| Abstract|| |
Context: Preterm low-birth-weight (PLBW) infants are at a higher risk for a number of acute and chronic disorders. Studies point to an association between periodontal infection and increased rates of preterm birth, and pregnant mothers with periodontal diseases are at increased risk of subsequent preterm birth or low birth weight. However, the awareness level of gynecologists about this relationship is unknown.
Aims: The aim of the present survey was to assess the awareness about the effects of periodontal disease on pregnancy among practicing gynecologists, and also compare such awareness between gynecologists in two places-Khammam (a district headquarter) and Hyderabad (a state capital).
Settings and Design: Random, cross-sectional study in a population of practicing gynecologists from Andhra Pradesh.
Materials and Methods: A random study population was selected from the practicing gynecologists in Khammam and Hyderabad. Sixty practicing gynecologists, 30 each in Khammam and Hyderabad, were approached and they consented to join the study. Data were collected in questionnaire format from the subject population. Collected data were statistically analyzed. Chi-square test with Yates correction was used to analyze the data. A " P" value of <0.05 was taken as a significant difference.
Results: 73.3% of the gynecologists said that their patients complain of bleeding gums, swellings and mobility. 58.3% of the gynecologists were aware that gum diseases occur at a higher rate in pregnant females. 38.3% of the gynecologists were aware that periodontal diseases can affect the outcome of delivery. No significant difference was found between the awareness levels of gynecologists in Khammam and in Hyderabad.
Conclusions: There is a need for interdisciplinary approach for the prevention of PLBW cases by the integration of periodontal care into obstetric management. Effort should be made to increase awareness among the gynecologists.
Keywords: Awareness, gynecologists, periodontal disease, pregnant, preterm low birth weight
|How to cite this article:|
Nutalapati R, Ramisetti A, Mutthineni RB, Jampani ND, Kasagani SK. Awareness of association between periodontitis and PLBW among selected population of practising gynecologists in Andhra Pradesh. Indian J Dent Res 2011;22:735
Low birth weight (LBW) is weight under 2500 g at birth and preterm delivery is delivery before 37 weeks of gestation.  Gingivitis is inflammation of the gingiva.  Periodontitis is an inflammatory disease of the supporting tissues of the teeth, caused by specific microorganisms or groups of specific microorganisms, resulting in progressive destruction of the periodontal ligament and alveolar bone with pocket formation, recession, or both. 
|How to cite this URL:|
Nutalapati R, Ramisetti A, Mutthineni RB, Jampani ND, Kasagani SK. Awareness of association between periodontitis and PLBW among selected population of practising gynecologists in Andhra Pradesh. Indian J Dent Res [serial online] 2011 [cited 2015 Nov 27];22:735. Available from: http://www.ijdr.in/text.asp?2011/22/5/735/93474
Pregnant women with periodontal disease may be at increased risk for having preterm low-birth-weight (PLBW) children.  Estimates suggest that 18.2% of all PLBW cases may be attributable to periodontal disease.  Studies have shown that periodontal disease is present before the preterm low-weight birth (a necessary condition for causation) and the patients with the most severe periodontal disease have the greatest risk for pre-term low-weight births even after adjusting for known risk factors. ,,,,
Preterm birth associated with LBW represents the major cause of neonatal mortality and, among survivors, a major contributor to long-term disability. , Globally, about 16% (more than 200 million) of the babies born are LBW cases.  PLBW infants are at a higher risk for a number of acute and chronic disorders, including respiratory distress syndrome, cerebral palsy, pathologic heart conditions, epilepsy and severe learning problems. ,
Multiple factors have been associated with preterm delivery and LBW.  Maternal risk factors include age, height, weight, socioeconomic status, ethnicity, smoking, alcohol, nutritional status, and stress.  Social, demographic, and reproductive risk factors for preterm birth include low socioeconomic status, maternal smoking, maternal infections, young maternal age (<20 years of age), older maternal age (>35 years), and multiple pregnancy.  In addition, parity, birth interval, previous complications, pre- and ante-natal care, maternal hypertension, infections, and cervical incompetence may also be important. 
