Original Article

Poor periodontal health of pregnant women as a risk factor

for preterm and low birth weight
Shaila Kothiwale, mds phd*, Vivek Panwar, mds*
*Professor, Department of Periodontics, KLE VK Institute of Dental Sciences, Belgaum.

Abstract

Background: Preterm delivery of low birth weight infants remains a significant public health issue and a leading cause of neonatal death,
long term neurodevelopmental disturbances, and health problems. Several recent studies have suggested a relationship between preterm
delivery and periodontal disease. The aim of the study was to determine the association between maternal periodontitis and pre-term/low
birth weight (PLBW).
Method: The case-control study included 400 patients between the age group of 18–35 years. The mothers were categorized based on the
weight of the infants as cases (< 2500 g and < 37 weeks) and controls (≥ 2500 g and ≥ 37 weeks). The associated risk factors for periodontal
diseases and PLBW like age of mother, literacy status, hemoglobin levels, history of previous deliveries, history of previous PLBW deliver-
ies, history of dental treatment, and periodontal status were ascertained by means of structured questionnaires and maternity case records.
Periodontal parameters were assessed using the community periodontal index (CPI).
Results: The risk factors significantly associated with PLBW are literacy status of the mother (χ2 = 17.062, p < 0.001), hemoglobin level of
the mother (χ2 = 55.62, p < 0.0001), history of previous PLBW deliveries (χ2 = 102.797, p < 0.0001), and CPI scores (χ2 = 83.28, p < 0.0001).
Conclusion: Our findings showed an association of periodontal disease with PLBW as an independent risk factor. Thus, it remains important
to promote good oral hygiene during routine prenatal visits during pregnancy.

Keywords: Low birth weight, periodontitis, preterm

INTRODUCTION born before 37 weeks of gestation and low birth weight

The commonest systemic condition that leads to periodontal
disease is the variation in the hormonal levels. The increased
levels of the hormones during pregnancy affect many organs
in the body and periodontium is no exception. Gingivitis is a
common feature of pregnancy. It is caused by bacterial
plaque just as it is in non-pregnant individuals.
The estrogen and progesterone receptors have been recog-
nized in the gingiva, these receptors exacerbate the gingival
response to plaque. The imbalance or increased levels of
these hormones modifies the bacterial composition of plaque
resulting in the growth of gram-negative anaerobic microbiota
which modifies the resultant clinical picture in pregnancy.
Pre-term/low birth weight (PLBW) infants represent a
major medical, social and economic problem accounting for
a large proportion of maternal and especially neonatal mor-
tality and morbidity. Offenbacher et al showed the relation
between the periodontal disease and preterm infants who are
Correspondence: Dr. Shaila Kothiwale, Professor, Department of
Periodontics, KLE VK Institute of Dental Sciences, Belgaum.
E-mail: shailakothiwale2000@yahoo.co.in
Received: 21.09.2011
Accepted: 31.10.2011
doi: 10.1016/S0975-962X(11)60032-4
infants, birth weight < 2500 g.
The various risk factors for preterm delivery and low birth
weight infants are low maternal age, first delivery, history of
PLBW, abortion, habits like tobacco, coffee, drug abuse, edu-
cation, and gender of fetus. Offenbacher et al hypothesized that
gram-negative anaerobic pathogens from periodontium and
associated endotoxins and maternal inflammatory mediators
could have a possible adverse effect on the developing fetus.1
Experiments carried out by Collins et al in the pregnant
hamster model showed that periodontitis can affect fetal
growth.2 Later human case-control studies performed by
Dasanayke, Davenport et al, Offenbacher et al, demonstrated
that women who have low birth weight infants as a consequence
of premature rupture of membranes tend to have more severe
periodontal disease than mother with normal weight infants.1,3,4
Since birth weight is easier to ascertain than gestational
age, especially in countries like India, where no ultrasound
scan is carried out in early pregnancy, many have advocated
the use of birth weight for the definition of preterm birth
rather than gestational age.
The following study was undertaken to study the risk fac-
tors for preterm delivery and low birth weight infants and
the prevalence of periodontal disease among mothers of the
study population.

