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Contents lists available at ScienceDirect

Women and Birth

journal homepage: www.elsevier.com/locate/wombi

Original Research – Quantitative

Oral, systemic and socioeconomic factors associated with preterm birth

Anna Clara F. Vieiraa,* , Cláudia M. Alvesa , Vandilson P. Rodriguesa , Cecília C. Ribeiroa ,
Isaac S. Gomes-Filhob , Fernanda F. Lopesa
a
Postgraduate Program in Dentistry, Dental School, Federal University of Maranhão, São Luis, MA, Brazil
b
Department of Health, Feira de Santana State University, Feira de Santana, BA, Brazil

A R T I C L E I N F O A B S T R A C T

Article history: Background: The rates of preterm births have been increasing worldwide. Complications related to
Received 5 October 2017 preterm births are associated with increased costs of care, and have a direct impact on the health system
Received in revised form 23 January 2018 of the countries. Therefore, it is important to address factors associated with preterm birth in order to
Accepted 28 February 2018
provide prevention strategies.
Available online xxx
Objective: This case–control study investigated oral, systemic, and socioeconomic factors associated with
preterm birth in postpartum women. Participants were 279 postpartum women that gave birth to a
Keywords:
singleton live-born infant. Cases were women giving birth before 37 completed weeks of gestation
Premature birth
Pregnancy complications
(preterm birth). Controls were women giving birth at term (37 weeks). Data were collected through
Dental caries questionnaires, medical records and intra-oral clinical examinations, which included dental caries
Oral health registration according to World Health Organization criteria and oral biofilm evaluation through visible
plaque index.
Results: Ninety-one women had preterm birth (cases) and 188 women had birth at term (controls), ratio
1:2. Caries lesions were present in 62.3% of the cases and in 62.5% of the controls. The univariate analysis
showed no association between dental caries and preterm birth (Odds Ratio = 1.08, p = 0.90). The
multivariate analysis showed that maternal educational level (Odds Ratio = 2.56, p = 0.01) and arterial
hypertension (Odds Ratio = 2.32, p = 0.01) were associated with prematurity.
Conclusion: This study demonstrated that dental caries is frequent in postpartum women, but it does not
appear to be associated with preterm birth. Meanwhile, maternal education level and arterial
hypertension were associated with prematurity in this population.
© 2018 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.

few studies have evaluated the relationship between caries

Statement of significance and preterm birth.

What this paper adds

Problem
Dental caries may not be associated with preterm birth, but it
Preterm birth rates are increasing in almost all countries, so appears to be associated with maternal education level and
the factors associated with premature births need to be arterial hypertension. Despite evidence of no association
investigated. between dental caries and preterm birth, this study calls
attention for the high rates of dental caries in pregnant
What is already known women and also shows the important role of midwives to
increase oral awareness during pregnancy.
Oral diseases have been associated with adverse pregnancy
outcomes. Periodontal disease has been linked to preterm
birth and it may be a potential independent risk factor. Only a
1. Introduction

* Corresponding author at: Avenida dos Portugueses, Campus do Bacanga s/n,
CEP: 65085-580, Prédio de Odontologia, Programa de Pós-Graduação, São Luís, MA,
Brazil.
E-mail address: annaclara@ifpi.edu.br (A.C.F. Vieira).
Dental caries, which result from the metabolism of bacteria
present in the oral biofilm,1 may be exacerbated in pregnant
women.2–4 A recent survey with pregnant women carried out in

https://doi.org/10.1016/j.wombi.2018.02.007
1871-5192/© 2018 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.

