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Periodontal disease is a significant risk factor for PTD

Preterm delivery (PTD) remains the greatest problem in obstetrical medicine. Estimates put PTD at 5-11% of all pregnancies, increasing in western countries. In addition to morbidity, mortality and high medical costs, preterm children can suffer systemic health problems throughout life.

Researchers at the University of Zagreb in Croatia wanted to determine the strength of periodontal disease as a potential risk factor for PTD. The prevalence of moderate to severe periodontal disease in women of child-bearing age in Croatia is estimated to be as high as 11% – considerably higher than what other countries reported. Between March, 2002, and June, 2003, study subjects were randomly recruited from women delivering babies at the General Hospital in Zagreb. The study included only first-time mothers delivering a single child vaginally. Those who participated in the study agreed to undergo a periodontal examination at the hospital within two days of giving birth. Questions were also asked about other potential risk factors: age, tobacco use, alcohol use, nutrition, infections during pregnancy and prenatal care.

Babies who were delivered before 37 weeks were considered PTD (17 babies) and those born with an uncomplicated delivery after 37 weeks were considered full-term delivery (FTD) (64 babies). Tobacco was used by 10 of the 17 PTD mothers and 26 of the 64 FTD mothers. None of the PTD mothers used alcohol, compared to half of the FTD mothers. Periodontal disease as measured by attachment levels was a significant risk factor for PTD. Attachment loss of 4 mm or more at 60% of sites or more was found in 11 out of 17 PTD mothers, compared to 13 out of 64 FTD mothers. Based on these findings, both tobacco use and periodontal disease should be considered risk factors for PTD in Croatian women.

Clinical Implications: Periodontal therapy should be a part of prenatal care in Croatia. With periodontal treatment, perhaps 500 of the 2,000 PTDs in Croatia could be avoided, saving both lives and money.

Bosnjak, A., Relja, T., Vucicevic-Boras, V., Plasaj, H., Plancak, D.: Pre-Term Delivery and Periodontal Disease: A Case-Control Study from Croatia. J Clin Perio 33: 710-716, 2006.

Tooth decay may be risk factor for preeclampsia

Preeclampsia is the development of elevated blood pressure during pregnancy. Hypertension is a serious condition affecting 8% of pregnant women and can lead to adverse outcomes. Preeclampsia is characterized by new onset hypertension and protein in the urine (proteinuria). Several research studies suggest a link between periodontal disease and preeclampsia.

Researchers at the Jordan University of Science and Technology evaluated deliveries between January 1, 2005, and May 1, 2005, at the Princes Badea Teaching Hospital in North Jordan. For each preeclampsia subject in the study, two controls were included from deliveries on the same day. A total of 115 preeclampsia cases were evaluated in the study, compared to past studies that only included 41, 39 and 15 pereclampsia cases.

Many risk factors for preeclampsia are known: personal or family history of preeclampsia, multiple births, previous births, stress, body weight, and age. These factors were considered in this study. None of the study participants used tobacco or alcohol.

No corrolation was found between periodontal disease and preeclampsia. Periodontal disease levels were similar for both groups. However, an association was found between tooth decay and preeclampsia. Oral systemic link research has focused primarily on periodontal disease, and should now be extended to include the potential risk of tooth decay on systemic health.

The authors suggested an important point for future studies. Third molars should be included when evaluating periodontal disease, since this can be a problem area for women of child-bearing age. Research design routinely excludes third molars from data collection, missing a potential site of periodontal disease.

Clinical Implications: Check the blood pressure of your pregnant patients, keeping in mind that periodontal disease may or may not be a risk factor for preeclampsia. Be sure pregnant patients have no active decay.

Khader, Y., Jibreal, M., Al-Omiri, M., Amarin, A.: Lack of Association Between Periodontal Parameters and Preeclampsia. J Perio 77: 1681-1687, 2006.

Perio treatment no risk for PTD

Approximately 11% of all single births in the United States occur before 37 weeks. No known risk factors are identified for half of all preterm deliveries (PTD). Theories suggest bacteria and/or cytokines associated with periodontal disease may be factors in PTD. Published research both supports and refutes these theories. Two studies showed scaling and root planing (SRP) reduced PTD, while another one reported no reduction in PTD following SRP during pregnancy.

A multi-center study headed by University of Minnesota researchers evaluated the effects of SRP on the outcomes of single births of approximately 400 women with moderate periodontitis, at four centers (Minnesota, Kentucky, New York and Mississippi). Test subjects received SRP in a series of no more than four visits, followed by monthly polishing visits with instrumentation as needed. A control group of 400 women received only oral hygiene instructions, but had as many visits as the treatment group. At each visit, women received a $20 gift certificate and an infant’s toy.

Both groups showed improvement in oral health, with greater improvement in the treatment group. It was difficult to tell from the data as presented just how much healing each group experienced.

There were 14 spontaneous abortions or stillbirths in the control group compared to five in the treatment group. Total PTD for the control group was 52 or 12.8% compared to 49 PTD or 12% in the treatment group, showing no added protection due to SRP. Other studies have demonstrated PTD rates reduced to 1%-4%, much greater reduction than shown in this study. However, variations do exist between studies and outcomes cannot be directly compared. Based on these findings, SRP is safe for pregnant women.

Clinical Implications: Providing necessary periodontal treatment to a pregnant woman poses no increased risk for preterm delivery, low birthweight or the potential for a small baby.

