Prevention of Periodontal Prevention of Periodontal Disease and PrematurityDisease and Prematurity

MCH 2007 NSU-COMMCH 2007 NSU-COM

Kenneth E. Johnson, D.O., FACOOG

Associate Professor, OB/GYN

Nova Southeastern University

College of Osteopathic Medicine

Director, Women’s Health Center

OverviewOverview

Pregnancy changes a woman’s body physically, hormonally and physiologically.

The contribution of periodontal disease to preterm/low birth weight infants is a totally new and poorly understood public health condition.

Periodontal DiseasePeriodontal Disease

According to the National Institute of Dental and Craniofacial Research (NIDCR), an estimated 80 percent of American adults currently have some form of periodontal disease. (Epidemic?)

All start by a bacterial infection that can lead to the destruction of gums, bone, and ligaments supporting the teeth.

Periodontal DiseasePeriodontal Disease

Peridontal disease progresses silently, often without pain or overt symptoms that would alert the patient to its presence.

If only the gums are involved in this breakdown, the disease is called gingivitis. If only the connecting tissues and bone are involved, it is termed periodontitis.

Risk Factors for Periodontal Risk Factors for Periodontal DiseaseDisease

Smoking or chewing tobacco-dulled immune response and less oxygen in the mouth, smokers are 2-7 times more likely to develop periodontitis.

Poorly fitting crowns, bridges, fillings etc.Clenching or grinding teeth.Poor Diet

Risk FactorsRisk Factors

Pregnancy-increases in hormone levels.Current evidence suggests that Pregnant

women who have periodontal disease, are seven times more likely to have premature or low birth weight babies!

Since periodontal disease is easily detected and treated, a periodontal evaluation should be a part of prenatal care.

Risk FactorsRisk Factors

AIDSCardiovascular Disease- People with

periodontal disease may be at risk for heart disease, and have nearly twice the risk of having a fatal heart attack than people without periodontal disease.

If MOM DIES BABY DIES!

Risk FactorsRisk Factors

Prescription medications- Some drugs decrease the flow of saliva, irritating the mouth and increasing the risk of infection of the mouth.

Stress- Research shows that stress can make it more difficult for the body to fight infection, including periodontal disease.

Treatment of Periodontal Treatment of Periodontal DiseaseDisease

The most important goal of treatment is to control the infection. The type of treatment will vary, depending on the extent of the gum disease.

Deep Cleaning (Scaling and Root Planing) Removal of plaque through a deep-cleaning method called scaling and root planing.

MedicationsMedications

Prescription antimicrobial mouth RinseAnitseptic “chip”-gelatin to reduce the size

of periodontal pockets.Antibiotic micro-spheresEnzyme suppressants-decreases enzymes

that can break down gum tissues.Surgery-Flap Surgery, Bone and Tissue

Grafts.

PreventionPrevention

Brush your teeth twice a day(with fluoride toothpaste)

Floss every day! (MOST IMPORTANT)Visit the dentist routinely for a check-up

and professional CLEANING.Eat a well balanced DIETBehavior Modification: smoking cessation

Preterm LaborPreterm Labor

Delivery before 37 weeks gestation, problem-immature lungs, rds, death.

Public Health Cost $36 Billion dollars per year! And Climbing!!!

Preterm delivery has INCREASED by 27% in the U.S. from 9.5% in 1982 to 12.1% in 2002!!!

Risk Factors for Preterm Risk Factors for Preterm LaborLabor

Previous preterm deliveryLow socioeconomic status (?)Non-white raceMaternal age<18 or >40 (?)PPROM (?)Multiple gestation, Smoking, stress, Illicit

drug use

IncidenceIncidence

Each year over 400,000 infants are born prematurely as a result of preterm labor. Preterm birth is the LEADING cause of neonatal mortality in the United States.

It is not understood what signals the onset of labor in these women.

The preterm birth rate remains UNCHANGED in the last 30 years!

What is The Connection?What is The Connection?

Recent research linking periodontal disease and general health highlights the importance of assessing periodontal disease, espically for pregnant women who may be at risk of delivering a preterm low birth weight (PLBW) infant.

A recent study in North Carolina provided new evidence that poor oral hygiene is associated with delivery of PLBW infants.

ConnectionConnection

NIH reports that as many as 18% of the 250,000 premature low-weight infants born in the United States each year may be attributed to infectious oral disease.

Since there may be a connection, and there is no known downside of improving pregnant women’s oral health there is great enthusiasm for dealing with this public health problem.

LETS DO IT!

Some StudiesSome Studies

There appears to be a consistent trend toward the relationship between gum disease and PLBW infants.

Animals with induced gum disease show higher levels of blood-borne chemical mediators that are known to stimulate uterine contractions, cervical dilation, labor, and abortion.

Human StudiesHuman Studies

Human studies that compare birth outcomes with periodontal disease to women with healthy mouths suggest that women with periodontal infections have up to seven times the risk of delivering a low birth weight infant.

Another study describes a dose-response relationship between increasing periodontal disease severity and and increasing incidence of prematurity and low birth weight.

