of the adult offspring. This article is protected by copyright. All rights reserved.

Association between Endodontic Infection, Its Treatment and Systemic Health: A Narrative Review

The 'Focal Infection Era in Dentistry' in the late 19th and early 20th century resulted in widespread implementation of tooth extraction and limited the progress of endodontics. The theory proposed that bacteria and toxins entrapped in dentinal tubules could disseminate systemically to remote body parts, resulting in many types of degenerative systemic diseases. This theory was eventually refuted due to anecdotal evidence. However, lately there has been increased interest in investigating whether endodontic disease could have an impact on general health. There are reviews that have previously been carried out on this subject, but as new data have emerged since then, this review aims to appraise the available literature investigating the dynamic associations between apical periodontitis, endodontic treatment, and systemic health. The available evidence regarding focal infection theory, bacteraemia and inflammatory markers was appraised. The review also collated the available research arguing the associations of apical periodontitis with cardiovascular diseases, diabetes mellitus, adverse pregnancy outcome and autoimmune disorders, along with the effect of statins and immunomodulators on apical periodontitis prevalence and endodontic treatment prognosis. There is emerging evidence that bacteraemia and low-grade systemic inflammation associated with apical periodontitis may negatively impact systemic health, e.g., development of cardiovascular diseases, adverse pregnancy outcomes, and diabetic metabolic dyscontrol. However, there is limited information supporting the effect of diabetes mellitus or autoimmune disorders on the prevalence and prognosis post endodontic treatment. Furthermore, convincing evidence supports that successful root canal treatment has a beneficial impact on systemic health by reducing the inflammatory burden, thereby dismissing the misconceptions of focal infection theory. Although compelling evidence regarding the association between apical periodontitis and systemic health is present, further high-quality research is required to support and establish the benefits of endodontic treatment on systemic health.

Prevalence and Risk Factors for Periodontal Disease Among Women Attending Antenatal Care in Public Hospitals, Southwest Ethiopia, 2022: A Multicenter Cross-Sectional Study

Background

Periodontal disease is characterized by the inflammation of all tissues that surround and support the teeth, and it is the most common public health problem worldwide. It has many different contributing factors, such as poor oral hygiene, smoking, anemia, bacterial plaque, poor economic status, and nutritional deficiency. It also causes different feto-maternal complications like preeclampsia, gestational diabetes, preterm labor, low birth weight, and early abortion. Thus, this study aimed to assess the prevalence and associated factors of periodontal disease among pregnant women.

Methods

A cross-sectional study was conducted among 618 women at public hospitals in the Southwest Ethiopia. Data were collected using a systematic random sampling method and a structured interviewer administered questionnaire. The data were entered into Epi-Data Manager 4.2 and then transferred to a statistical package for social science (SPSS) version 21 for analysis. The logistic regression analysis was done to see the significant association between each predictor with periodontal disease by considering a p-value of <0.05 and a CI of 95%.

Results

A total of 618 women attending ANC with a 100% response rate were enrolled in this study. The mean and standard deviation of the age of the study participants was 31.07 ± 7.8 years. The periodontal disease was observed among 240 (38.8%) of the total participants with 95% C.I of (35%, 43%). Predictors like rural residency, women who could not read and write, women with poor wealth index, nutritional status of underweight, had no information about periodontal disease, depression, history of diabetes mellitus, self-perceived halitosis, no history of ANC, and lower gestational age were found to be significantly associated with periodontal disease.

Conclusion

In this study, the prevalence of periodontal disease was found to be significantly higher. Therefore, in order to minimize the burden of periodontal disease among pregnant women, oral, medical, and mental health education should be promoted.

Dexmedetomidine and LPS co-treatment attenuates inflammatory response on WISH cells via inhibition of p38/NF-κB signaling pathway

Background

Inflammatory dental diseases that occur during pregnancy can cause preterm labor and/or intrauterine growth restriction. Therefore, proactive treatment of dental diseases is necessary during pregnancy. Dexmedetomidine (DEX) is a widely used sedative in the dental field, but research on the effect of DEX on pregnancy is currently insufficient. In this study, we investigated the effects of co-treatment with DEX and lipopolysaccharide (LPS) on inflammatory responses in human amnion-derived WISH cells.

Methods

Human amnion-derived WISH cells were treated with 0.001, 0.01, 0.1, and 1 µg/mL DEX with 1 µg/mL LPS for 24 h. Cytotoxicity of WISH cells was evaluated by 3-(4,5-dimethylthiazol)-2,5-diphenyltetrazolium bromide (MTT) assay. The protein expression of cyclooxygenase-2 (COX-2), prostaglandin E₂ (PGE₂), p38, and nuclear factor kappa B (NF-κB) was examined by western blot analysis. The mRNA expression of pro-inflammatory cytokines such as interleukin (IL)-1β and tumor necrosis factor (TNF)-α was analyzed by real-time quantitative polymerase chain reaction.

Results

Co-treatment with DEX and LPS showed no cytotoxicity in the WISH cells. The mRNA expression of IL-1β and TNF-α decreased after co-treatment with DEX and LPS. DEX and LPS co-treatment decreased the protein expression of COX-2, PGE₂, phospho-p38, and phospho-NF-κB in WISH cells.

