| Abstract|| |
Introduction: The oral microbiome is influenced by numerous immediate environmental factors including pH, anaerobic conditions, nutrition, and hormone levels. During pregnancy, due to the associated hormonal changes, periodontal tissues show an enhanced inflammatory response to plaque microbiome. This is mediated by female sex hormones that are drastically altered in pregnancy. This study was undertaken to estimate the association of birth weight and the influence of the oral periodontal health in pregnant women in Chennai, South India and correlate the same with education and body mass index (BMI). Methods: This was a controlled, minimal interventional, prospective, observational study to identify the relationship of gingival health in the first trimester of pregnancy and on birth weight. Potential participants were referred by health-care providers. Pregnant women (≥18 years and ≤25 years) in the first trimester were enrolled for this study. Results: Of the 165 pregnant women, 121 pregnant women formed the study group. Conclusion: It was found that low birth weight could be a consequence of several modifiable and non-modifiable factors. This study shows the association of oral health of the mother in the first trimester with low birth weight. The findings of this study need to be confirmed with a large-scale, multi-centric study accounting for all known confounders. Till such a study is performed, the need for optimal oral health of an expectant mother cannot be discounted and there is no absolute harm in having good oral hygiene.
Keywords: First trimester, low birth weight, Periodontal disease
|How to cite this article:|
Rani Balaji VC, Saraswathi K, Manikandan S. Periodontal heath in first trimester of pregnancy and birth weight outcomes. Indian J Dent Res 2021;32:181-6
|How to cite this URL:|
Rani Balaji VC, Saraswathi K, Manikandan S. Periodontal heath in first trimester of pregnancy and birth weight outcomes. Indian J Dent Res [serial online] 2021 [cited 2021 Dec 8];32:181-6. Available from: https://www.ijdr.in/text.asp?2021/32/2/181/330934
| Background|| |
The oral microbiome is influenced by numerous immediate environmental factors including pH, anaerobic conditions, nutrition, and hormone levels. During pregnancy, due to the associated hormonal changes, periodontal tissues show an enhanced inflammatory response to plaque microbiome. This is mediated by female sex hormones, which are drastically altered in pregnancy. Periodontal pathogens, such as Prevotella intermedia, Porphyromonas gingivalis, Treponema forsythia, Campylobacter rectus, Fusobacterium nucleatum, Treponema denticola, Campylobacter rectus egatibacter actinomycetemcomitans, are reported to increase in oral cavity of pregnant patients, especially who neglect their oral health and have frequent gingival bleeding.
Both direct and indirect mechanisms are the route through which the oral microorganisms cause adverse pregnancy outcomes. In direct mechanism, the pathogens or their components invade the foetal-placenta unit via haematogenous dissemination or in an ascending route via the genitourinary tract directly causing the anomaly. In indirect mechanisms, the inflammatory mediators locally produced in periodontal tissues, subsequent to oral microbial infection, affect the foetal-placental unit, or circulating to the liver and increasing the systemic inflammation state through protein responses, such as C-reactive protein, which would later impact the foetal-placental unit. Irrespective of the modality, the foetal-placental unit is influenced by the oral health and when it crosses a threshold, there is adverse birth outcome including preterm, low birth weight and host of other health issues to the foetus-child including growth restriction. There have been several aspects of these studied and reported in both dental and gynaecologic literature.,,,,,,,,,,, However, not much Indian data are available on this vital and important aspect, given the fact that India is one of the most populous countries. Superimposed is the awareness of the gynaecologists for the need to maintain oral hygiene during pregnancy and their subsequent referral pattern. An Indian study identified that the studied gynaecologists were aware of the facts about association of oral/periodontal health-pregnancy outcome. But they failed to execute at the clinical level.
This study was undertaken to estimate the association of birth weight and the influence of the oral periodontal health in general population in Chennai, South India and correlate the same with education and body mass index (BMI).
| Materials and Methods|| |
This was a controlled, minimal interventional, prospective, observational study to identify the relationship of gingival health in the first trimester of pregnancy and on birth weight. The institutional review board approved the study as it is non-interventional and all participants provided written informed consent.