Please cite this article in press as: A.C.F. Vieira, et al., Oral, systemic and socioeconomic factors associated with preterm birth, Women Birth
(2018), https://doi.org/10.1016/j.wombi.2018.02.007
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Brazil showed a 70% prevalence of caries, with a mean of
11.84  6.54 in Decayed, Missing or Filled Teeth Index (DMFT),
demonstrating the high rate of the disease in the referred group.4
Oral diseases have been associated with adverse pregnancy
outcomes. The possible association between oral diseases and
premature birth is based on the possibility that a subclinical but
persistent oral infection causes the induction of a systemic
inflammatory response. The production of systemic pro-inflam-
matory mediators could, in turn, promote mechanisms that initiate
labor prematurely.5,6 Indeed, oral streptococcal species were found
in the amniotic fluid and in dental plaque of pregnant women,
suggesting that the Streptococcus spp. found in the amniotic fluid
may have an oral origin.7
The rates of preterm births, considered those occurring before
37 weeks of gestation, have been increasing worldwide.8 Compli-
cations related to preterm birth include infant morbidity and
mortality, increased costs of care, and have a direct impact on the
health system of the countries.9
Common risk factors for prematurity include: maternal age
(<17 and >34 years), multiple pregnancy, genetic predisposition,
socioeconomic status, alcohol, smoking, low maternal weight gain,
infections and chronic conditions such as diabetes, high blood
pressure and periodontal disease.6,9,10 In some cases, however,
prematurity occurs without any obvious cause, and therefore, a
better understanding of the mechanisms that cause preterm birth
is necessary.9 Furthermore, oral bacteria associated with carious
lesions have been identified in the intra-amniotic cavity,11 so
dental caries can be a source of either direct or systemic subclinical
infection.12
Hence, it is important to assess oral, systemic and socioeco-
nomic factors that can be associated with preterm birth. The
purpose of this study was to evaluate factors that are associated
with preterm birth in a population of postpartum women, with a
particular focus on dental caries.
2. Material and methods
For dental caries registration, teeth were considered sound if
they presented no clinical evidence of treated or untreated caries.
Crowns were recorded as decayed when a lesion in a pit or fissure,
or on a smooth tooth surface had an unmistakable cavity,
undermined enamel, or a detectably softened floor or wall
(confirmed through the use of WHO periodontal probe). Filled
teeth that had one or more areas with caries were also considered
decayed. Filled teeth without caries and missing teeth due to caries
were also recorded.14
The data collected from the women’s records were: gestational
age, current and previous gestational history and general health
data. Information about the mother’s oral health habits and access
to dental services, socioeconomic characteristics of the mother and
harmful habits were obtained through the questionnaires.
Analyses were performed by the Statistical Package for Social
Sciences (SPSS, version 17.0, USA). The outcome variable was
preterm birth and the exposure variables were sociodemographic
characterization, health status of the newborn and mother, and
variables related to dental caries and oral health of the women.
Descriptive statistics included measures of absolute frequency,
percentages, and means and standard deviation. Numeric variables
were analyzed using the independent Student t-test. Categorical
variables were compared between groups using the chi-square test
or Fisher’s exact test. The level of significance adopted was 5%
(p < 0.05).
The study was estimated to have power of at least 90% with a
minimum sample of 82 women with preterm birth (cases) and 164
with term birth (controls) to estimate statistically significant
differences in the proportion of the variables hypertension and
hospitalization during pregnancy, considering a significance level
of 5% in the two-tailed t-test.
The odds ratio (OR) and 95% confidence intervals (CIs) was used
to estimate the association of exposure variables and prematurity.
For adjusted OR, the multivariate logistic regression model
included the variables educational level, arterial hypertension
and hospital admission during pregnancy, and each association
was adjusted for the other variables included in the model.

This was a case–control study nested within the Multi-Centre 3. Results

Geravida Project. Data collection was performed at the University
Hospital of the Federal University of Maranhão (HUUFMA), in São The total sample of 279 women included 91 cases (birth before
Luís — MA, Brazil. The research was approved by the HUUFMA 37 weeks) and 188 controls (birth at 37 weeks or more), case–
Research Ethics Committee (protocol 240/11). All subjects gave controls ratio 1:2.16 Table 1 shows the distribution of the numeric
their informed consent prior to participating in the study. variables related to the newborn, and to the postpartum woman,
The study population was postpartum women recruited from
the Maternal and Child Unit of HUUFMA from October 2011 to
November 2012. Women infected by HIV and with twin pregnan- Table 1
Distribution of the numerical variables related to the newborn and the postpartum
cies were excluded. Cases were defined as women giving birth to a
women according to preterm birth (n = 279).
singleton live-born infant before 37 completed weeks of gestation
(preterm birth). Controls were women giving birth to a singleton Variables Preterm birth p-valuea
live-born infant at term (37 weeks). Yes (n = 91) No (n = 188)
A single investigator, previously trained and blind to the birth
Mean (SD) Mean (SD)
condition, conducted the intraoral clinical examination. Partic-
Newborn datab
ipants also answered a structured questionnaire, and information
Weight (g) 2.307 (713) 3.207 (569) <0.01*
from the women’s medical records were collected. Postpartum women data
The oral examination was performed in the ward where the Age 26.5 (6.6) 25.7 (6.7) 0.84
women were hospitalized and occurred within the immediate Family income (MW)c 1.8 (1.5) 1.9 (1.7) 0.68
postpartum period.13 The examination was accomplished in the BMI 23.6 (4.5) 23.7 (4.6) 0.83
Postpartum women oral health
sitting position, under ambient lighting, using a tweezer, a plane Daily tooth brushing 1.5 (0.7) 1.5 (0.6) 0.86
intraoral mirror and a World Health Organization (WHO) 621 Number of teeth 23.4 (2.9) 25.7 (2.5) 0.84
periodontal probe.14 % of decayed teeth 5.1 (6.4) 4.5 (6.5) 0.51
The oral biofilm was quantitatively examined to obtain the Visible plaque index 35.3 (23.5) 32.8 (20.9) 0.39
percentage visible plaque index (VPI) through the total number of BMI: body mass index; SD: standard deviation.
a
positive surfaces, divided by the total number of examined surfaces Student t-test.
b
and multiplied by 100.15 VPI was categorized into two levels, Measured at birth.
c
Minimum wages.
according to the median of the sample (<30% and 30%). *
Statistically significant difference (p < 0.05).

