The Role of Oral Health Education and Intervention Programs in Preventing Periodontal Disease and Improving Pregnancy Outcomes

Abstract

This meta-analysis aims to assess the effectiveness of oral health education and intervention programs in preventing periodontal disease and improving pregnancy outcomes, particularly preterm birth and low birth weight incidences. By synthesizing findings from multiple studies, this analysis endeavors to provide clearer insights into the impact of maternal periodontal health on pregnancy and identify evidence-based interventions that optimize maternal and neonatal outcomes. This study was conducted as a systematic review and meta-analysis of the literature. The protocol was developed per the updated PRISMA 2020 statement guidelines. The inclusion and exclusion criteria were predetermined to ensure a rigorous selection of relevant studies. The study design included randomized controlled trials, cohort studies, and case–control studies. A systematic search was conducted across the following databases: PubMed, Web of Science, Scopus, Embase, Google Scholar, and the Cochrane Library. Grey literature sources and reference lists of included studies were also reviewed. Data were synthesized using a random-effects model to account for heterogeneity among studies. The results suggest a possible trend toward a protective effect for preterm birth. Integrating oral health services into prenatal care represents a promising, cost-effective strategy for improving maternal and neonatal outcomes. This study reinforces the potential role of periodontal therapy in reducing adverse pregnancy outcomes, particularly preterm birth, through its ability to reduce systemic inflammation.

 

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Keywords

oral health education - periodontal disease - pregnancy - periodontal therapy

Introduction

Periodontal disease encompasses inflammatory conditions that affect the supporting structures of the teeth, including the gingiva (gums), periodontal ligament, and alveolar bone. The two most common forms of periodontal disease in pregnant women are gingivitis, characterized by gum inflammation, and periodontitis, a more severe condition marked by gingival inflammation, deep periodontal pockets, and bone loss.[1] Importantly, maternal periodontal disease has been linked to adverse pregnancy outcomes, including preterm birth (PTB), defined as delivery before 37 weeks of gestation, and low birth weight (LBW)—infants weighing less than 2,500 grams at birth.[2] These outcomes remain significant risk factors for neonatal mortality and long-term developmental complications.

The pathogenesis of periodontal disease is primarily driven by an imbalance in the oral microbiome, where pathogenic bacteria such as Fusobacterium nucleatum and Prevotella intermedia provoke local and systemic inflammatory responses.[3] During pregnancy, hormonal changes—particularly elevated estrogen and progesterone levels—exacerbate gingival inflammation and vascular permeability, increasing susceptibility to gingivitis (Parry et al, 2007).[4] If untreated, gingivitis may progress to periodontitis, facilitating the transmission of bacteria and inflammatory mediators into the systemic circulation. This systemic inflammation can adversely influence placental function and fetal development, and may contribute to preterm labor and fetal growth restriction.[5]

The association between periodontal disease and adverse pregnancy outcomes has been well-documented. For instance, Boggess and Edelstein (2006) noted that pregnant women with periodontal disease face higher risks of delivering preterm or LBW infants. However, evidence regarding the effectiveness of periodontal interventions, such as scaling and root planing (SRP), during pregnancy remains inconsistent. While some studies have reported that treatment reduces adverse pregnancy outcomes,[6] (Lopez et al, 2002), others, such as Davenport et al. (2002) and Moore et al. (2004) found no statistically significant effect. This disparity highlights the need for further systematic investigation.[1] [5] [6] [7]

According to a study by Mesa et al, periodontal disease is more severe, and a periodontitis diagnosis is more frequent in mothers with preterm or LBW versus normal delivery.[8]

Maternal oral health is particularly critical among populations with limited access to dental care, where untreated periodontal disease may amplify pregnancy risks. Cost-effective and accessible strategies, such as oral health education and preventive interventions—including antimicrobial mouth rinses and comprehensive oral hygiene regimens—have shown promise in mitigating periodontal disease and its systemic effects.[3] Levels of inflammatory biomarkers in the oral biofilm were found to be highest in pregnant women with systemic conditions. Increased inflammatory biomarkers in the oral biofilm were also associated with worse oral health outcomes.[9]

Given the global burden of adverse pregnancy outcomes and the prevalence of untreated periodontal disease among women of childbearing age, this study aims to systematically evaluate the effectiveness of oral health education and intervention programs in improving maternal periodontal health. Conducting a meta-analysis allows for the synthesis of existing evidence to clarify the relationship between maternal oral health and pregnancy outcomes, specifically focusing on reducing PTB and LBW. By identifying whether specific interventions yield consistent benefits, this study seeks to guide prenatal care policies, public health strategies, and clinical practices.