We enrolled consecutive prima gravidum patients at Sree Balaji Medical College and Hospital, between September 2019 and September 2020. Potential participants were referred by health-care providers. Pregnant women (≥18 years and ≤25 years) in first trimester were enrolled for this study and study was undertaken with all COVID precautions. Smokers, alcohol users, those with known systemic diseases, severe anaemia and those who developed gestational diabetic were excluded from the study. If during the course of study, they develop these excluded conditions, they were excluded from the study. Women with fewer than 20 natural teeth, presence of clinically established periodontal disease were excluded from the disease [Figure 1]. Women were also ineligible if they had multiple foetuses, required antibiotic prophylaxis for periodontal procedures, have a medical condition that precluded elective dental treatment, had extensive tooth decay, or were likely to have fewer than 20 teeth after initial treatment.
|Figure 1: Spectrum of Periodontal condition observed in first trimester of pregnancy (not necessarily included in the study group)|
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They underwent screenings for periodontal status and clinical attachment loss (CAL, in millimetres). The whole-mouth average gingival index, fraction of sites bleeding on probing, whole-mouth average pocket depth, whole-mouth average CAL, whole-mouth average calculus index and whole-mouth average plaque index as described earlier. Based on the same, if required, they were referred to the hospital dental unit for managing their dental status. If any aggressive dental intervention were planned, the patient was subsequently not enrolled in the analysis. All participants also received instruction in oral hygiene after a brief oral examination at monthly follow-ups. At the end of the study, those with spontaneous abortion, pre-term birth for any reason, unsuccessful pregnancy outcomes were not included for the analysis. The birth weights of the child in grams were measured.
The standardization of the dental examination techniques of the examiners was assessed at the start of the study by all authors. The same was ensured to be followed consistently. Reproducibility of gingival and periodontal examination was checked often and ensured that the average agreement for probing depth and measures of attachment loss (within 1 mm) was 98%.
From the data, age, education status (<8 years, 9-12; >12 years), BMI (<18.5 – underweight; 18.51 – 25 – healthy weight; 25.1–30.0 – overweight and above 30 – Obese), whole-mouth average gingival index, fraction of sites bleeding on probing, whole-mouth average pocket depth, whole-mouth average CAL, whole-mouth average calculus index, whole-mouth average plaque index and birth weight of the child were collected.
All data were entered and analysed using SPSS (Statistical Package for the Social Sciences for Windows, version 20.0, IBM Corp, 2011, NY) Descriptive statistics for the predictor variables and outcome variables were presented. Normality of the data distribution was checked using Shapiro-Wilk Test. If P ≥ 0.05, then the data were considered normal. Kruskal–Wallis test was used to assess the difference among the education and BMI with depiction of the mean ± standard deviation (SD). A bi-variate Spearman correlation was performed to assess the relationship between the birth weight and the whole-mouth average gingival index, fraction of sites bleeding on probing, whole-mouth average pocket depth, whole-mouth average CAL, whole-mouth average calculus index and whole-mouth average plaque index. P ≤ 0.05 was considered statistically significant.
| Results|| |
In all 165 pregnant patients were screened for this study of which 24 were lost to follow-up. Thirty five pregnant women did not meet the inclusion and exclusion criteria – of which 12 had severe dental problem that required aggressive dental treatment, 3 had preterm delivery, 4 developed systemic condition including gestational diabetics and two patients had spontaneous abortion in the first/second trimester. The remaining 121 pregnant women formed the study group. The outcome variables were non-normally distributed. [Table 1] [Table 2] shows the various predictor and outcome variable of the study group. [Table 3] depicts the influence of education on the various outcome parameters. None of the studied variables were significant for the education or the BMI of the patient [Table 4]. [Table 5] shows the Spearman's correlation and its significance are given. It was observed that of all the parameters studied, birth weight correlated with whole-mouth average gingival index (correlation constant ρ = –0.831, P = 0.000), fraction of sites bleeding on probing (ρ = –0.104, P = 0.255), whole-mouth average pocket depth (ρ = –0.602, P = 0.000), whole-mouth average CAL (ρ = –0.602, P = 0.000), whole-mouth average calculus index (ρ = –0.546, P = 0.000) and whole-mouth average plaque index (ρ = –0.003 P = 0.977).
|Table 2: The predictor and outcome variable of the study population (n=121)|
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|Table 3: Study population (n=121) compared by level of education on the primary predictors and outcome variable|
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|Table 4: Study population (n=121) compared by Body mass Index on the primary predictors and outcome variable|
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|Table 5: Study population (n=121) maternal periodontal parameters in first trimester correlation by Birth weight of the baby at full term|
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Pregnant women with poor periodontal health results in 7.5 fold increased risk of low birth weight (LBW) Risk of having a LBW infant in mothers with periodontal disease was 2.83 times as compared with mothers without the disease.
