CHICAGO – November 21, 2001 – Pregnant diabetics have more gingival inflammation and deeper pockets between their teeth and gums, which are symptoms of periodontal disease, than non-diabetic pregnant women, according to a new study in the Journal of Periodontology. These findings are significant because periodontal disease is a bacterial infection that may make diabetes more difficult to control. Previous studies have shown that periodontal disease may increase women’s risk of delivering a preterm, low birth weight baby. Study Abstract *

The study compared 13 type-1 diabetic and 20 non-diabetic women in their 20-39th week of pregnancy. “Many women experience periodontal problems, such as bleeding and swollen gums, during pregnancy,” explained Janet Guthmiller, D.D.S., Ph.D., the lead researcher of the study conducted at the University of Iowa, Colleges of Dentistry and Medicine. “But the more advanced periodontal disease we observed in pregnant diabetics, who are already considered high risk for pregnancy problems, may affect blood sugar control during this critical time.”

Exacerbating the problem, periodontal disease may independently be a risk factor for preterm, low birth weight babies. Periodontal disease may trigger increased levels of biological fluids that induce labor, and this response may be amplified in diabetics. “This self-perpetuating destruction could potentially further complicate diabetic control and pregnancy outcome in diabetic subjects,” according to the study.

“This study vividly illustrates just how connected our bodies’ processes can be. Periodontal disease is a bacterial infection, and the infection may impact other parts of the body,” said Kenneth Bueltmann, D.D.S., president of the American Academy of Periodontology (AAP). “Treating periodontal disease and reducing the bacteria load may benefit diabetic control as well as pregnancy outcomes.”

“Our hope is that periodontal evaluations will be routinely included in the prenatal care of pregnant diabetic women, just as ophthalmologic exams are,” said Guthmiller. The AAP recommends that all women considering pregnancy have a periodontal exam.

A referral to a periodontist in your area and free brochure samples including one titled Diabetes & Gum Disease are available by calling 800-FLOSS-EM or visiting the AAP’s Web site at www.perio.org.

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CHICAGO – May 6, 2003 – Increase your intake of folic acid …Discontinue using birth control…And, visit your periodontist before becoming pregnant? Yes. Women contemplating motherhood may want to visit their periodontist or dental professional for a periodontal evaluation before becoming pregnant.

Studies in the Journal of Periodontology have shown a relationship between periodontal disease and preterm, low birthweight babies. Women with periodontal disease may be seven times more likely to have a baby that is born too early and too small.

“Any infection, including periodontal infection, is cause for concern during pregnancy,” said Gordon Douglass, D.D.S., president of the American Academy of Periodontology (AAP). “Pre-existing periodontal disease or periodontal disease that increases in severity during pregnancy can also increase a woman’s chances of a preterm low birthweight baby. Because periodontal disease is often “silent,” many women don’t know they have it, so a periodontal evaluation is definitely a good idea prior to becoming pregnant.”

Treating periodontal disease and/or removing gingivitis may also prevent other oral complications. “Beginning in the second or third month of pregnancy, expectant mothers often experience increased gingivitis also called pregnancy gingivitis that increases in severity throughout the eighth month,” said Douglass. “Significant progression of pregnancy gingivitis can lead to more severe periodontal infections.” The increase in estrogen and progesterone levels during this time causes the gums to react differently to the bacteria in plaque. This reaction causes swelling, bleeding, redness or tenderness in the gum tissue.

“The good news is women who treat their periodontal health prior to pregnancy decrease their chances of experiencing pregnancy gingivitis.” said Douglass. “Women should always take extra care of their oral health because their hormonal fluctuations can affect many tissues, including gum tissues.”

The Centers for Disease Control and Prevention (CDC) is encouraging women to take care of themselves before, during and after they become pregnant. The AAP co-sponsored an event with the CDC this past April about public health implications of periodontal infections in adults.

If you’re looking for last minute gift items for mother’s-to-be, don’t forget to add a toothbrush and dental floss to the gift basket or bouquet of flowers.

A referral to a periodontist in your area and free brochure samples including one titled Women and Periodontal Disease are available by calling 800-FLOSS-EM or visiting the AAP’s Web site at www.perio.org.

