MORE ABOUT PREGNANCY

MORE ABOUT PREGNANCY

COMMENTARY ings to the extant science. Because the hypothesis tested in most studies fails to mimic any reasonable approach to managing periodontitis...

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COMMENTARY

ings to the extant science. Because the hypothesis tested in most studies fails to mimic any reasonable approach to managing periodontitis, it’s the wrong question on that count as well. By this I mean that a single treatment consisting of scaling and root planing (SRP) alone—the sole intervention in most of these studies—produces little or no lasting improvement in a patient’s periodontal health. Therefore, the intervention used in most of these studies is not what would be performed in clinical practice, where self-care instructions, follow-up monitoring and additional periodontal therapy (if needed) would be the norm. Indeed, the 2010 findings of Macones and colleagues,2 namely that SRP may actually prompt PTW/LBW deliveries, is plausible insofar as SRP will induce a bacteremia and temporarily increase a patient’s systematic inflammatory load that may help induce premature labor. Furthermore, the beneficial effects of periodontal therapy that include enhanced personal oral hygiene, such as that reported by Offenbacher and colleagues3 in 2006, suggest that most other studies haven’t tested the appropriate clinical question, namely: if my patient is pregnant and has periodontitis, should I endeavor to bring her to optimal periodontal health during her pregnancy or not? My educated guess, despite this well-done systematic review, remains “yes.” Michael P. Rethman, DDS, MS Adjunct Assistant Professor, College of Dentistry The Ohio State University Columbus and Adjunct Assistant Professor Baltimore College of Dental Surgery

University of Maryland and Vice-President (Scientific Research) American Dental Association Foundation Honolulu 1. Goldenberg RL, Culhane JF. Preterm birth and periodontal disease. N Engl J Med 2006;355(18):1925-1927 2. Macones GA, Parry S, Nelson DB, et al. Treatment of localized periodontal disease in pregnancy does not reduce the occurrence of preterm birth: results from the Periodontal Infections and Prematurity Study (PIPS). Am J Obstet Gynecol 2010;202(2): 147.e141-147e-148. 3. Offenbacher S, Lin D, Strauss R, et al. Effects of periodontal therapy during pregnancy on periodontal status, biologic parameters, and pregnancy outcomes: a pilot study. J Periodontol 2006;77(12):2011-2024.

MORE ABOUT PREGNANCY

Dr. Anna Uppal and colleagues’ rigorous systematic review in December JADA, “The Effectiveness of Periodontal Treatment During Pregnancy in Reducing the Risk of Experiencing Preterm Birth and Low Birth Weight: A Meta-analysis” (Uppal A, Uppal S, Printo A, et al. JADA 2010;141[12]: 1423-1434), ends by suggesting stricter criteria for diagnosing periodontitis and guidelines for documenting the effectiveness of periodontal treatment in decreasing preterm births (PTBs) and low birth weight (LBW). Agreed. I would like to add adequate criteria to stricter criteria. The pathophysiology postulated is increased inflammatory response and maternal bacteremia along with placental transmission. If the goal of such research is to evaluate the effect of periodontal treatment in decreasing PTB and LBW by decreasing inflammation, then the criterion for patient selection should be expectant mothers who have enough inflammation that would cause you concern to expect a PTB or low birth weight; that is, women at risk. Yet the criteria in Table 1 JADA 142(5)

LETTERS

indicate that most of the researchers evaluated results in patients with one or more 4-millimeter or 5-mm pocket depths, clinical attachment loss (CAL) and/or bleeding on probing (BOP). Each of these criteria can be present without inflammation—for example, a physiological 4-mm probing, a 5-mm restorative pocket, gingival recession or postperiodontal treatment CAL, or a site with BOP when examining six sites per tooth in a patient with 28 or 32 teeth. No inflammation, no risk. I suggest that future research continue regarding our profession’s role in trying to have a positive effect on the problem of PTB and LBW infants, many of whom become special-care patients. Successful intervention will have a great human and financial benefit to society. But subject selection must focus on women at risk—women for whom we are concerned because they exhibit enough periodontal inflammation that we might expect a PTB or LBW infant. The criteria in Table 1 do not necessarily raise that concern. Research to identify women at risk owing to their periodontal inflammation might result in a paradigm shift in future interventional research. Abraham M. Speiser, DDS Newark, N.J.

ANOTHER VIEWPOINT

Like many dentists struggling to untangle the possible relationships between oral and systemic disease from among confusing and contradictory reports, I was excited to see Dr. Anna Uppal and colleagues’ December JADA article, “The Effectiveness of Periodontal Treatment During Pregnancy in Reducing the Risk of Experiencing Preterm Birth and Low Birth Weight: A Meta-analysis” http://jada.ada.org

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May 2011

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