Preterm delivery, delivery before 37 completed weeks of gestation, has been shown to cause significant morbidity in infants and to be a cause of lifelong health problems in these children. The World Health Organization (WHO) reports,

Preterm birth is a leading cause of neonatal and infant mortality as well as short- and long-term disability. Rates for preterm birth range between 6% and 12% in developed countries and are generally higher in developing countries. About 40% of all preterm births occur before 34 weeks and 20% before 32 weeks. The contribution of these preterm births to overall perinatal morbidity and mortality is more than 50%.'

Low birth weight - below 5 lbs 8 ounce (or 2500 grams) - is usually a consequence of preterm birth but is also a singularly significant cause of morbidity and mortality in neonates and children. According to the March of Dimes, 67% of preterm infants are low birth weight and in the United States, they estimate that about 1 in every 12 infants is born low birth weight.

Despite attempts to positively impact maternal health and nutrition, and aggressively treat preterm labor, the rates of preterm birth and low birth infants are still on the rise globally. Physicians and researchers continue to examine cases and studies trying to identify potential causes and treatments that could slow, halt and eventually reverse these trends. In 1996, Offenbacher et al first reported an association between periodontal disease and preterm birth. Since that time, evidence has been growing to support the idea that periodontal disease may be associated with preterm birth, low birth weight and other adverse birth outcomes.

Xu Xiong et al hypothesize in their article, Optimal timing of periodontal disease treatment for prevention of adverse pregnancy outcomes: before or during pregnancy?, that since periodontal disease treatment during pregnancy has not been shown to significantly reduce the rates of preterm birth and low birth weight, that preconception treatment (either in the year prior to conception in primiparas or between pregnancies in multiparous women) may be more effective.

Xiong and his colleagues reached this conclusion following a systematic review of the observational studies which showed that there is an association between periodontal disease and adverse birth outcomes (especially in lower socioeconomic populations), and meta analyses of randomized control trials (RCT's); one in which preterm birth was the end point and one in which low birth weight was the end point. RCT's performed in low to middle-income countries found a stronger link between treatment of periodontal disease during pregnancy and reduction in adverse pregnancy outcomes. RCT's performed in high income countries such as the United States only showed that treating periodontal disease during pregnancy may reduce the rates of low birth weight. With these findings, Xiong and his colleagues present the following recommendations for future RCT's to determine whether or not treating periodontal disease prior to conception can actually reduce the rates of preterm birth, low birth weight and other adverse pregnancy outcomes.

• Study participants would be women planning to conceive within one year and with documented periodontal disease
• Participants would be randomized to treatment vs. non treatment groups
• Treatment groups would receive intense periodontal therapies and use of antibiotics to aggressively treat and eradicate periodontal disease
• Endpoints of the studies would be delivery, and assessment of rates of adverse pregnancy outcomes would determine the efficacy of the intervention.

Xiong et al hypothesize that if preconception periodontal treatments reduce adverse pregnancy outcomes lowering infant morbidity and mortality, then improving oral health prior to pregnancy could be recommended, especially in low and middle income nations, as a means of reducing infant morbidity and mortality worldwide.

At face value Xiong's hypothesis may seem like a lot of 'ifs.' However, the presumed link between periodontal disease and adverse birth outcomes provides a simple portal for intervention and measurement of effect. While it may be more difficult to amass study participants as most women don't receive preconception care, Xiong suggests recruitment within communities. He also suggests training of dental professionals so that the diagnoses and treatments of periodontal disease remain as uniform as possible worldwide.

I agree with Xiong's hypothesis and proposed course of action. My concern is that here in the United States, many citizens are without dental coverage and will be unable to afford the preconception periodontal treatments should they become a standard of preconception care. While women may receive treatment during the study, how will low income and/or uninsured women receive such treatment once preconception treatment becomes a recommendation? Medicaid doesn't cover dental procedures 'for health' and preconception would need to be listed as treatment of overall health and that may prove a difficult task -at least initially. Medicaid is currently facing increasing budget cuts nationwide so adding another benefit may not be admissible, despite being effective in lowering other health care costs associated with the long term care of preterm and low birth weight infants.

While I hope that Xiong's hypothesis is proven and preconception periodontal treatment is a solution to help reduce the rates of preterm birth and low birth weight infants, I fear that as a solution, it may not be available to many women, especially in the United States, due to costs. I hope that worldwide, if preconception periodontal treatment is effective in reducing adverse pregnancy outcomes, resources will be allocated for such treatment as it will reduce not only infant morbidity and mortality but also the burden of life long care costs for these children.

Posted by: Darline Turner-Lee, BS, MHS, PA-C

References

Stacy Beck, Daniel Wojdyla, Lale Say, Ana Pilar Betran, Mario Merialdi, Jennifer Harris Requejo, Craig Rubens, Ramkumar Menon & Paul FA Van Look

The worldwide incidence of preterm birth: a systematic review of maternal mortality and morbidity Bulletin 37 World Health Organizaton2010;88:31-38 | doi:10.2471/BLT.08.062554

The March of Dimes http://www.marchofdimes.com/medicalresources_lowbirthweight.html

Steven Offenbacher, Vern Katz, Gregory Fertik, John Collins, Doryck Boyd, Gayle Maynor,Rosemary McKaig, and James Beck

'Periodontal Infection as a Possible Risk Factor for Preterm Low Birth Weight'

Journal of Periodontology October 1996, Vol. 67, No. 10s, Pages 1103-1113,

DOI 10.1902/jop.1996.67.10s.1103 (doi:10.1902/jop.1996.67.10s.1103)

Xiong X, Buekens P, Goldenberg RL, et al. 'Optimal timing of periodontal disease treatment for prevention of adverse pregnancy outcomes: before or during pregnancy?' American Journal of Obstetrics and Gynecology 2011; 205:111.e1-6.

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