Mahjabeen Khan1 , Nadya Sultan Ali2 , Amyna Sajwani3
How to CITE:
Khan M Ali SA, Sajwani A. The implication of maternal periodontal disease and c reactive protein on adverse pregnancy outcome. J Pak DentAssoc. 2012 (1): 16-19
To determine the role of periodontal disease in the development of adverse pregnancy outcome including low birth weight, preterm labor and to measure abnormal C reactive protein and its impact on adverse pregnancy outcome
This was a case control study. Periodontal disease was considered as 3 mm in 33 or more teeth.Adverse pregnancy outcome (APO)was defined as a singleton preterm birth and low birth weight.All mothers were interviewed and examined for periodontal disease. A blood sample of 3 ml was taken for C reactive protein assessment at the time of examination.Data was entered and analyzed on SPSS windows version 17
There were 600mothers observed for periodontal disease and c reactive protein and adverse pregnancy outcome. The adverse pregnancy outcome (APO) included preterm labour and low birth weight 29(21.5%).The birthweight < 2500 gms (low birthweight) was twicemore prone to developAPO due to Periodontal disease (PD) compared to controlswith birthweight> 2500gms.The gestational age before 37weeks (preterm)was 4 timesmore commonwith PDcompared to controls.
Adverse pregnancy outcome is a possible complication ofmaternal periodontal disease.
Periodontal disease, adverse pregnancy outcome, preterm labour, low birth weight, C reactive protein, risk factors
he association of maternal Periodontal Disease (PD) and adverse pregnancy outcome (APO) is still debated in several studies since 1990. In 1996, a potential association between maternal periodontal disease and delivery of a preterm/low-birth-weight infant was reported. Periodontal diseases have been associated with infections. Knowledge about the link between periodontal disease and systemic diseases are growing rapidly. Adult periodontal infection affects up to 40% of reproductive-age women. According to a study from Argentine, Mothers had severe periodontal disease (17.5%) , and 34.3% had gingivitis along with 9.5% cases of premature labor; 10.3%low birth weight, and 10.0% preeclampsia. There is an increased risk for systemic health problems when inflammatory periodontal disease is present. Therefore C reactive protein measurements can be a risk factor to define this mechanism.Chronic infections and oral sub mucos lesions are important determinants of elevated CRP among mothers with periodontal disease. Several studies have been conducted on C reactive protein detection in mothers developing Periodontal Disease and its impact on adverse pregnancy. Outcome stirelise. The adverse pregnancy outcome included low birth weight in 6.0%, preterm labor 6.6% and intrauterine growth restriction compared to normal healthy outcomes at term singleton pregnancies.
Currently few studies have been found from the developing world to detect association between maternal periodontitis and APO. The dental care particularly in low social groups requires an investigation to determine the association between periodontal disease and adverse pregnancy.
This was a case control study conducted at Obstetrics and Gynecology hospital with collaboration of Department of Periodontology Dr. Ishrat-ul- Ebad Institute of Oral Health Sciences,Dow University of Health Sciences, Karachi. The study duration was 1st April to 30th Sep 2010.Sample size calculation was performed to obtain 80% power and detect an odds ratio of at least 1.6. The sample size was further increased to 20% for multivariate modeling and refusals. The sample size of 599 was calculated for cases and control in each group. The sampling technique was non probability convenience.
All mothers of 20-35 years age group, parity less than 5, at least 3 or more antenatal visits during current Pregnancy and non Smokers were included in the study.Mothers with history of previous recurrent preterm labor, low birth weight and intrauterine growth restriction, urinary tract infection and vaginitis were not included in the study. A case of periodontal disease was considered at 3 mm in 33 or more teeth. Oral examination was done by mouth mirror, examination and periodontal probes, excavator and tweezers. APO was defined as mothers delivered a singleton neonate with birth weight less than 2500 grams and preterm birth (Delivery before estimated 37 weeks of gestation). The control population included mothers delivered at term pregnancy (37-41 weeks gestation) ,birth weight >2500 grams and delivered a normal alive healthy baby.
All mothers were interviewed and examined for oral pathology by both an Obstetrician and Periodontist. Women admitted for delivery after 32 weeks of gestation were selected to collect data on pregnancy out come through a pre structured questionnaire. The information collected from mother included demographic factors, age, income, education level, parity. Reproductive factors, previous gynecological history, previous history of abortion Low birth weight(LBW), Preterm labour (PTL) and Intrauterine growth retardation (IUGR), Antenatal care and pregnancy outcome observations were collected on Performa.
History of current pregnancy from Obstetric chart including clinical estimate and Laboratory reports were also collected.Drug history and smoking during or before pregnancy were also taken as a risk factor for exclusion. A complete physical examination including Periodontal Assessment according to WHO guidelines through a full mouth examination after delivery was conducted. According to the requirement for laboratory test a blood sample of 3ml was taken for C reactive protein assessment at the time of examination.
