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Volume 8 • Number 1 • December 2003

Periodontal Disease as a Risk Factor for Adverse

Pregnancy Outcomes. A Systematic Review
Frank A. Scannapieco, Renee B. Bush,† and Susanna Paju*

* Department of Oral Biology, School of Dental Medicine, University at Buffalo, State University of New York, Buffalo, New York.
† Health Sciences Library.

Background: Recent studies have implicated a variety of infections, including periodontal diseases, as
risk factors for adverse pregnancy outcomes such as prematurity and low birth weight.
Rationale: A number of studies have shown that bacterial vaginosis is related to preterm and/or low birth
weight (PT/LBW), which continues to be a significant cause of infant morbidity and mortality. It is also possible
that other infectious processes, including periodontal diseases, contribute to PT/LBW. This systematic review
examines the literature to determine the possible relationship between PT/LBW and periodontal diseases.
Focused Question: Does prevention/control of periodontal disease as compared to controls have an
impact on the initiation/progression of adverse pregnancy outcomes?
Search Protocol: MEDLINE, pre-MEDLINE, MEDLINE Daily Update, and the Cochrane Oral Controlled
Trials Register were searched to identify published studies that related variables associated with PT/LBW
and periodontal disease. Searches were performed for articles published through October 2002.
Inclusion criteria: Randomized controlled clinical trials (RCTs), case-control, and cohort studies were
included. Study populations included mothers, with or without periodontal disease, who gave birth to preterm
and/or mature infants. The interventions considered included all forms of periodontal therapy.
Exclusion criteria: Only studies on humans were included.
Data Collection and Analysis: Due to study heterogeneity, meta-analysis was not possible.
Main Results
1. Of the over 660 studies identified, 12 (6 case-control, 3 cross-sectional and longitudinal, and 3
intervention) met inclusion and exclusion criteria and were included in the analysis.
2. While several studies implicated periodontal disease as a risk factor for PT/LBW, few assessed the impact
of the prevention and treatment of periodontal disease on outcomes.
3. Several epidemiologic studies did not support periodontal disease as a risk factor for PT/LBW.
Reviewers’ Conclusions
1. Periodontal disease may be a risk factor for PT/LBW.
2. Additional longitudinal, epidemiologic, and interventional studies are needed to validate this association
and to determine whether it is causal.
3. It is not yet clear whether periodontal diseases play a causal role in adverse pregnancy outcomes.
4. Preliminary evidence to date suggests that periodontal intervention may reduce adverse pregnancy
outcomes.
Ann Periodontol 2003;8:70-78
KEY WORDS
Infant, low birthweight, infections; periodontal diseases/complications; pregnancy complications,
infections; infant, premature; pregnancy outcomes; review literature.