Conclusion

Co-treatment with DEX and LPS suppressed the expression of COX-2 and PGE₂, as well as pro-inflammatory cytokines such as IL-1β and TNF-α in WISH cells. In addition, the anti-inflammatory effect of DEX and LPS co-treatment was mediated by the inhibition of p38/NF-κB activation.

Evolution of endodontic medicine: a critical narrative review of the interrelationship between endodontics and systemic pathological conditions

Endodontics has gained emphasis in the scientific community in recent years due to the increase in clinical and in animal models studies focused on endodontic medicine, which aims to evaluate the interrelationship between systemic and periapical tissues pathological conditions. These studies have shown that systemic changes can boost the pathogenesis of endodontic infection, favoring its development and progression. A contrary relationship is reported in numerous studies that affirm the potential of endodontic infection to trigger systemic damage and may lead to the worsening of pre-existing pathologies. Recently, the potential of filling materials to develop systemic changes such as neurological alterations had been evaluated, also showing that systemic diseases can negatively influence tissue responses to filling materials after endodontic treatment. Despite advances in endodontic medicine studies, there are still gaps in knowledge on the mechanisms of interactions between apical periodontitis (AP) and systemic diseases and much research to be done. In this sense, this critical narrative literature review aimed to show the evolution of studies in endodontic medicine to help the endodontist to know the role of systemic diseases in the pathogenesis of AP and the possible interference in the repair of periapical tissues after endodontic treatment, as well as to evidence the systemic complications that can be triggered or aggravated in the presence of endodontic infection.

The association between apical periodontitis and adverse pregnancy outcomes: a systematic review

BACKGROUND

The association between adverse pregnancy outcomes (APOs) and maternal apical periodontitis remains unclear as it has not been examined rigorously or reviewed systematically.

OBJECTIVE

To systematically review and critically evaluate the available evidence on the association of maternal apical periodontitis with several APOs.

METHODS

A literature search was conducted using the following electronic databases: Clarivate Analytics' Web of Science, Scopus, PubMed, and Cochrane Central Register of Controlled Trials (CENTRAL), from inception to 25 February 2021, with no language restrictions. Observational studies including longitudinal clinical trials, cohort, case-control and cross-sectional studies of prospective and retrospective design were included. Articles with duplicate or overlapping results, abstract-only papers, case reports, case series, animal studies and reviews were excluded. Two independent reviewers were involved in study selection, data extraction and appraising the included studies; disagreements were resolved by a third reviewer. The Newcastle-Ottawa Scale (NOS) and the adapted form of the NOS were used to assess the quality for case-control and cross-sectional studies, respectively.

RESULTS

Two case-control and one cross-sectional study were included in the current review. The included studies were published between 2015 and 2017, with a total of 1187 participating individuals with an approximate age range of 15 to 40 years. As the included studies reported different outcomes, the heterogeneity of data prevented a meta-analysis being undertaken. The overall quality of the evidence was 'Fair' for two out of three included studies, while one study was categorized as 'Good'.

DISCUSSION

Two out of three included primary studies had a substantial number of methodological inconsistencies and flaws, and therefore caution should be exercised in interpreting the results of this systematic review because several important covariates were not considered in the original investigations.

CONCLUSION

Based on a limited volume and 'Fair' and 'Good' quality of evidence, a positive association between maternal apical periodontitis and APOs was observed. However, more 'Good' quality clinical studies are needed to confirm the results of the current review.

FUNDING

None REGISTRATION: PROSPERO database (CRD42-2191987).

The impact of minimally invasive restorative techniques on perception of dental pain among pregnant women: a randomized controlled clinical trial

BACKGROUND

The public dental care sector is striving to fulfill the preventive and restorative needs of Egyptians, including pregnant women, who may not receive timely care due to misconceptions about dental treatment during pregnancy. Because of this, they are likely to suffer dental pain, with higher risk of infection affecting their offsprings.

AIM OF THE STUDY

To compare the effectiveness of chemo-mechanical caries removal using Papacarie-Duo and Atraumatic Restorative Treatment (ART) in reducing dental pain among pregnant women.

MATERIALS AND METHODS

A randomized controlled clinical trial was conducted, in 2019, and included 162 pregnant women visiting family health centers in Alexandria, Egypt, with dental pain due to dental caries not extending to pulp. Patients were randomly assigned to Papacarie-Duo group (n = 82) and ART group (n = 80) after stratification by number of treated surfaces. The outcome variables were reduction in pain assessed using Visual Analogue Scale (VAS), satisfaction with treatment, and time taken for dental caries removal. T test/ Mann Whitney U test were used to compare groups and Freidman test was used to compare change across time.

RESULTS

Pain reduction was significantly greater in the Papacarie-Duo than the ART group (81.55% and 69.43%, P = 0.001). Patients in the Papacarie-Duo group were significantly more satisfied with treatment than those in the ART, immediately after treatment (mean = 9.60 and 8.00, P =  < 0.01) and after 6 months (mean = 9.63 and 8.16, P =  < 0.01). Significantly less excavation time was recorded in the Papacarie-Duo group than in the ART group (mean = 10.38 and 11.56 min, P =  < 0.01).

CONCLUSION

Chemo-mechanical caries removal using Papacarie-Duo is more effective in reducing dental pain, in pregnant women, and is associated with more satisfaction and less excavation time than ART.

TRIAL REGISTRATION

ID NCT04573608 ( https://clinicaltrials.gov/ ); 5/10/2020, retrospective registration.

