Several large randomized controlled clinical trials failed to find that standard periodontal therapy during pregnancy reduces the incidence of adverse pregnancy outcomes (eg, preterm birth and low birthweight). However, treating periodontal disease during pregnancy may be too late to reduce the inflammation that is related to the adverse pregnancy outcomes. Moreover, periodontal treatment during pregnancy can cause bacteremia, which itself may initiate the pathway leading to the adverse pregnancy outcomes. Finally, the periodontal treatments provided during pregnancy are not always effective in preventing the progression of periodontal disease during pregnancy. Pregnancy may not be an appropriate period for periodontal intervention(s). We hypothesize that periodontal treatment before pregnancy may reduce the rates of adverse pregnancy outcomes. Future randomized controlled trials are needed to test if treating periodontal disease in the prepregnancy period reduces the rate of adverse pregnancy outcomes.
Over the past 2 decades, there has been increasing evidence suggesting associations between periodontal disease and conditions such as atherosclerosis, myocardial infarction, stroke, diabetes mellitus, and adverse pregnancy outcomes. Since Offenbacher et al first reported an association between periodontal disease and preterm birth in 1996, substantial evidence has accumulated suggesting that periodontal disease may be associated with an increased risk of various adverse birth outcomes. Adverse pregnancy outcomes that have been linked to periodontal disease include preterm birth, low birthweight, miscarriage or early pregnancy loss, preeclampsia, and gestational diabetes mellitus.
Based on our prior systematic review of existing observational studies (eg, case-control, cross-sectional and cohort) on the relationship between periodontal disease and adverse birth outcomes, we concluded that there is evidence of an association between periodontal disease and increased risk of preterm birth and low birthweight, especially in economically disadvantaged populations. However, because of potential biases (eg, inconsistent definitions of periodontal disease and pregnancy outcomes, insufficient sample size, or lack of controlling for key confounders), observational studies are unable to offer a clear conclusion about the relationship between periodontal disease and pregnancy outcomes. Randomized controlled treatment trials (RCTs) of periodontal disease are likely to offer the best evidence of whether periodontal disease is in the causal pathway leading to adverse pregnancy outcomes.
The Table presents a summary of 13 clinical trials published to date to examine if periodontal treatment during pregnancy reduces the incidence of adverse pregnancy outcomes. Earlier RCTs showed very promising results of periodontal treatment during pregnancy. These RCTs, which tended to be conducted in low socioeconomic status populations or low- and middle-income countries (eg, Chile and India), were pilot studies, or had relatively small sample sizes, suggested that periodontal treatment during pregnancy led to significant reductions in the rates of preterm birth and low birthweight. However, several large RCTs conducted in high-income countries (eg, United States and Australia) failed to find that periodontal therapy during pregnancy reduced the incidence of preterm birth and low birth weight. A metaanalysis of the nine clinical trials that had preterm birth as an outcome suggested that periodontal treatment did not significantly reduce the rate of preterm birth (pooled relative risk [RR], 0.82; 95% confidence interval [CI], 0.64–1.06; P > .05) ( Table and Figure 1 ). A metaanalysis of the 5 clinical trials that had low birthweight as an outcome suggested that treatment of periodontal disease during pregnancy may reduce the rate of low birthweight (pooled RR, 0.64; 95% CI, 0.40–1.00; P = .05) ( Table and Figure 2 ).
| Authors published year country (reference) | Sample size | Characteristics of population | Definitions of periodontal disease | Outcomes and OR or RR (95% CI) | Conclusions |
|---|---|---|---|---|---|
| Mitchell-Lewis et al, 2001 USA |
| 60% African American, 39% Hispanic, all of low socioeconomic status | Oral prophylaxis group was enrolled during pregnancy and received oral intervention. Control group is recruited postpartum | PLBW: 13.5% in oral prophylaxis group, 18.9% in control group, RR: 0.72 (0.4–1.47) a | There was a 28% reduction in PLBW in the periodontally treated group, but it was not statistically significant. |
| Lopez NJ et al, 2002 Chile |
| Low socioeconomic status | ≥4 teeth with ≥1 sites with PD ≥4 mm and with CAL ≥3 mm | Periodontal disease is an independent risk factor for PLBW. | |
| Jeffcoat MK et al, 2003 USA | Group 1: prophylaxis plus placebo capsule, n = 123; Group 2: SRP plus placebo capsule, n = 123; Group 3: SRP and metronidazole capsule (250 mg for 1 wk), n = 120 |
| >3 sites with CAL ≥3 mm |
| Performing SRP in pregnant women with periodontitis may reduce PTB. Metronidazole therapy did not improve pregnancy outcome. |
| Sadatmansouri S et al, 2006 Iran |
| All women with moderate or advanced periodontitis | PLBW: 4 cases (26.7%) in controls vs 0 (0%) in treatment group ( P < .05) | Periodontal therapy results in a reduction in PLBW. | |
| Michalowicz BS et al, 2006 USA |
|
| ≥4 teeth with PD ≥4 mm and CAL ≥2 mm and BOP ≥35% |
| Treatment of periodontitis in pregnant women does not significantly reduce rates of PTB, LBW, or SGA. |
| Offenbacher S et al, 2006 USA | Intervention group (SRP and sonic toothbrush): 35 Control group: 32 |
| ≥2 sites measuring ≥5 mm PD plus periodontal attachment loss of 1 to 2 mm at ≥1 sites with PD ≥5 mm |
| Results from this pilot study (67 subjects) provide further evidence supporting the potential benefits of periodontal treatment on pregnancy outcomes. |
| Tarannum F et al, 2007 India |
| Mean age: 23.0 ± 3.3 in treatment group; 22.9 ± 3.6 in control group | With ≥20 completely erupted teeth, excluding the third molars; or with ≥2 mm attachment loss at ≥50% of examined sites | Nonsurgical periodontal therapy can reduce the risk for preterm births in mothers who are affected by periodontitis. | |
| Gazolla CM et al, 2007 Brazil |
|
| Disease status was classified according to PD and CAL: P1: ≥4 teeth with PD of 4 to 5 mm and CAL of 3 to 5 mm at the same site; P2: ≥4 teeth with PD and CAL of 5 to 7 mm at the same site; P3: ≥4 teeth with PD and CAL >7 mm at the same site |
| Periodontal disease was related significantly to preterm low birthweight. |
| Radnai M et al, 2008 Hungary |
| Nonsmoking women | N/A |
| Periodontal treatment might have contributed to a more optimal date of delivery and to achieving a larger birthweight. |
| Offenbacher S et al, 2009 USA |
|
| ≥20 teeth, with ≥3 sites with CAL ≥3 mm |
| Periodontal therapy did not reduce the incidence of preterm delivery |
| Radnai M et al, 2009 Hungary |
|
| Periodontitis: ≥4 mm PD at ≥1 site, and BOP for ≥50% of teeth. | Periodontal treatment completed before the 35th wk appeared to have a beneficial effect on birthweight and time of delivery | |
| Herrera JA et al, 2009 Colombia |
|
| Periodontal diagnosis was established according to the report consensus criteria of the American Academy of Periodontology. |
| Periodontal intervention does not alter the frequency of maternal complications in mild preeclampsia subjects. |
| Newnham JP et al, 2009 Australia |
|
| PD ≥4 mm at ≥12 probing sites in fully erupted teeth (typically excluding wisdom teeth). |
| The evidence provided by the present study does not support the hypothesis that treatment of periodontal disease during pregnancy in this population prevents preterm birth, fetal growth restriction, or preeclampsia. |
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