© 2011 Indian Journal of Dentistry. Published by Elsevier Ltd. 129

 Kothiwale and Panwar
AIM AND OBJECTIVES
1. To estimate the prevalence of periodontal disease among
mothers of the study population delivering at District
Hospital, Belgaum.
2. To estimate the association of periodontal disease and
other risk factors for preterm delivery and low birth
weight infants in this population.
MATERIALS AND METHOD
The study was designed in the Department of Periodontics,
KLE’s VK Institute of dental sciences and conducted in the
Department of Obstetrics and Gynecology, District Hospital
Belgaum. An informed consent of the patient was taken
prior to the examination.
A study included 400 patients, with 200 patients in the
experimental group and 200 patients in the control group.
The experimental group and control group were matched for
the gender of the infants and age of the mother. The param-
eters were taken by interview and study of case records of
the patients. The community periodontal index (CPI) was
recorded to measure the periodontal status of the patients.
The hemoglobin levels were taken to assess the physical
health of the mother.
INCLUSION CRITERIA
Experimental Group
• Mothers who had delivered an infant weighing < 2.5 Kg or
born before 37 weeks gestation.
• Mothers within age group of 18–35 years
Control Group
• Mothers who had delivered an infant weighing ≥ 2.5 Kg
and born after 38 weeks gestation.
• Mothers within age group of 18–35 years.
EXCLUSION CRITERIA
• Patients with history of systemic diseases.
COMMUNITY PERIODONTAL INDEX
Indicators
Three indicators of periodontal status are used for this
assessment: gingival bleeding, calculus and periodontal
pockets. A specially designed lightweight CPI probe with
a 0.5 mm ball tip was used, with a black band between
130
3.5 and 5.5 mm and the rings at 8.5 and 11.5 mm from
the ball tip. Examination was done with all the teeth present
in the individual’s oral cavity using CPI index in the labor
ward.
EXAMINATION AND PROBING
All remaining teeth in an individual were probed and
the highest score recorded in the appropriate box. The
codes are:
0 – Healthy.
1 – Bleeding observed, directly or by using a mouth mir-
ror, after probing.
2 – Calculus detected during probing, but the entire black
band on the probe visible.
3 – Pocket 4–5 mm (gingival margin within the black
band on the probe).
4 – Pocket 6 mm or more (black band on the probe not
visible).
X – Excluded sextant (< 2 teeth present).
9 – Not recorded.
The individual CPI score was taken as the highest CPI
score in that individual.
DATA COLLECTION
After obtaining the institutional and patient consent hospital
records associated risk factors for periodontal disease and
PLBW were ascertained by means of a structured question-
naire and maternity notes.
ADMINISTERED STRUCTURED
QUESTIONNAIRE
A structured questionnaire was framed to ascertain con-
cerned details. The data were collected as a hard copy on
questionnaire sheets (Figure 1).
DATA ANALYSIS
Student t-test was used to compare means and χ2 test was
used to test the association between attributes.
RESULTS
There was a significant difference between the two means of
CPI scores with the p value < 0.0001 of the t-test and an
association of CPI scores and the two groups (χ2 = 83.28,
DF = 3, p < 0.00010). There was an indication of increase in
the percentages (a trend) in the experimental group with the
increased values of CPI scores.
© Indian Journal of Dentistry 2011/Volume 2/Issue 4
 Poor periodontal health of pregnant women as a risk factor for preterm and low birth weight

PROFORMA

Name: _____________________________________________________________________________ Age: _______________________________

Address: _________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________

Physical status: ______________________________________________________________________________________________________________________________

Hb%: ______________________________________________________________________________________________________________________________________

