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Preeclampsia Is Not Related to Clinical Periodontal Disease in Nonsmoking and Nondrinking Jordanian Women
HARM/ETIOLOGY
ARTICLE ANALYSIS & EVALUATION Preeclampsia Is Not Related to Clinical Periodontal Disease in Nonsmoking and Nondrinking Jordanian Women ARTICLE TITLE AND BIBLIOGRAPHIC INFORMATION Lack of Association Between Periodontal Parameters and Preeclampsia Khader YS, Jibreal M, Al-Omiri M, Amarin Z. J Periodontol 2006;77(10):1681-7
LEVEL OF EVIDENCE 3b
PURPOSE/QUESTION Authors evaluated the association between periodontal parameters and preeclampsia among a group of Jordanian pregnant women.
SOURCE OF FUNDING Information not available
TYPE OF STUDY/DESIGN Case-Control Study with 115 Cases and 230 Random Controls
SUMMARY Subjects Cases were Jordanian women (n = 115) who delivered babies in Prince Badea Teaching Hospital between September 2004 and May 2005 who had confirmed preeclampsia (blood pressure $140/90 mm Hg after 20 weeks of gestation with proteinuria not due to urinary tract infection). Controls were randomly selected (n = 230) from women who delivered on the same day as the cases but did not have preeclampsia or proteinuria. Cases were significantly older (mean age 30.5 years among cases compared to 29.0 among controls; P = .001). Subjects and controls were nonsmokers and non–alcohol drinkers according to self-reports. Most controls were housekeepers, only about one third had an education beyond 12 years, and two thirds were multiparous. In both cases and controls 14% to 18% of the sites had $4-mm probing depth. Cases had more decayed surfaces (mean of 2.17) compared to controls (mean 0.97; P = .002).
Exposure Clinical periodontal disease was the primary exposure. It was measured using an oral examination conducted by a masked examiner. Periodontal status of all teeth was recorded using probing depth, clinical attachment level, and gingival recession. Oral hygiene status was measured using 6 selected teeth and standard indices. No details on examiner calibration are given.
Main Outcome Measure Primary outcome was preeclampsia. Preeclampsia was defined as having blood pressure $140/90 mm Hg after 20 weeks of gestation with proteinuria that is not due to urinary tract infection.
Main Results After controlling for age, prepregnancy body mass index (BMI), history of preeclampsia, family history of cardiovascular disease, family history of preeclampsia, twin birth, and gestational age, there were no statistically significant associations between any of the clinical periodontal disease parameters and preeclampsia (ie, Odds Ratio for percentage of sites with $4-mm probing depth is 1.0; 95% Confidence Interval = 0.99 to 1.01).
Conclusions There is no association between clinical periodontal disease parameters and preeclampsia.
COMMENTARY AND ANALYSIS J Evid Base Dent Pract 2007;7:176-177 1532-3382/$35.00 Ó 2007 Elsevier Inc. All rights reserved. doi:10.1016/j.jebdp.2007.09.008
Even though 3 previous studies1-3 reported an association between periodontal disease and preeclampsia, these authors failed to support this hypothesis even though they used a larger number of subjects compared to the previous studies. Jordanian women who were the study subjects
JOURNAL OF EVIDENCE-BASED DENTAL PRACTICE
are self-reported to be nonsmokers and non–alcohol drinkers. This might explain the observed lack of association to some extent, indicating that the previous reports are subjected to some residual confounding due to these variables. A similar scenario can be found in the literature regarding the association between periodontal disease and prematurity where Rajapakse et al4 failed to observe the hypothesized association among nonsmoking, non– alcohol drinking, and non–drug using Sri Lankan women. In this Jordanian study, periodontal disease was not evaluated on third molars. As authors indicated, this might dilute the results to a certain extent as well. If the previously reported associations between periodontal disease and preeclampsia are in fact true for those populations, the possibility exists that this may not be true for Jordanian women due to other underlying parameters that might be related to periodontal disease and preeclampsia among them that are different from the parameters in previously studied populations. This however, is purely speculative. To properly evaluate the association between periodontal disease and preeclampsia, one needs to study a larger sample, measure the clinical periodontal status before the onset of preeclampsia (some have suggested gathering information on other aspects of periodontal disease such as bacteriological, immunological, and inflammatory aspects, as clinical disease may not reflect the true underlying infection and inflammation), and gather valid data on potential confounders. These investigators have studied a considerably larger sample of a group of somewhat homogeneous women who were supposedly free of at least 2 major confounding factors (smoking and
Volume 7, Number 4
alcohol use). However, their clinical periodontal assessment is postpartum and did not include the third molars. The emerging data from randomized controlled trials will provide us with a clearer picture to what extent links between periodontitis and preeclampsia reflect causality. This study in Jordanian women is not promising for those betting on a causal link.