Michalowicz, B. et al: Treatment of Periodontal Disease and the risk of Preterm Birth. New England Journal of Medicine. 355: 1885-1894, 2006.

Tooth loss low in well-maintained patients

Many studies have shown that periodontal treatment and supportive periodontal maintenance (SPT) care will maintain periodontal health and reduce tooth loss. In 1978 Drs. Hirschfeld and Wasserman published the classic study measuring tooth loss in 600 patients during SPT. They reported only 7% of teeth present after initial therapy were lost over an average 22-year period of SPT. Most of the tooth loss occurred in a small group of those patients. Other studies confirm that poor compliance with maintenance increases the risk of tooth loss by nearly six times.

Periodontists in Brazil evaluated their private practice to determine the rate of tooth loss. The average length of maintenance was 17.4 years for the 120 maintenance patients in the study and the average SPT interval was 9.4 months. Following initial therapy, 2,927 teeth were present in the study group. Of these, 3.8% were lost, with only 1.8% lost due to periodontal disease. Other reasons for tooth loss included root fracture, caries, and endodontic problems. In this group, 8.4% of the subjects accounted for more than half the number of teeth lost. Molars were the most frequently lost. More than half the group, 64.2% lost no teeth.

Twenty of the subjects were smokers and accounted for 24 of the teeth lost, compared to 29 teeth lost in the 100 non-smokers. Age was also a factor. Those under 60 years of age (78 patients) lost only 12 teeth, compared to 41 teeth lost by those over 60 years (42 patients).

Clinical Implications: Smokers and those who are older are more susceptible to tooth loss due to periodontal disease.

Chambrone, L.A., Chambrone, L.: Tooth Loss in Well-Maintained Patients with Chronic Periodontitits During Long-Term Supportive Therapy in Brazil. J Clin Perio 33: 759-764, 2006.

Chewing fails to induce bacteremia

According to research published in 2002, chewing does drive endotoxins through the epithelial attachment and into the blood stream. Studies claiming that chewing drives oral bacteria into the blood stream are not conclusive and often followed study designs that omitted several key factors: baseline test for bacteremia, positive diagnosis of periodontal disease, and confirmation of oral bacteria in the blood stream. Skin bacteria are often found in the blood stream, due to the needle insertion necessary for blood samples.

Researchers at the University of Sydney in Australia wanted to know if those with untreated chronic periodontitis and those with gingivitis would experience bacteremia from chewing. Twenty-one adults with periodontitis and 20 adults with gingivitis each chewed paraffin wax for four minutes. Blood samples were taken from the inside of the arm at baseline, during the four minutes of chewing and five minutes after chewing was complete.

The only bacteria found in the blood samples were skin surface bacteria. No oral bacteria were detected at any of the time points tested. Blood samples were cultured for 21 days to detect species that require a long incubation period, yet none were detected.

These findings refute a claim made in 1984 that “chewing increases the risk of bacteremia 100,000 times compared to a single extraction.” Chewing alone does not appear to force bacteria into the blood stream. Chewing does force endotoxins into the blood stream. Toothbrushing and interdental cleaning can traumatize the epithelium, thus providing access for bacteria to underlying tissues and the vascular system.

Clinical Implications: Chewing does not cause a bacteremia in people with chronic periodontitis or plaque induced gingivitis.

Murphy, A., Daly, C., Mitchell, D., Stewart, D., Curtis, B.: Chewing Fails to Induce Oral Bacteraemia in Patients with Periodontal Disease. J Clin Perio 33: 730-736, 2006.

Sonic scaler and curettes produce similar results

Power scaler use is increasing. According to an AAP position paper, the gold standard for subgingival instrumentation remains hand instruments. However, the thoroughness of instrumentation is thought by researchers to be more important than the choice of treatment modality. Several studies show that sonic and ultrasonic instruments and curettes are equally effective for deposit removal.

Researchers at the University of Regensburg in Germany compared the KaVo SonicFlex 2003L sonic scaler to Hu-Friedy, Gracey curettes (1/2, 7/8, 11/12 and 13/14) in a group of 20 subjects with generalized chronic periodontitis. Prior to baseline data collection, subjects received detailed oral hygiene instructions, supragingival deposit removal and any necessary restorative dental work. When checked two-weeks later, plaque and bleeding scored needed to be below 25% to begin the study. Using a split-mouth study design, subjects received sonic scaling in two quadrants and hand instruments for the other two quadrants. Local anesthesia was provide upon request by the patients. The clinician wore 2x magnification while working. Instrumentation time was measured using a stopwatch. Subjects were evaluated four weeks and six months later.

Pocket depths were reduced 1 mm in moderately deep pockets and 2 mm in deep pockets for both groups. Bleeding in deep sites was reduced 67% in the sonic scaler group and 76% in the hand instrument group at six months. This is statistically significant, but it may not be clinically relevant. Sonic scaling averaged 4.3 minutes per tooth compared to 6.1 minutes per tooth for hand instruments. Tooth sensitivity was reported at four weeks after hand instrumentation while no sensitivity was found for teeth treated with the sonic scaler. At six months, neither group demonstrated sensitivity.

Clinical Implications: The sonic scaler and the curettes produced generally similar healing after six months although sonic scaling took less treatment time and produced no post treatment sensitivity.

Christgau, M., Männer, T., Beuer, S., Hiller, K., Schmalz, G.: Periodontal Healing After Non-Surgical Therapy With a Modified Sonic Scaler: A Controlled Clinical Trial. J Clin Perio 33: 749-758, 2006.

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