Patterns of periodontal disease progression based on linear mixed models of clinical attachment loss.

AIM: The goal of the present longitudinal cohort study was to examine patterns of periodontal disease progression at progressing sites and subjects defined based on linear mixed models (LMM) of clinical attachment loss (CAL). MATERIALS AND METHODS: A total of 113 periodontally healthy and 302 periodontitis subjects had their CAL calculated bimonthly for 12 months. LMMs were fitted for each site and the predicted CAL levels used to categorize their progression state. Participants were grouped based on the number of progressing sites into unchanged, transitional and active subjects. Patterns of periodontal disease progression were explored using descriptive statistics. RESULTS: Progression occurred primarily at molars (50% of progressing sites) and inter-proximal sites (72%), affected a higher proportion of deep than shallow sites (2.7% versus 0.7%), and pocketing was the main mode of progression (49%). We found a low level of agreement (47%) between the LMM and traditional approaches to determine progression such as change in CAL ≥3 mm. Fourteen per cent of subjects were classified as active and among those 93% had periodontitis. The annual mean rate of progression for the active subjects was 0.35 mm/year. CONCLUSION: Progressing sites and subjects defined based on LMMs presented patterns of disease progression similar to those previously reported in the literature.

Modelling changes in clinical attachment loss to classify periodontal disease progression.

AIM: The goal of this study was to identify progressing periodontal sites by applying linear mixed models (LMM) to longitudinal measurements of clinical attachment loss (CAL). METHODS: Ninety-three periodontally healthy and 236 periodontitis subjects had their CAL measured bi-monthly for 12 months. The proportions of sites demonstrating increases in CAL from baseline above specified thresholds were calculated for each visit. The proportions of sites reversing from the progressing state were also computed. LMM were fitted for each tooth site and the predicted CAL levels used to categorize sites regarding progression or regression. The threshold for progression was established based on the model-estimated error in predictions. RESULTS: Over 12 months, 21.2%, 2.8% and 0.3% of sites progressed, according to thresholds of 1, 2 and 3 mm of CAL increase. However, on average, 42.0%, 64.4% and 77.7% of progressing sites for the different thresholds reversed in subsequent visits. Conversely, 97.1%, 76.9% and 23.1% of sites classified as progressing using LMM had observed CAL increases above 1, 2 and 3 mm after 12 months, whereas mean rates of reversal were 10.6%, 30.2% and 53.0% respectively. CONCLUSION: LMM accounted for several sources of error in longitudinal CAL measurement, providing an improved method for classifying progressing sites.

Nurse practitioner's and certified nurse midwives' knowledge, opinions and practice behaviors regarding periodontal disease and adverse pregnancy outcomes.

PURPOSE: The purpose of this study was to assess the knowledge, opinions and practice behaviors of nurse practitioners (NP) and certified nurse midwives (CNM) regarding periodontal disease and adverse pregnancy outcomes. METHODS: A 45 item survey was developed, approved, pretested, revised and mailed to 404 North Carolina NPs and CNMs who provide prenatal care. Data was entered into an excel database and transferred to SPSS for Windows for complete analysis. Linear regression modeling was used to determine statistical significance. RESULTS: A total of 219 NPs and CNMs responded to the mailed survey, achieving a response rate of 54%. NPs and CNMs reported having limited knowledge regarding oral health. The majority felt they should collaborate with oral health care professionals to screen patients for periodontal disease. Most agreed they needed more information about periodontal disease and adverse pregnancy outcomes. CONCLUSION: NPs and CNMs who frequently examine women could serve an important role in screening for oral health problems and making appropriate dental health referrals. Increased basic and continuing education could prepare these professionals for collaborative care with oral health care professionals. This study suggests that collaboration between NPs and CNMs with dental professionals could lead to improved oral health care for pregnant patients.

Effects of periodontal therapy on rate of preterm delivery: a randomized controlled trial.

OBJECTIVE: To test the effects of maternal periodontal disease treatment on the incidence of preterm birth (delivery before 37 weeks of gestation). METHODS: The Maternal Oral Therapy to Reduce Obstetric Risk Study was a randomized, treatment-masked, controlled clinical trial of pregnant women with periodontal disease who were receiving standard obstetric care. Participants were assigned to either a periodontal treatment arm, consisting of scaling and root planing early in the second trimester, or a delayed treatment arm that provided periodontal care after delivery. Pregnancy and maternal periodontal status were followed to delivery and neonatal outcomes until discharge. The primary outcome (gestational age less than 37 weeks) and the secondary outcome (gestational age less than 35 weeks) were analyzed using a chi test of equality of two proportions. RESULTS: The study randomized 1,806 patients at three performance sites and completed 1,760 evaluable patients. At baseline, there were no differences comparing the treatment and control arms for any of the periodontal or obstetric measures. The rate of preterm delivery for the treatment group was 13.1% and 11.5% for the control group (P=.316). There were no significant differences when comparing women in the treatment group with those in the control group with regard to the adverse event rate or the major obstetric and neonatal outcomes. CONCLUSION: Periodontal therapy did not reduce the incidence of preterm delivery. LEVEL OF EVIDENCE: I.