The global prevalence of apical periodontitis: a systematic review and meta-analysis

BACKGROUND

Apical periodontitis (AP) frequently presents as a chronic asymptomatic disease. To arrive at a true diagnosis, in addition to the clinical examination, it is mandatory to undertake radiographic examinations such as periapical or panoramic radiographs, or cone-beam computed tomography (CBCT). Thus, the worldwide burden of AP is probably underestimated or unknown. Previous systematic reviews attempted to estimate the prevalence of AP, but none have investigated which factors may influence its prevalence worldwide.

OBJECTIVES

To assess: (i) the prevalence of AP in the population worldwide, as well as the frequency of AP in all teeth, nontreated teeth and root filled teeth; (ii) which factors can modify the prevalence of AP.

METHODS

A search was conducted in the PubMed-MEDLINE, EMBASE, Cochrane-CENTRAL, LILACS, Google scholar and OpenGrey databases, followed by hand searches, until September 2019. Cross-sectional, case-control and cohort studies reporting the prevalence of AP in humans, using panoramic or periapical radiograph or CBCT as image methods were included. No language restriction was applied. An adaptation of the Newcastle-Ottawa Scale was used to evaluate the quality of the studies. A meta-analysis was performed to determine the pooled prevalence of AP at the individual level. Secondary outcomes were the frequency of AP in all teeth, nontreated teeth and rootfilled teeth. Subgroup analyses using random-effect models were carried out to analyse the influence of explanatory covariables on the outcome.

RESULTS

The search strategy identified 6670 articles, and 114 studies were included in the meta-analysis, providing data from 34 668 individuals and 639 357 teeth. The prevalence of AP was 52% at the individual level (95% CI 42%-56%, I²  = 97.8%) and 5% at the tooth level (95% CI 4%-6%; I²  = 99.5%). The frequency of AP in root-filled teeth and nontreated teeth was 39% (95% CI 36%-43%; I²  = 98.5%) and 3% (95% CI 2%-3%; I²  = 99.3%), respectively. The prevalence of AP was greater in samples from dental care services (DCS; 57%; 95% CI 52%-62%; I²  = 97.8%) and hospitals (51%; 95% CI 40%-63%; I²  = 95.9%) than in those from the general population (GP; 40%; 95% CI 33%-46%; I²  = 96.5%); it was also greater in people with a systemic condition (63%; 95% CI 56%-69%, I²  = 89.7%) compared to healthy individuals (48%; 95% CI 43%-53%; I²  = 98.3%).

DISCUSSION

The subgroup analyses identified explanatory factors related to the variability in the prevalence of AP. However, the high clinical heterogeneity and high risk of bias across the primary studies indicate that the findings must be interpreted with caution.

CONCLUSIONS

Half of the adult population worldwide have at least one tooth with apical periodontitis. The prevalence of AP is greater in samples from the dental care services, but it is also high amongst community representative samples from the general population. The present findings should bring the attention of health policymakers, medical and dental communities to the hidden burden of endodontic disease in the population worldwide.

Neonatal mortality rates and association with antenatal corticosteroids at Kamuzu Central Hospital

OBJECTIVE

Malawi has one of the highest child mortality rates in the world, and neonates account for nearly half of all under-five mortality. No previous study has reported neonatal outcomes in Malawi over 12 months. We aimed to evaluate outcomes in the neonatal intensive care unit (NICU) at Kamuzu Central Hospital (KCH) and to determine if there was an association between increased survival and antenatal corticosteroid (ACS) exposure.

STUDY DESIGN

We introduced a prospective, observational electronic database to collect 122 de-identified variables related to neonatal outcomes for all neonates admitted to the KCH NICU over 12 months. Patients with congenital anomalies were excluded. We compared neonatal mortality rates in neonates who were exposed to ACS compared to those who were not. Statistical methodology included the Wilcoxon rank sum test, Fisher's exact test, and logistic regression.

RESULTS

Of 2051 neonates admitted to the KCH NICU, the overall neonatal mortality rate was 23.1% and remained similar across 12 months. Mortality was inversely related to birth weight, and outborn neonates referred to KCH had the highest mortality rate (29%). After controlling for confounding covariates, inborn infants exposed to ACS had significantly lower odds of death compared to those without exposure to ACS (adjusted odds ratio = 0.46, 95% confidence interval: 0.24-0.88, p = 0.020).

CONCLUSION

Lower birth weight, outborn, and no ACS exposure were associated with increased mortality. ACS was associated with a 54% reduction in odds of mortality in inborn neonates highlighting the need for further evaluations of ACS use in resource-limited settings.

Oxidative Stress Markers Differ in Two Placental Dysfunction Pathologies: Pregnancy-Induced Hypertension and Intrauterine Growth Restriction

Aim

Pregnancy-induced hypertension (PIH) and intrauterine growth restriction (IUGR) are both multisystemic disorders of pregnancy that cause perinatal morbidity and mortality. Recently, researchers focused on the role of oxidative stress (OS) as a pathophysiological mechanism in the development of these pathologies. The aim of this study was to compare OS in placental-related pathologies (PIH and IUGR) and uncomplicated pregnancies. We also investigated which salivary OS markers reflect systemic oxidative status and which only reflect the state of the oral cavity. Material and Methods. A total of 104 pregnant women (n = 104; 27 with PIH, 30 with IUGR, and 47 controls) were evaluated. Malondialdehyde (MDA), total antioxidant capacity (ORAC), aldehyde dehydrogenase (ALDH), and activity of glutathione peroxidase (GPx) and glutathione transferase (GST) in plasma/whole blood and/or saliva were analysed. Dietary nutrient intake was calculated using a Semiquantitative Food Frequency Questionnaire (SFFQ). Oral health was assessed to eliminate patients with bleeding, severe periodontitis, and other dental pathologies.