Data was entered and analyzed on SPSS windows version 17. Means with standard deviation for numerical variables and proportions for categorical variables were analyzed. Significance of difference was calculated using T test and Chi square test. Univariate analysis for descriptive data was performed, odds ratios and confidence interval were also obtained
The case control study was conducted on 600 mothers (300 controls, 300 cases) to determine the association of maternal PD & CRP onAPO. The age Mean ± SD was 26.89 ±I 5.35 years .The gestational weightMean ± SD was 2883.53 ± 413.2 Grams. The nonbooked mothers( mother with less than 3 visits during current pregnancy) among cases & controls were 347(57.8%) as shown inTable I.
The APO included preterm labour, low birth weight 129(21.5%) and alive health baby born were 471 (78.5%).The adverse permanency was among 143(23.8%) of study population.There was a weak association OR(CI) 1.014(0.64 to 1.600)with PD and perinatal outcome in cases compared to controls.
Other factors showed a relatively stronger association birth weight OR (CI) 2.671(1.783 to 4.001) and gestational age OR (CI) 4.421(2.756 to 7.091). The birth weight < 2500 Gms (low birth weight)was twice more prone to develop APO due to PD compared to controls with birth weight > 2500 Gms. The gestational age before 37 weeks (preterm) was 4 times more common with PD compared to controls without PD as shown in Table II.
Most obstetrician-gynecologists agree that routine dental care during pregnancy is required and periodontal disease can have adverse effects on pregnancy outcome. About 66% also agree that treating periodontal disease positively affects pregnancy outcome. There has been an increase in the incidence of LBW around the world.
There are oral microbiologic and immunological findings that strongly support the association of PD in mothers. Some studies also indicate that periodontal infection can lead to placental-fetal exposure and, when coupled with a fetal inflammatory response, can lead to preterm delivery Our study have shown that most mothers were non booked 347(57.8%), not educated 423 (70.5%) and non-employed 441(73.51%).
In Pakistan LBW (37%) and infant mortality as 98 per 1000 live births which is a public health issue. There is a need for preventable determination in developed countries. Periodontal Disease have shown adverse pregnancy outcome in Pakistan. Maternal Periodontal Disease estimated vary greatly in different studies. There were 471(78.5%) babies born alive and healthy compared to 129(21.5%) with APO. This study was conducted in a single center with medium to low resources mothers which is a logistic limitation. Therefore these require further multi center and community based studies. Mothers booked 253 (42 %) had at least three visits during entire pregnancy and were never subjected to oral examination and counseled for oral hygiene. Our population has been facing problems of low income, poor social setup and inadequate antenatal visits due to several reasons. Pregnant mother at any time should have oral examination and along with optimum breastfeeding counseling information regarding their oral health and hygiene care should be communicated. Single blood test for CRP along with other tests during antenatal care before conception and early in pregnancy can also predict some systematic infections in the body. If oral examination findings show mild ,moderate or severe periodontitis and poor health then immediate treatment for PD should be started to reduce APO.
Adverse Pregnancy outcome have been associated with several other exposures that predict low birth weight and preterm labor. This study showed a weak association (OR, 1.014, CI 0.64 to 1.600)with PD. This finding has been found in several studies and the associations of PD and APO have been debated in various studies. Other factors birth weight (OR, 2. 67, CI, 1.783 to 4.001) and gestational age (OR, 4.421, CI 2.756 to 7.091) were very strong risk factors resulting in APO due to PD. The birth weight < 2500 Gms (low birth weight) was twice more prone to develop APO due to PD compared to controls with birth weight > 2500 Gms. The gestational age before 37 weeks (preterm) was 4 times more common with PD compared to controls without PD. These risk factors low birth weight and pretermdeliveries have been the strong risk factors in our population.
There is evidence that failure to treat periodontitis appropriately can result in progressive loss of periodontal supporting tissues, an adverse change in prognosis, tooth loss, and compromise of the dentition. Therefore information should be given to patients and an informed decision regarding their periodontal therapy will be useful in further management.
Systemic health is often closely linked to the state of the oral cavity. There are many systemic diseases having oral manifestations. Oral microbiological infections may also affect general health status. Periodontal diseases may be linked with systemic diseases including cardiovascular diseases, diabetes, respiratory diseases, adverse pregnancy outcomes, and osteoporosis. However several primary studies have suggested that periodontal intervention may reduce adverse pregnancy outcome.
There have been several studies confirming the association of systemic infections with elevated CRP levels and periodontal disease. In developing countries like Pakistan this study have shown Periodontal disease and abnormal (>1) CRP as the strongest, explicit and defined risk factors for pretermand low birth weight.
There is an increased odd of adverse pregnancy outcomes (low birthweight and pre-termlabor) in the presence ofmaternal periodontal disease..
Conflict of Interest
The authors declared no conflict of interest for this study
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