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CHICAGO – August 26, 2003 – A non-surgical dental procedure may reduce the risk of preterm birth in pregnant women with periodontal disease, according to new study findings. Nearly 12 percent of babies in this country are born preterm (before 37 completed weeks of pregnancy), which increases their risk of death and lasting disabilities, such as mental retardation, cerebral palsy, lung and gastrointestinal problems, and vision and hearing loss. Study Abstract *

The report was published in the Journal of Periodontology and is based on 366 pregnant women who had periodontitis (a serious gum infection that destroys attachment fibers and supporting bone that hold teeth in the mouth) and found as much as an 84 percent reduction of premature births in women who were less than 35 weeks pregnant and who received scaling and root planing. Researchers also found that adjunctive metronidazole therapy (an antibiotic used to treat infections) did not improve pregnancy outcome. In fact, women who were given the antibiotic after scaling and root planing had more preterm births than patients receiving scaling and root planing and a placebo.

“What this tells us is that scaling and root planing may significantly reduce a mother’s chance of having a preterm birth,” said said Marjorie Jeffcoat, D.M.D, study author and former Rosen professor and chair at the University of Alabama at Birmingham school of dentistry.

“We found no evidence that the addition of an antibiotic to scaling and root planing was of benefit in this study. However, more research needs to be conducted to determine the reason for the decrease in efficacy.”

Scaling and root planing is a common periodontal procedure that is performed by a periodontist, a dental practitioner who specializes in prevention, diagnosis and treatment of diseases of the supporting tissues and placement of dental implants. The tooth-root surfaces are cleaned to remove plaque and tartar from deep periodontal pockets and to smooth the root to remove bacterial toxins.

“In light of these findings, I recommend that all women who are thinking of becoming pregnant or who are pregnant receive a full periodontal exam and diagnosis,” said Jeffcoat. “Women who are already pregnant when periodontal disease is detected are ideally treated with scaling and root planing in the second trimester, which is a pragmatic protocol according to most Ob-Gyn specialists.”

Previous research reported that periodontal infections cause a faster-than-normal increase in the levels of prostaglandin and tumor necrosis factor molecules that induce labor, thus causing premature delivery before the fetus can grow to a normal birth weight. However, this is the first intervention study that offers advice on reducing the risk of premature births with scaling and root planing therapy alone.

“This is important information for the public and the medical community,” said Gordon Douglass, D.D.S., president of the American Academy of Periodontology. “Every mother wants to reduce her risk of having an unhealthy baby. A simple periodontal examination can give her the comfort of knowing that her oral health will not contribute to increasing her risk of having a preterm baby.”

Study Background

The blinded, controlled, randomized study compared three treatment groups: dental prophylaxis plus placebo, scaling and root planing plus placebo, and scaling and root planing plus metronidazole to determine if periodontitis treatment reduces the risk of spontaneous preterm birth in pregnant women.

Study participants were recruited from a large prospective study of 3,000 pregnant women who were between 21 and 25 weeks gestation and who had at least three sites (the area between teeth and gums) with clinical periodontal attachment loss greater than or equal to three millimeters. Patients were randomly assigned to one of the three treatment groups with stratification on the following factors: previous spontaneous birth at less than 35 weeks, body mass index less than 19.8, or bacterial vaginosis (vaginal bacterial infection). Participants were 85 percent African-American, 13.4 percent married and had a mean maternal age of 22 at delivery.

Similarity of treatment groups was compared for selected demographic data and the extent of periodontal disease. There were no significant differences among groups in the proportion of subjects having the following risk factors; maternal cigarette smoking, history of preterm birth prior to 35 weeks gestation, body mass index, positive vaginal fetal fibronectin, or the presence of bacterial vaginosis.

Periodontal diseases are serious bacterial infections that destroy the attachment fibers and supporting bone that hold your teeth in your mouth. When the attachment fibers are destroyed, gums separate from the teeth, forming pockets that fill with plaque and even more infection. As the disease progresses, these pockets deepen even further, more gum tissue and bone are destroyed and the teeth eventually become loose. Approximately 15 percent of adults between 21 and 50 years old and 30 percent of adults over 50 have the disease, with higher percentages often found in a pregnant population.