Results

In the IUGR group, increased concentration of ORAC was observed both in saliva and plasma. Also, lower plasma levels of MDA in IUGR compared to the control group was detected. No sign of oxidative stress was confirmed in the PIH group. The examined groups did not differ regarding diet and markers of inflammation. ORAC in saliva was correlated with its level in plasma. No such correlations for MDA were observed. In the IUGR group, there were no differences in OS markers in plasma, but there was a lower ALDH level in the blood compared to the control group. It confirms OS occurrence in IUGR. In IUGR, a higher activity of salivary ALDH was probably due to worse oral health.

Conclusion

Oxidative stress differs between IUGR and PIH groups: the presence of oxidative stress was confirmed only in the IUGR group. Salivary ORAC can be used to estimate ORAC in plasma. The activity of salivary ALDH reflects the state of the oral cavity.

Prevalence of and risk factors for periodontal disease among pregnant women in an antenatal care clinic in Khartoum, Sudan

Objectives

The aim was to investigate the prevalence of and factors associated with periodontal disease among pregnant Sudanese women. A cross-sectional study was conducted at the Antenatal Care Clinic of Saad Abualila Hospital (Khartoum, Sudan) from August to October 2018. Socioeconomic-demographic information and reproductive history were gathered using a questionnaire. Body mass index was computed from the weight and height. The diagnosis of periodontal disease was performed using criterion that also evaluated bleeding upon probing.

Results

Four hundred and four women were enrolled in the study, with a mean (SD) gestational age of 30.0 (8.7) weeks. Their mean (SD) age and parity were 27.0 (5.7) years and 1.6 (1.7), respectively. Ninety-seven (24.0%) of these 404 women had periodontal disease, which was mild, moderate and severe in 49 (12.1%), 36 (8.9%) and 12 (3.0%) women respectively, while 307 (76.0%) women had no periodontal disease. In logistic regression, age, parity, education, and brushing were not associated with periodontitis, but lower gestational age was associated with periodontal disease (OR = 0.96, 95% CI 0.94–0.99, P = 0.011).

Population-Based Estimation of the Preterm Birth Rate in Lilongwe, Malawi: Making Every Birth Count

Objective  The objective of this study was to perform a population-based estimation of the preterm birth (PTB) rate in regions surrounding Lilongwe, Malawi. Study Design  We partnered with obstetrician specialists, community health workers, local midwives, and clinicians in a 50 km region surrounding Lilongwe, Malawi, to perform a population-based estimation of the PTB rate during the study period from December 1, 2012 to May 19, 2015. Results  Of the 14,792 births captured, 19.3% of births were preterm, including preterm early neonatal deaths. Additional PTB risk factors were similarly prevalent including domestic violence, HIV, malaria, anemia, and malnutrition. Conclusion  When performing a population-based estimation of the rate of PTB, including women without antenatal care and women delivering at home, the 19.3% rate of PTB is among the highest recorded globally. This is accompanied by a high rate of risk factors and comorbid conditions.

Population-Based Estimation of Dental Caries and Periodontal Disease Rates of Gravid and Recently Postpartum Women in Lilongwe, Malawi

Objectives  The objective of this study was to determine the rate of dental caries and periodontal disease among gravid and recently postpartum women at five delivery centers within and surrounding Lilongwe, Malawi. Study Design  We partnered with obstetric specialists, community health workers, and dentists to perform dental history interviews and dental examinations during the study period from December 2012 to May 2014. Dental examinations were performed according to World Health Organization standards to assess periodontal and oral health status. Results  Among the 387 gravid and recently postpartum women, the rate of dental caries was 69.3% and the rate of composite dental disease (caries and periodontal disease) was 76.7%. The majority (69.5%) of women examined had a decayed-missing-filled (DMF) index greater than or equal to one; the average DMF Index was 2.48. The majority of women had never seen a dentist (62.8%). However, most did perform oral hygiene, two or more times per day (90.2%); most women reported brushing with toothpaste (88.1%). Conclusion  When assessing this population for dental caries and periodontal disease, the rate of dental disease was high. Therefore, this may be an ideal setting to test for impactful interventions aimed at reducing caries and periodontal disease.