Please cite this article in press as: A.C.F. Vieira, et al., Oral, systemic and socioeconomic factors associated with preterm birth, Women Birth
(2018), https://doi.org/10.1016/j.wombi.2018.02.007
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Table 2
Univariate analysis of the association of the variables related to the postpartum women profile with preterm birth.

Variables Preterm birth OR (IC95%) p-valuea

Yes No

n (%) n (%)
Age (in years)
Less than 17 years old 6 (8.6) 10 (4.8) 1.78 (0.61–5.16) 0.28
17 to 19 years old 5 (7.1) 26 (12.4) 0.57 (0.20–1.57) 0.28
20 to 34 years old 50 (71.4) 149 (71.3) Reference
Over 34 years old 9 (12.9) 24 (11.5) 1.11 (0.48–2.56) 0.79
Skin color (self-referenced)
White 24 (34.3) 60 (28.7) Reference
Black 11 (15.7) 24 (11.5) 1.14 (0.48–2.69) 0.75
Dark-skinned 35 (50.0) 125 (59.8) 0.70 (0.38–1.28) 0.24
Socioeconomic levelb
B 4 (5.7) 8 (3.9) Reference
C 21 (30.0) 40 (19.3) 1.05 (0.28–3.89) 0.94
D 39 (55.7) 129 (62.3) 0.60 (0.17–2.11) 0.43
E 6 (8.6) 30 (14.5) 0.40 (0.09–1.76) 0.22
Education level
8 years 25 (35.7) 47 (23.0) 1.85 (1.03–3.33) 0.05*
>8 years 45 (64.3) 157 (77.0) Reference
Marital status
Without domestic partner 12 (17.4) 43 (20.6) 0.81 (0.40–1.64) 0.68
With domestic partner 57 (82.6) 166 (79.4) Reference
Tobacco use
Yes 10 (14.3) 32 (15.3) 0.92 (0.42–1.98) 0.98
No 60 (85.7) 177 (84.7) Reference
Alcohol intake
Yes 33 (47.1) 105 (50.2) 0.88 (0.51–1.51) 0.75
No 37 (52.9) 104 (49.8) Reference
a
Chi-square test or Fisher exact test.
b
To determine socioeconomic level, the Brazilian Economic Classification Criteria/2008, proposed by the Brazilian Market Research Association (accessed at: http://www.
abep.org/criterio-brasil) was used.
*
Statistically significant difference (p < 0.05).