| Discussion|| |
The role of oral health in contributing to overall health is being increasingly reported. It is now known that the oral health is a major determinant for general well-being and this in Asian perspective has more medical ramification, as it houses significant percentage of global population in India and China., Of all the systemic conditions, influence of maternal oral health during pregnancy on the childbirth weight has been deeply divided. There are certain sections of literature to show the intimate relationship while there are literary evidence available to refute the same.,,,,,,,,,,,,, However, in spite of the contradictory evidence, having an optimal oral health does have its own benefits though at certain researches, it fails to reach statistically significant influence. Most of the studies have concentrated on the adverse pregnancy outcomes such as pre-term labour, low birth weight and others. The maternal oral health in these studies is often considered after 21 weeks and nearly the role of the oral health in the first trimester is literally unknown. The study design of several research projects could not accommodate the rigorous requirement of ethicality of studying maternal-foetal outcomes when poor oral health is identified and left untreated for about 20 weeks. In this aspect, this study design is unique as it correlates the range of optimal, population-level oral health parameters to birth weight of the child. The design also selectively eliminates conditions that could jeopardize the birth weight of the child. In addition, the role of the BMI is also accounted and its correlation studied to observe the association of oral health and birth weight. With the selective inclusion and exclusion criteria, in this study we were able to show that the oral health among this study population was not normally distributed, indicating that oral health does not follow the traditional “bell curve” distribution. Hence we have employed statistics to suit these outcomes.
There are many factors that have been associated with low birth weight babies. Certain pregnancy outcomes were reported to be associated with inadequate maternal gestational weight gain, parity, higher diastolic blood pressure, maternal education, multiple birth, smoking, alcohol consumption, gestational nutrition, caloric expenditure, prenatal care, vitamins, diabetes, maternal age, and infections. While a few can be modified some cannot be modified. Controlling modifiable factors such as alcohol/tobacco usage and infections can bring about better outcomes. This study was to control one such modifiable factor – oral health.
The distribution of education and BMI as compared in the study population, for the predictor and outcome variable indicated that none of these parameters were statistically being influenced. This is in agreement with previous findings where in this part of the world, the awareness levels of the need of optimal oral health among the pregnant women regarding this pregnancy outcome–poor oral health association were low. Hence the role of education and BMI as an influencing factor can be safely ruled out.
The childbirth weight was not correlated to mother's BMI. This finding is in concordance with earlier reports. The identified oral health indicator's association with child birth weight has not been previously described. The health of the gingiva was inversely correlated to birth weight (ρ = –0.831, P = 0.000). This correlation was significant finding which was not reported in the literature. On the contrary, the number of sites that were bleeding on probing were not significant (ρ = –0.104, P = 0.255). This indicates, the intensity of oral health is important rather than the number of infected sites. This observation, without statistical significance has been reported earlier. Similarly, the other indicators of optimal oral health, VIZ., whole-mouth average pocket depth (ρ = –0.602, P = 0.000), whole-mouth average CAL (ρ = –0.602, P = 0.000) and whole-mouth average calculus index (ρ = –0.546, P = 0.000) were statistically significant. These results indicate that inverse relationship between the oral health of the pregnant mother in the first trimester is important. As this study is first of its kind, in this part of the world, there is no literature to support or refute the findings. However, the absence of a significant correlation of whole-mouth average plaque index (ρ = –0.003 P = 0.977), which is a dynamic entity is not significant, which is in concordance with earlier reports.
The current literature evidence reflects that infectious aetiology as one of the main cause for a large percentage of cases for low and preterm birth.,, The most common infectious causes are genitourinary tract infections, such as bacterial vaginosis, and inflammatory mediators resulting from such infections have been considered a biologically plausible pathway. Also, it was proposed that such low birth weight may be indirectly mediated through distant infections resulting in translocation of bacterial vesicles and lipopolysaccharide (LPS) in the systemic circulation, albeit without proof or exact mechanisms. This study when confirmed with multi-centric, large-scale trials can be considered as evidence that chronic low-grade infectious challenge in the first trimester also can have long-lasting effect on the rapidly developing foetus. Till such a concrete evidence emerges and confirmation studies performed, the necessity to maintain optimal oral hygiene in the first trimester of pregnancy cannot be ignored.
Strength and limitation
This study sample was nearly homogenous from a single centre. All had received oral health education and evaluation. As an observational study, this study does not have a control group and causality cannot be determined as a result. However, studies of pregnant women, a vulnerable population, have ethical considerations in research and observational studies provide much-needed knowledge concerning pregnancy outcomes. This study is semi-ecological in that the women were from the same culture, same geographical area, and same race/ethnicity. Having a homogeneous group is a benefit in understanding the specific group, but the results may not be generalizable to other populations. The oral health and pregnancy outcomes are multi-factorial in nature and the sample size may not be sufficient to capture the significance and role of every plausible factor.
| Conclusion|| |
Low birth weight could be a consequence of several modifiable and non-modifiable factors. This study shows the association of oral health of the mother in the first trimester with low birth weight. The findings of this study need to be confirmed with a large-scale, multi-centric study accounting for all known confounders. Till such a study is performed, the need for optimal oral health of an expectant mother cannot be discounted and there is no absolute harm in having good oral hygiene.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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Dr. Varsha Christy Rani Balaji
Department of Obstetrics and Gynecology, Sree Balaji Medical College and Hospital, Chrompet, Chennai - 600 044, Tamil Nadu
Source of Support: None, Conflict of Interest: None
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]