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BACKGROUND
Preterm and/or low birth weight (PT/LBW) continues
to be a significant cause of infant morbidity and mor-
tality. PT/LBW is associated with risk for mortality in
the first year of life, with developmental problems in
childhood, and with risk of several diseases in adult-
hood. About 75% of perinatal deaths occur in infants
born prematurely, with the majority of deaths occur-
ring in infants delivered before 32 weeks gestation.1
The prevalence of preterm birth varies from 6% to 15%
of all deliveries, depending on the population studied,
and the prevalence has risen in recent years. Risk fac-
tors that appear to contribute to PT/LBW include low
socioeconomic status, race (with higher rates in
African-Americans than in white women), multiple
births, mother’s age, a previous history of preterm
birth or delivery of a low-birth weight infant, parity,
past reproductive history, drug and alcohol abuse, and
systemic maternal infection. Bacterial vaginosis (BV)
is a clinical condition caused by overgrowth of the
vaginal flora with certain aerobic and anaerobic bac-
teria. A variety of studies have shown that spontaneous
abortion, preterm labor, premature birth, premature
rupture of the membranes, amniotic fluid infection,
postpartum endometriosis, and post-cesarean wound
infections are all related to the onset of bacterial vagi-
nosis during pregnancy.1
RATIONALE
It is also possible that other infectious processes occur-
ring elsewhere in the body may contribute to neonatal
morbidity and mortality. It has recently been suggested
that periodontal disease may be one such infection. In
1996, Offenbacher and coworkers published results
from a case-control study that suggested that women
who delivered PT/LBW infants had poorer periodon-
tal health than the mothers of normal birth weight
infants.2 Since this study was published there has been
considerable interest in validating this observation,
with 12 studies subsequently published to date. The
goal of this systematic review is to identify all perti-
nent literature on the association of periodontal disease
with PT/LBW, to understand the current state of knowl-
edge on this subject and to point out future research
directions.
FOCUSED QUESTION
We attempted to answer the following focused question:
“Does prevention/treatment of periodontal disease as
compared to controls impact the risk for adverse preg-
nancy outcomes?”
SEARCH PROTOCOL
Data Sources and Search Strategy
Papers selected for analysis were limited to those on
humans. Our search strategy was defined to include
Scannapieco, Bush, Paju
randomized controlled clinical trials, longitudinal, cohort,
and case-control studies.
Search terms: Searches were run by one of the
reviewers (RB) using Ovid Search software of MEDLINE,
MEDLINE Daily Update and Cochrane Controlled Trials
Register (CCTR) updated to the third quarter of 2002.
MEDLINE and MEDLINE Daily Update were searched
using medical subject headings (MeSH terms). All MeSH
terms employed were exploded to expand retrieval of
those records that were assigned the more narrow related
MeSH terms. The CCTR database and Pre-MEDLINE
required use of keywords; both American and British
spellings were used. All searches included the term
“human.” We also searched reference lists of previously
published review papers to identify additional articles.
Search cut-off date was October 2002.
MeSH terms: Infant or newborn, low birth weight,
postmature, premature, or pregnancy, or pregnancy
complications.
Oral conditions: Periodontal diseases, or tooth dis-
eases, or dental plaque index.
Key words: Infant, or pregnant (birth adj weight), or
labor.
Oral conditions: Periodontal disease, or periodontitis,
or periodontal attachment loss, or alveolar bone loss,
or dental plaque, or oral hygiene.
Inclusion criteria: The types of participants recruited
for each study included those with prematurity (gesta-
tional age [GA] <37 weeks) and fetal growth restriction;
i.e., low weight for GA, low infant GA, and prematu-
rity at birth (e.g., infant weighing less than 2,500 g
and born before 37 weeks of gestation). The oral con-
ditions considered were: periodontal disease as mea-
sured by assessments of gingival inflammation, prob-
ing depth, clinical attachment level, and/or radiographic
bone loss; elevated oral cytokine levels, elevated peri-
odontopathogen levels in plaque, and elevated mater-
nal serum IgG levels against periodontopathogens. The
interventions considered included all forms of peri-
odontal therapy.
Exclusion criteria: The search was limited to human
studies.
Outcomes: The following outcome measures were
assessed:
1. Primary outcome: reduced rate of prematurity
and/or low birth weight.
2. Secondary outcomes: reduced rate of complica-
tions of prematurity.
3. Patient-centered outcomes: improved maternal
health.
4. Intraoral adverse effects: increased rate of pre-
maturity and/or low birth weight.
Data Collection and Analysis
Titles and abstracts of articles obtained using the above
described search strategy were screened by 2 independent
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readers (FAS and SP) and checked for agreement. The
full text of the articles judged by title and abstract to be
relevant (by either FAS or SP) were read and indepen-
dently assessed against the stated inclusion criteria.
For cohort studies that measured differences in rates
of disease between groups with oral disease and groups
without oral disease, weighted mean differences, rela-
tive risks or odds ratios were compared. There were
insufficient data to conduct a meta-analysis.
Ranking of Studies
Included papers were graded according to previously
reported classifications.3,4
1. Systematic review of randomized controlled clin-
ical trials. RCTs with narrow confidence intervals.
2. Randomized, controlled clinical trial. Low quality
systematic review.
3. Case-control study. Systematic review of case-
control studies.
4. Cross-sectional or longitudinal epidemiologic
study.
5. Case series or case study.
The quality of randomized controlled clinical trials
was assessed according to the following scale:
Randomization 1 point
Treatment assignment concealment 1 point
Subject and examiners masked 1 point
Appropriate follow-up 1 point
RESULTS AND DISCUSSION
The search strategy outlined above yielded 663 titles.
Scrutiny of the titles and abstracts reduced the number
of papers for review to 12.5-15
The first paper to suggest an association between
periodontal disease and PT/LBW was published in 1996
by Offenbacher and coworkers (Table 1).2 They exam-
ined 93 mothers who gave birth to preterm or low birth
weight children. These were matched with 31 control
mothers who gave birth to children of normal term
and birth weight. They defined low birth weight as less
than 2,500 grams, or spontaneous abortion prior to 12
weeks gestation. Preterm birth was defined as preterm