In spite of all the facts presented, the awareness of practicing gynecologists about this relationship (between periodontal disease and PLBW) is not known. As a higher level of awareness among the gynecologists would improve the diagnosis and prognosis of PLBW and the related effects, it is essential to estimate the awareness levels of practicing gynecologists to this end. This study was conducted with the objective of assessing the awareness about the effects of periodontal disease on pregnancy among the practicing gynecologists and also comparing such awareness between gynecologists in two places - Khammam and Hyderabad.
| Materials and Methods|| |
Subjects and sampling
This study was a randomized, cross-sectional, collateral study conducted in Khammam and Hyderabad in the first quarter of 2009. A study population was selected from the practising gynecologists in Khammam and Hyderabad. Sixty gynecologists, 30 each from Khammam and Hyderabad took part in the study. The data were collected based on a questionnaire format. The principal investigator approached the gynecologists individually and distributed the questionnaires by hand after obtaining their consent. The questionnaires were answered and sent back to the investigator.
The questionnaire had 14 queries [Box 1]. The questionnaire was filled by all the subjects who took part in the study. Questions 4, 5, 10, and 12-14 assessed the awareness of the subjects about the current interrelationship and their willingness to update themselves with the latest advances. Questions 6-9, and 11 assessed the clinical approach of the subjects in diagnosis and treatment planning.
Chi-square test with Yates correction was used to analyze the data. A "P " value of <0.05 was taken as a significant difference. Questions 1-3, 5, and 7 were not statistically compared for both groups as they were non-contributory to the results of the study.
| Results|| |
A total of 60 gynecologists, 30 each from Khammam and Hyderabad, took part in the survey. The results obtained are summarized in [Table 1] and [Figure 1].
Twenty gynecologists in Khammam and 28 gynecologists in Hyderabad had private practices. On an average, gynecologists in Khammam and Hyderabad saw 15 and 21 patients daily and 7 and 5 cases of PLBW per month, respectively (numerical values rounded off to the nearest whole number).
Fifty-eight gynecologists were aware of gum (periodontal) disease, of whom 25 noticed some kind of gum disease in their patients [Figure 2]. Forty-four gynecologists said that their patients regularly complained of bleeding gums, small swellings and mobile teeth, and 36 of them referred their patients to an oral health care professional [Figure 3].
|Figure 2: Awareness of gynecologists about the current relationship and willingness to update themselves with latest advances|
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|Figure 3: Assessment of the approach of gynecologists to clinical diagnosis and treatment planning|
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Thirty-five gynecologists were aware that periodontal diseases occur at a higher rate in pregnant females [Figure 2], but only 21 of them made their patients aware of such relationship [Figure 3]. Twenty-three gynecologists were aware that periodontal disease could affect the outcome of delivery. Only 18 had come across this relationship in their journals, newsletters or during CMEs, and none of the 60 gynecologists who took part in the survey had ever worked or presented on this relationship.
The level of awareness between the gynecologists of Khammam and Hyderabad was not significantly different.
| Discussion|| |
Evidence has shed light on the potential effects of periodontal disease on a wide range of organ systems. The field of periodontal medicine addresses two important questions:
- Can periodontitis have an effect remote from the oral cavity? and
- Is periodontitis a risk factor for systemic diseases that affect human health?  The incidence of PLBW cases remains one of the most commonly addressed issues in periodontal medicine.
Multiple lines of evidence support a role for infection as an etiologic factor in preterm birth.  Evidence has associated preterm birth with genito-urinary infections, which appear to be an important factor in the premature rupture of membranes.  Microorganisms may gain direct access to the amniotic fluid and fetus in several waysscending via the vagina through the cervix into the choriodecidual sac during pregnancy, via the endometrium which may be chronically infected prior to pregnancy, or alternatively through a hematogenous route. 
In humans, there have been several recent observational studies that show a significant association between periodontal disease and adverse pregnancy outcome including preterm birth, preterm prelabor rupture of the membranes (PPROM), pre-eclampsia and post-cesarean endometritis.  To date, many studies have demonstrated the effect of maternal periodontal disease on the outcome of delivery. However, very little information is available regarding the awareness levels of gynecologists about this particular relationship.
