OBJECTIVES: To determine whether periodontal disease or bacterial vaginosis (BV) diagnosed before pregnancy increase the risk for adverse pregnancy outcome. METHODS: We enrolled a total of 252 women who had discontinued contraception in order to become pregnant. The first 130 pregnant women were included in the analyses. RESULTS: Multivariate analysis showed a strong association between periodontal disease and adverse pregnancy outcome (OR 5.5, 95% confidence interval 1.4-21.2; p = 0.014), and a borderline association between BV and adverse pregnancy outcome (OR 3.2, 95% confidence interval 0.9-10.7; p = 0.061). CONCLUSION: Our study suggests that pre-pregnancy counseling should include both oral and vaginal examinations to rule out periodontal disease and BV. This may ultimately have an impact on antenatal healthcare, and decrease the risk for adverse pregnancy outcome

Asikainen, Sirkka

Kekki, Minnamaija

Kurki, Tapio

Kuusisto, Minna

Nieminen, Anja

Oittinen, Juha

Paavonen, Jorma

Pussinen, Pirkko

Vilkuna-Rautiainen, Tiina

English

PubMed

Juha Oittinen

Tapio Kurki

Minnamaija Kekki

Minna Kuusisto

Pirkko Pussinen

Tiina Vilkuna-Rautiainen

Anja Nieminen

Sirkka Asikainen

Jorma Paavonen

Directory of Open Access Journals

Infectious Diseases in Obstetrics and Gynecology

Periodontal Disease and Bacterial Vaginosis Increase the Risk for Adverse Pregnancy Outcome

Objectives.  To determine whether periodontal disease or bacterial vaginosis (BV) diagnosed before pregnancy increase the risk for adverse pregnancy outcome

Jorma  Paavonen

Sirkka  Asikainen

Anja  Nieminen

Tiina  Vilkuna-Rautiainen

Pirkko  Pussinen

Minna  Kuusisto

Minnamaija  Kekki

Tapio  Kurki

Juha  Oittinen

Objectives.To determine whether periodontal disease or bacterial vaginosis (BV) diagnosed before pregnancy increase the risk for adverse pregnancy outcome.Methods.We enrolled a total of 252 women who had discontinued contraception in order to become pregnant. The first 130 pregnant women were included in the analyses.Results.Multivariate analysis showed a strong association between periodontal disease and adverse pregnancy outcome (OR 5.5, 95% confidence interval 1.4–21.2;p= 0.014), and a borderline association between BV and adverse pregnancy outcome (OR 3.2, 95% confidence interval 0.9–10.7;p= 0.061).Conclusion.Our study suggests that pre-pregnancy counseling should include both oral and vaginal examinations to rule out periodontal disease and BV. This may ultimately have an impact on antenatal healthcare, and decrease the risk for adverse pregnancy outcome.</jats:p