Sulphadoxine-pyrimethamine plus azithromycin may improve birth outcomes through impacts on inflammation and placental angiogenesis independent of malarial infection

Intermittent preventive treatment with sulphadoxine-pyrimethamine (SP) and SP plus azithromycin (SPAZ) reduces low birthweight (<2,500 g) in women without malarial and reproductive tract infections. This study investigates the impact of SPAZ on associations between plasma biomarkers of inflammation and angiogenesis and adverse pregnancy outcomes in 2,012 Papua New Guinean women. Concentrations of C-reactive protein (CRP), α-1-acid glycoprotein (AGP), soluble endoglin (sEng), soluble fms-like tyrosine kinase-1 (sFlt-1) and placental growth factor (PlGF) were measured at enrolment and delivery in a trial comparing SPAZ to SP plus chloroquine (SPCQ). At antenatal enrolment higher CRP (adjusted odds ratio 1.52; 95% confidence interval [CI] 1.03–2.25), sEng (4.35; 1.77, 10.7) and sFlt1 (2.21; 1.09, 4.48) were associated with preterm birth, and higher sEng with low birthweight (1.39; 1.11,3.37), in SPCQ recipients only. Increased enrolment sFlt1:PlGF ratios associated with LBW in all women (1.46; 1.11, 1.90). At delivery, higher AGP levels were strongly associated with low birthweight, preterm birth and small-for-gestational age babies in the SPCQ arm only. Restricting analyses to women without malaria infection did not materially alter these relationships. Women receiving SPAZ had lower delivery AGP and CRP levels (p < 0.001). SPAZ may protect against adverse pregnancy outcomes by reducing inflammation and preventing its deleterious consequences, including dysregulation of placental angiogenesis, in women with and without malarial infection.

Qualitative assessment of knowledge transfer regarding preterm birth in Malawi following the implementation of targeted health messages over 3 years

Background

In 2012, we performed a needs assessment and gap analysis to qualitatively assess providers’ and patients’ knowledge and perceptions regarding preterm birth (PTB). During the study, we identified knowledge gaps surrounding methods to reduce the risk of occurrence of PTB and management options if preterm labor/birth occur. We targeted health messages toward these gaps. The objective of the present study was to assess the impact of our community health worker-based patient education program 3 years after it was implemented.

Methods

Fifteen focus groups including 70 participants were included in the study. The groups comprised either patients/patient couples or health providers. A minimum of two facilitators led each group using 22 a priori designed and standardized lead-in prompts for participants with four additional prompts for providers only. A single researcher recorded responses, and transcript notes were reviewed by the facilitators and interpreters immediately following each group discussion to ensure accuracy.

Results

The understanding of term vs preterm gestation was generally accurate. Every participant knew of women who had experienced PTB, and the general perception was that two to three women out of every ten had this experience. The majority of respondents thought that women should present to their local health clinic if they experience preterm contractions; few were aware of the use of antenatal steroids for promoting fetal lung maturity, but many acknowledged that the neonate may be able to receive life-sustaining treatment if born at a higher level of care facility. The majority of participants were aware that PTB could recur in subsequent pregnancies. All respondents were able to list ways that women could potentially reduce the risk of PTB.

Conclusion

After employing targeted health messages, the majority of participants expressed improved understanding of the definition of PTB, methods to prevent risk of PTB, and management options for preterm labor or PTB.

Diagnosis of Newly Delivered Mothers for Periodontitis with a Novel Oral-Rinse aMMP-8 Point-of-Care Test in a Rural Malawian Population

A novel qualitative point-of-care test of activated matrix metalloproteinase-8 (aMMP-8) using noninvasive oral rinse sampling procedures has been developed for the early detection of collagen breakdown indicating periodontal tissue destruction. The main object of this study was to assess the reliability of the test in a low-income setting to identify participants with history of periodontal destruction detected as alveolar bone loss (ABL) in radiographs. This cross-sectional study included 486 women who had recently delivered in rural Malawi. The aMMP-8 test and dental panoramic radiographs were taken within 48 h of delivery. The performance of the test in comparison to radiological examinations was tested by following the standards for reporting of diagnostic accuracy studies protocol (STARD) with respective statistical measures and 95% confidence intervals. From the 486 eligible participants, 461 mothers with complete data, aged from 15 to 46 years (mean 24.8, SD 6.0) were included in the analysis. ABL was identified in 116 of 461 participants. There was 56% agreement between the aMMP-8 test results and detected ABL (yes or no) in radiographs. Calculated sensitivity of the test was 80% (72–87%), specificity 48% (43–54%), positive predictive value 34% (31–37%), negative predictive value 88% (83–91%), positive likelihood ratio 1.55 (1.35–1.77), and negative likelihood ratio 0.41(0.28–0.60). The aMMP-8 test sensitivity and negative predictive value to identify the ABL cases were relatively high, but there was additionally a high rate of test-positive results in participants without ABL, especially in young mothers, leading to low overall agreement between the test results and radiological bone loss. Further longitudinal studies are needed to examine if the test positive subjects are in risk of future bone loss before the detectable signs of periodontitis in radiographs.

Periodontal diseases and adverse pregnancy outcomes: Is there a role for vitamin D?

Studies have shown a relationship between maternal periodontal diseases (PDs) and premature delivery. PDs are commonly encountered oral diseases which cause progressive damage to the periodontal ligament and alveolar bones, leading to loss of teeth and oral disabilities. PDs also adversely affect general health by worsening of cardiovascular and metabolic diseases. Moreover, maternal PDs are thought to be related to increasing the frequency of preterm-birth with low birth weight (PBLBW) in new-borns. Prematurity and immaturity are the leading causes of prenatal and infant mortality and is a major public health problem around the world. Inflamed periodontal tissues generate significantly high levels of proinflammatory cytokines that may have systemic effects on the host mother and the fetus. In addition, the bacteria that cause PDs produce endotoxins which can harm the fetus. Furthermore, studies have shown that microorganisms causing PDs can get access to the bloodstream, invading uterine tissues, to induce PBLBW. Another likely mechanism that connects PDs with adverse pregnancy outcome is maternal vitamin D status. A role of inadequate vitamin D status in the genesis of PDs has been reported. Administration of vitamin D supplementation during pregnancy could reduce the risk of maternal infections and adverse pregnancy outcomes. As maternal PDs are significant risk factors for adverse pregnancy outcome, preventive antenatal care for pregnant women in collaboration with the obstetric and dental professions are required.

