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 Table of Contents  
Year : 2022  |  Volume : 9  |  Issue : 4  |  Page : 279-285

Periodontitis to placenta: An awareness-based survey

Department of Periodontology, Bharati Vidyapeeth (Deemed to be University), Dental College and Hospital, Pune, Maharashtra, India

Date of Submission12-Jul-2022
Date of Acceptance01-Nov-2022
Date of Web Publication12-Feb-2023

Correspondence Address:
Aishwarya Sabharwal
Department of Periodontology, Bharati Vidyapeeth (Deemed to be University), Dental College and Hospital, Pune, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jdrr.jdrr_99_22

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Introduction: Surprising how a small part of our body, the mouth, can alter and result in a variety of systemic complications if not taken care of. The primary factor for maternal and newborn morbidity and mortality is thought to be periodontitis. Gynecologists have a crucial role in educating their patients about the need of keeping good dental health because it can improve the success of pregnancies and reduce mouth pain. Objective: The objective of this study was to understand the awareness of gynecologists practicing in Pune, Maharashtra, about periodontal status and its outcome in pregnant women. Materials and Methods: A questionnaire-based study was conducted on 60 gynecologists. We evaluated people's knowledge of the negative effects of female sex hormones on periodontal health. Results: Eighty percent were aware of the correlation between periodontal health and female sex hormones. 56.7% agreed that periodontal microorganisms can pass through the placenta and harm the fetus. 76.7% were unaware that the possibility of prenatal growth restriction has increased. Most participants did not motivate pregnant women for an oral health checkup. Conclusion: It can be inferred that gynecologists are not aware of the connection between mouth findings and worse pregnancy outcomes.

Keywords: Gynecologists, periodontal inflammation, periodontium, pregnancy, sex hormones

How to cite this article:
Sabharwal A, Patil VS, Sinha R, Saripalli N. Periodontitis to placenta: An awareness-based survey. J Dent Res Rev 2022;9:279-85

How to cite this URL:
Sabharwal A, Patil VS, Sinha R, Saripalli N. Periodontitis to placenta: An awareness-based survey. J Dent Res Rev [serial online] 2022 [cited 2023 Mar 27];9:279-85. Available from: https://www.jdrr.org/text.asp?2022/9/4/279/369590

  Introduction Top

A set of infectious disorders known as periodontal diseases are mostly brought on by various Gram-negative anaerobic and microaerophilic bacterial species that invade the subgingival region and elevate pro-inflammatory prostaglandins and cytokines.[1] It is one of the most prevalent chronic infectious diseases, with prevalence rates ranging from 10% to 90% in adults[2],[3],[4] and from 10% to 74% in pregnant women.[5],[6],[7]

Recent epidemiological studies have shown that periodontitis increases the chance of developing a number of systemic disorders, including diabetes mellitus, atherosclerosis, and pneumonia (especially aspiration pneumonia in the elderly).[8] Additionally connected to the emergence of pregnancy issues is periodontal disease. A mechanistic model describing the biological connection between periodontal disease and unfavorable pregnancy outcomes has been put out by Bobetsis et al. in 2006.[9] Inflammatory mediators including interleukin-1 (IL-1), IL-6, IL-8, tumor necrosis factor-alpha (TNF-α), or prostaglandin E2 (PGE2) acting on the fetoplacental unit are two possible methods by which periodontal disorders can alter the fetoplacental unit.

Numerous unfavorable pregnancy outcomes, such as premature labor, preeclampsia (PE), and low birth weight (LBW), have been linked to it. They have an impact on many pregnancies and are a major source of illness and mortality in both pregnant women and newborns. According to a meta-analysis,[10] pregnant women with periodontitis are more likely to deliver prematurely and have babies who are underweight. According to Jeffcoat et al.,[11] periodontitis increases a woman's risk of premature birth by five times before 35 weeks of pregnancy and by seven times before 32 weeks of pregnancy. Numerous studies reveal a strong link between PE and periodontal disease.

The first medical professionals to interact with expectant women are gynecologists. Identification of modifiable periodontal disease risk factors associated with pregnancy depends on their comprehension of the association between periodontal disease and unfavorable pregnancy outcomes.[12] Incorporating periodontal treatment into gynecologic care can boost pregnancy outcomes as well as prevent the oral problems that can get aggravated during pregnancy. Despite a lot of gynecologists present in the vicinity of our area, we have hardly encountered any pregnant patients coming to the hospital for dental care. This indirectly indicates the lack of awareness about oral health and its role in adverse pregnancy outcomes (APOs) or lack of reference by gynecologists.