REFERENCES 1. Boggess KA, Lieff S, Murtha AP, Moss K, Beck J, Offenbacher S. Maternal periodontal disease is associated with an increased risk for preeclampsia. Obstet Gynecol 2003 Feb;101(2):227-31. 2. Canakci V, Canakci CF, Canakci H, Canakci E, Cicek Y, Ingec M, et al. Periodontal disease as a risk factor for pre-eclampsia: a case control study. Aust N Z J Obstet Gynaecol 2004 Dec;44(6):568-73. 3. Oettinger-Barak O, Barak S, Ohel G, Oettinger M, Kreutzer H, Peled M, et al. Severe pregnancy complication (preeclampsia) is associated with greater periodontal destruction. J Periodontol 2005;76(1): 134-7. 4. Rajapakse PS, Nagarathne M, Chandrasekra KB, Dasanayake AP. Periodontal disease and prematurity among non-smoking Sri Lankan women. J Dent Res 2005;84(3):274-7.
REVIEWER Ananda P. Dasanayake, BDS, MPH, PhD, FACE Professor Director, Graduate Program in Clinical Research New York University College of Dentistry Department of Epidemiology and Health Promotion 345 East 24th Street New York, NY 10010 [email protected]
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ARTICLE ANALYSIS & EVALUATION Preeclampsia Is Not Related to Clinical Periodontal Disease in Nonsmoking and Nondrinking Jordanian Women ARTICLE TITLE AND BIBLIOGRAPHIC INFORMATION Lack of Association Between Periodontal Parameters and Preeclampsia Khader YS, Jibreal M, Al-Omiri M, Amarin Z. J Periodontol 2006;77(10):1681-7
LEVEL OF EVIDENCE 3b
PURPOSE/QUESTION Authors evaluated the association between periodontal parameters and preeclampsia among a group of Jordanian pregnant women.
SOURCE OF FUNDING Information not available
TYPE OF STUDY/DESIGN Case-Control Study with 115 Cases and 230 Random Controls
SUMMARY Subjects Cases were Jordanian women (n = 115) who delivered babies in Prince Badea Teaching Hospital between September 2004 and May 2005 who had confirmed preeclampsia (blood pressure $140/90 mm Hg after 20 weeks of gestation with proteinuria not due to urinary tract infection). Controls were randomly selected (n = 230) from women who delivered on the same day as the cases but did not have preeclampsia or proteinuria. Cases were significantly older (mean age 30.5 years among cases compared to 29.0 among controls; P = .001). Subjects and controls were nonsmokers and non–alcohol drinkers according to self-reports. Most controls were housekeepers, only about one third had an education beyond 12 years, and two thirds were multiparous. In both cases and controls 14% to 18% of the sites had $4-mm probing depth. Cases had more decayed surfaces (mean of 2.17) compared to controls (mean 0.97; P = .002).
Exposure Clinical periodontal disease was the primary exposure. It was measured using an oral examination conducted by a masked examiner. Periodontal status of all teeth was recorded using probing depth, clinical attachment level, and gingival recession. Oral hygiene status was measured using 6 selected teeth and standard indices. No details on examiner calibration are given.