Crossref

CLINICAL STUDYPeriodontal disease and bacterial vaginosis increase the risk for adversepregnancy outcomeJUHA OITTINEN1, TAPIO KURKI2, MINNAMAIJA KEKKI2, MINNA KUUSISTO2,PIRKKO PUSSINEN1, TIINA VILKUNA-RAUTIAINEN1, ANJA NIEMINEN1,SIRKKA ASIKAINEN3, & JORMA PAAVONEN21Institute of Dentistry, Oral and Maxillofacial Diseases, University of Helsinki, Biomedicum Helsinki, Helsinki, Finland,2Department of Obstetrics and Gynecology, University of Helsinki, Finland, and 3Division of Oral Microbiology, Faculty ofMedicine and Odontology, Umea˚ University, Umea˚, Sweden(Received 19 January 2005; accepted 27 April 2005)AbstractObjectives. To determine whether periodontal disease or bacterial vaginosis (BV) diagnosed before pregnancy increase therisk for adverse pregnancy outcome.Methods. We enrolled a total of 252 women who had discontinued contraception in order to become pregnant. The first130 pregnant women were included in the analyses.Results. Multivariate analysis showed a strong association between periodontal disease and adverse pregnancy outcome(OR 5.5, 95% confidence interval 1.4–21.2; p=0.014), and a borderline association between BV and adverse pregnancyoutcome (OR 3.2, 95% confidence interval 0.9–10.7; p=0.061).Conclusion. Our study suggests that pre-pregnancy counseling should include both oral and vaginal examinations to ruleout periodontal disease and BV. This may ultimately have an impact on antenatal healthcare, and decrease the risk foradverse pregnancy outcome.Keywords: Periodontal disease, bacterial vaginosis, adverse pregnancy outcomeIntroductionKnown risk factors for preterm delivery includeprevious preterm birth, multiple births, low socio-economic status, low education, low maternalweight, smoking, alcohol consumption [1,2], andspecific genitourinary tract infections [3]. However,attempts to reduce the rate of preterm deliverybased on risk scoring systems have largely failed[4]. Often the cause of preterm delivery remainsunknown.Maternal infections, such as periodontitis andbacterial vaginosis (BV) have been linked to anincreased risk for adverse pregnancy outcome. BVhas been consistently associated both withmiscarriageand preterm delivery [5,6]. However, interventiontrials on treatment of BV during pregnancy havelargely failed to reduce the rates of preterm birth[7,8] or only marginally reduced the rates [9,10].Recent studies have demonstrated that maternalperiodontal disease diagnosed during pregnancy alsoincreases the risk for low birth weight and prema-turity [11–16] even though contradictory results havealso been reported [17]. Furthermore, periodontaltherapy may reduce the risk for adverse pregnancyoutcome [18,19]. These observations are not un-expected since both BV and periodontal disease areassociated with high bacterial burden and increase ofpro-inflammatory cytokines and other mediators ofinflammation [19,20]. We conducted a prospectivestudy among women planning pregnancy to clarifywhether periodontal disease or BV diagnosed beforepregnancy increase the risk for adverse pregnancyoutcome.Correspondence: Jorma Paavonen, MD, University of Helsinki, Department of Obstetrics and Gynecology, Haartmaninkatu 2, 00290 Helsinki, Finland.Tel: +358 9 4 717 2807. Fax: +358 9 4 717 4902. E-mail: jorma.paavonen@hus.fiInfectious Diseases in Obstetrics and Gynecology, December 2005; 13(4): 213–216ISSN 1064-7449 print/ISSN 1098-0997 online  2005 Taylor & FrancisDOI: 10.1080/10647440500240730Material and methodsA total of 256 healthy Finnish women were enrolledby newspaper advertisements, between May 2001and July 2004. All women were Caucasian, notpregnant, menstruating regularly, had discontinuedcontraception and wanted to get pregnant. Exclusioncriteria included history of preterm delivery and useof antibiotics within the preceding 2 weeks. Thestudy protocol was approved by the Ethics Commit-tee of the Department of Obstetrics and Gynecology,University of Helsinki. Each subject signed aninformed consent. The first 130 women who becamepregnant were included in this report.The medical history was systematically collected.Oral and gynecological examinations were per-formed before pregnancy. The investigator (J.O.)performing oral examinations was blinded to theresults obtained by gynecological examinations.Oral examination included recording the presenceof caries lesions extending to dentin, and thepresence of periodontal disease (periodontal pocketdepth, gingival