Owing to the lack of published material in India, the prevalence of periodontal health and disease among practicing gynecologists is still unknown.

Therefore, the goal of the current study was to ascertain the level of periodontal disease awareness and pregnancy outcomes among gynecologists working in Pune, Maharashtra.

  Materials and Methods Top

Study design and setting

In order to determine how knowledgeable gynecologists were regarding periodontal status and how it affected pregnant women, a cross-sectional survey of 60 gynecologists in the Pune district of India was carried out. Informed consent was obtained from each participant, and the study was carried out in numerous hospitals, clinics, and medical schools located around the city.

The research doctors approached the gynecologists to fill out the questionnaire using a straightforward random selection technique.

Questionnaire design

The survey had 21 questions, and the last one allowed participants to provide comments on the study in an open-ended manner. Five gynecologists participated in a pilot study to evaluate how well questions were understood and how long it took to complete. According to the pilot study, gynecologists could finish the questionnaire in 8–10 min. A small number of changes were made to the survey to improve participant understanding of the questions and to simplify complex language.

There were three sections to the questionnaire. Age, gender, and the type of hospital were among the data gathered in the first section (governmental, private, medical college). The second section examined what was known about the following topics: (i) female sex hormones and their impact on periodontal health; (ii) whether oral microflora affects periodontal health; (iii) who should be consulted if there are any changes in gingival tissue; (iv) the impact of periodontal disease on preterm LBW (PLBW) deliveries; (v) the impact of oral contraceptives on gingival health; and (vi) whether periodontal condition treatment.

It had multiple choice questions with correct = 1 code and incorrect = 0 code for each question. The third section looked into the practices of the respondents when it came to treating female patients with gingival hypertrophy or bleeding.

The questionnaire was collected from each participant, and the number of participants with similar answers was sorted out and arranged in a master table.

Statistical analysis

The data collected (i.e., responses of the participants) were expressed as numbers and percentages. Descriptive statistics were performed using SPSS (Statistical Package for the Social Sciences) Software version 20. The percentage of right responses a respondent provided was used to determine their degree of knowledge.

  Results Top

A total of 60 gynecologists from various age groups, genders, practice lengths, and sectors took part in the study. The response rate was 100% with no dropouts because the doctors were contacted one by one to collect the forms. Nearly 35% of gynecologists were between the ages of 31 and 39. Eighty percent of gynecologists were female. According to [Figure 1], [Figure 2], [Figure 3], [Figure 4], 43% of gynecologists were private practitioners, with the majority (31.7%) having between 10 and 15 years of experience.
Figure 1: Age group

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Figure 2: Gender

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Figure 3: Area of practice

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Figure 4: Years of experience

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The results presented in [Table 1] reveal that 80% of participants were aware that alteration in female sex hormones (hormonal changes) across the female life cycle affects the oral cavity and 51 participants out of 60 (85%) believed that improper brushing could alter oral microflora. However, only 34 (56.7%) participants agreed that periodontal microorganisms can pass through the placenta and harm the fetus whereas only 27 (45%) respondents knew that periodontitis can cause infertility. It is also surprising to know that only 30 (50%) out of 60 participants insisted pregnant women get an oral health checkup done.
Table 1: Percentage of knowledge-based responses

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[Figure 5] displays the responses of the gynecologists to the questions aimed at the assessment of awareness that hormonal fluctuations may cause oral changes across a woman's reproductive phases. A very high percentage of the respondents 51 (85%) believed that hormonal changes that occur during pregnancy cause an increased response to plaque bacteria which can lead to gingivitis, while 39 (65%) believed that plaque was the main cause of gum disease during pregnancy [Figure 5]a. 46%–70% of participants knew that hormonal fluctuations in all trimesters of pregnancy manifest with oral findings whereas only 56%–64% of respondents believed that menopause and use of oral contraceptives preceded alterations in oral microflora which then resulted in oral findings [Figure 5]b. It is clear from the questionnaire that 45 (75%) gynecologists believed gingival swelling to be an outcome of hormonal changes, while 43 (71.7%) out of 60 considered gum bleeding to be a result of hormonal changes [Figure 5]c.
Figure 5: Awareness of the association of oral findings with hormonal fluctuations. (a) What according to you is the cause of gum disease during pregnancy? (b) Which of the following with alteration in the levels of hormones can lead to oral findings? (c) Which of the following oral changes are seen due to hormonal changes?

