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

Daniel J Erchick, Subarna K Khatry, Nitin K Agrawal, Joanne Katz, Steven C LeClerq, Bhola Rai, Mark A Reynolds, Luke C Mullany, Daniel J Erchick, Subarna K Khatry, Nitin K Agrawal, Joanne Katz, Steven C LeClerq, Bhola Rai, Mark A Reynolds, Luke C Mullany

Abstract

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

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

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

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

Trial registration number: Nepal Oil Massage Study, NCT01177111.

Keywords: community child health; epidemiology; obstetrics; oral medicine; perinatology; public health.

Conflict of interest statement

Competing interests: None declared.

© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY. Published by BMJ.

Figures

Figure 1
Figure 1
Cohort study participation flow chart. Data on eligible pregnancies, enrolled pregnancies, refusals, lost to follow-up and birth outcomes.

References

    1. United Nations Inter-agency Group for Child Mortality Estimation (UN IGME) Levels & trends in child mortality. New York: UNICEF, 2018.
    1. Blencowe H, Cousens S, Chou D, et al. . Born too soon: the global epidemiology of 15 million preterm births. Reprod Health 2013;10:S2. 10.1186/1742-4755-10-S1-S2
    1. Barros FC, Bhutta ZA, Batra M, et al. . Global report on preterm birth and stillbirth (3 of 7): evidence for effectiveness of interventions. BMC Pregnancy Childbirth 2010;10:S3. 10.1186/1471-2393-10-S1-S3
    1. Brown LJ, Löe H, Prevalence LH. Prevalence, extent, severity and progression of periodontal disease. Periodontol 2000 1993;2:57–71. 10.1111/j.1600-0757.1993.tb00220.x
    1. Loe H, Silness J. Periodontal disease in pregnancy. I. prevalence and severity. Acta Odontol Scand 1963;21:533–51. 10.3109/00016356309011240
    1. Laine MA. Effect of pregnancy on periodontal and dental health. Acta Odontol Scand 2002;60:257–64. 10.1080/00016350260248210
    1. Figuero E, Carrillo-de-Albornoz A, Martín C, et al. . Effect of pregnancy on gingival inflammation in systemically healthy women: a systematic review. J Clin Periodontol 2013;40:457–73. 10.1111/jcpe.12053
    1. Wu M, Chen S-W, Jiang S-Y. Relationship between gingival inflammation and pregnancy. Mediators Inflamm 2015;2015:1–11. 10.1155/2015/623427
    1. Offenbacher S, Katz V, Fertik G, et al. . Periodontal infection as a possible risk factor for preterm low birth weight. J Periodontol 1996;67:1103–13. 10.1902/jop.1996.67.10s.1103
    1. Chambrone L, Guglielmetti MR, Pannuti CM, et al. . Evidence grade associating periodontitis to preterm birth and/or low birth weight: I. A systematic review of prospective cohort studies. J Clin Periodontol 2011;38:795–808. 10.1111/j.1600-051X.2011.01755.x
    1. Ide M, Papapanou PN. Epidemiology of association between maternal periodontal disease and adverse pregnancy outcomes--systematic review. J Periodontol 2013;84:S181–94. 10.1902/jop.2013.134009
    1. Offenbacher S, Lieff S, Boggess KA, et al. . Maternal periodontitis and prematurity. Part I: obstetric outcome of prematurity and growth restriction. Ann Periodontol 2001;6:164–74. 10.1902/annals.2001.6.1.164
    1. Offenbacher S, Boggess KA, Murtha AP, et al. . Progressive periodontal disease and risk of very preterm delivery. Obstet Gynecol 2006;107:29–36. 10.1097/01.AOG.0000190212.87012.96
    1. Jeffcoat MK, Geurs NC, Reddy MS, et al. . Periodontal infection and preterm birth: results of a prospective study. J Am Dent Assoc 2001;132:875–80. 10.14219/jada.archive.2001.0299
    1. Michalowicz BS, Hodges JS, DiAngelis AJ, et al. . Treatment of periodontal disease and the risk of preterm birth. N Engl J Med 2006;355:1885–94. 10.1056/NEJMoa062249
    1. Offenbacher S, Beck JD, Jared HL, et al. . Effects of periodontal therapy on rate of preterm delivery: a randomized controlled trial. Obstet Gynecol 2009;114:551–9. 10.1097/AOG.0b013e3181b1341f
    1. Offenbacher S, Lin D, Strauss R, et al. . Effects of periodontal therapy during pregnancy on periodontal status, biologic parameters, and pregnancy outcomes: a pilot study. J Periodontol 2006;77:2011–24. 10.1902/jop.2006.060047
    1. Iheozor-Ejiofor Z, Middleton P, Esposito M, et al. . Treating periodontal disease for preventing adverse birth outcomes in pregnant women. Cochrane Database Syst Rev 2017;6:Cd005297. 10.1002/14651858.CD005297.pub3
    1. Kim AJ, Lo AJ, Pullin DA, et al. . Scaling and root planing treatment for periodontitis to reduce preterm birth and low birth weight: a systematic review and meta-analysis of randomized controlled trials. J Periodontol 2012;83:1508–19. 10.1902/jop.2012.110636
    1. Cetin I, Pileri P, Villa A, et al. . Pathogenic mechanisms linking periodontal diseases with adverse pregnancy outcomes. Reprod Sci 2012;19:633–41. 10.1177/1933719111432871
    1. Jeffcoat MK, Jeffcoat RL, Tanna N, et al. . Association of a common genetic factor, PTGER3, with outcome of periodontal therapy and preterm birth. J Periodontol 2014;85:446–54. 10.1902/jop.2013.130006