Fetal exposure to oral pathogens and subsequent risk for neonatal intensive care admission.

BACKGROUND: Maternal periodontal infection has been associated with adverse maternal and neonatal outcomes. In utero fetal exposure to oral pathogens was also recognized as deleterious to the fetus. The objective of this study was to determine the relationship between fetal exposure to oral pathogens and neonatal intensive care unit (NICU) admission. METHODS: This was a secondary analysis of a prospective cohort study of maternal oral health and pregnancy outcome. Fetal immunoglobulin M against oral pathogens was detected in umbilical cord serum by immunoblot. The presence of at least one oral pathogen-specific antibody was considered seropositivity. The cord level of C-reactive protein was determined by enzyme-linked immunosorbent assay and categorized as detectable versus undetectable. Chi-square and logistic regression analyses were used to determine the association between cord serum seropositivity or detectable C-reactive protein and NICU admission and length of stay. RESULTS: Of 650 infants, 45 (6.9%) were admitted to the NICU. The admission rate was higher among seropositive infants compared to seronegative infants (11% versus 5%; P = 0.0019). Seropositive infants were also more likely than seronegative infants to stay >3 or >7 days (8% versus 3% and 6% versus 2%; P = 0.004 and 0.003, respectively). Adjusting for gestational age, the odds ratio (95% confidence interval) for NICU admission was 2.14 (1.01 to 4.54); for a length of stay >3 or >7 days, it was 2.38 (1.01 to 5.60) and 3.29 (1.13 to 9.58), respectively. The NICU admission rate was not significantly higher for those with detectable versus undetectable umbilical cord serum C-reactive protein (8% versus 6%; P = 0.3). CONCLUSIONS: In utero fetal exposure to oral pathogens increases the risk for NICU admission and the length of stay. Interventions that interrupt fetal exposure to oral pathogens may reduce these risks.

Periodontal disease early in pregnancy is associated with maternal systemic inflammation among African American women.

BACKGROUND: Maternal periodontal disease is a chronic oral infection with local and systemic inflammatory responses and may be associated with adverse pregnancy outcomes. This study determined whether maternal periodontal disease in early pregnancy is associated with elevated serum C-reactive protein (CRP) levels and whether maternal race influences the relationship between maternal periodontal disease and systemic inflammatory responses. METHODS: A secondary analysis of prospectively collected data from the Oral Conditions and Pregnancy study was conducted. Healthy women at <26 weeks of gestation underwent an oral health examination and had blood collected. Periodontal disease was categorized by clinical criteria, and maternal serum was analyzed for CRP levels using highly sensitive enzyme-linked immunosorbent assay kits. An elevated CRP level was defined as >75th percentile. Demographic and medical data were obtained from the women's charts. Chi-square and multivariable logistic regression models were used to determine maternal factors associated with an elevated CRP. An adjusted odds ratio (OR) for elevated CRP levels was calculated and stratified by race and periodontal disease category. RESULTS: The median (interquartile) CRP level was 4.8 (0.6 to 15.7) microg/ml, and an elevated CRP level (>75th percentile) was 15.7 microg/ml. African American race and moderate/severe periodontal disease were significantly associated with elevated CRP levels. When stratified by race, moderate/severe periodontal disease remained associated with an elevated CRP level among African American women (adjusted OR: 4.0; 95% confidence interval [CI]: 1.2 to 8.5) but not among white women (adjusted OR: 0.9; 95% CI: 0.2 to 3.6) after adjusting for age, smoking, parity, marital status, insurance status, and weight. CONCLUSION: Among African American women, moderate/severe periodontal disease is associated with elevated CRP levels early in pregnancy.

Racial differences in C-reactive protein levels during normal pregnancy.