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The results presented in [Figure 6] reveal that 35 (58.3%) respondents were aware that Prevotella intermedia was the predominant microorganism in the mouth of pregnant women and 34 (56.7%) believed Porphyromonas gingivalis to be the predominant microorganism [Figure 6]a. Regarding the most common oral complaint, 39 out of 60 (65%) felt that gum enlargement requires dental intervention [Figure 6]b. Regarding pregnancy outcomes, approximately 60%–65% of the respondents thought that gingivitis and periodontitis could adversely affect pregnancy outcomes [Figure 6]c.
Figure 6: Awareness of the oral findings and pregnancy outcomes. (a) Which is the predominant microorganism seen in the mouth of pregnant women? (b) Which according to you is the most common oral complaint of a pregnant patient which needs dentist intervention? (c) Which oral problems really affect the outcomes of pregnancy?

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[Figure 7] shows the percentage of participants aware of APOs due to oral disease. A high percentage of gynecologists 51 (85%) answered that gum disease would lead to the delivery of a preterm or low-birth-weight infant. Likewise, a substantial percentage of gynecologists 44 (73.3%) knew that oral disease can lead to PE in expecting mothers [Figure 7]a whereas 34 (56.7%) respondents answered that oral diseases and gestational diabetes (GDM) had a bidirectional relationship [Figure 7]b.
Figure 7: Awareness of adverse pregnancy outcomes due to oral disease. (a) Which pregnancy outcome is seen due to oral disease? (b) What is the association between oral diseases and gestational diabetes?

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[Figure 8] shows the references and treatments advised for pregnant patients. The majority of the gynecologists believed that second trimester was the best time to visit a dentist and get the treatment done for the oral problems faced during pregnancy [Figure 8]a. Regarding the medications prescribed by the gynecologists for gingival enlargement or bleeding, majority 48 (81.4%) of participants said that they refer their patients directly to the dentist, 24 (40.7%) prescribed vitamin supplements and advised them to regular brushing, 14 (23.7%) prescribed mouthwash for their patient, and 4 (6.8%) prescribed antibiotics [Figure 8]b.
Figure 8: References and treatments advised for pregnant patients. (a) Which according to you is the best time to recommend your pregnant patient to go for dental treatment? (b) What do you prescribe your patients who have oral complaints?

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[Table 2] shows the correlation of age group and expertise with the level of awareness seen among gynecologists. Interestingly, our data showed that gynecologists in the age group of 50 or more with an experience of a minimum of 15 years were more aware of the implications oral health had on the adverse outcomes associated with pregnancy.
Table 2: Correlation of age group and expertise with the level of awareness

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  Discussion Top

Although various studies have looked into clinicians' attitudes and awareness of the link between oral health and pregnancy outcomes, the current study stands out since it assesses gynecologists' awareness about oral health status and its implications on a woman's life as she passes through all the reproductive phases. Despite increased public awareness and improvements in prenatal care, APOs is a serious health issue for health professionals in both developed and developing countries.[13] LBW and preterm delivery are the two most frequent causes of morbidity and mortality in newborns. Preterm labor (caused by uterine contractions) and LBW babies are thought to be caused by the release of pro-inflammatory mediators such as IL-1, TNF-α, and PGE2.[14] Inflammatory mediators such as IL-1, IL-6, TNF-α, and PGE2 are produced as a result of periodontal inflammation brought on by bacterial biofilm. Once locally created, it moves into the circulatory system[15] which may act as a trigger for initiation of adverse pregnancy outcomes.

Gynecologists are the primary health-care providers for pregnant women. If they are aware of this correlation, it can help in preventing the untoward consequences of neglecting oral findings. Our study highlights the percentage of gynecologists aware and unaware of the correlation between oral findings and APOs.

Our data revealed, in an interesting finding, that gynecologists with at least 15 years of experience and a minimum age of 50 were more cognizant of the effects oral health had on pregnancy's unfavorable outcomes. This demonstrates that older participants had a higher level of general knowledge than younger participants. This gap in knowledge may be explained by the fact that older gynecologists have more experience than those who are younger.

Although there were some limitations in their understanding, the general knowledge and awareness of periodontal health in this study were adequate. Even though 80%–85% of participants were aware of the term dental plaque, 41.7%–43.3% were not aware of the microbial content of dental plaque. According to the mechanistic model given by Bobetsis et al. in 2006, pathogenic bacteria entering the fetoplacental unit can harm the fetus. Our study indicates that 43.3% of participants were not aware that periodontal microorganisms can pass through the placenta and harm the fetus.