Obstetric history:
No. of previous deliveries: ___________________________________________________________________________________________________________________
No. of previous PLBW: ______________________________________________________________________________________________________________________
No. of previous pregnancy aborted: __________________________________________________________________________________________________________
No. of spontaneous abortions: _______________________________________________________________________________________________________________

Antenatal care: Yes/No

Habits:

Tobacco: Yes No If yes: In which form: _________________________ Quantity: __________________ Duration: ________________

Coffee: Yes No If yes: Quantity: ____________________ Duration: __________________

Demographic status: Education

Dental treatment/visit during current pregnancy: Yes No

Gender of infant: ___________________________________________________________________________________________________________________________

Weight of infant (Kg): _______________________________________________________________________________________________________________________

CPI:
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28

Figure 1 Administered structured questionnaire.

PLBW: pre-term/low birth weight, CPI: community peridontal index.

Table 1 Comparison of age of mothers. Table 2 Comparison of number of previous deliveries.

Experimental group No. of previous deliveries Experimental group Control group
Age group Control group
PTB LBW 0 54 (27%) 55 (27.5%)
1 48 (24%) 57 (28.5%)
18–23 45 39 84
2 62 (31%) 56 (28%)
24–29 38 66 104
3 29 (14.5%) 26 (13%)
30–35 2 10 12
4 7 (3.5%) 6 (3%)
Total 85 115 200
Total 200 200
PTB: preterm birth, LBW: low birth weight.
χ2 = 1.326; DF = 4; p = 0.85.
The p value of the χ2 test indicates that the number of previous deliveries is inde-
pendent of the experimental or control group; i.e. the percentage in two groups for
DISCUSSION the various number of deliveries are more or less the same.

The hypothesis that poor oral health of pregnant women is
associated with PLBW of the infant, which was tested by
using matched case and control groups. The literacy, hemo-
globin poor periodontal status emerged as risk factors for
PLBW in this study.
To minimize the confounding of primary association due
to age, each age group was matched with equal number of
mothers in control and experimental group (Table 1). The
study shows chances that PLBW were more in age group
of 18–23 years. This is supported by Kristenson et al who
reported in his study that maternal age (< 20 years) was a
risk factor for pre-term delivery.5 The explanation lies in the
fact that younger women are not completely developed ana-
tomically to conceive a child.
In our current study, there was no correlation between
number of previous deliveries and PLBW (Table 2). In other
previous studies, women in the first pregnancies have a
higher incidence of PLBW.6 Other studies reported that cross-
sectional analysis also showed a higher rate in women of
high parity. Thus, parity and maternal age are interrelated.

© Indian Journal of Dentistry 2011/Volume 2/Issue 4 131

 Kothiwale and Panwar

Table 3 Comparison of antenatal care. Table 6 Comparison of number of previous pre-term/low birth weight.
Antenatal care Experimental group Control group No. of previous PLBW Experimental group Control group

Yes 140 (70%) 156 (78%) 0 114 (57%) 198 (99%)

No 60 (30%) 44 (22%) 1 41 (20.5%) 2 (2%)
Total 200 200 2 35 (17.5%) 0 (0%)
3 10 (5%) 0 (0%)
Experimental group: yes vs no; control group: yes vs no
Total 200 200
χ2 = 3.326; DF = 1; p = 0.068.
The p value 0.068 of the χ2 test accepts the null hypothesis that the categories of χ2 = 102.797; DF = 1; p = 0; PLBW: pre-term/low birth weight.
antenatal care and the two groups are independent. More number of PLBW was observed in experimental group than in control group
(χ2 = 102.797; DF = p < 0.0001). The p value < 0.0001 of the χ2 test confirms that
there is no uniformity in the percentages in the two groups for the values of number
Table 4 Comparison of education of the mother. of previous PLBW.

