1. Periodontal Disease and Preterm Birth GazabpreetBhandal 1st year Resident, Dept. of Periodontics

2. Outline • Pathogenesis of Periodontitis • Pathogenesis of Preterm Birth • Inter-relationship between Periodontitis and Preterm Birth • Conclusion

3. Periodontal Disease An infectious disease resulting in inflammation within the supporting tissues of the teeth, progressive attachment and bone loss and is characterized by pocket formation and/or recession of the gingiva. RISK FACTORS: • Bacterial factors • Smoking • Age • Host Response Related • Systemic ( eg: Diabetes, Pregnancy ) • Stress • Genetics * Periodontal diseases are “a specific mixed infections which cause periodontal destruction in the appropriately susceptible host” (Offenbacher 1996)

4. Bacterium involved: Microbial complexes in subgingival plaque: Socransky et al, 1998

5. Pathophysiology of the Periodontal Disease

7. CD14/TLR4/MD2 receptor complex

8. Pathogenesis

9. Low Birth Weight Preterm Birth • According to WHO, preterm birth is defined as delivery before 37 completed weeks of gestation. • Low Birth Weight is defined as weight less than 2,300gms

10. Pathophysiology of Preterm Birth

11. Chorioamnionitis • Chorioamnionitis or intraamniotic infection is an acute inflammation of the membranes and chorion of the placenta, typically due to ascending microbial infection in the setting of membrane rupture. • Overall, 1-4% of all births in the US are complicated by chorioamnionitis.

12. Routes of chorioemnionitis

13. Ascending Infection Aspiration/swallowing of the micro-organisms Immune response triggered on the amniotic sac by infection Induction of labor

14. Role of pro-inflammatory cytokines in preterm birth Infected sites (eg: Periodontium) or Placenta Pro-inflammatory cytokines (IL-1, IL-6, TNF-alpha) Stimulation of PGE2 synthesis by human placenta and chorioamnion Induction of Abortion or labor • Examination of effect of P.gingivalis on pregnant hamsters revealed elevation of PGE2 and TNF-alpha levels (Collins 1994)

15. PGE2 synthesis

16. Inter-relationship between Periodontal disease and Preterm Birth

17. Offenbacher(1996), Jeffcoat (2001), Jarjoura (2005) : Proposed that periodontal disease is a risk factor for PLBW. Scaling and Root Planing in pregnant females reduced the incidence of preterm birth (Jeffcoat 2001)

18. Negative evidences: • Davenport et al(2002), Noack et al(2004), Veltore et al (2008), Rajapakse et al(2005): No evidence for association between periodontal disease and preterm low birth weight. • Hoolbrook et al(2004), Moore et al(2005) : Reported no association between the severity of the periodontal disease and pregnancy outcome. • Buduneti et al(2005): No difference in dental and periodontal parameters between cases and controls.

19. Sources of Bias: • Variation in the definition of the periodontal disease. • Variation in the definition of the Adverse Pregnancy Outcomes (APOs) • Confounding factors (eg: socio-economic status and smoking)

20. Conclusion • There are numerous studies that support a positive association between periodontal disease and preterm birth but unfortunately trials of antibiotic treatment have not shown any significant decrease in the rate of preterm birth. • The effectiveness of antimicrobial therapy in eradicating these infections suggests that its failure to prevent preterm births is evidence that the infections alone are not causal. • Longitudinal studies are warranted to establish a stronger and causal relationship between the two.