Assessing the association between periodontitis and premature birth: a case-control study

Dietary Inflammatory Index is associated with periodontitis risk in pregnant women with gestational diabetes mellitus

Recent studies suggest a link between periodontitis and the Dietary Inflammatory Index (DII). We hypothesize that a more proinflammatory diet is associated with periodontitis risk in pregnant women with gestational diabetes mellitus (GDM). This study aimed to explore the association between DII scores and periodontitis risk in GDM women. In this cross-sectional study, 302 eligible GDM women from a Maternal and Child Health Hospital were enrolled between February and July 2023. DII scores were calculated based on dietary intake data collected using a validated semiquantitative food frequency questionnaire. Periodontal health was assessed through periodontal parameters including bleeding on probing, probing depth, and clinical attachment loss. Logistic regression models were employed to evaluate the odds ratios (ORs) for periodontitis risk across DII tertiles. Our study found that the prevalence of periodontitis across the DII tertiles 1, 2, and 3 was 34.7%, 56.4%, and 54.0%, respectively. Comparing the highest DII tertile (tertile 3) with the lowest (tertile 1), a significant association was found between higher DII scores and periodontitis risk (univariate OR: 2.21; 95% CI: 1.25, 3.90; P = .006), which remained significant in the fully adjusted model (adjusted OR: 2.30; 95% CI: 1.21, 4.37; P = .011). In conclusion, elevated DII scores are associated with an increased risk of periodontitis, underscoring the crucial role of a proinflammatory diet in periodontitis progression. Future well-designed experimental studies are needed to verify if tailored dietary strategies can effectively reduce periodontitis risk among pregnant women with GDM.

Microbiota-immune-brain interactions: A new vision in the understanding of periodontal health and disease

This review highlights the significance of interactions between the microbiota, immune system, nervous and hormonal systems, and the brain on periodontal health and disease. Microorganisms in the microbiota, immune cells, and neurons communicate via homeostatic nervous and hormonal systems, regulating vital body functions. By modulating pro-inflammatory and anti-inflammatory adaptive immune responses, these systems control the composition and number of microorganisms in the microbiota. The strength of these brain-controlled responses is genetically determined but is sensitive to early childhood stressors, which can permanently alter their responsiveness via epigenetic mechanisms, and to adult stressors, causing temporary changes. Clinical evidence and research with humans and animal models indicate that factors linked to severe periodontitis enhance the responsiveness of these homeostatic systems, leading to persistent hyperactivation. This weakens the immune defense against invasive symbiotic microorganisms (pathobionts) while strengthening the defense against non-invasive symbionts at the gingival margin. The result is an increased gingival tissue load of pathobionts, including Gram-negative bacteria, followed by an excessive innate immune response, which prevents infection but simultaneously destroys gingival and periodontal tissues. Thus, the balance between pro-inflammatory and anti-inflammatory adaptive immunity is crucial in controlling the microbiota, and the responsiveness of brain-controlled homeostatic systems determines periodontal health.

Incorporating basic periodontal screening into antenatal care services provided in Rwanda: A policy brief

Background

Preterm birth, which is child delivery before 37 weeks of pregnancy, is the primary cause of perinatal mortality worldwide. Preterm birth remains a major public health challenge in Rwanda, affecting approximately 13.8% of birth. The World Health Organization estimates that 15 million babies are born prematurely each year. While the association between periodontitis and preterm deliveries is increasingly recognized, little is known about this link in Rwanda. This policy brief aims to bridge this knowledge gap by presenting the findings of a recent study investigating the prevalence of periodontitis among pregnant women in Rwanda and its association with preterm deliveries. This policy brief also aims to inform and guide decision making towards incorporating periodontal screening into the antenatal care package in Rwanda. This has the potential to improve pregnancy outcomes and contribute to improved oral health in the future.

Policy outcome and Implications

Contemporary evidence has shown a six-fold increased risk of preterm delivery for women with periodontitis in Rwanda, with a concerningly high prevalence (60%) among pregnant women. Additionally, nurses working in antenatal clinics displayed insufficient knowledge about gum disease.

Actionable recommendations

The adoption of basic periodontal screening within existing antenatal care packages is recommended. This, coupled with nurse training and public awareness campaigns, can empower women and healthcare professionals to prioritize oral health for better pregnancy outcomes.

