Treatment of Periodontal Disease and Prevention of Preterm Birth: Systematic Review and Meta-analysis

Abstract

Objective There is a controversy regarding the benefits of periodontal treatment during pregnancy. We aimed to evaluate its effect on the risk of preterm birth and to explore the heterogeneity between studies.

Study Design A systematic review and meta-analysis of randomized controlled trials were performed. Studies in which women were randomized for periodontal treatment versus no treatment were included. Pooled risk ratios (RRs) with their 95% confidence intervals (CIs) were calculated using random-effect models. A sensitivity analysis was performed.

Results Twelve randomized trials were included in the meta-analysis. Pooled estimates showed no significant reduction of preterm birth with periodontal treatment (RR: 0.89; 95% CI: 0.73 to 1.08). However, the substantial heterogeneity among studies (I² = 52%) could be explained either by the risk of bias, the level of income, or by the use of chlorhexidine mouthwashes as a cointervention. Daily use of chlorhexidine mouthwash was associated with a reduction of preterm birth (RR: 0.69; 95% CI 0.50 to 0.95), with moderate heterogeneity among the five studies included (I² = 43%).

Conclusion There is an important heterogeneity between randomized trials that evaluated the effect of periodontal treatment on the risk of preterm birth. Chlorhexidine mouthwash as a preventive agent should be further evaluated.