Table 1.
Case-Control Studies Relating Oral Health to Preterm Low Birth Weight (PT/LBW)

N PT/LBW N Normal BW
Reference (Cases) (NBW) (Controls) Oral Assessment PT/LBW Criteria

Offenbacher 93 31 CAL, PD on 6 sites BW: <2500 g with spontaneous abortion prior

et al.2 1996 per tooth, BOP. to 12 weeks after gestation; preterm labor
requiring medical intervention; premature
rupture of membranes requiring delivery
<36 weeks of gestational age, or birth
with gestational age <36 weeks.

Offenbacher 25 15 CAL, PD on 6 sites BW <2500 g; gestational age <36 weeks.

et al.10 1998 per tooth, BOP.

Davenport 236 507 PD, BOP; CPITN. BW: <2500 g; gestational age <37 weeks.
et al.11 2002 Attachment loss for
10 worst teeth.

Dasanayake12 55 55 Diseased/missing/filled BW: <2500 g.

1998 teeth; CPITN.

Romero et al.13 56 13 Russell periodontal BW; gestational age.

2002 index.

Dasanayake 17 63 P. gingivalis (P.g.)-specific BW

et al.12 2001 maternal serum IgG.

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labor requiring medical intervention, premature rupture
of the membranes prior to 36 weeks of gestational age
of birth, with gestational age less than 36 weeks. They
found that the odds ratio for periodontal disease and
premature birth were significant, with the risk for
PT/LBW 7.5-fold greater if the mother had evidence of
periodontal disease (diagnosed as clinical attachment
loss) as compared to mothers without evidence of peri-
odontal disease. Other studies11-14 have since been
published that provide evidence supporting the con-
tention that women with periodontal disease have a
greater risk for having preterm or low birth weight chil-
dren (Table 1).
Like studies of cardiovascular disease and peri-
odontal disease, these studies are sometimes difficult
to compare since investigators do not use a standard
measure for periodontal disease. The assessments of
periodontal disease range from clinical attachment lev-
els to the Community Periodontal Index of Treatment
Needs and other less direct measures, such as antibody
response to periodontal pathogens.
Not all published studies support the contention. A
recent case-control study of 236 cases of PT/LBW and
507 controls found no association between maternal
periodontal disease and increased risk for PT/LBW.11
In fact, these authors found that increasing mean prob-
ing depth at the time of delivery was associated with
a reduction in the risk of PT/LBW (Table 1).
There may be an explanation for the differences
in conclusions between these studies. Davenport
et al.11 studied a multi-ethnic patient population in
the United Kingdom (primarily native-born whites
and Bengali immigrants) that was quite a different
population than studied by the North American inves-
tigators,2,5,6 where the subjects enrolled were African-
Americans (Tables 1 and 2). It is conceivable that
heretofore unrecognized genetic or environmental fac-
tors (e.g., race, diet, or other environmental exposures)
may account for the differences in results between
these studies.
These conflicting results demonstrate the need for
large scale, multi-center randomized trials of periodontal

Table 1. (continued)
Case-Control Studies Relating Oral Health to Preterm Low Birth Weight (PT/LBW)

Risk Calculations Conclusions Study Ranking

Odds ratios (OR) for periodontal disease and
PT/LBW and primiparous PT/LBW to 7.5 (95%
confidence interval [CI] 1.95-28.8) and
7.9 (95% CI 1.52-41.4), respectively.
PT/LBW cases and primiparous PT/LBW cases had 3
significantly worse periodontal disease than the res-
pective controls. After controlling for other risk factors
and covariates, it was found that the presence of
periodontal disease increased the risk ratios for PT/LBW
and primiparous PT/LBW to 7.9 and 7.5, respectively.