A referral to a periodontist in your area and free brochure samples including one titled Women and Periodontal Disease are available by calling 800-FLOSS-EM or visiting the AAP’s Web site at www.perio.org.

The American Academy of Periodontology has joined forces with the March of Dimes in its National Prematurity Campaign to improve the health of babies by preventing birth defects and infant mortality. This five-year, $75 million initiative includes more than 25 health professional, consumer and government groups who all share a common goal – to help families have healthier babies.

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CHICAGO – June 22, 2004 – Researchers found that women undergoing ovulation induction for infertility treatment for more than three menstrual cycles experience higher gingival inflammation, bleeding and gingival crevicular fluid (GCF). This study appeared in the recent issue of the Journal of Periodontology Study Abstract *

In this study, the gingival inflammation levels of women undergoing infertility treatment and subjected to ovulation induction were investigated and compared with women who were not using these drugs. It found that despite similar plaque levels, women who received ovulation induction medications for more than three menstrual cycles had higher levels of gingival inflammation, bleeding and GCF. GCF is a fluid that contains enzymes and tissue breakdown products that have been examined as potential markers for the progression of periodontitis.

“These effects are presumably correlated with the increased levels of progesterone and estrogen,” explains Dr. Cenk M. Haytac, Cukurova University, Adana, Turkey. “Gingiva is a target tissue for estrogen since it contains specific high-affinity estrogen receptors.”

Several studies provided evidence that the presence of infection is associated with unsuccessful embryo development and implantation failure in in vitro fertilization patients. Since periodontal diseases are chronic bacterial infections, the study suggests that periodontal status may also affect reproduction success and the outcome of infertility treatment.

“It is reasonable to assume that if low levels of plaque are established and maintained during the infertility treatment, gingival inflammation would not effect the success of infertility treatment,” said Dr. Michael P. Rethman, DDS, MS, and president of the American Academy of Periodontology. “This would require meticulous oral hygiene and routine professional cleanings, perhaps at the beginning of each menstrual cycle to ensure the presence of healthy gums.”

Periodontal diseases are risk factors for several systemic conditions including preterm low birthweight babies. “It will be interesting to see if further intervention studies will determine the effects of periodontal status and the periodontal therapy on the outcome of infertility treatment,” said Rethman.

“A woman undergoing infertility treatment is often given drugs to stimulate the ovaries to produce as many healthy follicles as possible to increase the chances of conception,” said Haytac. “This method has been used worldwide for more than 30 years, and the World Health Organization estimates that approximately 8% to 10% of couples worldwide experience some form of fertility problem.”

A referral to a periodontist in your area and free brochure samples including one titled Women and Periodontal Disease are available by calling 800-FLOSS-EM or visiting the AAP’s Web site at www.perio.org.

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CHICAGO – March 2, 2005 – Periodontal inflammation plays a possible role in the development of preeclampsia, a potentially deadly condition that affects approximately 5 percent of U. S. pregnancies, according to a study in the Journal of Periodontology. Study Abstract *

“This finding may pave the way for screening and treating periodontal disease as a preventive method to reduce the occurrence of preeclampsia,” said Vincent J Iacono DMD and AAP president.

“The chronic inflammation of periodontal infection, together with evidence linking periodontitis with atherosclerosis indicates a possible association between periodontal disease and preeclampsia,” said Dr. Orit Oettinger-Barak, Periodontal Unit, Maxillofacial Surgery Center at the Technion Faculty of Medicine in Haifa, Israel. Atherosclerosis is a multistage process set in motion when cells lining the arteries are damaged as a result of high blood pressure, smoking, toxic substances and other agents. “We found that periodontal disease was more severe in the preeclamptic patients, which suggests an interaction between periodontal disease and pregnancy.”

Researchers performed periodontal examinations in pregnant women with and without preeclampsia. The periodontal examination was performed up to 48 hours prior to delivery by collecting gingival crevicular fluid, which is a fluid that contains enzymes and pieces of tissue that have been examined as potential markers for the progression of periodontitis. This was followed with a full-mouth periodontal examination. Researchers found that the protein levels, known as cytokines in the preeclamptic group were nearly three times greater than the healthy group.