Biological MechanismsBiological Mechanisms

In attempting to understand the biological mechanisms underlying observed associations between perterm birth, low birth weight, and periodontal disease, researchers have focused primarily on the possibility that periodontal infections interfere with the normal physiological regulation of Labor and Delivery.

Biological MechanismsBiological Mechanisms

Throughout pregnancy, levels of prostaglandins and certain regulatory proteins known as cytokines steadily increse until a critical threshold level is reached inducing labor.

Studies have documented a statistically significant relationship between gingival disease and cytokine levels.

Biological MechanismsBiological Mechanisms

In case control study of Offenbacher et al. measured levels of PGE2 and IL-1 in the gingival crevicular fluid (GCF) of 48 mothers of PLBW infants. In addition, the levels of 4 periodontal pathogens were measured.(Bacteroides forsythus, P.gingivalis, Actinobacillus actinomycetememcomitans and Treponema denticola.

BugsBugs

These were measured with microbe-specific DNA probes. Gingival crevicular fluid levels of PGE2 were significantly higher in mothers of PLBW infants than mothers of infants with normal weight (controls).

The 4 periodontal pathogens, characteristically associated with mature plaque and progressing peiodontitis, WERE detected at significantly higher levels in the mothers of PLBW infants.

BugsBugs

Among the primiparous mothers of PLBW infants, a significant increased association of GCF PGE2 was found suggesting a dose-response for increased PGE2 as a marker of current periodontal disease activity and decreasing birth weight infants.

Fusobacterium NucleatumFusobacterium Nucleatum

Fusobacterium nucleatum is a gram-negative anaerobe ubiquitous to the oral cavity.

It is associated with preterm birth and HAS been isolated from the amniotic fluid , placenta and chorioamniotic membranes of women delivering prematurely.

Journal of Infection and Journal of Infection and ImmunityImmunity

In the April 2004 issue researchers showed F. nucleatum can directly infect the placenta and adversely affect pregnancies in mice.

EstrogenEstrogen

Changes in estrogen and progesterone levels associated with puberty, menses and the use of Ocs can provoke a disproportionate gingival inflammatory response.

Gingivitis is the most common oral manifestation of pregnancy, occuring in 60-70% of pregnant women.

Pilot StudiesPilot Studies

The results from a pilot study showed women who were less than 35 weeks pregnant had as much as an 84 percent reduction in premature births following the scaling and root planing in one group of 366 women.

ConclusionConclusion

Preterm birth and low birth weight are responsible for 70% of all perinatal deaths and 50% of all long-term nuerologic morbidity in the United States.

Efforts to investigate the reason for this public health crisis have led researchers to look closely at periodontal disease and overall oral health.

ConclusionConclusion

New studies suggest that periodontal disease and overall oral health may be among the remote infections that increase the risk for prematurity.

Possible mechanisms include the ability of bacterial pathogens, such as F. nucleatum and endotoxins stimulating prostaglandin production in amniotic tissue causing pre-term labor.

ConclusionConclusion

“Public Health Research and Advocacy will play a critical role in the elucidation, management and understanding of this tragic crisis in women’s health.”

Healthy People 2010Healthy People 2010

The Healthy People 2010 objective is to reduce preterm delivery to 7.6%. Instead as stated there has been an INCREASE in preterm deliveries in the US, whith considerable racial disparities such that African-Americans, Native Americans, and Hispanics have higher rates than Whites and Asians.

Specific Aims of Our Specific Aims of Our ResearchResearch

New studies are warranted to look at the full spectrum of clinical, molecular, biological and immunological aspects of periodontal disease and preterm delivery.

The purpose of our research will be to generate new knowledge to further the health of families in the US and possibly eliminate disparities related to preterm delivery.

Performance Goal of our Performance Goal of our ResearchResearch

The performance goal of the project is to identify biological and behavorial risk factors influencing prematurity with special reference to periodontal disease related factors.

The Objective of our ResearchThe Objective of our Research

The objective of the proposed project is to gain a better understanding of the susceptibility to preterm delivery in a public health framework through research that explores the social, behavorial, community, historical, and biologic determinants of preterm birth. The combination of these determinants can then be used to perdict the risk of preterm birth and target those at-risk patients early on in pregnancy for MODIFICATION of the relevant RISK FACTORS.

Global HypothesisGlobal Hypothesis

Women with signs of systemic infection related to periodontal disease will have a higher RISK of preterm delivery that is independent of other known risk factors for preterm delivery.

Systemic Infection and Systemic Infection and inflammationinflammation

The signs of systemic infection and inflammation will be measured by detecting the presence of selected periodontal pathogens (P.gingivalis, T.forsythensis, T.denticola, F.nucleatum, and C. rectus) in the chorioamniotic interface of the placental membranes and dental plaque samples, elevated levels of c-reactive protein and serum antibodies against those periodontal pathogens, and elevated levels of inflammatory mediators in gingival crevicular fluid,serum, amniotic fluid, and placental membranes. And MORE.

Thank You!Thank You!

Kenneth E. Johnson, D.O., FACOOG

Associate Professor, OB/GYN

Nova Southeastern University

College of Osteopathic Medicine

kjohnson@nsu.nova.edu