Not done GCF-PGE2 levels were significantly higher in PT/LBW 3

mothers, as compared with NBW controls. Four
organisms associated with periodontitis, Bacteroides
forsythus, Porphyromonas gingivalis, Actinobacillus
actinomycetemcomitans, and Treponema denticola,
were detected at higher levels in PT/LBW
mothers, as compared to NBW controls.

OR for periodontal disease and PT/LBW
0.83 (95% CI 0.68-1.00).
After adjustment for maternal age, ethnicity, 3
maternal education, smoking, alcohol consumption,
infections, and hypertension during pregnancy, no
evidence for an association between PT/LBW and
periodontal disease was noted.

More healthy areas of gingiva (OR = 0.3, 95% Poor periodontal health of the mother is a potential 3
CI = 0.12-0.72) had a lower risk of LBW. independent risk factor for low birth weight (LBW).

Increasing severity of the Russell PI was A decrease in the average newborn’s weight and 3
associated with decreases in LBW. gestational age was observed as the mother’s level
of periodontal disease increased.

Women with higher levels of P.g.-specific IgG had Higher maternal serum antibody levels against P.g at 3
higher odds of giving birth to LBW infants mid-trimester were associated with greater
(OR: 4.1; 95% CI 1.3-12.8). risk for LBW infants.

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Table 2.
Cross-Sectional and Longitudinal Studies Relating Oral Health to PT/LBW

Reference Study Population Oral Assessment Assessment of PT/LBW

Jeffcoat et al.6 2001 1,313 CAL. Infant gestational age <37 weeks.

Offenbacher et al.15 2001 812 CAL, PD on 6 sites per BW; gestational age.
tooth; BOP.

Madianos et al.5 2001 386 maternal plaque CAL, PD on 6 sites per BW; gestational age.
samples; 367 maternal tooth; BOP.
serum samples; 339 fetal
serum samples.

Table 3.
Intervention Studies of Periodontal Intervention to Prevent PT/LBW

Reference N Test Subjects N Controls Randomization Double Masked Appropriate Concealment

López et al.8 2002 406 with gingivitis received 233 with periodontal No No Not stated
the oral intervention. disease.

López et al.7 2002 200 received periodontal 200 received Yes No Not stated.
treatment before 28 periodontal
weeks of gestation treatment after
(37 dropped out). delivery (12
dropped out).

Mitchell-Lewis et al.9 2001 74 90 Not stated No Not stated.

disease treatment to establish causal relationships
between periodontal status and PT/LBW. Recently, 3
studies have been published that have tested the effect
of periodontal intervention to reduce adverse pregnancy
outcomes (Table 3).7-9 López and colleagues have pub-
lished 2 such studies.7,8 One study in particular exami-
ned 200 pregnant women who received periodontal
treatment before 28 weeks of gestation. These were
compared to another 200 mothers who received peri-
odontal treatment after delivery. While this was a ran-
domized trial, it was not double-masked. Oral inter-
vention included plaque control instruction, scaling and
root planing, with oral rinsing once a day. They found
that periodontal therapy before 28 weeks gestation sig-
nificantly reduced the rate of PT/LBW in women with
periodontal disease.8 Another study by Mitchell-Lewis

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Table 2. (continued)
Cross-Sectional and Longitudinal Studies Relating Oral Health to PT/LBW

Adjusted Odds Ratio (CI) Conclusions Study Ranking

5.28 (2.05-13.6) preterm birth <35 weeks; 7.07 (1.7-27.4) ORs were adjusted for maternal 4
for preterm birth <32 weeks. smoking, parity, race, and age.
There is an association between periodontitis
at second trimester and PT/LBW.

The adjusted prevalence of moderate-severe periodontal Periodontal disease incidence/progression 4

disease increased with diminished gestational age (4.5%
for full-term mothers; 9% for GA <37 weeks; 10.2% for
GA <35 weeks; 13.6% for GA <32 weeks; and 18.4% at
GA <28 weeks). A similar pattern was noted for birth
weight and periodontal status.
during pregnancy was associated with
significantly smaller births for gestational
age adjusting for race, parity, and baby gender.