OBJECTIVE: The purpose of this study was to characterize serum C-reactive protein (CRP) levels in a diverse population of healthy pregnant women with the use of a high sensitivity assay. STUDY DESIGN: We conducted a cross-sectional analysis of a cohort of 775 pregnant women. CRP was measured on serum specimens that were drawn at < 26 weeks of gestation with highly sensitive enzyme-linked immunosorbent assay kits. RESULTS: Median CRP was 4.8 mg/L (interquartile range, 0.63-15.7). Black women had higher median CRP values than did white women (7.68 vs 2.59 mg/L; P < .001). Black women demonstrated higher levels of CRP, even after the data were controlled for known confounding factors such as smoking and maternal weight. CONCLUSION: Pregnancy is an inflammatory stressor. The cause of racial differences is unclear but may be important for understanding racial disparities in the incidence of inflammatory disorders such as preterm labor and preeclampsia.

Periodontal-systemic disease education in United States dental hygiene programs.

The relationship between periodontal disease and systemic disease has gained much attention in recent years in the dental profession and from national health care agencies. Two third-party providers are now modifying their dental reimbursements for patients who have periodontal disease and are pregnant or have cardiovascular disease. However, there are few reports in the dental or dental hygiene literature about how students are taught this information and how it is incorporated into the didactic and clinical aspects of the curriculum. A thirty-item survey and cover letter on these subjects were emailed to the directors of the 286 accredited dental hygiene programs in the United States in 2007. The response rate was 63 percent. According to these responses, the three most emphasized topics regarding oral-systemic disease are diabetes, tobacco use, and cardiovascular disease. Most programs (90 percent) use journal articles for instructional content, and 87 percent use the American Academy of Periodontology website for reference. Only 4 percent have content taught jointly with nursing, medical, or allied health students. The majority of directors (87 percent) indicated they could use more evidence-based educational materials to help teach the concepts to students. Only 9 percent of survey respondents thought that nurses and physicians are knowledgeable about the relationship of oral health to systemic disease. The findings indicate that dental hygiene program directors are confident about the education on oral-systemic content provided to their dental hygiene students, but would like additional evidence-based materials to help their students learn this topic.

Maternal periodontal disease, systemic inflammation, and risk for preeclampsia.

OBJECTIVE: Maternal periodontal disease, a chronic oral infectious and inflammatory disorder, is associated with an increased risk for preeclampsia. Our objective was to determine the relationship between maternal periodontal disease, maternal systemic inflammation, and the development of preeclampsia. STUDY DESIGN: A secondary analysis of data from the Oral Conditions and Pregnancy Study was performed. A cohort of healthy pregnant women enrolled at less than 26 weeks underwent an oral health examination, serum sampling, and delivery follow-up. Periodontal disease was categorized clinically as present or absent. Maternal serum was assayed for C-reactive protein by high-sensitivity enzyme-linked immunosorbent assay and stratified as elevated (> or = 75th percentile) or not elevated (< 75th percentile). Preeclampsia was defined as blood pressure > 140/90 mmHg and at least 1+ proteinuria on a catheterized urine specimen. Risk ratios (RR) for preeclampsia were calculated, stratified by periodontal disease and C-reactive protein level. RESULTS: Thirty-one (4%) of 775 women with complete data developed preeclampsia. Women with CRP > or = 75th percentile were more likely than those with CRP < 75th percentile to develop preeclampsia (7% vs 3%, P < .03; RR, 95% CI 2.2, 1.1-4.4). Women with periodontal disease and CRP > or = 75th percentile were at increased risk for preeclampsia (adjusted RR 5.8, 1.2-26.9), compared to women without periodontal disease and either CRP < 75th or > or = 75th percentile. CONCLUSION: Maternal periodontal disease with systemic inflammation as measured by C-reactive protein is associated with an increased risk for preeclampsia.

Obstetricians' knowledge and practice behaviors concerning periodontal health and preterm delivery and low birth weight.

INTRODUCTION: Investigators have reported that periodontal disease may be a risk factor for pregnancy complications including preterm delivery (PTD) and low birth weight (LBW). This study assessed obstetricians' knowledge and practice behaviors concerning periodontal disease and its role in adverse pregnancy outcomes. METHODS: One hundred ninety four practicing obstetricians in a 5 county area in central North Carolina were surveyed. Of the 138 eligible physicians, 55 responded yielding a 40% response rate. RESULTS: Most answered correctly when asked about the description of gingivitis (95%). A lower number of respondents were correct when asked about the description of periodontitis (67%). When asked about what causes periodontal disease or what is associated with periodontal disease, most answered correctly with bacteria (94%), although many answered tooth decay (73%), aging (69%), and excess dietary sugar (51%). Most were correct in responding that periodontitis was more serious than gingivitis (80%). Twenty-two percent looked into patients' mouths at initial prenatal examination, 9% periodically, and 48% only when a problem was mentioned by the patient. Forty-nine percent rarely or never recommended a dental examination. Most (84%) considered periodontal disease to be as important a risk factor to adverse pregnancy events as those currently known in obstetrics practice. CONCLUSIONS: Data from this study demonstrate that there is knowledge of periodontal disease and its potential role as a pregnancy risk factor but suggest limited incorporation of dental care into clinical medical practice.