“Circulating proteins known as cytokines have previously been associated with the cause of preeclampsia,” said Iacono. “Nevertheless, this is the first time that cytokines related to periodontal disease have been implicated. Additional studies will be required to support the findings, including a treatment study designed to eliminate periodontal disease as a preventive measure to reduce the incidence of preeclampsia.”

Most periodontal diseases are chronic inflammatory conditions caused by the body’s response to bacterial gum infections that can destroy the gum tissue and supporting bone that hold teeth in the mouth. The main cause of this disease is bacterial plaque, a sticky, colorless film that constantly forms on the teeth. Prevention includes daily flossing to break up the bacterial colonies between the teeth, proper daily brushing to prevent plaque buildup and professional cleanings at least twice a year to remove calculus from places the toothbrush and floss may have missed. Since there are often no symptoms of the disease in its early stages, a periodontal evaluation by your dentist or periodontist is the best way to know if you have any periodontal disease.

A referral to a periodontist in your area and free brochure samples including one titled Women and Periodontal Disease are available by calling 800-FLOSS-EM or visiting the AAP’s Web site at www.perio.org.

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CHICAGO – March 23, 2005 – Researchers from New York University found that certain bacteria from the mouth may be related to preterm delivery and low birthweight according to a study in the Journal of Periodontology (JOP). Study Abstract *

It’s been reported in the past that periodontal disease may be a factor in the occurrence of preterm low birthweight babies. Now it is believed that bacteria commonly found in dental plaque biofilms may also be related.

Researchers evaluated bacterial levels in the saliva of 297 women in their third trimester of pregnancy. They found that a higher salivary level of the bacteria called Actinomyces naeslundii Genospecies2 (A. naeslundii gsp2) is associated with low birth weight and preterm delivery, while higher levels of the bacteria Lactobacillus casei (L. casei) during pregnancy positively affected the birthweight.

“Our observation that A.naeslundii gsp2 reduced birthweight and preterm delivery fits well with the theory that oral bacteria and the molecules the body produces against them can enter the uterine environment through the blood stream and may influence the delivery process,” explained Dr. Ananda P. Dasanayake, Department of Epidemiology and Health Promotion, New York University College of Dentistry. “Whereas the bacteria L.casei secretes acids that maintain the vaginal pH level below 4.5. This pH level has a protective effect and prevents the overgrowth of more bacteria, including those associated with bacterial vaginosis (a condition associated with preterm labor and deliver).”

“What’s interesting is that the research shows that for each ten-fold increase in A. naeslundii gsp 2 levels, there was a 60 gram (0.13 pound) decline in birthweight and a 0.17 week decrease in gestational age. On the other hand, for one unit increase of L. casei levels there was a 42 gram increase (0.9 pounds) in birth weight and a 0.13 week increase in gestational age,” said Vincent J Iacono, DMD and president of the American Academy of Periodontology. “Future studies should evaluate both oral bacteria and bacteria that are not related to periodontal diseases to better understand this potential important link between periodontal status and prematurity.”

This issue of the JOP included another study, Periodontal Diseases and the Risk of Preterm Birth and Low Birth Weight: A Meta-Analysis. Findings from this study indicate that periodontal diseases in the pregnant mother significantly increase the risk of subsequent preterm birth or low birth weight. Researchers feel it remains important to promote good oral hygiene during routine prenatal visits, but caution that more studies need to be conducted to further our understanding about the effects of periodontal treatment on preterm birth.

A referral to a periodontist in your area and free brochure samples including one titled Women and Periodontal Disease are available by calling 800-FLOSS-EM or visiting the AAP’s Web site at www.perio.org.

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CHICAGO – November 21, 2005 – Pregnant women will want to include a periodontal evaluation as part of their prenatal care. That’s because researchers found that periodontal treatment significantly reduced the risk of having a preterm birth or a low birthweight infant, according to a study published in the Journal of Periodontology. Study Abstract *

“We found a significant association between gingivitis and preterm birth after adjusting for the major risk factors for preterm delivery, suggesting that gingivitis, the earliest form of periodontal disease, is an independent risk factor for preterm birth and low birthweight,” said Dr. Néstor J. López, Professor of the University of Chile. “Periodontal therapy reduced preterm birth and low birthweight infant rates by 68 percent in women with pregnancy-associated gingivitis.”