 

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Methods

This study was conducted as a systematic review and meta-analysis of the literature. The protocol was developed per the updated PRISMA 2020 statement guidelines. The study has been registered with the International Prospective Register of Systematic Reviews (PROSPERO) under registration ID CRD42024617282, with the most recent edits completed on December 7, 2024.

The study population was pregnant women diagnosed with periodontal disease or gingivitis.

Oral health interventions were mechanical debridement (e.g., SRP), antiseptic mouth rinses, oral hygiene education programs, or combinations thereof.

Comparators were control groups of pregnant women who did not receive any periodontal intervention or received usual care.

The study design included randomized controlled trials (RCTs), cohort studies, and case–control studies. The time frame was studies published up to 2023. Only studies published in English were included. Publication status was peer-reviewed publications, and relevant grey literature was considered.

Exclusion criteria were studies that did not report on PTB or LBW outcomes; studies that were editorials, reviews, case reports, or animal studies; studies included populations that did not meet the inclusion criteria, such as nonpregnant participants or those without periodontal disease; and studies involving mixed populations (pregnant and nonpregnant women).

A systematic search was conducted across the following databases: PubMed, Web of Science, Scopus, Embase, Google Scholar, and the Cochrane Library, LILACS. Grey literature sources and reference lists of included studies were also reviewed. Controlled vocabulary (e.g., MeSH terms) and keywords were combined using Boolean operators (AND/OR) to refine the search.

The search terms included: “Periodontal disease,” “gingivitis,” “periodontitis”, “Oral health intervention, dental hygiene education,” “scaling and root planing,” “Pregnancy outcomes,” “preterm birth,” and “low birth weight”.

Two independent reviewers screened the titles and abstracts of all retrieved studies against the predefined eligibility criteria. Articles that passed the initial screening were retrieved for full-text review to confirm eligibility. Discrepancies between reviewers were resolved through discussion and consensus.

A total of 1,299 records were identified (from PubMed, CINAHL, EMBASE, Cochrane Library, and Scopus).

Ten duplicated articles were removed, 1,250 ineligible records excluded (automation tools), 24 records removed for other reasons, 24 records screened (title/abstract), 15 full-text articles assessed for eligibility, 9 records excluded after full-text review, and 5 studies included in the final review.

Data were extracted independently by two reviewers using a standardized data extraction form. The following data were collected: study details: author(s), publication year, country, and study design, Population: sample size and pregnancy stage. Interventions: type and duration of periodontal interventions. Outcomes: rates of PTB and LBW. Methodology: assessment of periodontal health and pregnancy outcomes.

The risk of bias was assessed for each study using the Center for Evidence-Based Medicine (CEBM) Critical Appraisal Tools. Assessment domains included: randomization methods; blinding of participants, clinicians, and assessors; completeness of outcome data and follow-up; and outcome measurement reliability.

Each study was rated as low, moderate, high, or an unclear risk of bias. Studies with a high risk of bias were excluded from the final analysis to ensure data reliability and validity.

Data were synthesized using a random-effects model to account for heterogeneity among studies. The effect sizes for PTB and LBW were expressed as risk ratios (RRs) with corresponding 95% confidence intervals (CIs). Heterogeneity was assessed using the I² statistic and Q-test:

• I² < 25%: low heterogeneity.

• I² = 25–50%: moderate heterogeneity.

• I² > 50%: high heterogeneity.

All studies included adhered to standardized definitions. Analyses were performed using IBM SPSS Statistics, with significance set at p <0.05.

As this is a secondary analysis of published data, ethical approval was not required.

 

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Results

The study selection process is detailed in the PRISMA flow diagram ([Fig. 1]). A total of 1,309 records were identified through searches in CINAHL (n = 76), Cochrane Library (n = 170), EMBASE (n = 552), PubMed (n = 227), and Scopus (n = 284). After 10 duplicate records were removed, 1,299 records were screened for eligibility based on titles and abstracts. Out of the screened studies, 1,283 records were excluded for not meeting the eligibility criteria. Further, 19 studies were removed due to overlapping reasons.

Fig. 1 PRISMA flow diagram.

The remaining 34 records were retrieved for full-text review, of which 10 studies were excluded for the following reasons: lack of an intervention group or control group, missing data on LBW outcomes, and observational study design rather than clinical trials; a total of 5 studies met the inclusion criteria and were included in the final analysis; 5 studies evaluated the impact of oral health interventions on PTB; and 3 studies evaluated the impact on LBW outcomes ([Fig. 1]).