Main Outcome Measure Primary outcome was preeclampsia. Preeclampsia was defined as having blood pressure $140/90 mm Hg after 20 weeks of gestation with proteinuria that is not due to urinary tract infection.
Main Results After controlling for age, prepregnancy body mass index (BMI), history of preeclampsia, family history of cardiovascular disease, family history of preeclampsia, twin birth, and gestational age, there were no statistically significant associations between any of the clinical periodontal disease parameters and preeclampsia (ie, Odds Ratio for percentage of sites with $4-mm probing depth is 1.0; 95% Confidence Interval = 0.99 to 1.01).
Conclusions There is no association between clinical periodontal disease parameters and preeclampsia.
COMMENTARY AND ANALYSIS J Evid Base Dent Pract 2007;7:176-177 1532-3382/$35.00 Ó 2007 Elsevier Inc. All rights reserved. doi:10.1016/j.jebdp.2007.09.008
Even though 3 previous studies1-3 reported an association between periodontal disease and preeclampsia, these authors failed to support this hypothesis even though they used a larger number of subjects compared to the previous studies. Jordanian women who were the study subjects
JOURNAL OF EVIDENCE-BASED DENTAL PRACTICE
are self-reported to be nonsmokers and non–alcohol drinkers. This might explain the observed lack of association to some extent, indicating that the previous reports are subjected to some residual confounding due to these variables. A similar scenario can be found in the literature regarding the association between periodontal disease and prematurity where Rajapakse et al4 failed to observe the hypothesized association among nonsmoking, non– alcohol drinking, and non–drug using Sri Lankan women. In this Jordanian study, periodontal disease was not evaluated on third molars. As authors indicated, this might dilute the results to a certain extent as well. If the previously reported associations between periodontal disease and preeclampsia are in fact true for those populations, the possibility exists that this may not be true for Jordanian women due to other underlying parameters that might be related to periodontal disease and preeclampsia among them that are different from the parameters in previously studied populations. This however, is purely speculative. To properly evaluate the association between periodontal disease and preeclampsia, one needs to study a larger sample, measure the clinical periodontal status before the onset of preeclampsia (some have suggested gathering information on other aspects of periodontal disease such as bacteriological, immunological, and inflammatory aspects, as clinical disease may not reflect the true underlying infection and inflammation), and gather valid data on potential confounders. These investigators have studied a considerably larger sample of a group of somewhat homogeneous women who were supposedly free of at least 2 major confounding factors (smoking and
Volume 7, Number 4
alcohol use). However, their clinical periodontal assessment is postpartum and did not include the third molars. The emerging data from randomized controlled trials will provide us with a clearer picture to what extent links between periodontitis and preeclampsia reflect causality. This study in Jordanian women is not promising for those betting on a causal link.
REFERENCES 1. Boggess KA, Lieff S, Murtha AP, Moss K, Beck J, Offenbacher S. Maternal periodontal disease is associated with an increased risk for preeclampsia. Obstet Gynecol 2003 Feb;101(2):227-31. 2. Canakci V, Canakci CF, Canakci H, Canakci E, Cicek Y, Ingec M, et al. Periodontal disease as a risk factor for pre-eclampsia: a case control study. Aust N Z J Obstet Gynaecol 2004 Dec;44(6):568-73. 3. Oettinger-Barak O, Barak S, Ohel G, Oettinger M, Kreutzer H, Peled M, et al. Severe pregnancy complication (preeclampsia) is associated with greater periodontal destruction. J Periodontol 2005;76(1): 134-7. 4. Rajapakse PS, Nagarathne M, Chandrasekra KB, Dasanayake AP. Periodontal disease and prematurity among non-smoking Sri Lankan women. J Dent Res 2005;84(3):274-7.
REVIEWER Ananda P. Dasanayake, BDS, MPH, PhD, FACE Professor Director, Graduate Program in Clinical Research New York University College of Dentistry Department of Epidemiology and Health Promotion 345 East 24th Street New York, NY 10010 [email protected]
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