Conclusions

Integrating periodontal screening into antenatal care has the potential to significantly reduce preterm deliveries and contribute to a healthier future generation in Rwanda.

The Influence of Dental Status and Blood Parameters Characterizing Endogenous Intoxication on the Timing of Childbirth

Background and Objectives: Epidemiological and microbiological-immunological studies have led to the conclusion that periodontal disease may be a risk factor for preterm birth. The aim of this study was to investigate and identify the relationship of some hematological cellular biomarkers characterizing the chronic oral focus of infection with pregnancy outcomes and their impact on those outcomes. Materials and Methods: Clinical and laboratory tests were conducted on 100 pregnant women, grouped by full-term or preterm births, with the assessment of the following markers: DMF, CPI and PIRI, PHP, microbiological examination of periodontal pockets and amniotic fluid, WBS count, WBCSI, LGI, and NMR. A statistical analysis was carried out with SPSS Statistics version 19.0. Results: Women with preterm labor had higher-grade caries (CSL > 0.3), while women with full-term childbirth had moderate caries (CSL < 0.3). A satisfactory level of oral hygiene efficiency was found in 50% (group 1) and 38.1% (group 2) of the expectant mothers. The periodontal status by the PIRI showed tissue lesions in 20.7% (group 1) and 92.9% (group 2) of the women. The WBCSI was 2.27 ± 0.82 and 2.15 ± 0.68, the NMR was 9.29 ± 5.119 and 11.62 ± 7.78, and the LGI was 3.54 ± 1.1 and 3.73 ± 0.81 in groups 1 and 2, respectively. Comparative analysis of bacterial contamination of the amniotic fluid revealed the predominance of Fusobacterium nucleatum (64.3%), Tannerella forsythia (57.1%), Prevotella intermedia (50%), Porphyromonas gingivalis (57.1%), Staphylococcus aureus (45.2%), and Candida albicans (50%) in women with premature birth. Conclusions: In women with preterm birth, the values of the indices characterizing a chronic oral focus of infection evoke more significant correlations with the timing of delivery, which indicates the significant role of an oral focus of infection. The presence of microbial invasion of amniotic fluid may indicate the role of periodontopathogenic bacteria in pregnant women diagnosed with a risk of preterm birth.

Maternal periodontitis as a risk factor for preterm birth: A cross-sectional study

Background

Preterm birth is a heterogeneous condition with multiple underlying causes, and periodontal diseases are one of them. Approximately 900000 preterm births are reported in Pakistan each year. Oral infections such as periodontitis during pregnancy are associated with adverse pregnancy outcomes such as low birth weight and preterm births. However, different studies have reported contradictory findings. We conducted a cross-sectional study to assess the association of preterm birth with oral infection in pregnancy.

Methods

We conducted a cross-sectional analytical study on 400 postpartum pregnant women in Khyber Teaching Hospital, Peshawar. Only women within the age bracket of 18‒40 years were recruited. Data were collected by an interview-based structured questionnaire. The extent and severity index were used to assess the periodontal health of participants. Frequency tables were generated, and the chi-squared test was used to determine associations between different categorical variables.

Results

The mean age of the participants was 25.8±4.9 years. Approximately 87.5% of the women had generalized periodontitis. Approximately 68% of mothers had moderate severity of periodontitis. The extent index showed no notable difference between the preterm and full-term birth groups. In contrast, the severity index displayed a statistically significant difference between the preterm and full-term birth groups.

Conclusion

The majority of women had generalized periodontitis. The severity index demonstrated a significant association between maternal periodontitis and preterm births. There was no association between the age of mothers and preterm births. Complications in pregnancy were not associated with preterm births.

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.

Interleukin 1 beta and its association with the periodontal health of pregnant women

Objectives

In this study, we measured and compared serum and gingival crevicular fluid (GCF) levels of interleukin 1 beta (IL-1β) in pregnant women with periodontitis and pregnant women with a healthy periodontium. We also determined the prevalence of periodontitis among pregnant women attending Omdurman Midwifery Hospital.

Materials

This was a hospital-based clinical study and laboratory investigation using ELISA tests of 80 pregnant women in the third trimester conducted at the Omdurman Midwifery Hospital in Khartoum, Sudan. The study group consisted of 50 women while the control group consisted of 30 women.