This is in concordance with two other intervention studies in which periodontal treatment reduced the incidence of preterm births and low birth weight infants between 71 percent and 84 percent in pregnant women with moderate to severe chronic periodontitis.

“Ideally, women should begin their pregnancy without periodontal infections, and they should be educated and motivated to maintain a high level of oral hygiene prior to and throughout pregnancy,” said López. “If periodontal infection is diagnosed at any time during pregnancy, the treatment should be administered as soon as possible in order to reduce the risk of preterm birth and low birthweight.”

“Pregnancy-associated gingivitis is a preventable and easy to treat disease,” explains Kenneth A. Krebs, DMD and AAP president. “Although it is still not known what are the precise mechanisms involved in the association between periodontal infections and preterm birth, to date, no harmful damaging effect caused by periodontal intervention in pregnant women has been reported.”

High health care costs are generated by preterm birth, and any strategy that reduces the preterm birth rate is likely to produce both health and economic benefits for mothers and infants. “The real cost saving is best represented by the lives of children saved from premature death and biological and social impairment,” said Lopez.

Researchers from Chile conducted this trial in a population of 870 pregnant women at low risk for preterm birth and low birthweight. Upon entering the study, all women received a full-mouth periodontal examination and the following variables were measured:

• Gingival inflammation
• Probing depth
• Clinical attachment level
• Oral hygiene status was assessed
• Percentages of surfaces demonstrating plaque
• Bleeding on probing (In this study bleeding on probing was selected as the variable describing gingivitis, the earliest stage of periodontal inflammation.)

Researchers divided the women into two groups—a control group and a treatment group. Women in the treatment group received periodontal therapy before 28 weeks of gestation, and maintenance therapy was provided every two to three weeks until delivery. The periodontal therapy consisted of plaque control instructions, supragingival and subgingival scaling and crown polishing. At the beginning of treatment, each woman was provided with toothbrushes and chlorhexidine and instructed to rinse once a day with .12% chlorhexidine until delivery. Women in the control group were monitored two to three times during pregnancy and repeated periodontal examinations were performed after 30 weeks of gestation to assess changes in periodontal status.

A referral to a periodontist in your area and free brochure samples including one titled Women and Periodontal Disease are available by calling 800-FLOSS-EM or visiting the AAP’s Web site at www.perio.org.

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CHICAGO – February 6, 2006 – Results of a new study support the hypothesis that chronic periodontal infection increases the risk of developing preeclampsia in pregnant women. This study printed in February’s issue of the Journal of Periodontology. Study Abstract *

The results also suggest that maternal chronic periodontal disease is a risk factor for low birthweight babies among preeclamptic mothers compared to those women who did not have preeclampsia.

“We found that chronic periodontitis was more prevalent in the preeclamptic group by almost 64 percent than the non-preeclamptic group at 36 percent,” said Dr. Adolfo Contreras from the School of Dentistry, University of Valle, Cali-Columbia. “Women in the preeclamptic group had more clinical attachment loss than the healthy women group. Moreover, mothers having preeclampsia showed greater periodontal destruction.”

Researchers also found that chronic periodontal disease and the presence of the microorganisms, such as Porphyromonas gingivalis (P.gingivalis); Tannerella forsythia (T. forsythia); and Eikenella corrodens (E.corrodens) were significantly associated with preeclampsia in pregnant women.

This might mean that periodontal bacterium could find its way into the bloodstream in patients with periodontal disease. “P. gingivalis has not only been found in the blood circulation but also in atherosclerotic plaques, which has been linked to periodontal disease and cardiovascular disease,” explains Contreras.

“The results of this study provide additional evidence that periodontal infection is linked to preeclampsia; however, further research is needed to support a causal association and its clinical implications,” said Kenneth A. Krebs, DMD and AAP president. “Pregnancy-associated gingivitis is a preventable and easy to treat disease. It is still not known what is the precise mechanisms involved are in the association between periodontal infections and preterm birth. To date, no harmful damaging effect caused by periodontal intervention in pregnant women has been reported.”