Keywords

pregnancy - periodontitis - preterm birth - meta-analysis

• References

• 1 Boggess KA, Lieff S, Murtha AP, Moss K, Beck J, Offenbacher S. Maternal periodontal disease is associated with an increased risk for preeclampsia. Obstet Gynecol 2003; 101: 227-231
• 2 Jeffcoat MK, Geurs NC, Reddy MS, Cliver SP, Goldenberg RL, Hauth JC. Periodontal infection and preterm birth: results of a prospective study. J Am Dent Assoc 2001; 132: 875-880
• 3 Offenbacher S, Katz V, Fertik G , et al. Periodontal infection as a possible risk factor for preterm low birth weight. J Periodontol 1996; 67 (10 Suppl) 1103-1113
• 4 Oliver RC, Brown LJ, Löe H. Periodontal diseases in the United States population. J Periodontol 1998; 69: 269-278
• 5 Challis JR, Lockwood CJ, Myatt L, Norman JE, Strauss III JF, Petraglia F. Inflammation and pregnancy. Reprod Sci 2009; 16: 206-215
• 6 Romero R, Espinoza J, Gonçalves LF, Kusanovic JP, Friel L, Hassan S. The role of inflammation and infection in preterm birth. Semin Reprod Med 2007; 25: 21-39
• 7 Polyzos NP, Polyzos IP, Zavos A , et al. Obstetric outcomes after treatment of periodontal disease during pregnancy: systematic review and meta-analysis. BMJ 2010; 341: c7017
• 8 Uppal A, Uppal S, Pinto A , et al. The effectiveness of periodontal disease treatment during pregnancy in reducing the risk of experiencing preterm birth and low birth weight: a meta-analysis. J Am Dent Assoc 2010; 141: 1423-1434
• 9 Liberati A, Altman DG, Tetzlaff J , et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration. PLoS Med 2009; 6: e1000100
• 10 Dickersin K, Scherer R, Lefebvre C. Identifying relevant studies for systematic reviews. BMJ 1994; 309: 1286-1291
• 11 Glanville JM, Lefebvre C, Miles JN, Camosso-Stefinovic J. How to identify randomized controlled trials in MEDLINE: ten years on. J Med Libr Assoc 2006; 94: 130-136
• 12 DerSimonian R, Laird N. Meta-analysis in clinical trials. Control Clin Trials 1986; 7: 177-188
• 13 Deeks JJ, Higgins JPT, Altman DG. on behalf of the Cochrane Statistical Methods Group. Chapter 9: Analysing data and undertaking meta-analyses. In: Higgins JPT, Green S, , eds. Cochrane Handbook for Systematic Reviews of Interventions, Version 5.1.0 [updated March 2011]. The Cochrane Collaboration. 2011. . Available at: www.cochrane-handbook.org . Accessed June 1, 2012
• 14 The World Bank. Countries and Economies. 2012 ; Available from: http://data.worldbank.org/country . Accessed June 1, 2012
• 15 Higgins JPT, Altman DG, Sterne JAC. on behalf of the Cochrane Statistical Methods Group and the Cochrane Bias Methods Group. Chapter 8: Assessing risk of bias in included studies. In: Higgins JPT, Green S, , eds. Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0 [updated March 2011]. The Cochrane Collaboration. 2011. . Available at: www.cochrane-handbook.org . Accessed June 1, 2012
• 16 López NJ, Smith PC, Gutierrez J. Periodontal therapy may reduce the risk of preterm low birth weight in women with periodontal disease: a randomized controlled trial. J Periodontol 2002; 73: 911-924
• 17 Jeffcoat MK, Hauth JC, Geurs NC , et al. Periodontal disease and preterm birth: results of a pilot intervention study. J Periodontol 2003; 74: 1214-1218
• 18 López NJ, Da Silva I, Ipinza J, Gutiérrez J. Periodontal therapy reduces the rate of preterm low birth weight in women with pregnancy-associated gingivitis. J Periodontol 2005; 76 (11) (Suppl): 2144-2153
• 19 Michalowicz BS, Hodges JS, DiAngelis AJ , et al; OPT Study. Treatment of periodontal disease and the risk of preterm birth. N Engl J Med 2006; 355: 1885-1894
• 20 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: 2011-2024
• 21 Sadatmansouri S, Sedighpoor N, Aghaloo M. Effects of periodontal treatment phase I on birth term and birth weight. J Indian Soc Pedod Prev Dent 2006; 24: 23-26
• 22 Tarannum F, Faizuddin M. Effect of periodontal therapy on pregnancy outcome in women affected by periodontitis. J Periodontol 2007; 78: 2095-2103
• 23 Newnham JP, Newnham IA, Ball CM , et al. Treatment of periodontal disease during pregnancy: a randomized controlled trial. Obstet Gynecol 2009; 114: 1239-1248
• 24 Offenbacher S, Beck JD, Jared HL , et al; Maternal Oral Therapy to Reduce Obstetric Risk (MOTOR) Investigators. Effects of periodontal therapy on rate of preterm delivery: a randomized controlled trial. Obstet Gynecol 2009; 114: 551-559
• 25 Macones GA, Parry S, Nelson DB , et al. Treatment of localized periodontal disease in pregnancy does not reduce the occurrence of preterm birth: results from the Periodontal Infections and Prematurity Study (PIPS). Am J Obstet Gynecol 2010; 202: 147 , e1–e8
• 26 Oliveira AM, de Oliveira PA, Cota LO, Magalhães CS, Moreira AN, Costa FO. Periodontal therapy and risk for adverse pregnancy outcomes. Clin Oral Investig 2011; 15: 609-615
• 27 Weidlich P, Moreira CH, Fiorini T , et al. Effect of nonsurgical periodontal therapy and strict plaque control on preterm/low birth weight: a randomized controlled clinical trial. Clin Oral Investig 2012; [epub ahead of print]
• 28 Jeffcoat M, Parry S, Gerlach RW, Doyle MJ. 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–e6
• 29 Xiong X, Buekens P, Goldenberg RL, Offenbacher S, Qian X. Optimal timing of periodontal disease treatment for prevention of adverse pregnancy outcomes: before or during pregnancy?. Am J Obstet Gynecol 2011; 205: 111 , e1–e6
• 30 Himaya E, Rhalmi N, Girard M , et al. Midtrimester intra-amniotic sludge and the risk of spontaneous preterm birth. Am J Perinatol 2011; 28: 815-820
• 31 Debiève F, Ska S, Williams O , et al. Evaluation of a universal real-time polymerase chain reaction for detection of amniotic fluid infection in premature rupture of membranes. Am J Perinatol 2011; 28: 501-508
• 32 Thomakos N, Daskalakis G, Papapanagiotou A, Papantoniou N, Mesogitis S, Antsaklis A. Amniotic fluid interleukin-6 and tumor necrosis factor-alpha at mid-trimester genetic amniocentesis: relationship to intra-amniotic microbial invasion and preterm delivery. Eur J Obstet Gynecol Reprod Biol 2010; 148: 147-151
• 33 Gauthier S, Tétu A, Himaya E , et al. The origin of Fusobacterium nucleatum involved in intra-amniotic infection and preterm birth. J Matern Fetal Neonatal Med 2011; 24: 1329-1332
• 34 Fogacci MF, Vettore MV, Leão AT. The effect of periodontal therapy on preterm low birth weight: a meta-analysis. Obstet Gynecol 2011; 117: 153-165