according to the outcome variable (preterm birth). A statistically
significant difference was found between groups regarding the
mean weight of the babies (p  0.01). The oral health outcomes did
not present statistical difference between groups, with mean
percentage of decayed teeth of 5.1  6.4% in cases and of 4.5  6.5%
in controls.
Table 2 shows the univariate analysis of the association of
variables referring to the women’s profile according to the
outcome variable. Women who had 8 years of schooling were
1.85 times more likely to have preterm infants when compared to
women with >8 years of formal education (p = 0.05).
In relation to outcomes related to the current pregnancy and
previous gestational history of the mother (Table 3), maternal
hypertension (OR = 3.62, p  0.01) and hospitalization during
pregnancy (OR = 2.64, p  0.01) were associated with preterm
birth.
Table 4 shows the univariate analysis of the association of
variables related to the women’s oral health with preterm birth.
The presence of caries was identified in 62.3% of the cases and in
62.5% of the controls, showing no association with prematurity.
In the multivariate logistic regression analysis (Table 5),
educational level (OR = 2.56, p = 0.01) and hypertension (OR = 2.32,
p = 0.01) remained associated with prematurity.
4. Discussion
This study investigated oral, systemic and socioeconomic
factors in a group of women in the immediate postpartum period,
and their relation to preterm births. The distribution of maternal
dental caries was similar in cases and controls, thus, no association
was found between dental caries and preterm birth. Taking into
account the pathogenesis of the caries disease,17 lesions found at
the time of examination (24–48 h postpartum) were considered to
have been present during pregnancy.
A great heterogeneity of the methods used to evaluate dental
caries can be observed among researches, however, this study and
others found no significant differences between caries and adverse
outcomes of pregnancy.10,17,18 Moreover, some aspects related to
the etiopathogenesis of caries have not been evaluated, such as the
level of caries activity, and salivary and microbiological character-
istics of pregnant or postpartum women.
However, epidemiological studies that address the relationship
between dental caries and the outcomes of pregnancy are still
scarce and conflicting, contrary to the relationship between
periodontal disease and outcomes of pregnancy, in which there
are many studies about it.6,9,10 One clinical study19 and two
microbiological studies20,21 tried to identify an association
between caries and premature births. In the clinical study,19 the
mean number of decayed and filled teeth of mothers of preterm
infants was significantly higher than of mothers of full-term
infants. However, we evaluated only decayed teeth and no
association between dental caries and preterm birth was found,
without considering filled teeth by means of decayed as done by
Raylat et al.19 All the same, microbiological studies found no
association between Streptococcus mutans and prematurity.20,21
In the present study, prematurity was associated with maternal
educational level and hypertension. The association between
prematurity and low educational level is already well estab-
lished,17,22 as well as the association between preterm birth and
maternal hypertension.9,23 Interestingly, some of the variables that
are considered risk factors for prematurity,8,9,23 such as urinary
tract infection, eclampsia, primiparity and type of birth, were not
shown to be associated with this condition in the present study.
Another information that also calls attention is the rates of