The effect of periodontal therapy on TNF-alpha, IL-6 and metabolic control in type 2 diabetics.

PURPOSE: This pilot study investigated if scaling and root planing (S&RP) was an effective intervention in reducing levels of inflammatory markers TNF-alpha and IL-6 in a type 2 diabetic population. METHODS: Twenty-five patients with type 2 diabetes, 18-64 years of age were enrolled having 4 or more sites with pocket depths > or = 5mm and 2 or more sites with attachment loss > or = 3mm. Participants received S&RP following collection of gingival crevicular fluid and serum which were analyzed for TNF-alpha and IL-6. After 3 months post-treatment levels were collected. Serum pre-and post-treatment levels were analyzed using a paired t test at a significance level of p < or = 0.05. Mean TNF-alpha was 1.7 pg/ml at baseline and post-treatment was 4.0 pg/ml. Mean IL-6 was 2.8 pg/ml at baseline and post-treatment 6.0 pg/ml. RESULTS: Both mean TNF-alpha and IL-6 were increased following S&RP ; however, the observed increases were not statistically significant. While participants improved on periodontal measures following therapy, systemic measures of inflammation (TNF-alpha and IL-6) did not show the hypothesized reductions. CONCLUSION: Further studies are needed to determine effectiveness of S&RP on inflammatory mediators in a population with type 2 diabetes.

Progressive periodontal disease and risk of very preterm delivery.

OBJECTIVE: The goal was to estimate whether maternal periodontal disease was predictive of preterm (less than 37 weeks) or very preterm (less than 32 weeks) births. METHODS: A prospective study of obstetric outcomes, entitled Oral Conditions and Pregnancy (OCAP), was conducted with 1,020 pregnant women who received both an antepartum and postpartum periodontal examination. Predictive models were developed to estimate whether maternal exposure to either periodontal disease at enrollment (less than 26 weeks) and/or periodontal disease progression during pregnancy, as determined by comparing postpartum with antepartum status, were predictive of preterm or very preterm births, adjusting for risk factors including previous preterm delivery, race, smoking, social domain variables, and other infections. RESULTS: Incidence of preterm birth was 11.2% among periodontally healthy women, compared with 28.6% in women with moderate-severe periodontal disease (adjusted risk ratio [RR] 1.6, 95% confidence interval [CI] 1.1-2.3). Antepartum moderate-severe periodontal disease was associated with an increased incidence of spontaneous preterm births (15.2% versus 24.9%, adjusted RR 2.0, 95% CI 1.2-3.2). Similarly, the unadjusted rate of very preterm delivery was 6.4% among women with periodontal disease progression, significantly higher than the 1.8% rate among women without disease progression (adjusted RR 2.4, 95% CI 1.1-5.2). CONCLUSION: The OCAP study demonstrates that maternal periodontal disease increases relative risk for preterm or spontaneous preterm births. Furthermore, periodontal disease progression during pregnancy was a predictor of the more severe adverse pregnancy outcome of very preterm birth, independently of traditional obstetric, periodontal, and social domain risk factors. LEVEL OF EVIDENCE: II-2.

Clinical trial of a novel interdental brush cleaning system.