Periodontitis: facts, fallacies and the future

This volume of Periodontology 2000 represents the 25th anniversary of the Journal, and uses the occasion to assess important advancements in periodontology over the past quarter-century as well as the hurdles that remain. Periodontitis is defined by pathologic loss of the periodontal ligament and alveolar bone. The disease involves complex dynamic interactions among active herpesviruses, specific bacterial pathogens and destructive immune responses. Periodontal diagnostics is currently based on clinical rather than etiologic criteria, and provides limited therapeutic guidance. Periodontal causative treatment consists of scaling, antiseptic rinses and occasionally systemic antibiotics, and surgical intervention has been de-emphasized, except perhaps for the most advanced types of periodontitis. Plastic surgical therapy includes soft-tissue grafting to cover exposed root surfaces and bone grafting to provide support for implants. Dental implants are used to replace severely diseased or missing teeth, but implant overuse is of concern. The utility of laser treatment for periodontitis remains unresolved. Host modulation and risk-factor modification therapies may benefit select patient groups. Patient self-care is a critical part of periodontal health care, and twice-weekly oral rinsing with 0.10-0.25% sodium hypochlorite constitutes a valuable adjunct to conventional anti-plaque and anti-gingivitis treatments. A link between periodontal herpesviruses and systemic diseases is a strong biological plausibility. In summary, research during the past 25 years has significantly changed our concepts of periodontitis pathobiology and has produced more-effective and less-costly therapeutic options.

Periapical infection may affect birth outcomes via systemic inflammation

OBJECTIVES

Maternal dental periapical infections are associated with preterm birth and intrauterine growth restriction. This study investigates whether the association is mediated through bacterial spread from periapical lesions to placenta (direct pathway) or systemic inflammatory reaction (indirect pathway).

MATERIALS AND METHODS

We compared birth outcomes in Malawian mothers with and without periapical infection. As markers of a direct pathway, we identified placental bacteria using a 16S rDNA approach and assessed histological evidence of inflammation in the placenta and amniotic membranes. We measured C-reactive protein, alpha-1-acid glycoprotein, and salivary cortisol as markers of an indirect pathway. We used regression models to associate the predictor variables with duration of pregnancy and newborn size.

RESULTS

Of 1,024 women, 23.5% had periapical infection. There was no association of periapical infection with either bacterial DNA or histological inflammation in placenta or membranes. Periapical infection was associated with C-reactive protein, alpha-1-acid glycoprotein, and cortisol concentrations in a dose-dependent manner at 36 weeks. Addition of alpha-1-acid glycoprotein or cortisol concentration into regression models attenuated the association between periapical infection and pregnancy outcomes.

CONCLUSION

There was no evidence of direct spread of periapical bacteria to the placenta. Periapical infections and adverse pregnancy outcomes are in part mediated through systemic inflammation.

Dental caries and preterm birth: a systematic review and meta-analysis

OBJECTIVES

The primary objective of this systematic review was to evaluate the association between dental caries and preterm birth (PTB). The secondary objective was ascertaining the difference between women with dental caries who experienced PTB and those who did not with regard to decayed, missing and filled teeth (DMFT), and decayed, missing and filled surfaces (DMFS) indices.

METHODS

MEDLINE, Embase, CINAHL and Cochrane databases were searched initially in November 2015 and repeated in December 2016. We included observational cohort and case-control studies. Only studies reporting the risk of PTB in women affected compared with those not affected by dental caries in pregnancy were included. Random-effect meta-analyses were used to compute the summary OR of PTB among women with caries versus women without caries, and the mean difference in either DMFT or DMFS indices between women experiencing PTB and those without PTB.

RESULTS

Nine observational studies (4826 pregnancies) were included. Women affected by dental caries during pregnancy did not show a significantly higher risk of PTB (OR: 1.16, 95% CI 0.90 to 1.49, P=0.25, I2=35%). Also, the women with PTB did not show significantly higher DMFT or DMFS indices (summary mean differences: 1.56, P=0.10; I2=92% and -0.15, P=0.9, I2=89%, respectively).

CONCLUSION

Dental caries does not appear to be a substantial risk factor for PTB.

TRIAL REGISTRATION NUMBER

NCT01675180; Pre-results.

Child Health Outcomes After Presumptive Infection Treatment in Pregnant Women: A Randomized Trial

BACKGROUND AND OBJECTIVES

We showed earlier that presumptive infection treatment in pregnancy reduced the prevalence of neonatal stunting in a rural low-income setting. In this article, we assess how these gains were sustained and reflected in childhood growth, development, and mortality.

METHODS

We enrolled 1320 pregnant Malawian women in a randomized trial and treated them for malaria and other infections with either 2 doses of sulfadoxine-pyrimethamine (SP) (control), monthly SP, or monthly sulfadoxine-pyrimethamine and 2 doses of azithromycin (AZI-SP). Child height or length and mortality were recorded at 1, 6, 12, 24, 36, 48, and 60 months and development at 60 months by using Griffith's Mental Development Scales.