Results

Independent samples t-tests were used to compare serum and GCF levels of IL-1β between the study and control groups. Pearson's correlation analysis was also used to compare gingival parameters and IL-1β levels in the GCF. For each comparison, the p-value was fixed at 0.05. The GCF in the research group showed a considerable increase in IL-1β levels. There was also a strong positive association between high IL-1β levels in the research group's GCF and probing pocket depth (PPD) and clinical attachment level (CAL) levels.

Conclusions

Our study provides further evidence that periodontitis, as measured by a PD ≥4 mm and a CAL ≥3 mm, is associated with an increased level of IL-1β in the GCF of pregnant women with active periodontal disease during pregnancy and may include the transient translocation of oral organisms to the utero-placental unit, inciting placental inflammation or oxidative stress early in pregnancy, ultimately resulting in placental damage and clinical manifestations.

The potential role of the gingival crevicular fluid biomarkers in the prediction of pregnancy complications

Early and minimally invasive methods are required to predict the risk of multiple adverse pregnancy outcomes. A potential technique with growing interest utilizes the gingival crevicular fluid (GCF), a physiological serum exudate found in the healthy gingival sulcus and in the periodontal pocket in inflammatory conditions. Analysis of biomarkers in the GCF is a minimally invasive method that can be feasible and cost-effective. The potential use of GCF biomarkers along with other clinical indicators in early pregnancy may provide reliable predictors of several adverse pregnancy outcomes, therefore, reducing both maternal and fetal morbidities. Various studies have reported that increased or decreased concentrations of different biomarkers in GCF are associated with a high risk of developing pregnancy complications. In particular, such associations have been commonly demonstrated with gestational diabetes, pre-eclampsia, and pre-term birth. However, limited evidence is available regarding other pregnancy complications such as preterm premature rupture of membranes, recurrent miscarriage, small for gestational age, and hyperemesis gravidarum. In this review, we discuss the reported association between individual GCF biomarkers and common pregnancy complications. Future research is required to provide more solid evidence of the predictive value of those biomarkers in estimating women's risk for each disorder.

Maternal, obstetric and gynecological factors associated with preterm birth in Rwanda: findings from a national longitudinal study

BACKGROUND

Preterm birth is one of the key causes of morbidity and mortality among neonates in low-income countries. In Rwanda, at least 35,000 babies are born prematurely each year, and 2600 children under the age of five die due to direct complications of prematurity each year. A limited number of studies have been conducted locally, many of which are not nationally representative. Thus, this study determined the prevalence as well as the maternal, obstetric, and gynecological factors associated with preterm birth in Rwanda at the national level.

METHODS

A longitudinal cohort study was conducted from July 2020 to July 2021 among first-trimester pregnant women. A total of 817 women from 30 health facilities in 10 districts were included in the analysis. A pre-tested questionnaire was used to collect data. In addition, medical records were reviewed to extract relevant data. Ultrasound examination was used to assess and confirm gestational age on recruitment. A multivariable logistic regression analysis was performed to determine the independent maternal, obstetric, and gynecological factors associated with preterm birth.

RESULTS

The prevalence of preterm births was 13.8%. Older maternal age- 35 to 49 years [Adjusted odds ratio (AOR) = 2.00; 95% Confidence Interval (CI) = 1.13-3.53)], secondhand smoke exposure during pregnancy (AOR = 1.91; 95% CI = 1.04-3.51), a history of abortion (AOR = 1.89; 95% CI = 1.13-3.15), premature membrane rupture (AOR = 9.30; 95% CI = 3.18-27.16), and hypertension during pregnancy (AOR = 4.40; 95% CI = 1.18-16.42) were identified as independent risk factors for preterm birth.

CONCLUSION

Preterm birth remains a significant public health issue in Rwanda. The associated risk factors for preterm birth were advanced maternal age, secondhand smoke, hypertension, history of abortion, and preterm membrane rupture. This study therefore recommends routine antenatal screening to identify and closely follow-up of those high-risk groups, in order to avoid the short- and long-term effects of preterm birth.