Periodontal infections are preventable and treatable. Therefore, periodontitis can be viewed as a modifiable risk factor.  Attempts are now being made to use advances in our understanding of physiological processes during periodontal disease to reduce the number of preterm low-weight births.  Integration of periodontal care into obstetric management may improve pregnancy outcomes as early intervention may reduce the microbial challenge to oral tissues already altered due to hormonal changes. 
A study conducted by Shenoy et al.,  in Mangalore, India, assessed the gynecologists' knowledge of periodontal disease as a risk factor in PLBW. The study showed that while knowledge regarding periodontal infection as a potential risk factor for systemic complications, importance of regular dental check-ups, and the oral manifestations of periodontal disease was high, awareness regarding periodontal disease as a risk factor in PLBW was low.
Khammam, a district headquarter (of Khammam District), is a town in the northern part of Andhra Pradesh, close to Chhattisgarh and Orissa. Being a district headquarter, most health care facilities are concentrated in Khammam and people from all over the district visit Khammam. In contrast, Hyderabad is a state capital located in the central part of Andhra Pradesh, close to Karnataka on its west. Being a state capital, Hyderabad has seen a lot of development in the field of medicine. Corporate hospitals are abundant in the city and there is no dearth of the availability of latest facilities in medicine as well as dentistry. In comparison to their counterparts in Khammam, gynecologists in Hyderabad have easy access to new literature as well as newer technology. Also, because of the heavy competition, all of them try to keep themselves updated about the latest happenings in their field of expertise. Thus, it seemed probable that more number of gynecologists in Hyderabad would be aware of periodontal diseases in pregnant women and of the ill effects of such disease in the newborn. However, the present study showed that the level of awareness between gynecologists of Khammam and Hyderabad was not significantly different.
Among the practicing gynecologists in Khammam and Hyderabad, knowledge regarding the higher incidence of periodontal diseases in pregnant women was moderate (58.3%), in spite of 96.6% of them being aware of periodontal diseases in general. Only 41.6% of gynecologists noticed periodontal diseases in their patients, indicating that not all practicing gynecologists were keen on examining the periodontal status of their pregnant patients. Awareness regarding periodontal disease as a risk factor for PLBW was low (38.3%). This indicates that a considerable section of the gynecologists did not relate periodontal diseases to adverse pregnancy outcomes. Also, not all of the gynecologists who were aware of such a relationship were willing to extend the awareness to their patients or opt for an interdisciplinary approach. Referral to an oral health care professional was low and was based mainly on the complaint of the patient and not on the awareness of the gynecologist about the possible relationship of periodontal disease and delivery outcome. Non-referral cases were treated symptomatically with analgesics and anti-inflammatory drugs by the consulted gynecologists.
The results of the present study throw light on the lack of interdisciplinary approach between medical and dental professionals, especially in regards to overall maternal health care. The need of the hour is the integration of periodontal care in obstetric management as a preventive approach to PLBW. Within the limits of this study, it can be suggested that posting of oral health care professionals in gynecology wings on a mandatory basis will help in improving the awareness of interrelationship between periodontal diseases and outcome of delivery among gynecologists. This will also encourage the referral of such patients to periodontists by gynecologists, thus ensuring a systematic and synchronized maternal health care rather than a symptomatic approach. Continuing dental and medical education programs should be conducted, and periodontists and gynecologists should actively participate in such programs. The subject of periodontal diseases in pregnant women should be included in the obstetric curriculum and an interdisciplinary approach to the prevention of PLBW should be encouraged.