Education Experimental group Control group

Illiterate 47 (23.5%) 18 (9%) This finding reveals the low hemoglobin level may act as one
Primary (I–V) 43 (21%) 40 (20%) of the risk factors for PLBW. Hence routine iron supplements
Secondary (VI–VIII) 51 (23.5%) 70 (35%) is becoming a part of antenatal care in countries like India.
Senior secondary (XI–XII) 60 (30%) 72 (36%)
Total 200 200
The chances of the current delivery being PLBW were
more in patients with previous history of PLBW (Table 6).
χ2 = 17.062; DF = 3; p = 0.001.
From the percentages we can note that there is a higher percentage of illiterates in
Hoffman et al proposed that those women might either be
the experimental group, but the percentage of secondary and senior secondary is prone to give birth to PLBW infants by genetic or constitu-
more in control group. This is confirmed by the p value 0.001 of the χ2 test. In this tional factors.8
sense there is an association between levels of education and two groups.
In the light of the above and the fact that we are able to
observe some of known association for PLBW, the first
Table 5 Comparison of hemoglobin level of mother. possible mechanism due to poor oral health would be
Hb% Experimental group Control group reduced intake of nutritious food. But, the periodontal dis-
8.05 85 (42%) 18 (9%) ease was not so severe in this study to interfere with the food
10.05 65 (32.5%) 87 (43.5%) intake.
12.05 49 (24.5%) 87 (43.5%) Offenbacher et al hypothesized that gram-negative anaero-
14.5 1 (0.5%) 8 (4%)
Total 200 200 bic pathogens from the diseased periodontium and associated
Experimental group: 9.70 ± 1.62, control group: 10.86 ± 1.35;
endotoxins and maternal inflammatory mediators who have
χ2 = 55.62%; DF = 398, DF = 2; p = 0, p = 0; t = 7.75. Hb: hemoglobin.
possible adverse effect to the developing fetus. Inflammation
The mean Hb% for experimental group is 9.7% and for the control group it is of the extra placental membrane has been detected in up to
10.86%. The p value < 0.0001 indicates that there is significant difference between 4 times as many mothers with preterm deliveries as in those
these two means. The χ2 value and the associated p value < 0.0001 show that the
levels of Hb% is associated with the two groups. The percentages of the cases in the
with normal term deliveries.9 One line of reasoning suggest
two groups is not uniform with the levels of Hb. Prevalence of anemia is significantly that maternal infections may lead to excessive production
more in the experimental group than in the control group (χ2 = 55.62, DF = p < 0.0001).
of proinflammatory cytokines and prostaglandins, all of
which are established biochemical mediators of parturition.9
The risk factors like tobacco and smoking were not found However the observation of elevated prostaglandin E (PGE)
to be significantly associated with PLBW in our study. This and TNF-α as a consistent and reproducible feature.
maybe due to the fact that women in our study groups were However, the observation of elevated level of PGE2 and
not indulged in such practices due to social taboos. TNF-α as a constituent and reproducible feature of PLBW
Lack of motivation, lack of attention to antenatal care and in the absence of any clinical or subclinical genito-urinary
education (Table 3) are consistently associated with PLBW,4 tract infections has lead to the conclusion that most PLBW
though it is difficult to identify any particular component of cases are probably caused by an infection of unknown ori-
antenatal care that might be effective in preventing preterm gin. The possibility that periodontal infection may constitute
birth. Our findings in this study revealed patients with higher remote maternal infection that may adversely influence preg-
qualification in education had better periodontal health, nancy outcome has been recently raised. It has been proved
(Table 4) which indicated mothers with higher education that gingivitis increases significantly during pregnancy in the
maybe more aware about preventive health care and healthy presence of local factors. It is well established that periodontal
practices during pregnancy. infections are dominated by gram-negative anaerobic micro-
The hemoglobin carries nutrition for mothers and the biota and are characterized by high levels of inflammatory
fetus which acts as an important factor for the development mediators in the periodontal tissues. It is also known that tran-
of fetus.5,7 But in developing countries pregnancy anemia is sient bacteremias commonly occurs in subjects with inflamed
common which may be due to the of antenatal care beliefs gingival and may conceivably reach the placental tissues
and practiced exclusively in rural areas. Thus in our study providing the inflammatory impetus for labor induction.10
mothers who had hemoglobin levels below normal (Table 5) In our study CPI scores (Table 7) indicate statistical sig-
had increased number of PLBW compared to other groups. nificance in experimental group compared to control group