The characteristics of the studies included are presented in [Tables 1] and [2] (PTB and LBW). The quality of the studies included was assessed using the CEBM Critical Appraisal Tool for RCTs. As shown in [Table 3], most studies demonstrated a low to moderate risk of bias. Randomization methods were clearly described in three studies, blinding of assessors and patients was adequately conducted in two studies, and outcome measurement and data completeness were reported across all studies.

Table 1 Characteristics of included studies—preterm birth

Study ID (first author)	Study design	Year	Intervention group_preterm birth	Intervention group_non-preterm birth	Nonintervention group_preterm birth	Nonintervention group_non-preterm birth
Boggess[1]	RCT	2006	10	64	17	73
López[5]	RCT	2005	12	548	19	264
Soroye[16]	RCT	2016	18	123	35	247
Macones[10]	RCT	2023	21	281	32	279
Jiang[3]	RCT	2016	9	223	6	228

Abbreviation: RCT, randomized controlled trial.

Table 2 Characteristics of included studies—low birth weight

Study ID (first author)	Study design	Year	Intervention group-LBW	Intervention group_non-LBW	Control group_LBW	Control group_non-LBW
Jiang[3]	RCT	2016	7	225	2	232
López[5]	RCT	2005	4	556	3	280
Soroye[16]	RCT	2016	17	124	17	124

Abbreviations: LBW, low birth weight; RCT, randomized controlled trial.

Table 3 Quality assessment of studies

Study 2 examiners' % agreement? 90/100%	Was the assignment of patients to treatments randomized?	Were the groups similar at the start of the trial?	Aside from the allocated treatment, were groups treated equally?	Were all patients who entered the trial accounted for?	Were measures objective, or were the patients and clinicians “blind”?
Boggess and Edelstein (2006)[1]	No	No	No	No	No
López et al (2002)[5]	Yes	Yes	Yes	Yes	No
Soroye (2016)[16]	No	Unclear	Yes	Yes	No
Macones et al (2010)[10]	Yes	Yes	Yes	Yes	Yes
Jiang et al (2016)[3]	yes	Yes	yes	yes	no

Five studies were included in the meta-analysis to evaluate the effect of oral health interventions on PTB. The results showed an RR of 0.73 (95% CI: 0.37–1.41), p = 0.25. While the intervention group demonstrated a 27% reduction in PTB risk compared to the control group, this effect was not statistically significant. Moderate heterogeneity was observed across studies (I² = 56%).

Interpretation: the RR of 0.73 suggests a potential protective effect of oral health interventions for PTB. However, the evidence is not conclusive due to the lack of statistical significance ([Fig. 2]).

Fig. 2 Forest plot—intervention treatment and low birth weight event.

Three studies assessed the impact of oral health interventions on LBW outcomes. The results showed:

RR: 1.11 (95% CI: 0.28–4.37), p = 0.78.

An RR of 1.1 showed that the interventions used were not protective and did not differ significantly from the control group for the outcome of LBW.

The difference between the intervention and control groups was not statistically significant. In addition, there was no observed heterogeneity among the studies (I² = 0%).

The RR of 1.11 suggests that oral health interventions did not reduce the risk of LBW since results show no significant difference between the intervention and control groups ([Fig. 3]).

Fig. 3 Forest Plot - Low Birth Weight Outcomes.

The meta-analysis found no statistically significant effects of oral health interventions on PTB or LBW:

PTB: RR = 0.73, indicating a potential protective effect that was not statistically significant.

LBW: RR = 1.11, showing no significant benefit for the intervention group. While the evidence remains inconclusive, the results suggest a possible trend toward a protective effect for PTB. Further studies with larger sample sizes and robust methodologies are needed to determine the clinical significance of oral health interventions during pregnancy.

 

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Discussion

This study highlights the importance of periodontal therapy in improving pregnancy outcomes, specifically PTB and LBW. Maternal periodontal disease is increasingly recognized as a modifiable risk factor for adverse pregnancy outcomes due to its link with systemic inflammation and bacterial dissemination.[1] [2] [3] However, the variability in findings across studies underscores the complexity of this association, influenced by differences in intervention protocols, population characteristics, and the timing of therapy.