OBJECTIVE: This single-blind, five parallel-arm, four-week randomized clinical trial was designed to compare the efficacy of a 0.05% cetylpyridinium chloride gel-releasing interdental brush (IDB) with standard interproximal cleaning devices for plaque and gingivitis reduction, and decreased frequency in interproximal gingival bleeding. METHODOLOGY: After consenting, participants meeting inclusion criteria brushed their teeth, received a baseline examination and a professional cleaning, and were then block-randomized into five groups, with the plaque level serving as the blocking variable. All five groups performed standard tooth brushing as a background regimen. Three of the groups were respectively assigned to one of three interdental brush regimens, the fourth group was assigned to a standard flossing regimen (positive control), and the fifth group was assigned to a standard tooth brushing only regimen (control). Clinical outcome data were collected at two and four weeks. RESULTS: Of a total of 162 starting participants, 152 completed the study. There were no baseline differences among the five groups with respect to age, interproximal plaque score, interproximal gingivitis score, or percent of interproximal bleeding on probing. After two and four weeks, the 3 IDB groups exhibited 30-40 percent lower plaque levels than the control (p < 0.05). With respect to interproximal gingival scores, the active agent IDB group exhibited a statistically significant effect after two weeks, and all three IDB groups demonstrated significantly better outcomes after four weeks (p < 0.05). At two and four weeks, the three IDB groups demonstrated a greater reduction in interproximal bleeding points upon probing compared to the two control groups (p < 0.05). The group using the 0.05% cetylpyridinium gel-releasing IDB system did not demonstrate superior clinical results when compared to the two other IDB groups. CONCLUSION: When compared to control and positive control interdental cleaning procedures, daily use of IDBs was effective in reducing interproximal plaque and gingivitis scores, as well as interproximal bleeding on probing. The benefits were evident at two weeks, but were more consistent after four weeks. The 0.05% cetylpyridinium gel-releasing IDB system did not appear to confer a consistently independent incremental benefit.

Maternal serum C-reactive protein concentration early in pregnancy and subsequent pregnancy loss.

The purpose of this study was to determine the relationship between maternal inflammation and first or second trimester pregnancy loss. A nested case-control analysis was performed among the cohort enrolled in the Oral Conditions and Pregnancy study. We compared maternal serum C-reactive protein concentration between women with a pregnancy loss at < 21 weeks gestation to control women without gestational diabetes or preeclampsia who delivered at term. Participants were 2:1 frequency matched to cases by maternal age, race, and prior preterm birth. Median concentration of serum C-reactive protein between cases and controls was compared using Wilcoxon rank sum test. The potential effects of maternal smoking, gestational age at blood draw, and insurance status were evaluated and an adjusted odds ratio (95% confidence interval) for pregnancy loss was calculated using multivariable logistic regression. Among 1224 participants, 102 (9.8%) experienced pregnancy loss and 44 had complete information available. Median serum C-reactive protein concentration was significantly higher in controls compared with all cases (3.2 versus 0.5 microg/mL; p < 0.001). However, when stratified by gestational age at the time of the loss, median serum C-reactive protein level among controls was similar to those with a loss at less than 12 weeks (3.2 versus 2.0 microg/mL) but significantly higher compared with those whose loss occurred at greater than 12 weeks gestation (3.2 versus 0.5 microg/mL; p < 0.05). After adjusting for maternal smoking, gestational age at blood draw, and insurance status, women whose serum C-reactive protein level was greater than the 75% percentile had a decreased odds ratio for pregnancy loss (0.20; 95% confidence interval, 0.06 to 0.65). Pregnancy loss is not associated with increased systemic inflammation as measured by maternal serum C-reactive protein. Future study should be directed at determining the role of maternal inflammation during early pregnancy development and placentation.

The oral conditions and pregnancy study: periodontal status of a cohort of pregnant women.

BACKGROUND: Our objective was to describe the oral health of pregnant women, to determine oral health changes during pregnancy, and to determine factors associated with maternal periodontal health or disease. MATERIALS AND METHODS: Between December 1997 and July 2001, 1,224 pregnant women at < 26 weeks' gestation were enrolled in the study and oral health examinations were performed at enrollment and within 48 hours of delivery. Demographic, medical, and health behavior data were determined by chart abstraction and questionnaire. Comparisons between oral health at enrollment and delivery were made by student t test or Fisher's exact test. Ordinal logistic regression analysis was used to identify risk factors for maternal periodontal disease. RESULTS: Among 903 women, there was a significant increase in those with health/periodontal disease absence between enrollment and delivery (P < 0.001). However, we also observed a significant increase in women with four or more sites with attachment loss > or = 2 mm or > or = 3 mm (P < 0.05, 0.001). Race, smoking, and insurance status were significantly associated with maternal periodontal disease. Black women were more likely than white women to have periodontal disease at enrollment (adj. odds ratio 2.9, 95% confidence interval 2.2 to 3.9) and delivery (adj. odds ratio 3.1, 95% confidence interval 2.2 to 4.2), and experience incident disease (adj. odds ratio 2.3, 95% confidence interval 1.6 to 3.4). CONCLUSIONS: Oral health examinations were well accepted by pregnant women. An increase in attachment loss may represent active periodontal infection accelerated by pregnancy. Further study on racial disparity in oral health among pregnant women is needed. Continued efforts to evaluate and establish appropriate definitions of oral disease in pregnancy are warranted.