Progesterone and estrogen levels typically increase gradually throughout pregnancy, peaking at 100 ng/ml and 6 ng/ml, respectively, around the end of the third trimester. When compared to the menstrual period, these hormone levels are 10–30 times higher.[16] These increased levels of hormones lead to exacerbation of response to local factors causing oral changes. According to Zachariasen, 30%–100% of all expecting mothers manifest with gingival changes.[17] Otomo-Corgel,[18] 2007, also noticed that increased gingival bleeding and exudation are observed during the menstrual cycle and in women taking oral contraceptives. Even while the majority of the participants in our survey were aware that hormonal changes may result in gingival tissue changes during the female life cycle, it was not up to par. 36%–44% of individuals had an insufficient level of comprehension of the connection between gingival changes brought on by long-term oral contraceptive pill use. Additionally, 36.7% were not aware of oral menopausal female findings. These issues require education for gynecologists.

While considering the effect of oral changes on APOs, it is a known fact that in gingival and periodontal conditions, there is an inflammatory response to local deposits which gets disseminated into the systemic circulation and is exaggerated due to hormonal and circulatory changes that accompany pregnancy.[19]

In women with maternal periodontal disorders, the literature has revealed many APOs, including fetal growth restriction (FGR), LBW, PE, and GDM.[8] The first to document a link between periodontal conditions and PLBW[20] was Offenbacher et al. Periodontal disease has been identified by Vergnes and Sixou[21] as an independent risk factor for PLBW. Additionally, there is proof that PE and periodontitis are more closely related. Periodontal disease and PE have a beneficial relationship, according to Sgolastra et al.[22] According to Abariga and Whitcomb's meta-analysis,[23] women with periodontitis have a more than twofold greater risk of GDM. A study by Mobeen et al.[24] stated that stillbirth and neonatal and perinatal deaths increased with the severity of the periodontal disease. In the current study, the majority of gynecologists (76.7%–85%) were unaware that there is a higher risk of FGR leading to infant and maternal mortality, despite the fact that 85% of the gynecologists believed that gum disease would result in the delivery of a preterm or low-birth-weight infant (PLBW) and 73.3% of them believed gum disease to be a cause of PE.[25]

Recent epidemiological research has also discovered that dental health has an impact on male infertility. Kellesarian et al.[26] published a comprehensive study that found evidence of a link between chronic periodontitis and male infertility in six studies. However, few studies[27] have been done on the link between female infertility and periodontal disease. In our study, 55% of the participants were not aware of this fact.

Despite the fact that 80% of gynecologists were aware of the effects of hormones on the periodontium, they were less knowledgeable about the value of routine dental exams. Only half of the individuals in the study insisted on having their dental health examined because they were pregnant or intended to become pregnant. Similar results were found in a 2008 study by Al-Habashneh et al.,[28] where nearly 68% of respondents did not advise a periodontal evaluation for pregnant women as part of prenatal care, but the majority of participants prescribed mouthwash, antibiotics, and vitamin supplements to their patients with gingival enlargement or bleeding.

It is important to highlight that a recommendation has also been released by the American Academy of Periodontology[29] that all pregnant women, including those planning a pregnancy, should undergo periodontal examination and, if needed, should be provided with the appropriate preventive and/or therapeutic services.

  Conclusion Top

In light of the results of our investigation, it is reasonable to conclude that practitioners are not entirely aware of the connection between oral findings and unfavorable pregnancy outcomes. Gynecologists frequently recommend expectant patients for sonography scans, thyroid level testing, blood tests, and other diagnostic procedures. They must also advise getting regular dental checkups in order to prevent any negative effects that could result from poor oral health. Given that periodontal infection is both preventable and treatable,[30] risk identification variables and the confirmation of periodontal infection as an independent risk factor for unfavorable pregnancy outcomes are of substantial public utility. Because gynecologists are a woman's primary caregivers during her reproductive years, it is natural that they would be able to spot oral health issues early on and refer her to a periodontist for additional evaluation.

Ethical clearance

The research proposal was approved by the Institutional Ethics Committee (IEC) of Bharatividyapeeth dental college and hospital Pune, to carry out the research project (EC/NEW/INST/2019/329).