bleeding on probing, probingattachment loss at six sites per tooth). Periodontaldisease was diagnosed when at least one approximalperiodontal pocket was 54 mm and attachmentloss 51 mm.Gynecological speculum examination was per-formed before pregnancy and again during the firsttrimester (between 6 and 8 weeks of gestation), andtwice during the third trimester (between 28 and 32weeks of gestation). A vaginal swab was taken andGram-stained for the diagnosis of BV [7]. Thediagnosis of BV was based on validated Nugent’scriteria [21]. Miscarriage was defined as pregnancyloss before 22 weeks of gestation. Preterm deliverywas defined as birth before 37 weeks of gestation.The statistical significance of differences in fre-quency distributions between groups was tested bythe Chi-square test and the Fisher’s exact test; meansof continuous variables by the Mann–WhitneyU-test. Logarithmic transformation was used forskewed data. Univariate analyses and multivariatelogistic regression analyses were performed. Ap-value less than 0.05 was considered significant.ResultsThe 130 women who became pregnant did notdiffer from the total group of 256 women regardingdemographic variables or findings on oral andgynecological examinations. A total of 26 (20%)women had an adverse pregnancy outcome, inclu-ding 17 women with miscarriage and nine womenwith preterm birth. The mean gestational age in casesof preterm delivery was 34 weeks (range 30–36weeks). Women with or without adverse pregnancyoutcome did not differ by age, socioeconomic status,smoking, or general health problems (data notshown). Periodontal disease (defined as at least oneinflamed periodontal pocket 54 mm with period-ontal attachment loss51 mm)was found in 15 (12%)women. BV was found in 21 (16%) women. Byunivariate analyses, periodontal disease (p=0.012)and BV (p=0.014) were the only variables signifi-cantly associated with adverse pregnancy outcome(data not shown). Multivariate analyses showed thatperiodontal disease was significantly associatedwith adverse pregnancy outcome (OR 5.5, 95% CI1.4–21.2, p=0.014) (Table I). BV showed a border-line association with adverse pregnancy outcome (OR3.2, 95% CI 0.9–10.7, p=0.061). Of the five womenwith bothperiodontal disease andBV, threedevelopedadverse pregnancy outcome (OR 13.1, 95% CI 1.9–135,1, p=0.031).DiscussionWe showed that periodontal disease diagnosed priorto pregnancy was an independent predictor ofadverse pregnancy outcome. Thus, the results ofour prospective study emphasize the role of chronicperiodontal disease as a new risk factor for adversepregnancy outcome. Previous studies have alsosuggested an association between periodontal diseaseand preterm delivery [11–16], as well as demonstra-ting a reduced rate of preterm birth after periodontaltherapy [11,12]. Many earlier studies have shown astrong link between BV and miscarriage or pretermbirth [18,19].The mechanisms by which periodontal diseasemay cause pregnancy loss or preterm birth remainspeculative. Increased bacterial burden or qualitativechange of the microbial flora in inflamed periodontalpockets may lead to hematogenous spread ofmicroorganisms, their components, or proinflamma-tory mediators [19]. In some women this may thencause decidual infection or inflammation leading toadverse pregnancy outcome.BV is known to cause subclinical endometritis ordeciduitis with ascension of virulent BV-associatedpathogens to the upper genital tract [3]. In this study,BV was also associated with adverse pregnancyoutcome by univariate analyses. However, themost striking finding was that by multivariateanalyses this association was only of borderlinesignificance.The strength of our study was that it wasprospective. None of the previous case-control orcohort studies of the risk factors or risk markers forpreterm birth have simultaneously analysed the roleof periodontal disease and BV.Our preliminary data suggest that BV may furtherincrease the risk for adverse pregnancy outcome214 J. Oittinen et al.among women with periodontal disease. Thus,periodontal disease and BV may have additiveeffects. However, the total number of true endpointsin our study is still relatively low.One of the key questions clearly is to sort out thelink between periodontal disease and BV. Prelimin-ary data from our study suggest that BV andperiodontal disease are interrelated [22]. Womenwith BV may be more likely to practice receptive oralsex which may in turn