    1. Erchick DJ, Agrawal NK, Khatry SK, et al. . Feasibility of training community health workers to conduct periodontal examinations: a validation study in rural Nepal. BMC Health Serv Res 2020;20:412. 10.1186/s12913-020-05276-5
    1. Armitage GC. Development of a classification system for periodontal diseases and conditions. Ann Periodontol 1999;4:1–6. 10.1902/annals.1999.4.1.1
    1. Chapple ILC, Mealey BL, Van Dyke TE, et al. . Periodontal health and gingival diseases and conditions on an intact and a reduced periodontium: consensus report of Workgroup 1 of the 2017 world workshop on the classification of periodontal and peri-implant diseases and conditions. J Periodontol 2018;89:S74–84. 10.1002/JPER.17-0719
    1. Trombelli L, Farina R, Silva CO, et al. . Plaque-induced gingivitis: case definition and diagnostic considerations. J Periodontol 2018;89:S46–73. 10.1002/JPER.17-0576
    1. Holtfreter B, Albandar JM, Dietrich T, et al. . Standards for reporting chronic periodontitis prevalence and severity in epidemiologic studies: proposed standards from the joint EU/USA periodontal epidemiology Working group. J Clin Periodontol 2015;42:407–12. 10.1111/jcpe.12392
    1. Papapanou PN, Sanz M, Buduneli N, et al. . Periodontitis: consensus report of Workgroup 2 of the 2017 world workshop on the classification of periodontal and peri-implant diseases and conditions. J Periodontol 2018;89:S173–82. 10.1002/JPER.17-0721
    1. Tonetti MS, Greenwell H, Kornman KS. Staging and grading of periodontitis: framework and proposal of a new classification and case definition. J Periodontol 2018;89:S159–72. 10.1002/JPER.18-0006
    1. World Health Organization Epidemiology, etiology, and prevention of periodontal diseases. World Health Organ Tech Rep Ser 1978.
    1. Eke PI, Page RC, Wei L, et al. . Update of the case definitions for population-based surveillance of periodontitis. J Periodontol 2012;83:1449–54. 10.1902/jop.2012.110664
    1. Page RC, Eke PI. Case definitions for use in population-based surveillance of periodontitis. J Periodontol 2007;78:1387–99. 10.1902/jop.2007.060264
    1. Erchick DJ, Rai B, Agrawal NK, et al. . Oral hygiene, prevalence of gingivitis, and associated risk factors among pregnant women in Sarlahi district, Nepal. BMC Oral Health 2019;19:2. 10.1186/s12903-018-0681-5
    1. Xiong X, Buekens P, Goldenberg RL, et al. . Optimal timing of periodontal disease treatment for prevention of adverse pregnancy outcomes: before or during pregnancy? Am J Obstet Gynecol 2011;205:111.e1–6. 10.1016/j.ajog.2011.03.017
    1. Yee R, Mishra P. Nepal national oral health ‘pathfinder’ survey 2004. Kathmandu, Nepal: Oral Health Focal Point, Ministry of Health, 2004.
    1. Kruse AB, Kuerschner AC, Kunze M, et al. . Association between high risk for preterm birth and changes in gingiva parameters during pregnancy-a prospective cohort study. Clin Oral Investig 2018;22:1263–71. 10.1007/s00784-017-2209-9
    1. López NJ, Da Silva I, Ipinza J, et al. . Periodontal therapy reduces the rate of preterm low birth weight in women with pregnancy-associated gingivitis. J Periodontol 2005;76:2144–53. 10.1902/jop.2005.76.11-S.2144
    1. Sharma S, Saimbi CS, Koirala B, et al. . Effect of various mouthwashes on the levels of interleukin-2 and interferon-gamma in chronic gingivitis. J Clin Pediatr Dent 2008;32:111–4. 10.17796/jcpd.32.2.u01p135561161476
    1. Santos A. Evidence-Based control of plaque and gingivitis. J Clin Periodontol 2003;30:13–16. 10.1034/j.1600-051X.30.s5.5.x
    1. Jeffcoat M, Parry S, Gerlach RW, et al. . Use of alcohol-free antimicrobial mouth rinse is associated with decreased incidence of preterm birth in a high-risk population. Am J Obstet Gynecol 2011;205:382.e1–6. 10.1016/j.ajog.2011.07.016
    1. Forner L, Larsen T, Kilian M, et al. . Incidence of bacteremia after chewing, tooth brushing and scaling in individuals with periodontal inflammation. J Clin Periodontol 2006;33:401–7. 10.1111/j.1600-051X.2006.00924.x
    1. Madianos PN, Bobetsis YA, Offenbacher S. Adverse pregnancy outcomes (apos) and periodontal disease: pathogenic mechanisms. J Periodontol 2013;84:S170–80. 10.1902/jop.2013.1340015
    1. Litonjua LA, Andreana S, Bush PJ, et al. . Toothbrushing and gingival recession. Int Dent J 2003;53:67–72. 10.1111/j.1875-595X.2003.tb00661.x
    1. Khocht A, Simon G, Person P, et al. . Gingival recession in relation to history of hard toothbrush use. J Periodontol 1993;64:900–5. 10.1902/jop.1993.64.9.900
    1. Sconyers JR, Crawford JJ, Moriarty JD. Relationship of bacteremia to toothbrushing in patients with periodontitis. J Am Dent Assoc 1973;87:616–22. 10.14219/jada.archive.1973.0453
    1. Mobeen N, Jehan I, Banday N, et al. . Periodontal disease and adverse birth outcomes: a study from Pakistan. Am J Obstet Gynecol 2008;198:514.e1–8. 10.1016/j.ajog.2008.03.010

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