Prevalence of positive fetal IgM to Campylobacter rectus and to The maternal and fetal response to oral 4
Prevotella intermedia significanly higher for preterm when bacteria may play a role in prematurity.
compared to full-term neonates; IgG antibody to organisms
of the P. gingivalis/T. denticola/B. forsythus were absent in
mothers having PT/LBW infants OR = 2.2;
95% CI: 1.48 to 3.79.

Table 3. (continued)
Intervention Studies of Periodontal Intervention to Prevent PT/LBW

N Preterm Births or LW Babies

Outcome Variables Oral Intervention Test Subjects Controls Conclusion(s) Study Ranking

Preterm birth (<37 weeks Plaque control instructions 10/406 (2.5%) 20/233 (8.6%) Study not randomized. 0
gestation) and low BW and subgingival scaling; A subgroup of
(<2500 g). CHX rinse once a day. women with
periodontitis were
not treated.

Low BW; gestational age
<37 weeks.
Plaque control instructions 3/200 (1.5%) 19/200 (9.5%) Periodontal therapy 2
and subgingival SRP significantly reduces
completed before 28 the rates of PT/LBW in
weeks of gestation; women with
CHX rinse once a day. periodontal disease.

BW: <2500 g; gestational
age <37 weeks.
Plaque control instructions, 10 (13.5%) 17/90 (18.9%) The incidence of PT/ 0
scaling and root planing LBW in women
of all teeth. who received basic
periodontal therapy
during pregnancy
was lower than in
women who did not.

et al.9 compared 74 subjects who received mechanical
dental plaque control instructions and scaling and root
planing of all teeth, compared to 90 control subjects
not receiving periodontal intervention. They found a
reduction in the incidence of PT/LBW in women who
received periodontal therapy during pregnancy. These
preliminary intervention studies provide initial evidence
that periodontal therapy prior to 28 weeks of gestation
may reduce the incidence of preterm low birth weight
children.
REVIEWERS’ CONCLUSIONS
While there appears to be an association between peri-
odontal disease and PT/LBW, it is not yet clear that
periodontal disease plays a causal role in adverse preg-
nancy outcomes. Preliminary evidence to date suggests