132 © Indian Journal of Dentistry 2011/Volume 2/Issue 4

 Poor periodontal health of pregnant women as a risk factor for preterm and low birth weight
Table 7 Comparison of community periodontal index scores of the mothers.
CPI scores Experimental group
1 9 (4.5%)
2 22 (11%)
3 73 (36.5%)
4 96 (48%)
Total 200
Mean CPI score 3.28 ± 0.83
χ2 = 83.28; DF = 398; DF = 3; p = 0.000; p = 0.00; t = 9.75. CPI: community periodontal index.
Table 8 Comparison of dental treatment during current pregnancy.
Treatment Experimental group
Yes 6 (3%)
No 194 (97%)
Total 200
χ2 = 0.093; DF = 1; p = 0.760.
There is no difference between the two groups as regards to the treatment during
current pregnancy. This is indicated by the p value (0.760) of the χ2 test.
which indicates the severity of prevailing periodontal disease
in particular group.
This was further supported by the results obtained from
animal models, where subcutaneous injection with a perio-
dontal pathogen and experimental periodontitis in pregnant
hamsters resulted in decreased fetal growth as well as
increased inflammatory levels of these pathogens.11
In our study, there was no statistically significant result
found in any group for the dental treatment rendered during
current pregnancy (Table 8). This could be explained by the
fact that there were very few mothers in whole of the study
population who had taken dental treatment during current
pregnancy and the treatment given to them was not peri-
odontal treatment. Also mothers in our study did not present
with CPI scores of 0 suggesting that all the mothers were
found to have some periodontal disease (Table 7).
Thus, the link between maternal periodontal disease and
PLBW may be explained by the following points. Firstly,
the physiological mediators of parturition include PGE2 and
TNF-α, both of which have been shown to be locally ele-
vated as part of the host response to the microbial challenge
in periodontal disease. In the case of TNF-α, systemic levels
are also increased in periodontal patients with active dis-
eases. Secondly, PLBW has been shown to be associated
with infection of genitourinary tract, which do not necessar-
ily involve infection of the fetal-placental unit. Hence, infec-
tions remote from the developing fetus have the potential to
influence gestation. Thirdly, despite the considerable prog-
ress in describing the risk factors involved in PLBW, a high
proportion of PLBW cases have an unexplained etiology.11,12
Thus our findings can be safely regarded as possible etiologi-
cal risk factors for PLBW with which study was attempting to
develop probable relation to the pregnancy and poor oral health.
The observed relationship of PLBW with above factors is
consistent with previous database, perhaps lending further
credibility to the validates of our study. Thus, we conclude that
poor periodontal health of a pregnant woman is a potential
independent risk factor for PLBW. The importance of this
© Indian Journal of Dentistry 2011/Volume 2/Issue 4
finding lies in the fact that poor periodontal health is a factor
Control group that is easily amenable to prevention and its non-invasive
18 (9%)
procedure.13
40 (20%) The limitation of this study is that few aspects of data of
70 (35%) proforma like Hb, obstetric history, weight of the infant, are
72 (36%) taken from medical records as secondary data. Gestation
200
2.36 ± 1.04 period was not recorded due to the fact that preterm weigh
less than infants of same gestation age who remain in utero
and birth weight increases with greater gestational age.
However, within these limitations, we concluded that PLBW
was significantly associated with poor periodontal health of
Control group
the mother act as a risk factor for PLBW.
5 (2.5%) Pre-term/low birth weight infants are of a major concern
195 (97.5%)
200 leading to psychological trauma in family and society at large.
Hence there should be communication between medical and
dental professionals to include periodontal health care as a
part of antenatal care.
CONFLICT OF INTEREST
None.
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