predispose them to period-ontal disease. Alternatively, male partners withperiodontal disease may predispose women to BVor periodontal disease, or both [23]. Larger studiesare needed to explore this.In Finland, routine dental examination has beenrecommended to all pregnant women, although notall women seek dental care. Our results, if con-firmed, would suggest that pre-pregnancy counselingshould include both oral and vaginal examinations torule out periodontal disease and BV. This mayultimately have a major impact on antenatal health-care, and may be a new intervention to decrease therisk for unexplained or idiopathic adverse pregnancyoutcome.Table I. Multivariate analysis of risk factors for adverse pregnancy outcome in women planning pregnancy.Variable N (%) OR (95% CI) p-ValuePeriodontal breakdown*No 115 (88) 1.0 (reference group)Yes 15 (12) 5.5 (1.4–21.2) 0.014Bacterial vaginosisNo 109 (84) 1.0 (reference group)Yes 21 (16) 3.2 (0.9–10.7) 0.061Social classyI–II 36 (28) 1.0 (reference group)III–IV 94 (72) 0.3 (0.1–1.2) 0.086ParousYes 75 (58) 1.0 (reference group)No 55 (42) 0.4 (0.1–1.2) 0.087History of induced abortionNo 117 (90) 1.0 (reference group)Yes 13 (10) 3.0 (0.6–15.8) 0.202Continuous medicationNo 106 (82) 1.0 (reference group)Yes 24 (18) 1.7 (0.4–6.5) 0.446Antimicrobial treatmentzNo 78 (60) 1.0 (reference group)Yes 52 (40) 0.7 (0.2–2.1) 0.494SmokerNo 113 (87) 1.0 (reference group)Yes 17 (13) 0.6 (0.1–3.0) 0.549General health problemsNo 122 (94) 1.0 (reference group)Yes 8 (6) 1.6 (0.2–11.7) 0.638AllergyNo 108 (83) 1.0 (reference group)Yes 22 (17) 1.3 (0.4–4.7) 0.711Treatment for infertilityNo 124 (95) 1.0 (reference group)Yes 6 (5) 1.3 (0.1–14.1) 0.823Age (increase per year) 130 (100.0) 1.0 (0.9–1.1) 0.825Any gynecological infectionNo 76 (59) 1.0 (reference group)Yes 54 (41) 1.1 (0.4–3.1) 0.883History of miscarriageNo 95 (73) 1.0 (reference group)Yes 35 (27) 1.1 (0.3–3.6) 0.928Caries diseaseNo 101 (78) 1.0 (reference group)Yes 29 (22) 1.0 (0.3–3.4) 0.997*Periodontal attachment loss in inflamed periodontal pockets. ySocial class divided into two categories according to the woman’s profession(Low=non-skilled laborer or skilled laborer; High=non-academic white-collar or academic profession). zNo microbial treatment withinpreceding 2 weeks.Periodontal disease, bacterial vaginosis, and adverse pregnancy outcome 215AcknowledgmentsThis study was supported by research grants fromthe Helsinki University Research Funds (TYH 2239,TYH 4261, T1030A0029, T1030A0050), Umea˚University Research Funds, Paulon Sa¨a¨tio¨, andThe Finnish Dental Society Apollonia. The sponsorsof the study had no role in study design, datacollection, data analysis, data interpretation, or in thewriting of this report.References1. Kramer MS, Seguin L, Lydon J, Goulet L. Socio-economicdisparities in pregnancy outcome: why do the poor fare sopoorly? Paediat Perinat Epidemiol 2000;14:194–210.2. Slattery MM, Morrison JJ. Preterm delivery. Lancet2002;360:1489–1497.3. Goldenberg RL, Hauth JC, Andrews WW. Intrauterineinfection and preterm delivery. N Engl J Med 2000;342:1500–1507.4. Mercer B, Goldenberg R, Das A, Moawad A, Iams J, Meis P,Copper R, Jol F, Thom E, McNellis D. The preterm predic-tion study: a clinical risk assessment system. Am J ObstetGynecol 1996;174:1885–1895.5. Oakeshott P, Hay P, Hay S, Steinke F, Rink E, Kerry S.Association between bacterial vaginosis or chlamydial infec-tion and miscarriage before 16 weeks’ gestation: prospectivecommunity based cohort study. BMJ 2002;325:1334–1338.6. Leitich H, Bodner-Adler B, Brunbauer M, Kaider A, EgarterC, Husslein P. Bacterial vaginosis as a risk factor for pretermdelivery: A meta-analysis. Am J Obstet Gynecol 2003;189:139–147.7. Kekki M, Kurki T, Pelkonen J, Kurkinen-Ra¨ty M, CacciatoreB, Paavonen J. Vaginal clindamycin in preventing pretermbirth and peripartal infections in asymptomatic women withbacterial vaginosis: a randomized, controlled trial. ObstetGynecol 2001;97:643–648.8. Carey JC, Klebanoff MA, Hauth JC, Hillier SL, Thom EA,Ernest JM, Heine RP, Nugent RP, Fischer ML, Leveno KJ,et al. Metronidazole to prevent preterm delivery in pregnantwomen with asymptomatic bacterial vaginosis. N Engl J Med2000;342:534–540.9. Ugwumadu A, Manyonda I, Reid F, Hay P. Effect of earlyoral clindamycin on late miscarriage and preterm delivery inasymptomatic women with abnormal vaginal flora andbacterial vaginosis: a randomized controlled trial. Lancet2003;361:983–988.10. Kiss