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Rahman G, Asa'ad F, Baseer MA. Periodontal health awareness among gynecologists in Riyadh, Saudi Arabia. J Int Soc Prev Community Dent 2015;5:211-7.  Back to cited text no. 1
Pihlstrom BL, Michalowicz BS, Johnson NW: Periodontal diseases. Lancet 2005;366:1809-20.  Back to cited text no. 2
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Bobetsis YA, Barros SP, Offenbacher S. Exploring the relationship between periodontal disease and pregnancy complications. J Am Dent Assoc 2006;137 Suppl:7S-13S.  Back to cited text no. 9
Corbella S, Taschieri S, Francetti L, De Siena F, Del Fabbro M. Periodontal disease as a risk factor for adverse pregnancy outcomes: A systematic review and meta-analysis of case-control studies. Odontology 2012;100:232-40.  Back to cited text no. 10
Jeffcoat MK, Hauth JC, Geurs NC, Reddy MS, Cliver SP, Hodgkins PM, et al. Periodontal disease and preterm birth: Results of a pilot intervention study. J Periodontol 2003;74:1214-8.  Back to cited text no. 11
Rahman G, Asa'ad F, Baseer MA. Periodontal health awareness among gynecologists in Riyadh, Saudi Arabia. J Int Soc Prev Community Dent 2015;5:211-7.  Back to cited text no. 12
Avula H, Avula J. Periodontal Infections and Adverse Pregnancy Outcomes: The Oral Health—Fetal Connection. Journal of Gynecologic Surgery 2011;27:1-4. 10.1089/gyn.2009.0104.  Back to cited text no. 13
Sree GN, Jayasheela M, Vinayaka AM. Knowledge and awareness among gynecologists in Davangere about the association between periodontal disease and pregnancy outcomes and referral pattern of pregnant woman to periodontists - A cross sectional survey. Int J Health Sci Res 2020;10:183–9.  Back to cited text no. 14
Pihlstrom BL, Michalowicz BS, Johnson NW. Periodontal diseases. Lancet 2005;366:1809-20.  Back to cited text no. 15
Grodstein F, Colditz GA, Stampfer MJ. Post-menopausal hormone use and tooth loss: A prospective study. J Am Dent Assoc 1996;127:370-7.  Back to cited text no. 16
Zachariasen RD. Ovarian hormones and oral health: Pregnancy gingivitis. Compendium 1989;10:508-12.  Back to cited text no. 17
Otomo-Corgel J. Periodontal therapy in the female patient. In: Newman MG, Takei HH, Klokkevold PR, Carranza FA, editors. Clinical Periodontology. 10th ed. India: WB Saunders Co; 2007. p. 540-60.  Back to cited text no. 18
Madianos PN, Bobetsis YA, Offenbacher S. Adverse pregnancy outcomes (APOs) and periodontal disease: Pathogenic mechanisms. J Periodontol 2013;84:S170-80.  Back to cited text no. 19
Offenbacher S, Katz V, Fertik G, Collins J, Boyd D, Maynor G, et al. Periodontal infection as a possible risk factor for preterm low birth weight. J Periodontol 1996;67 Suppl 10S:1103-13.  Back to cited text no. 20
Vergnes JN, Sixou M. Preterm low birth weight and maternal periodontal status: A meta-analysis. Am J Obstet Gynecol 2007;196: 7.e1-7.  Back to cited text no. 21
Sgolastra F, Petrucci A, Severino M, Gatto R, Monaco A. Relationship between periodontitis and pre-eclampsia: A meta-analysis. PLoS One 2013;8:e71387.  Back to cited text no. 22
Abariga SA, Whitcomb BW. Periodontitis and gestational diabetes mellitus: A systematic review and meta-analysis of observational studies. BMC Pregnancy Childbirth 2016;16:344.  Back to cited text no. 23
Mobeen N, Jehan I, Banday N, Moore J, McClure EM, Pasha O, et al. Periodontal disease and adverse birth outcomes: A study from Pakistan. Am J Obstet Gynecol 2008;198:8.e1-8.  Back to cited text no. 24
Ananth CV, Andrews HF, Papapanou PN, Ward AM, Bruzelius E, Conicella ML, et al. History of periodontal treatment and risk for intrauterine growth restriction (IUGR). BMC Oral Health 2018;18:161.  Back to cited text no. 25
Kellesarian SV, Yunker M, Malmstrom H, Almas K, Romanos GE, Javed F. Male Infertility and Dental Health Status: A Systematic Review. Am J Mens Health 2018;12:1976-84. doi: 10.1177/1557988316655529.  Back to cited text no. 26
Machado V, Lopes J, Patrão M, Botelho J, Proença L, Mendes JJ. Validity of the association between periodontitis and female infertility conditions: A concise review. Reproduction 2020;160:R41-54.  Back to cited text no. 27
Al-Habashneh R, Aljundi SH, Alwaeli HA. Survey of medical doctors' attitudes and knowledge of the association between oral health and pregnancy outcomes. Int J Dent Hyg 2008;6:214-20.  Back to cited text no. 28
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  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]

  [Table 1], [Table 2]


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