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Periodontal Disease as a Risk Factor for Adverse Pregnancy Outcomes
that periodontal intervention may reduce adverse preg-
nancy outcomes. Additional large-scale longitudinal
epidemiologic and interventional studies are necessary
to validate this association and to determine if the
association is causal.
FUTURE DIRECTIONS FOR RESEARCH
Future research should focus on validation of the asso-
ciation between periodontal disease and adverse preg-
nancy outcomes. Large-scale longitudinal epidemiologic
investigations that include subjects from diverse racial,
socioeconomic and cultural backgrounds would address
the impact of these parameters on outcomes. Random-
ized controlled clinical trials that evaluate the effects of
periodontal intervention in the prevention of adverse
pregnancy outcomes are necessary to prove or disprove
this association.
REFERENCES
1. Slattery MM, Morrison JJ. Preterm delivery. Lancet 2002;
360:1489-1497.
2. Offenbacher S, Katz V, Fertik G, et al. Periodontal infec-
tion as a possible risk factor for preterm low birth weight.
J Periodontol 1996;67(Suppl.):S1103-S1113.
3. Newman MG, Hujoel PP. Statement of purpose and meth-
ods. J Evid Based Dent Prac 2001;1(1):3A-5A.
4. Kahn KS, Riet GT, Popay J, Nixon J, Kleijnen J. Under-
taking systematic reviews of research on effectiveness.
Phase 5. Study quality assessment. In: University of York
NHS Centre for Reviews and Dissemination; 2001.
5. Madianos PN, Lieff S, Murtha AP, et al. Maternal peri-
odontitis and prematurity. Part II: Maternal infection and
fetal exposure. Ann Periodontol 2001;6:175-182.
6. Jeffcoat MK, Geurs NC, Reddy MS, Cliver SP, Goldenberg
RL, Hauth JC. Periodontal infection and preterm birth:
Results of a prospective study. J Am Dent Assoc 2001;
132:875-880.
7. López NJ, Smith PC, Gutierrez J. Periodontal therapy
may reduce the risk of preterm low birth weight in
women with periodontal disease: A randomized con-
trolled trial. J Periodontol 2002;73:911-924.
8. López NJ, Smith PC, Gutierrez J. Higher risk of preterm
birth and low birth weight in women with periodontal
disease. J Dent Res 2002;81:58-63.
9. Mitchell-Lewis D, Engebretson SP, Chen J, Lamster IB,
Papapanou PN. Periodontal infections and pre-term birth:
Early findings from a cohort of young minority women
in New York. Eur J Oral Sci 2001;109:34-39.
10. Offenbacher S, Jared HL, O’Reilly PG, et al. Potential
pathogenic mechanisms of periodontitis-associated preg-
nancy complications. Ann Periodontol 1998;3:233-250.
11. Davenport ES, Williams CECS, Sterne JAC, Murad S,
Sivapathasundram V, Curtis MA. Maternal periodontal
disease and preterm low birthweight: Case-control study.
J Dent Res 2002;81:313-318.
12. Dasanayake AP. Poor periodontal health of the pregnant
woman as a risk factor for low birth weight. Ann Peri-
odontol 1998;3:206-212.
13. Romero BC, Chiquito CS, Elejalde LE, Bernardoni CB.
Relationship between periodontal disease in pregnant
women and the nutritional condition of their newborns.
J Periodontol 2002;73:1177-1183.
14. Dasanayake AP, Boyd D, Madianos PN, Offenbacher S,
Hills E. The association between Porphyromonas gingivalis-
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specific maternal serum IgG and low birth weight. J Peri-
odontol 2001;72:1491-1497.
15. Offenbacher S, Lieff S, Boggess KA, et al. Maternal peri-
odontitis and prematurity. Part I: Obstetric outcome of
prematurity and growth restriction. Ann Periodontol
2001;6:164-174.
Correspondence: Dr. Frank A. Scannapieco, Department of
Oral Biology, School of Dental Medicine, University at Buffalo,
State University of New York, 109 Foster Hall, Buffalo, NY
14214. Fax: 716/829-3942; e-mail: fas1@buffalo.edu.
Accepted for publication August 8, 2003.
APPENDIX A
CONSENSUS REPORT
Members of the Section read and studied the review
titled “Periodontal Disease as a Risk Factor for Adverse
Pregnancy Outcomes: A Systematic Review,” by Frank
A. Scannapieco, Renee B. Bush, and Susanna Paju.
The focused PICO question addressed by this evidence-
based systematic review is: “Does prevention/treatment
of periodontal disease as compared to controls have
an impact on the initiation/progression of adverse
pregnancy outcomes?”
1. Does the Section agree that the evidence-based
systematic review is complete and accurate?
Yes. Members of the Section unanimously agreed that
the systematic review was complete and accurate as of
October 1, 2002.
2. Has any new information been generated or
discovered since the evidence-based search cut-off
date?
Yes. Madianos et al. conducted a systematic review and
concluded that the heterogeneity in study design and
periodontitis measurements did not allow for meta-
analysis of the relationship between periodontal dis-
ease and preterm delivery.1 They also concluded that
the evidence linking periodontitis as a risk factor for
abnormal pregnancy outcome is limited, which is in
agreement with the current systematic review.
Romero et al. reported that among 56 pregnant
women the presence of maternal periodontal disease
was associated with a decrease in birth weight and
gestational age at delivery, and the strength of the
association increased in parallel with the severity of
maternal periodontal disease.2
In addition to the relationship between periodontal
disease and preterm delivery and fetal growth restric-
tion, new findings indicate a potential relationship of
periodontal disease and its progression with preeclamp-
sia.3 Results from a prospective study (OCAP, Oral
Conditions and Pregnancy) of 1,115 pregnant women
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Ann Periodontol
indicated that women were at higher risk for preeclamp-
sia if they had moderate to severe periodontal disease
at delivery (adjusted OR 2.4; 95% CI, 1.1 to 5.3), or
worsening of periodontal status during pregnancy
(adjusted OR 2.1; 95% CI, 1.0 to 4.4). The authors
concluded that after adjusting for other obstetric or
periodontal risk factors the progression of periodonti-
tis during pregnancy is associated with an increased risk
for developing preeclampsia.3
3. Does the Section agree with the interpretations
and conclusions of the reviewers?
Yes, there was general agreement that the data sup-
ported a positive association between periodontal dis-
ease and adverse pregnancy outcomes. However, the
data for a positive association were limited to 2 large
prospective studies4,5 and 1 study on a London-
dwelling Bengali population showing no association.6
The 2 large prospective studies, each with over 1,000
pregnant women, demonstrate that periodontal dis-
ease appears to be an independent risk factor for
preterm delivery.4,5 However, not all patient popula-
tions appear to be at increased risk based upon clin-
ical measures of periodontal disease.6 Measures of
clinical periodontal disease vary considerably across
studies, however, inclusion of assessments of peri-
odontal microbial infection (e.g., fetal IgM antibody)
as an exposure during pregnancy appears to
strengthen the relationship to preterm delivery.7 Cau-
tion in the interpretation of these associations appears
warranted, as confounding factors such as smoking
may obfuscate these relationships. Due to the high
social and economic costs of preterm deliveries the
role of infection of oral origin in the pregnant popu-
lation may make these associations potentially impor-
tant in a public health context. To date it is unclear
as to whether periodontal disease as a maternal-fetal
exposure can contribute to impaired placentation,
preterm rupture of membranes, premature labor, or
neonatal morbidity. It is unclear whether periodontal
disease is causally related to adverse pregnancy out-
comes or whether the risk is equivalent across all pop-
ulation groups.
Pilot studies suggest that periodontal therapy may
have the potential to reduce the incidence of preterm,
low birth weight deliveries. However, as stated by
Madianos et al., “There is a clear need for well-
designed observational and interventional studies to
confirm these observations and explore the validity of
the associations in diverse populations, establish
whether they are causal in nature and determine the
potential benefits of periodontal intervention in reduc-
ing the risk for these conditions”.1 If such studies iden-
tify periodontal disease as a modifiable cause of preg-
nancy complications, the medical need for periodontal
care in obstetric management would be justified.
Scannapieco, Bush, Paju
3. What further research needs to be done relative
to the focused question of the evidence-based
review?
Our recommendation is that additional epidemiologic or
case-control studies be conducted in high-risk populations
of different ethnic or racial origins and geographical envi-
ronments to assess the generalizability of the observed
association of maternal periodontal diseases and adverse
pregnancy outcomes. For example, the high prevalence
of periodontal disease among African Americans may, in
part, explain the observed racial disparity in the high rate
of prematurity in this population.
RCTs are underway to determine whether the treat-
ment or prevention of periodontal infection and inflam-
mation reduces the risk of adverse pregnancy outcomes.
Additional studies will be needed to elucidate the mech-
anisms of pathogenesis and biological effects of therapy.
Other studies should be conducted to determine the
effects of maternal periodontal disease on additional
obstetric outcomes such as preeclampsia as well as
neonatal outcomes (e.g., lung disease of prematurity
and neurological deficits).
Because of the high prevalence of gingival and peri-
odontal disease among pregnant women relative to
other obstetric risk factors and the strength of the
association, periodontal disease may serve as a con-
founder in other studies of obstetric risk and response
to therapies designed to reduce the incidence of
preterm delivery, growth restriction and preeclampsia.
Therefore, we strongly recommend that periodontal
assessments should be a component of obstetric stud-
ies. It is recommended that efficient, inexpensive, and
validated tools be developed to assess periodontal
disease as a systemic exposure for such large scale
trials.
5. How can the information from the evidence-
based review be applied to patient management?
The Section is in agreement with the current systematic
review that concludes that maternal periodontal disease
is associated with adverse pregnancy outcomes among
certain patient populations. Preliminary evidence also
suggests that periodontal intervention during preg-
nancy may reduce the incidence of adverse pregnancy
outcomes in these populations.8-10 This latter finding
is further supported by additional pilot intervention
studies that have been published (or in press) since the
review.
A. There is evidence to suggest that periodontal dis-
ease is associated with adverse pregnancy outcomes,
however causality is unclear.
Level of Evidence:11 Moderate.
Rationale: There are 3 level I studies and 10 level II
studies that demonstrate moderate to strong associa-
tions between periodontal disease and adverse preg-
nancy outcomes. Some benefits of periodontal therapy
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Periodontal Disease as a Risk Factor for Adverse Pregnancy Outcomes Volume 8 • Number 1 • December 2003