H, Petricevic L, Husslein P. Prospective randomizedcontrolled trial of an infection screening programme to reducethe rate of preterm delivery. BMJ 2004;329:371–374.11. Offenbacher S, Katz V, Fertig G, Collins J, Boyd D, MaynorG, McKaig R, Beck J. Periodontal infection as a possible riskfactor for preterm low birth weight. J Periodontol 1996;7:1103–1113.12. Offenbacher S, Javed HL, O’Reilly PG, Wells SR, Salvi GE,Lawrence HP, Socransky SS, Beck JD. Potential pathogenicmechanism of periodontitis-associated pregnancy complica-tions. Ann Periodontol 1998;3:233–250.13. Offenbacher S, Lieff S, Boggess K, Murtha AP, MadianosPN, Champagne CM, McKaig RG, Jared HL, Mauriello SM,Hauten RL, et al. Maternal periodontitis and prematurity.Part I: Obstetric outcome of prematurity and growthrestriction. Ann Periodontol 2001;6:164–174.14. Madianos PN, Lieff S, Murtha KA, Boggess KA, Auten RL,Beck JD, Offenbacher S. Maternal periodontitis and pre-maturity. Part II: Maternal infection and fetal exposure. AnnPeriodontol 2001;6:175–182.15. Jeffcoat MK, Geurs RC, Reddy MS, Goldenburg RL, HauthJC. Current evidence regarding periodontal disease as a riskfactor in preterm birth. Ann Periodontol 2001;6:183–188.16. Collins J, Windley III H, Arnold R, Offenbacher S. Effects ofa Porphyromonas gingivalis infection on inflammatory mediatorresponse and pregnancy outcome in hamsters. Infect Immun1994;62:4356–4361.17. Davenport ES, Williams CE, Sterne JA, Murad JS,Sivapathasundram V, Curtis MA. Maternal periodontal diseaseand preterm low birthweight: Case-control study. J Dent Res2002;81:313–318.18. Jeffcoat MK, Hauth JC, Geurs NC, Reddy MS, Cliver SP,Hodgkins PM, Goldenburg RL. Periodontal disease and pretermbirth: Results of a pilot intervention study. J Periodontol 2003;74:1214–1218.19. Lopez N, Smith P, Gutierrez J. Periodontal therapy mayreduce the risk of preterm low birth weight in women withperiodontal disease: a randomized controlled trial. J Period-ontol 2002;73:911–924.20. Andrews WW. Cervicovaginal cytokines, vaginal infection,and preterm birth. Am J Obstet Gynecol 2004;190:1179.21. Nugent RP, Krohn MA, Hillier SL. Reliability of diagnosingbacterial vaginosis is improved by a standardized method ofGram stain interpretation. J Clin Microbiol 1991;29:297–301.22. Oittinen J, Kurki T, Pussinen PJ, Vilkuna-Rautiainen T,Kekki M, Kuusisto M, Nieminen A, Paavonen J, Asikainen S.Periodontitis before pregnancy increases the risk for adversepregnancy outcome. IADR 81st General Session in Goteborg,Sweden, 2003. J Dent Res 2003;82(Special Issue B):0125.23. Saarela M, von Troil-Linden B, Torkko H, Stucki AM,Alaluusua S, Jousimies-Somer H, Asikainen S. Transmissionof oral bacterial species between spouses. Oral MicrobiolImmunol 1993;8:349–354.216 J. Oittinen et al.Submit your manuscripts athttp://www.hindawi.comStem CellsInternationalHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Hindawi Publishing Corporationhttp://www.hindawi.com Volume 2014MEDIATORSINFLAMMATIONofHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Behavioural NeurologyEndocrinologyInternational Journal ofHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Hindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Disease MarkersHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014BioMed Research InternationalOncologyJournal ofHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Hindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Oxidative Medicine and Cellular LongevityHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014PPAR ResearchThe Scientific World JournalHindawi Publishing Corporation http://www.hindawi.com Volume 2014Immunology ResearchHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Journal ofObesityJournal ofHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Hindawi Publishing Corporationhttp://www.hindawi.com Volume 2014 Computational and  Mathematical Methods in MedicineOphthalmologyJournal ofHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Diabetes ResearchJournal ofHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Hindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Research and TreatmentAIDSHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Gastroenterology Research and PracticeHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Parkinson’s DiseaseEvidence-Based Complementary and Alternative MedicineVolume 2014Hindawi Publishing Corporationhttp://www.hindawi.com