RESULTS

Throughout follow-up, the mean child length was 0.4 to 0.7 cm higher (P < .05 at 1-12 months), the prevalence of stunting was 6 to 11 percentage points lower (P < .05 at 12-36 months), and the 5-year cumulative incidence of stunting was 13 percentage points lower (hazard ratio: 0.70, 95% confidence interval [CI]: 0.60 to 0.83, P < .001) in the AZI-SP group than in the control group. The mean developmental score was 3.8 points higher in the AZI-SP group than in the control group (95% CI: 1.1 to 6.4, P = .005). Total mortality during pregnancy and childhood was 15.3%, 15.1%, and 13.1% (P = .60) in the control, monthly SP, and AZI-SP groups, respectively. Postneonatal mortality (secondary outcome) was 5.5%, 3.3%, and 1.9%, respectively (risk ratio of AZI-SP versus control: 0.34, 95% CI: 0.15 to 0.76, P = .008).

CONCLUSIONS

Provision of AZI-SP rather than 2 doses of SP during pregnancy reduced the incidence of stunting in childhood. AZI-SP during pregnancy also had a positive effect on child development and may have reduced postneonatal mortality.

Co-causation of reduced newborn size by maternal undernutrition, infections, and inflammation

More than 20 million babies are born with low birthweight annually. Small newborns have an increased risk for mortality, growth failure, and other adverse outcomes. Numerous antenatal risk factors for small newborn size have been identified, but individual interventions addressing them have not markedly improved the health outcomes of interest. We tested a hypothesis that in low‐income settings, newborn size is influenced jointly by multiple maternal exposures and characterized pathways associating these exposures with newborn size. This was a prospective cohort study of pregnant women and their offspring nested in an intervention trial in rural Malawi. We collected information on maternal and placental characteristics and used regression analyses, structural equation modelling, and random forest models to build pathway maps for direct and indirect associations between these characteristics and newborn weight‐for‐age Z‐score and length‐for‐age Z‐score. We used multiple imputation to infer values for any missing data. Among 1,179 pregnant women and their babies, newborn weight‐for‐age Z‐score was directly predicted by maternal primiparity, body mass index, and plasma alpha‐1‐acid glycoprotein concentration before 20 weeks of gestation, gestational weight gain, duration of pregnancy, placental weight, and newborn length‐for‐age Z‐score (p < .05). The latter 5 variables were interconnected and were predicted by several more distal determinants. In low‐income conditions like rural Malawi, maternal infections, inflammation, nutrition, and certain constitutional factors jointly influence newborn size. Because of this complex network, comprehensive interventions that concurrently address multiple adverse exposures are more likely to increase mean newborn size than focused interventions targeting only maternal nutrition or specific infections.

Factors affecting oral health determinants in female university students: a cross-sectional survey in Saudi Arabia

Objective This study aims at investigating factors affecting oral health patterns, attitudes and health risk behaviors among female university students. Methods An online questionnaire was distributed to female university students in Al Madinah in the western region of Saudi Arabia. Students were requested to answer questions on demographic data, oral hygiene practices, dental attendance, smoking history, practice of sports and body weight and height. Results Two hundred and fourteen students participated with age range of 18-31 years (mean = 21.64 ± 1.72 years). Oral hygiene habits were reported by a percentage of 97.2%, 34.6%, 30.8% and 19.2% who used a tooth brush, dental floss, mouthwash, and a miswak (a teeth cleaning twig made from the Salvadora persica tree), respectively. The only factor that was significantly associated with a good oral hygiene level was a university major of non-healthcare specialties (p = 0.009). Conclusion It is concluded that female university students use various oral hygiene methods, however, dental attendance is poor and a number of health risk factors are noticed like smoking, lack of practicing sport and unhealthy body mass index (BMI).

Bacterial communities found in placental tissues are associated with severe chorioamnionitis and adverse birth outcomes

Preterm birth is a major cause of neonatal mortality and morbidity worldwide. Bacterial infection and the subsequent inflammatory response are recognised as an important cause of preterm birth. It is hypothesised that these organisms ascend the cervical canal, colonise placental tissues, cause chorioamnionitis and in severe cases infect amniotic fluid and the foetus. However, the presence of bacteria within the intrauterine cavity does not always precede chorioamnionitis or preterm birth. Whereas previous studies observing the types of bacteria present have been limited in size and the specificity of a few predetermined organisms, in this study we characterised bacteria found in placental tissues from a cohort of 1391 women in rural Malawi using 16S ribosomal RNA gene sequencing. We found that specific bacteria found concurrently on placental tissues associate with chorioamnionitis and delivery of a smaller newborn. Severe chorioamnionitis was associated with a distinct difference in community members, a higher bacterial load and lower species richness. Furthermore, Sneathia sanguinengens and Peptostreptococcus anaerobius found in both matched participant vaginal and placental samples were associated with a lower newborn length-for-age Z-score. This is the largest study to date to examine the placental microbiome and its impact of birth outcomes. Our results provide data on the role of the vaginal microbiome as a source of placental infection as well as the possibility of therapeutic interventions against targeted organisms during pregnancy.

Apical periodontitis associates with cardiovascular diseases: a cross-sectional study from Sweden

BACKGROUND

Periodontal disease associates with systemic diseases but corresponding links regarding apical periodontitis (AP) are not so clear. Hence our aim was to study association between AP and the prevalence of systemic diseases in a study population from Sweden.

