Maternal Oral Health Experiences and Risk of Preterm Birth

In This Article

Abstract and Introduction

Abstract

The aim of this study is to investigate the association between oral health experiences of women in the peripartum period and the risk of preterm delivery (<37 weeks). We analyzed 2004–2006 data from the CDC Pregnancy Risk Assessment Monitoring System (PRAMS), a population-based surveillance system that collects data on pregnancy and postpartum experiences of mothers who have recently delivered a live infant. Ten states included in the analysis had a ≥70% weighted response rate and three standard questions pertaining to oral health. White non-Hispanic (WNH), Black non-Hispanic (BNH), and Hispanic women were selected for analysis. Chi-squared analysis was performed for our bivariate analysis and multivariate logistic regression models were created to calculate adjusted odds ratios, controlling for socio-demographic characteristics and peripartum morbidities. Weighted percentages and standard errors were used for all analyses. Among the 35,267 women studied, in the multivariate analysis, mothers who did not receive dental care during pregnancy and did not have a teeth cleaning during pregnancy were at higher risk for delivering a preterm infant (OR 1.15, CI 1.02–1.30; OR 1.23, CI 1.08–1.41). In this population-based study, women who did not receive dental care or have a teeth cleaning during pregnancy were at slightly higher risk for preterm delivery after adjustment for pertinent confounders.

Introduction

Improving the oral health of the US population has become a major public health issue. Recent studies have demonstrated that overall health cannot be achieved without oral health. For instance, periodontal disease has been implicated in the increased risk for coronary artery disease and stroke.^[1–3] For pregnant women, achieving and maintaining periodontal health also has additional implications for pregnancy outcome. Periodontal disease has been shown in some studies to contribute to a higher risk of preterm birth. The Oral Conditions and Pregnancy (OCAP) Study, a prospective observational study, has shown that maternal periodontal disease and disease progression during pregnancy conferred a significant increased risk for preterm delivery.^[4,5] The proposed mechanism involves the up-regulation of inflammatory markers in the mother as well as the fetus secondary to oral infection.^[6] Infection and inflammation have been shown to be important risk factors in causing preterm birth.^[7] However, significant controversy still exists; the most recent clinical trials which treated pregnant women with periodontal disease during their second trimester has shown no difference in rates of preterm birth when compared to untreated mothers.^[8–10] In these clinical trials, treatment took place in the second trimester, perhaps too late to reverse the lifelong exposure of poor oral health experienced by some pregnant women, thus offering some explanation for the discrepancy in results from longitudinal cohort studies and randomized clinical trials. Instead of treating active oral infection during pregnancy to prevent preterm birth, the maintenance of oral health to prevent disease before and during pregnancy may yield more significant results. This argument receives support from a recently published population-based study by Albert et al.^[11] in which, women who received preventive dental care during the study's period of observation, which included the time period prior to delivery, were less likely to deliver preterm or low birth weight infants. This study, however, included only privately insured women of mid to high socioeconomic status. Given that privately insured individuals are more likely to receive preventive dental services,^[12] the positive effect of dental care during pregnancy in potentially improving birth outcomes may have been biased toward the null given that these women may already have had optimal dental health.

In this report, we assess the association of maternal oral health experiences and the risk of preterm delivery in a population-based multi-state cohort of mothers of varying insurance and socioeconomic status.

Springer Science+Business Media

Table 1. PRAMS oral health questions
1. This question is about the care of your teeth during your most recent pregnancy. For each item, circle Y (Yes) if it is true or circle N (No) if it is not true.
a. I needed to see a dentist for a problem.
b. I went to a dentist or dental clinic.
c. A dental or other health care worker talked with me about how to care for my teeth and gums.
2. Have you ever had your teeth cleaned by a dentist or dental hygienist?
3. When did you have your teeth cleaned by a dentist or dental hygienist? For each of the three time periods, circle Y (Yes) if you had your teeth cleaned then or circle N (No) if you did not have your teeth cleaned then.
a. Before my most recent pregnancy.
b. During my most recent pregnancy.
c. After my most recent pregnancy.