Background Information

The study included 130 preeclamptic and 243 non-preeclamptic women between 26 to 36 weeks of pregnancy. A clinical record regarding personal information, marital status, race, education level, number of pregnancies and medical examination was completed for all patients. Preeclampsia was defined as high protein levels in urine (2+ proteinuria), confirmed by at least 0.3 g proteinuria/24 hours and hypertension. Clinical measures of periodontal health were determined in all subjects, including sulcus/probing depth (PD), gingival recession, and periodontal clinical attachment loss (CAL).

A referral to a periodontist in your area and free brochure samples including one titled Women and Periodontal Disease are available by calling 800-FLOSS-EM or visiting the AAP’s Web site at www.perio.org.

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CHICAGO – May 2, 2006 – Researchers found that pregnant women with periodontitis had 65 percent higher C-reactive protein (CRP) levels compared to periodontally healthy women. This study appears in the May issue of the Journal of Periodontology (JOP). Study Abstract *

CRP levels are a marker of systemic inflammation and are associated with periodontal disease, a chronic bacterial infection found in the gums of the mouth. CRP has also been associated with adverse pregnancy outcomes, including preeclampsia and preterm delivery.

“Elevated CRP may indeed be caused by periodontal infection and inflammation.” said Dr. Waranuch Pitiphat, Department of Community Dentistry, Faculty of Dentistry, Khon Kaen University, Thailand. “If this is the case, CRP could amplify the inflammatory response and ultimately cause adverse pregnancy outcomes. Alternatively, periodontal disease and CRP may share a common risk factor for predisposing individuals to a hyperinflammatory response. More research is clearly needed to further our understanding about the association between periodontal disease and adverse pregnancy outcomes.”

Past studies examining the relationship between periodontal disease and CRP found that often after standard non-surgical periodontal therapy, CRP levels decrease.

“This is one more study that really drives home the importance of taking care of the entire body including oral health,” explains Kenneth A. Krebs, DMD and AAP president. “In addition to this study about the relationship between CRP and pregnant women with periodontal disease, previous studies reported that inflammatory effects from periodontal disease could cause the liver to make proteins such as CRP that inflame arteries causing blood clots that contribute to heart attacks or strokes.”

Evidence supporting the association between periodontitis and CRP is based only on studies in men and non-pregnant women. This is the first study that looked at the association between CRP and periodontitis in pregnant women. The results of this study are consistent with previous studies conducted among men and non-pregnant women. CRP was higher in people with periodontal disease compared to those without disease.

A referral to a periodontist in your area and free brochure samples including one titled Women and Periodontal Diseases are available by calling 800-FLOSS-EM or visiting the AAP’s Web site at www.perio.org.

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CHICAGO – November 7, 2006 – Research presented in a recent paper by Michalowicz et al published in the New England Journal of Medicine (NEJM) suggests that treatment of periodontitis in pregnant women improves periodontal health and is safe but does not significantly alter rates of preterm birth, low birth weight, or fetal growth restriction. This outcome is at variance with findings of other studies, which have suggested that periodontal treatment positively affects birth outcomes.

There may be several explanations for the differences in research findings to date, including timing of the treatment intervention as well as the pregnancy outcomes studied. For example, the Michalowicz research did not study the effect of periodontal treatment on early adverse outcomes such as late miscarriage, stillbirth, and early spontaneous preterm birth, which previous observational studies have linked with periodontal disease.

According to the March of Dimes, the rate of infants born preterm increased nearly 14% from 1994 to 2004. And while the specific causes of spontaneous preterm labor and delivery are largely unknown, the March of Dimes believes they are likely due to a complex interplay of multiple risk factors, as opposed to any single isolated risk factors. The intriguing findings of the Michalowicz study support the need for additional research to clarify the potential effect of periodontal disease on adverse pregnancy outcomes, given the potential impact of the increasing problem of prematurity. Other trials are underway that should provide additional insight on this important topic. In the meantime, the recent NEJM study confirms that treatment of periodontitis in pregnant women improves oral health and is safe, which is an important message for the dental and medical communities and all patients.

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