Certain limitations exist in this study. First, the sample size was too small to make definite conclusions on the issue. Secondly, the responses obtained did not necessarily reflect the actual opinions of the participating gynecologists owing to bias on their part. Also, the actual oral health status of the pregnant women who visited these gynecologists could not be assessed and was based purely on the memory of the participating gynecologists. Therefore, it may not be possible to extrapolate the results of this study to other settings.
| Conclusion|| |
Although some gynecologists are aware of the higher prevalence of periodontal diseases in pregnant women and also of the risk of periodontal disease to the outcome of delivery, not all of them opt for a multidisciplinary approach along with an oral health care professional. Efforts should be made to increase the awareness about this relation and encourage a bilateral, interdisciplinary protocol for the prevention of PLBW cases by the integration of periodontal care with obstetric management, thereby reducing the incidence of maternal and neonatal complications.
| Acknowledgments|| |
The authors wish to acknowledge Dr. Inam ul Haq, Assistant Professor, Department of Community Medicine, Mamata Dental College, for help in the design and analysis of the study.
| References|| |
|1.||Davenport ES, Williams CE, Sterne JA, Murad S, Sivapathasundram V, Curtis MA. Maternal periodontal disease and preterm low birth weight: Case-control study. J Dent Res 2002;81:313-8. |
|2.|| Beck JD, Arbes SJ Jr. Epidemiology of gingival and periodontal diseases. In: Newmann MG, Takei HH, Klokkevold PR, Carranza FA, editors. Clinical periodontology, 10 th ed, Philadelphia: Saunders (Elsevier); 2006. p. 115. |
|3.|| John NM. Classification of diseases and conditions affecting the periodontium. In: Newmann MG, Takei HH, Klokkevold PR, Carranza FA, editors. Clinical Periodontology, 10 th ed, Philadelphia: Saunders (Elsevier); 2006. p. 103-4. |
|4.|| Rai B, Kharb S, Anand SC. Is periodontal disease a risk factor for onset of preclampsia and fetal outcome? Adv Med Dent Sci 2008;2:16-9. |
|5.|| Offenbacher S, Katz V, Fertik G, Collins J, Boyd D, Maynor G. Periodontal infection as a possible risk factor for preterm low birth weight. J Periodontol 1996;67:1103-13. |
|6.|| Offenbacher S, Lieff S, Boggess KA, Murtha AP, Madianos PN, Champagne CM, et al. Maternal periodontitis and prematurity, Part I: Obstetric outcome of prematurity and growth restriction. Ann Periodontol 2001;6:164-74. |
|7.|| Jeffcoat MK, Geurs NC, Reddy MS, Goldenberg RL, Hauth JC. Current evidence regarding periodontal disease as a risk factor in preterm birth. Ann Periodontol 2001;6:183-8. |
|8.|| Dasanayake AP. Poor periodontal health of the pregnant woman as a risk factor for low birth weight. Ann Periodontol 1998;3:206-12. |
|9.|| Moreu G, Téllez L, González-Jaranay M. Relationship between maternal periodontal disease and low-birth-weight pre-term infants. J Clin Periodontol 2005;32:622-7. |
|10.|| Khader YS, Taani Q. Periodontal diseases and the risk of preterm birth and low birth weight: A meta-analysis. J Periodontol 2005;76:161-5. |
|11.|| Crowther CA, Thomas N, Middleton P, Chua MC, Esposito M. Treating periodontal disease for preventing preterm birth in pregnant women. Cochrane Database Syst Rev 2005;2:CD005297. |
|12.|| Lopez NJ, Smith PC, Gutierrez J. Periodontal therapy may reduce the risk of preterm low birth weight in women with periodontal disease: A randomized control trial. J Periodontol 2002;73:911-24. |
|13.|| Mealey BL, Klokkevold PR. Periodontal medicine: Impact of periodontal infection on systemic health. In: Newmann MG, Takei HH, Klokkevold PR, Carranza FA, editors. Clinical Periodontology, 10 th ed, Philadelphia: Saunders (Elsevier), 2006: 312. |
|14.|| Shenoy RP, Nayak DG, Sequeira PS. Periodontal disease as a risk factor in pre-term low birth weight: An assessment of gynecologists' knowledge: A pilot study. Indian J Dent Res 2009;20:13-6. |
Department of Periodontics, Mamata Dental College, Giriprasadnagar, Khammam, Andhra Pradesh
Source of Support: None, Conflict of Interest: None
[Figure 1], [Figure 2], [Figure 3]