Table 2. Characteristics of study cohort
	Weighted %	SE
Race
WNH	79.12	0.36
BNH	13.60	0.30
Hispanic	7.28	0.25
Age (years)
<20	8.59	0.27
20–34	78.01	0.40
≥35	13.40	0.33
Education (years)
0–8	2.46	0.16
9–11	12.12	0.32
12	29.58	0.43
13–15	27.33	0.41
≥16	28.51	0.41
Annual Income
<$10,000	18.69	0.37
$10–19,999	15.92	0.35
$20–34,999	18.25	0.36
$35–49,999	12.15	0.30
>$50,000	34.99	0.44
Insurance before pregnancy
Private	61.58	0.45
Medicaid	13.99	0.34
Uninsured	24.43	0.40
Adequacy of prenatal care index
Inadequate	8.83	0.27
Intermediate	11.51	0.31
Adequate	46.69	0.47
Adequate plus	32.97	0.44
Smoking during pregnancy	18.30	0.38
Diabetes before pregnancy	1.81	0.12
Diabetes during pregnancy	8.99	0.27
Hypertension (before/during pregnancy)	13.64	0.31
Kidney/bladder infection	20.70	0.38
Placental problems	4.97	0.20

Table 3. Infant characteristics
	Weighted %	SE
Gestational age: <37 weeks	9.07	0.21
Birthweight: <2,500 grams	6.86	0.06
Plurality: twins or more	1.68	0.08
NICU admission	10.38	0.25

Table 4. Oral health experiences of study cohort
	Weighted %	SE
Tooth problem during pregnancy	26.35	0.41
Sought dental care during pregnancy	44.21	0.47
Received dental counseling during pregnancy	41.16	0.46
Ever had teeth cleaning	94.25	0.21
Teeth cleaning before pregnancy	80.94	0.38
Teeth cleaning during pregnancy	39.96	0.48
Teeth cleaning after pregnancy	33.31	0.47

Table 5. Bivariate analysis: preterm birth and maternal oral health practices
	≥37 Weeks weighted %	<37 Weeks weighted %	P-value
Teeth problem	26.17	28.24	0.073
Went for care	44.70	39.34	<0.0001
Dental counseling	41.36	39.23	0.099
Teeth clean-ever	94.28	93.93	0.530
Teeth clean-bef	81.13	79.11	0.048
Teeth clean-dur	40.65	32.98	<0.0001

Significance for P-values was 0.05

Table 6. Adjusted odds ratio and 95% confidence interval
	Preterm birth
Teeth problem	1.00 (0.87–1.14)
Did not seek care	1.15 (1.02–1.30)
Did not receive dental counseling	1.06 (0.94–1.20)
No teeth clean—ever	0.96 (0.77–1.20)
No teeth clean—before	1.09 (0.94–1.27)
No teeth clean—during	1.23 (1.08–1.41)

Significance for P-values was 0.05 * Adjusted for age, income, education, insurance status before pregnancy, adequacy of prenatal care, smoking, multiple gestation, maternal morbidities: diabetes, hypertension, placental problems, kidney/bladder infections

Table 7. Relative contributions for model assessing the association of dental care during pregnancy and preterm birth
Variable	Relative contribution (%)
Dental care during pregnancy	<1
Age	<1
Race	2.7
Income	<1
Maternal education	<1
Insurance	<1
Smoking	<1
Multiples	26.9
Diabetes before or during pregnancy	<1
Kidney/bladder infection	<1
Placental problems	8.2
Blood pressure	5.1
Inadequate, intermediate, adequate plus PNC	54.7

Table 8. Relative contributions for model assessing the association of teeth cleaning during pregnancy and preterm birth
Variable	Relative contribution (%)
Teeth cleaning during pregnancy	8.3
Age	<1
Race	3.0
Income	<1
Maternal education	<1
Insurance	<1
Smoking	<1
Multiples	24.9
Diabetes before or during pregnancy	<1
Kidney/bladder infection	<1
Placental problems	7.9
Blood pressure	4.5
Inadequate, intermediate, adequate plus PNC	49.1