Association between bacterial vaginosis or chlamydial infection and miscarriage before 16 weeks’ gestation: prospective community based cohort study.

Bacterial vaginosis as a risk factor for preterm delivery: A meta-analysis.

Cervicovaginal cytokines, vaginal infection, and preterm birth.

Current evidence regarding periodontal disease as a risk factor in preterm birth. Ann Periodontol

Effect of early oral clindamycin on late miscarriage and preterm delivery in asymptomatic women with abnormal vaginal ﬂora and bacterial vaginosis: a randomized controlled trial. Lancet

Effects of a Porphyromonas gingivalis infection on inﬂammatory mediator response and pregnancy outcome in hamsters. Infect Immun

Intrauterine infection and preterm delivery.

Maternal periodontal disease and preterm low birthweight: Case-control study.

Maternal periodontitis and prematurity. Part I: Obstetric outcome of prematurity and growth restriction. Ann Periodontol

Maternal periodontitis and prematurity. Part II: Maternal infection and fetal exposure.

Metronidazole to prevent preterm delivery in pregnant women with asymptomatic bacterial vaginosis.

Periodontal disease and preterm birth: Results of a pilot intervention study.

Periodontal infection as a possible risk factor for preterm low birth weight.

Periodontal therapy may reduce the risk of preterm low birth weight in women with periodontal disease: a randomized controlled trial.

Periodontitis before pregnancy increases the risk for adverse pregnancy outcome.

Potential pathogenic mechanism of periodontitis-associated pregnancy complications. Ann Periodontol

Prospective randomized controlled trial of an infection screening programme to reduce the rate of preterm delivery.

Reliability of diagnosing bacterial vaginosis is improved by a standardized method of Gram stain interpretation.

Socio-economic disparities in pregnancy outcome: why do the poor fare so poorly? Paediat Perinat Epidemiol

The preterm prediction study: a clinical risk assessment system.

Transmission of oral bacterial species between spouses. Oral Microbiol Immunol 1993;8:349–354.

Vaginal clindamycin in preventing preterm birth and peripartal infections in asymptomatic women with bacterial vaginosis: a randomized, controlled trial. Obstet Gynecol

http://downloads.hindawi.com/journals/idog/2005/642939.pdf

Periodontal disease and bacterial vaginosis increase the risk for adverse pregnancy outcome.

Periodontal disease and bacterial vaginosis increase the risk for adverse pregnancy outcome.

Abstract

Similar works

Full text

Available Versions

Directory of Open Access Journals

Directory of Open Access Journals

Crossref