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Table 3 Table 5
Univariate analysis of the association between the variables referring to the Logistic regression analysis of the association between exposure variables and
newborn, and women’s current and previous gestational history with preterm preterm birth.
birth.
Exposure variables Adjusted OR (IC95%) p-valuea
Variables Preterm birth OR (95%CI) p-valuea
Formal education (8 years) 2.56 (1.24–5.25) 0.01*
Yes No Arterial hypertension 2.32 (1.14–4.70) 0.01*
Hospitalization during pregnancy 1.72 (0.86–3.44) 0.11
n (%) n (%)
a
Newborn Sex Logistic regression model adjusted for the following variables: educational
Female 35 (50.0) 113 (54.1) 0.84 (0.49–1.46) 0.65 level, low birth weight, arterial hypertension, and hospitalization during pregnancy.
*
Male 35 (50.0) 96 (45.9) Reference Statistically significant difference (p < 0.05).
Newborn skin color
White 33 (47.1) 116 (55.5) Reference
Black 3 (4.3) 6 (2.9) 1.75 (0.41–7.40) 0.44
Dark-skinned 34 (48.6) 87 (41.6) 1.37 (0.78–2.39) 0.26
cesarean section in the studied population. In Brazil, caesarean
Urinary infection
Yes 23 (33.3) 68 (32.7) 1.02 (0.57–1.83) 0.96
sections comprise about 52% of all births, this rate is substantially
No 46 (66.7) 140 (67.3) Reference greater than the upper WHO recommended limit of 15%, and
Arterial hypertension higher than has been reported in any other country.24
Yes 32 (45.7) 39 (18.8) 3.62 (2.02–6.51) <0.01* Despite evidence that dental caries may not be associated with
No 38 (54.3) 168 (81.2) Reference
preterm birth, it was verified that pregnant women have high rates
Eclampsia
Yes 2 (2.9) 5 (2.4) 1.19 (0.22–6.29) 0.56 of dental caries.2,4,25 In this study, more than 60% of the women of
No 68 (97.1) 203 (97.6) Reference both groups had caries and most of the women (over 80%) did not
Parasitosis visit the dentist throughout pregnancy nor received oral health
Yes 2 (2.9) 11 (5.3) 0.52 (0.11–2.41) 0.31
instruction during pregnancy. This finding is important consider-
No 68 (97.1) 195 (94.7) Reference
Hospitalization in pregnancy
ing that dental caries is a chronic disease that can contribute to the
Yes 34 (48.6) 55 (26.3) 2.64 (1.50–4.63) <–0.01* reduction of the quality of life and well-being of women during and
No 36 (51.4) 154 (73.7) Reference after pregnancy.4,26 Moreover, studies show that the children of
Previous prematurity women with active caries lesions are more likely to develop the
Yes 8 (25.0) 17 (15.3) 1.84 (0.71–4.77) 0.31
disease, since this seems to be related to the adoption of poor
No 24 (75.0) 93 (84.7) Reference
Previous low weight eating habits and inadequate measures of oral hygiene.27–29 This
Yes 8 (25.0) 16 (14.7) 1.93 (0.74–5.06) 0.27 information is important since, unlike dentists, midwives are often
No 24 (75.0) 93 (85.3) Reference the first health professional pregnant women encounter, so the
Primiparity
targeting of midwives to increase awareness of the consequences
Yes 32 (45.7) 91 (43.8) 1.08 (0.62–1.86) 0.88
No 38 (54.3) 117 (56.3) Reference
of poor oral health during pregnancy, and refer women to dental
Type of birth services, may provide added encouragement to women to attend
Cesarean section 42 (60.0) 112 (53.8) 1.28 (0.74–2.22) 0.45 dental services.30
Normal birth 28 (40.0) 96 (46.2) Reference Because dental caries is still a highly prevalent oral disease, its
a
Chi-square test or Fisher exact test. study during pregnancy is a relevant issue. Although not
*
Statistically significant difference (p < 0.05). probabilistic, this study had a 90% power to detect statistically
significant differences between the groups. The use of an
examiner blind for prematurity contributed to minimize potential
measurement bias. However, as a limitation, this study analyzed
the presence or absence of dental cavities, without evaluating
Table 4 pulp involvement, a condition in which there is a greater
Univariate analysis of the association between oral health variables and preterm possibility of dissemination of the dental infection through the
birth. blood stream.12
Variables Preterm birth OR (95%CI) p-valuea
5. Conclusion
Yes No

n (%) n (%) This study demonstrated that dental caries is frequent in

Tooth brushing after meals postpartum women, but it does not appear to be associated with
b
Yes 70 (100) 198 (95.7) 0.06 preterm birth. On the other hand, maternal education level and
No 0 (0) 9 (4.3) Reference
arterial hypertension were associated with prematurity in this
Dental floss use
Yes 23 (33.3) 72 (34.4) 0.95 (0.53–1.69) 0.98 population.
No 46 (66.7) 137 (65.6) Reference
Visited the dentist (throughout pregnancy) Conflict of interest
Yes 8 (11.4) 38 (18.2) 0.58 (0.25–1.31) 0.25
No 62 (88.6) 171 (81.8) Reference
Oral health instruction during pregnancy The authors declare that they have no conflict of interest.
Yes 9 (12.9) 31 (14.8) 0.84 (0.38–1.87) 0.83
No 61 (87.1) 178 (85.2) Reference Ethical statement
Dental caries
Yes 45 (64.3) 130 (62.5) 1.08 (0.61–1.89) 0.90
Ethics approval to conduct the study was obtained from the
No 25 (35.7) 78 (37.5) Reference
Visible plaque index University Hospital of the Federal University of Maranhão Research
VPI < 30% 33 (47.1) 98 (46.9) 1.01 (0.58–1.73) 0.91 Ethics Committee (protocol 240/11; approval in: 19 August 2011).
VPI  30% 37 (52.9) 111 (53.1) Reference All subjects gave their informed consent prior to participating in
a
Chi-square test or Fisher exact test.
the study.
b
Unable to calculate the odds ratio.

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Funding
Financial support for the research’s carrying out was given by
the Foundation for the Support of Research and Scientific
Development of Maranhão — FAPEMA, that is a public foundation
of Maranhão State Government in Brazil.
Acknowledgements
We thank the Foundation for the Support of Research and
Scientific Development of Maranhão (FAPEMA) for the financial
support for this research’s carrying out. We also thank the Multi-
center Geravida Project, a case–control study in which the present
work was nested.
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