Prevalence, Severity of Extension, and Risk Factors of Gingivitis in a 3-Month Pregnant Population: A Multicenter Cross-Sectional Study

The scope of this study was to assess the prevalence, severity of extension, and risk factors of gingivitis among pregnant women. In this cross-sectional study, 220 nulliparous women at 3 months of pregnancy were recruited in 2022 at the first obstetrical visit in Dakar, Senegal. Demographic characteristics, lifestyle habits, prenatal clinical status, and oral clinical parameters were recorded. Multivariable logistic regression modeling was used to assess relationships between gingivitis and risk factors. Eighty-eight percent of women had gingivitis, 15% were classified as moderate and 73% as severe. A total of 66.7% (95% CI [28.8-92.1]) of the sites had bleeding on interdental brushing. The odds for gingivitis decreased significantly for women consuming more than five portions of fruits and vegetables per day (OR = 0.15; 95% CI [0.03-0.66]) and increased in women who had a professional activity (OR = 6.75; 95% CI [1.27-35.87]) and high education. Concomitantly, the percentage of dental plaque (OR = 131.6; 95% CI [10.80-1619.71] and the severity of clinical attachment loss (OR = 7.70; 95% CI [3.16-18.92]) were important risk factors. Inverse associations were observed with increasing body mass index (OR = 0.76; 95% CI [0.63-0.93]). Our results underline that gingivitis cases and bleeding were particularly high among 3-month pregnant women. Literacy and adequate oral hygiene actions to modify behaviors and to achieve meticulous biofilm disorganization could make a favorable change in the gingival health outcome. Additionally, further research is necessary to precisely determine the role of biofilm-induced gingivitis and systemic-induced gingivitis in improving gingival conditions.

Periodontal disease in pregnancy and adverse pregnancy outcomes: Progress in related mechanisms and management strategies

Periodontal disease is an inflammatory and destructive disease of tissues supporting the tooth. A large number of studies have confirmed that periodontal pathogens and their metabolites can lead to adverse pregnancy outcomes in direct or indirect ways. Adverse pregnancy outcomes, such as preterm birth, low birth weight, and pre-eclampsia, have a serious impact on human reproductive health. In recent years, although the level of global medical technology has gradually improved, the incidence of adverse pregnancy outcomes has not declined and is still a global public health problem. The purpose of this review is to summarize the current data on periodontal disease in pregnancy and adverse pregnancy outcomes, including the association between periodontal disease and adverse pregnancy outcomes, the pathogenic mechanism related to this association, the efficacy of different nutrition supplements for both periodontal disease and adverse pregnancy outcomes and the effect of providing periodontal treatment on the occurrence of adverse pregnancy outcomes, to provide guidance for the prevention and treatment of adverse pregnancy outcomes in clinical practice.

A Scoping Review of Preterm Births in Sub-Saharan Africa: Burden, Risk Factors and Outcomes

Preterm births (PTB) are the leading cause of neonatal deaths, the majority of which occur in low- and middle-income countries, particularly those in Sub-Saharan Africa (SSA). Understanding the epidemiology of prematurity is an essential step towards tackling the challenge of PTB in the sub-continent. We performed a scoping review of the burden, predictors and outcomes of PTB in SSA. We searched PubMed, Embase, and three other databases for articles published from the database inception to 10 July 2021. Studies reporting the prevalence of PTB, the associated risk factors, and/or its outcomes were eligible for inclusion in this review. Our literature search identified 4441 publications, but only 181 met the inclusion criteria. Last menstrual period (LMP) was the most commonly used method of estimating gestational age. The prevalence of PTB in SSA ranged from 3.4% to 49.4%. Several risk factors of PTB were identified in this review. The most frequently reported risk factors (i.e., reported in ≥10 studies) were previous history of PTB, underutilization of antenatal care (<4 visits), premature rupture of membrane, maternal age (≤20 or ≥35 years), inter-pregnancy interval, malaria, HIV and hypertension in pregnancy. Premature babies had high rates of hospital admissions, were at risk of poor growth and development, and were also at a high risk of morbidity and mortality. There is a high burden of PTB in SSA. The true burden of PTB is underestimated due to the widespread use of LMP, an unreliable and often inaccurate method for estimating gestational age. The associated risk factors for PTB are mostly modifiable and require an all-inclusive intervention to reduce the burden and improve outcomes in SSA.

The immunobiology of preterm labor and birth: intra-amniotic inflammation or breakdown of maternal-fetal homeostasis

In brief

The syndrome of preterm labor comprises multiple established and novel etiologies. This review summarizes the distinct immune mechanisms implicated in preterm labor and birth and highlights potential strategies for its prevention.