METHODS

The subjects were 150 patients from a randomly selected epidemiological sample of 1676 individuals. 120 accepted to participate and their basic and clinical examination data were available for these secondary analyses where dental radiographs were used to record signs for endodontic treatments and AP. Periapical Index and modified Total Dental Index scores were calculated from the x-rays to classify the severity of AP and dental infection burden, respectively. Demographic and hospital record data were collected from the Swedish National Statistics Center. T-test, chi-square and univariate analysis of covariance (ANCOVA) and regressions analyses were used for statistics.

RESULTS

Of the 120 patients 41% had AP and 61% had received endodontic treatments of which 52% were radiographically unsatisfactory. AP patients were older and half of them were smokers. AP and periodontitis often appeared in the same patient (32.5%). From all hospital diagnoses, cardiovascular diseases (CVD) were most common, showing 20.4% prevalence in AP patients. Regression analyses, controlled for age, gender, income, smoking and periodontitis, showed AP to associate with CVD with odds ratio 3.83 (95% confidence interval 1.18-12.40; p = 0.025).

CONCLUSIONS

The results confirmed our hypothesis by showing that AP statistically associated with cardiovascular diseases. The finding that subjects with AP also often had periodontitis indicates an increased oral inflammatory burden.

A Retrospective Analysis of Radiographic Jaw Findings in Young Women; Prevalence and Predictors

AIMS AND OBJECTIVES

To determine the prevalence and types of jaw pathologic findings as detected in panoramic radiographs of a sample of young women attending a teaching hospital in Al Madinah Al Munawarah, Saudi Arabia, and to determine the most important factors that predict the occurrence of jaw pathologic findings.

MATERIALS AND METHODS

The electronic clinical files of a representative sample of female patients who attended the outpatient dental clinics were retrieved. Patients were aged 18 to 25 years. Types of pathologic radiographic jaw findings and their prevalence were determined through screening of panoramic radiographs. Data were analyzed using the statistical analysis software [SPSS version 21 (IBM Corp.)]. Multiple linear regression was used to explore the significance of some types of dental lesions as predictor variables for the occurrence of jaw pathologic findings.

RESULTS

A total of 190 patients (mean age, 22.4 ± 2.46 years) were included in the study. Periapical lesions, retained roots, and alveolar bone loss were detected in 53.6%, 24.8%, and 17.4% of the participants, respectively. Other odontogenic abnormalities such as supernumerary and impacted teeth (6.4% and 33.7%, respectively) were also detected. Patients' age was found to be a good predictor for alveolar bone loss and number of periapical lesions (P ≤ 0.05).

CONCLUSIONS

A high prevalence of periapical lesions, retained roots, and alveolar bone loss was found among a sample of young female dental attendees, as shown by their panoramic radiographs. Further studies are needed to explore potential risk factors for such a noticeable trend of poor oral health, and the needed strategies to counteract this trend.

Distinguishing the Signals of Gingivitis and Periodontitis in Supragingival Plaque: a Cross-Sectional Cohort Study in Malawi

Periodontal disease ranges from gingival inflammation (gingivitis) to the inflammation and loss of tooth-supporting tissues (periodontitis). Previous research has focused mainly on subgingival plaque, but supragingival plaque composition is also known to be associated with disease. Quantitative modeling of bacterial abundances across the natural range of periodontal severities can distinguish which features of disease are associated with particular changes in composition. We assessed a cross-sectional cohort of 962 Malawian women for periodontal disease and used 16S rRNA gene amplicon sequencing (V5 to V7 region) to characterize the bacterial compositions of supragingival plaque samples. Associations between bacterial relative abundances and gingivitis/periodontitis were investigated by using negative binomial models, adjusting for epidemiological factors. We also examined bacterial cooccurrence networks to assess community structure. The main differences in supragingival plaque compositions were associated more with gingivitis than periodontitis, including higher bacterial diversity and a greater abundance of particular species. However, even after controlling for gingivitis, the presence of subgingival periodontitis was associated with an altered supragingival plaque. A small number of species were associated with periodontitis but not gingivitis, including members of Prevotella, Treponema, and Selenomonas, supporting a more complex disease model than a linear progression following gingivitis. Cooccurrence networks of periodontitis-associated taxa clustered according to periodontitis across all gingivitis severities. Species including Filifactor alocis and Fusobacterium nucleatum were central to this network, which supports their role in the coaggregation of periodontal biofilms during disease progression. Our findings confirm that periodontitis cannot be considered simply an advanced stage of gingivitis even when only considering supragingival plaque.

IMPORTANCE

Periodontal disease is a major public health problem associated with oral bacteria. While earlier studies focused on a small number of periodontal pathogens, it is now accepted that the whole bacterial community may be important. However, previous high-throughput marker gene sequencing studies of supragingival plaque have largely focused on high-income populations with good oral hygiene without including a range of periodontal disease severities. Our study includes a large number of low-income participants with poor oral hygiene and a wide range of severities, and we were therefore able to quantitatively model bacterial abundances as functions of both gingivitis and periodontitis. A signal associated with periodontitis remains after controlling for gingivitis severity, which supports the concept that, even when only considering supragingival plaque, periodontitis is not simply an advanced stage of gingivitis. This suggests the future possibility of diagnosing periodontitis based on bacterial occurrences in supragingival plaque.