have been reported. The level I studies are pilot in
nature and do not represent definitive multi-centered
RCTs. The results of 2 pivotal trials currently in progress
serve to strengthen the association.4,5 In addition the
association among African Americans is particularly
strong while one study in a London-dwelling Bengali
population has reported no association.6
B. There is currently limited evidence to recommend
that patients undergo periodontal treatment to reduce
the risk of adverse pregnancy outcomes.
Level of Evidence: Limited.
Rationale: The assignment of a “limited” level of
evidence is based upon the fact that the 3 level I studies
are pilot in nature and do not represent definitive multi-
centered RCTs.
7. Madianos PN, Lieff S, Murtha AP, et al. Maternal peri-
odontitis and prematurity. Part II. Maternal infection and
fetal exposure. Ann Periodontol 2001;6:175-182.
8. Mitchell-Lewis D, Engebretson SP, Chen J, Lamster IB,
Papapanou PN. Periodontal infections and pre-term birth:
Early findings from a cohort of young minority women
in New York. Eur J Oral Sci 2001;109:34-39.
9. López NJ, Smith PC, Gutierrez J. Higher risk of preterm
birth and low birth weight in women with periodontal
disease. J Dent Res 2002;81:58-63.
10. López NJ, Smith PC, Gutierrez J. Periodontal therapy
may reduce the risk of preterm low birth weight in women
with periodontal disease: A randomized controlled trial.
J Periodontol 2002;73:911-924.
11. Newman MG, Caton J, Gunsolley JC. The use of the evi-
dence-based approach in a periodontal therapy con-
temporary science workshop. Ann Periodontol 2003;8:
1-11.