The results suggest that periodontal therapy has a potential protective effect against PTB, but did not significantly influence LBW. The pooled RR for PTB was 0.73 (95% CI: 0.37–1.41), indicating a 27% reduction in risk among intervention groups, although this was not statistically significant. Studies such as López et al[6] observed significant reductions in PTB rates following periodontal therapy (67.89%), supporting the hypothesis that oral health interventions can mitigate systemic inflammation contributing to adverse pregnancy outcomes.[5]

Similarly, Parry et al reported a substantial improvement in PTB rates in disadvantaged populations receiving periodontal therapy, emphasizing the role of early interventions in high-risk groups.[10] However, inconsistent findings from Jiang et al and Michalowicz et al highlight the influence of intervention methods and patient demographics on outcomes.[3] [11] For LBW, the RR of 1.11 (95% CI: 0.28–4.37) suggests no significant difference between intervention and control groups, consistent with previous meta-analyses.[12]

The biological plausibility of the association between periodontal disease and pregnancy outcomes lies in the systemic inflammatory response triggered by oral pathogens such as Porphyromonas gingivalis, F. nucleatum, and P. intermedia.[2] Transient bacteremia during gingival inflammation allows bacterial toxins (e.g., lipopolysaccharides) to enter the maternal bloodstream, potentially triggering inflammatory cascades. These processes lead to elevated levels of prostaglandins (PGE2) and inflammatory cytokines such as tumor necrosis factor-α and intelukin-1β, which are associated with preterm labor and fetal growth restriction.[1] [13]

Jeffcoat et al demonstrated that women with severe periodontitis exhibited elevated gingival crevicular fluid PGE2 levels, which correlated with PTB.[14] Additionally, inflammatory markers like C-reactive protein and matrix metalloproteinases have been implicated as mediators of adverse outcomes, providing further evidence of the systemic nature of periodontal infections.[15]

The heterogeneity in findings across studies can be attributed to several factors:

Intervention methods: mechanical debridement, such as SRP, appears more effective than antiseptic mouth rinses in reducing systemic inflammation and improving outcomes.[5] [12] Noninvasive strategies like chlorhexidine mouth rinses are safer but demonstrate limited efficacy, particularly in advanced periodontitis cases.[16]

Timing of interventions: early intervention during pregnancy demonstrates greater efficacy in improving outcomes. López et al found significant benefits when periodontal therapy was administered in the first or second trimester, supporting the hypothesis that early treatment can prevent the systemic inflammatory cascade.[13] In contrast, studies initiating therapy in late pregnancy, such as Michalowicz et al, reported limited benefits.[11]

Socioeconomic factors, baseline oral health, and access to care influence the outcomes of periodontal interventions. Studies involving high-risk populations, such as low-income or uninsured women, have shown greater benefits. In these groups, periodontal disease prevalence is higher, and intervention effects are more pronounced.

The findings highlight the need to integrate periodontal care into routine prenatal care protocols. Obstetricians and midwives should conduct routine oral health assessments and educate pregnant women about periodontal disease risks and preventive strategies.[16] Periodontal therapy, particularly in early pregnancy, should be prioritized, especially for high-risk populations. Combining mechanical debridement with patient education and noninvasive therapies can optimize outcomes.[13] Policymakers should expand dental coverage for pregnant women, focusing on underserved regions where the burden of periodontal disease is disproportionately high.[2] Programs providing affordable or free oral health services could significantly improve maternal and neonatal health outcomes.

 

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Limitations and Future Directions

This study has several limitations that should inform future research.

Small sample sizes: many included studies had limited participant numbers, reducing the statistical power and generalizability of the findings.[12]

Study design variability: differences in study methodologies, outcome definitions, and follow-up durations contribute to heterogeneity.

Long-term outcomes: few studies have evaluated the long-term impact of maternal periodontal therapy on child health, which remains a critical gap.[15] Future research should focus on large-scale multicenter RCTs to confirm the efficacy of periodontal interventions, mechanistic studies exploring inflammatory pathways linking periodontal disease and pregnancy outcomes, and evaluating the cost-effectiveness of integrating periodontal care into prenatal programs to inform public health policies.

 

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Conclusion

This study reinforces the potential role of periodontal therapy in reducing adverse pregnancy outcomes, particularly PTB, through its ability to reduce systemic inflammation. While the observed effects were not statistically significant, trends suggest a protective benefit of periodontal care, particularly in high-risk populations. Integrating oral health services into prenatal care is a promising and cost-effective strategy for improving maternal and neonatal outcomes. Further research is essential to refine intervention protocols, understand underlying mechanisms, and address barriers to care.

 

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Conflict of Interest

None declared.

• References

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Publication History

Article published online:
08 September 2025