Abstract

Preterm birth, the leading cause of neonatal morbidity and mortality worldwide, results from preterm labor, a syndrome that includes multiple etiologies. In this review, we have summarized the immune mechanisms implicated in intra-amniotic inflammation, the best-characterized cause of preterm labor and birth, as well as novel etiologies non-associated with intra-amniotic inflammation (i.e. formally known as idiopathic). While the intra-amniotic inflammatory responses driven by microbes (infection) or alarmins (sterile) have some overlap in the participating cellular and molecular processes, the distinct natures of these two conditions necessitate the implementation of specific approaches to prevent adverse pregnancy and neonatal outcomes. Intra-amniotic infection can be treated with the correct antibiotics, whereas sterile intra-amniotic inflammation could potentially be treated by administering a combination of anti-inflammatory drugs (e.g. betamethasone, inflammasome inhibitors, etc.). Recent evidence also supports the role of fetal T-cell activation as a newly described trigger for preterm labor and birth in a subset of cases diagnosed as idiopathic. Moreover, herein we also provide evidence of two maternally-driven immune mechanisms responsible for preterm births formerly considered to be idiopathic. First, the impairment of maternal Tregs can lead to preterm birth, likely due to the loss of immunosuppressive activity resulting in unleashed effector T-cell responses. Secondly, homeostatic macrophages were shown to be essential for maintaining pregnancy and promoting fetal development, and the adoptive transfer of homeostatic M2-polarized macrophages shows great promise for preventing inflammation-induced preterm birth. Collectively, in this review, we discuss the established and novel immune mechanisms responsible for preterm birth and highlight the potential targets for novel strategies aimed at preventing the multi-etiological syndrome of preterm labor leading to preterm birth.

The Association between Maternal Periodontitis and Preterm Birth: A Case-Control Study in a Low-Resource Setting in Sudan, Africa

Background and Objectives: Vast data have been published recently on the association between periodontitis and preterm birth (PB). However, these studies have shown inconsistent results. Few of them were conducted in Africa, and data has not been published on the association between periodontitis and PB in Sudan. Materials and Methods: A case-control study was conducted at the Omdurman maternity hospital in Sudan from February through October 2021. The cases were women with spontaneous PB (<37 weeks), and healthy women with TB (37−42 weeks) were the controls. Questionnaires (demographics, medical and obstetric factors) were completed through face-to-face interviews. Periodontitis was diagnosed by the Community Periodontal Index as: “bleeding on probing and a pocket depth of ≥3 mm and clinical attachment loss of ≥6 mm, calculus with plaque deposits, and gingival recession”. Multivariate regression analysis was performed with PB as the dependent variable. Results: One hundred sixty-five women were enrolled in each arm of the study. The age, parity and body mass index did not significantly differ between the women with PB and those with TB. Compared with the controls, a significantly higher number of women with PB had periodontitis (50/165 (30.3%) vs. 30/165 (18.2%), p = 0.011). The association between periodontitis and PB was significant. Women who had periodontitis had double the odds of having PB compared to women who had no periodontitis (adjusted Odd Ratio = 2.05, 95% Confidence Interval = 1.20−3.52). Moreover, the haemoglobin level (adjusted Odd Ratio = 0.67, 95% Confidence Interval = 0.51−0.88) was inversely associated with PB. Conclusion: The study results indicate that periodontitis and low haemoglobin were strongly associated with PB. Preventive measures, including the use of periodontitis screening and the prevention of anaemia, are needed to reduce PB in this setting.

Oral bacteria, oral health, and adverse pregnancy outcomes

The link between oral health and adverse pregnancy outcomes has been suggested by numerous epidemiological studies. More recent studies indicate the relationship between severity of periodontal disease and adverse pregnancy outcomes. Two virulence mechanisms are proposed: direct invasion of oral microorganisms or their components into the fetal-placenta unit and inflammatory mediators produced in the oral cavity affecting the fetal-placenta unit. While interventional periodontal therapy still yielded contradictory results, animal studies suggest that maternal supplementation of omega-3 fatty acids protects the fetus by suppressing inflammation as well as bacteria proliferation in the placenta. This article reviews the recent epidemiological, mechanistic, interventional, and therapeutic studies of oral health and adverse pregnancy outcomes.