Concluding Remarks SECTION MEMBERS

In light of the strength and consistency of the associ- Gary Greenstein, Group Leader Thomas Hart
ation between periodontal disease and adverse preg- Steven Offenbacher, Chair Brian L. Mealey
nancy outcomes and the overall benefits of oral health, Denis Kinane, Secretary Richard J. Nagy
it is the opinion of Section members that patients and
Frank A. Scannapieco, Reviewer Maria E. Ryan
health care providers should be informed that peri-
Robert J. Genco Mark I. Ryder
odontal intervention may prevent adverse pregnancy
outcomes. Raul Garcia Marc Shlossman
Barbara Steinberg
REFERENCES
1. Madianos PN, Bobetsis GA, Kinane DF. Is periodontitis
associated with an increased risk of coronary heart dis-
ease and preterm and/or low birth weightbirths? J Clin
Periodontol 2002;29(Suppl. 3):22-36.
2. Romero BC, Chiquito CS, Elejalde LE, Bernardoni CB.
Relationship between periodontal disease in pregnant
women and the nutritional condition of their newborns.
J Periodontol 2002;73:1177-1183.
3. Boggess KA, Lieff S, Murtha AP, Moss K, Beck J,
Offenbacher S. Maternal periodontal disease is associ-
ated with an increased risk of preeclampsia. Obstet
Gynecol 2003;101:227-231.
4. Jeffcoat MK, Geurs NC, Reddy MS, Cliver SP, Goldenberg
RL, Hauth JC. Periodontal infection and preterm birth.
Results of a prospective study. J Am Dent Assoc 2001;
132:875-880.
5. Offenbacher S, Lieff S, Boggess KA, et al. Maternal peri-
odontitis and prematurity. Part I: Obstetric outcome of
prematurity and growth restriction. Ann Periodontol
2001;6:164-174.
6. Davenport ES, Williams CECS, Sterne JAC, et al. Mater-
nal periodontal disease and preterm low birthweight:
Case-control study. J Dent Res 2002;81:313-318.

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